不同病程梅毒性后葡萄膜炎患眼眼底影像特征观察

Multimodal fundus imaging in patients of syphilitic posterior uveitis at different stages

目的 观察分析不同病程梅毒性后葡萄膜炎患眼的眼底影像特征。 方法 回顾性分析32例梅毒性后葡萄膜炎患者46只眼的临床资料。按病程＜2个月、≥2个月将其分为急性期14例16只眼和慢性迁延期18例30只眼。所有患眼均行间接检眼镜、眼底彩色照相、荧光素眼底血管造影（FFA）及光相干断层扫描（OCT）检查。根据神经梅毒治疗原则对患者行正规驱梅治疗。治疗后重复行眼底彩色照相及OCT检查。观察分析不同病程患眼的眼底影像特征。 结果 间接检眼镜及眼底彩色照相检查发现，急性期16只眼中，视盘轻度水肿3只眼，黄斑区黄白色盘状渗出病灶4只眼，其余9只眼眼底表现正常；驱梅治疗后，部分患眼有少许色素改变，其余患眼均无其他特殊表现。慢性迁延期30只眼中，视盘轻度充血、边界欠清4只眼，黄斑囊样水肿3只眼，无明显异常或伴有不同程度的色素改变21只眼，合并黄斑区脉络膜新生血管、糖尿病视网膜病变各2只眼；驱梅治疗后，患眼黄斑囊样水肿逐渐消退，但仍可见黄斑区色素改变。FFA检查发现，急性期、慢性迁延期患眼均有不同程度的视网膜血管炎表现；慢性迁延期患眼黄斑区可出现水肿强荧光，病程2～3年者透见荧光增多。OCT检查发现，急性期患眼外层椭圆体带缺失，视网膜色素上皮（RPE）层颗粒状反射不均匀，合并黄斑区神经上皮层下渗出6只眼；驱梅治疗后，患眼外层椭圆体带结构逐渐恢复，RPE层结构基本规则。慢性迁延期患眼可见广泛外层椭圆体带缺失或不连续，色素移行或合并黄斑区囊样水肿；驱梅治疗后，患眼外层椭圆体带恢复不全，病程2～3年者仍存在外层椭圆体带不连续。 结论 急性期、慢性迁延期梅毒性后葡萄膜炎患眼眼底可无异常表现或仅出现黄斑盘状渗出性病灶；FFA以视网膜血管炎表现为主，慢性迁延期可见透见荧光增加；OCT表现为外层椭圆体带受累或合并黄斑神经上皮层下渗出。驱梅治疗后部分患眼眼底有少许色素改变，其余表现正常；急性期外层椭圆体带结构逐渐恢复，慢性迁延期外层椭圆体带恢复不全。

Objective To observe the fundus imaging characteristics of different stages of syphilitic posterior uveitis. Methods Retrospective cases series. Forty-six eyes of 32 patients with syphilitic posterior uveitis were included. There were 14 patients （16 eyes） and 18 patients （30 eyes） were assigned to acute stage group （with the course 〈2 months） and chronic stage group （with the course ≥2 months） respectively. All eyes received the examination of indirect ophthalmoscopy, color fundus photography, fundus fluorescein angiography （FFA） and optical coherence tomography （OCT）. All patients received regular anti-syphilitic treatment. Color fundus photography and OCT were followed after treatment. The fundus imaging characteristics of different stages of syphilitic posterior uveitis were observed. Results Indirect ophthalmoscopy and fundus color photography showed that in the acute stage group, there were 3/16 eyes with optic disc edema; 4/16 eyes with a yellowish, placoid lesion involving the macular. There were only some pigment alterations on the fundus after treatment. In the chronic stage group, there were 4/30 eyes with optic disc hyperemia, 3/30 eyes with cystoid macular edema. After treatment, the optic hyperemia vanished gradually, but there were still some pigment alterations. The FFA images of two groups showed various vascular leakages. In the chronic stage group, patients also showed hyper-fluorescence with cystoid macular edema. The patients with course 2 - 3 years have more transmitted fluorescence on FFA. OCT showed that all eyes in the acute stage group had lost the ellipsoid zone, with irregular granular reflectivity of the retinal pigment epithelium （RPE） layer, 6 eyes with subretinal fluid in the macular. After treatment, the ellipsoid zone and RPE layer structure recovered gradually. In the chronic stage group, all eyes showed widespread loss of the ellipsoid zone, pigment migration and （or） cystoid macular edema. After treatment, the ellipsoid zone showed partial recovery. The outer ellipsoid zone was still discontinuous in patients with long duration. Conclusions Syphilitic posterior uveitis patients generally had normal fundus, but some cases had a yellowish, placoid lesion involving the macular. FFA showed various vascular leakages, and the chronic stage group showed more transmitted fluorescence. The major OCT change was loss of the ellipsoid zone or with subretinal fluid. After treatment, fundus showed no abnormal manifestations except some pigment alterations; the ellipsoid zone structure recovered gradually in acute stage eyes, partially recovered in chronic stage eyes.