脉络膜结核瘤的临床特征及疗效观察

Clinical features and therapeutic outcomes of choroidal tuberculoma

目的观察脉络膜结核瘤的临床特征及治疗效果。设计回顾性病例系列。研究对象 2012-2018年北京同仁医院脉络膜结核瘤患者7例(7眼)。方法所有患者均行最佳矫正视力(BCVA)、裂隙灯显微镜、间接检眼镜,彩色眼底照相、荧光素眼底血管造影(FFA)、吲哚菁绿眼底血管造影(ICGA)、相干光断层扫描(OCT)及眼部B超等检查,以及结核菌素试验(PPD)、γ干扰素释放试验(IGRA)、胸部CT等结核相关检查。所有患者行全身抗结核治疗,随访6~18个月,平均(11.1±3.8)个月。主要指标眼底表现,FFA及ICGA表现。结果患者平均年龄(42±11.5)岁。7例患者中3例为活动性肺结核;2例既往有肺结核病史;1例曾有结核患者接触史;1例无明确结核病史及接触史,为潜伏性感染。7例患者均单眼发病,其中6例为孤立性结核瘤,1例为多发性结核瘤。眼底表现为黄白色视网膜下隆起。5例瘤体位于后极部,1例位于黄斑颞侧血管弓外,1例位于颞下血管弓处。均伴有渗出性视网膜脱离,其中5例有视网膜出血。视力手动/眼前~0.5。FFA 示2例早期低荧光,晚期荧光增强;5例早期高荧光,晚期荧光渗漏;4例瘤体边缘出现针尖样细小高荧光点。ICGA早期瘤体呈低荧光,晚期低荧光持续存在,病灶周围可出现弥散的高荧光。所有患者均接受标准化抗结核治疗,疗程6~18个月。治疗后7例患者瘤体均减小,渗出性视网膜脱离及视网膜出血吸收,随访期内未见复发。结论脉络膜结核瘤可伴有全身活动性结核或发生于结核的既往感染和潜伏感染,主要表现为后极部视网膜下黄白色病灶合并渗出性视网膜脱离,规范化的抗结核治疗可有效控制病灶。

Objective To observe the clinical features and treatment outcomes of choroidal tuberculoma. Design Retrospective case series. Participants The 7 cases (7 eyes) with choroidal tuberculoma presented to Beijing Tongren Hospital between June 2012 and June 2018. In the 7 patients, 4 were male and 3 were female. Method Best corrected visual acuity, slit lamp ophthalmoscopy, indirect ophthalmoscopy,fundus fluorescein angiography(FFA), indocyanine green fundus angiography (ICGA), optical coherence tomography(OCT), B ultrasound, computed tomography of the chest, Interferon-gamma release assay (IGRA) and Purified Protein Derivative(PPD)were performed. All patients had standard anti-tuberculosis treatment. Treatment outcomes were followed for 6 to 18 months with an average of (11.1±3.8) months. Main Outcome Measures Visual acuity, features of the fundus, FFA and ICGA. Results The average age of 7 cases was (42±11.5) years-old. Three patients had active pulmonary tuberculosis, 2 patient had history of tuberculosis,1 patient had the history of contact with tuberculosis, and 1 patient was latent tuberculosis infection. All cases were affected unilaterally. Six patients had solitary granuloma and 1 patient had multiple granuloma. Fundus examination showed 7 eyes with subretinal yellow-white lesions and exudative retinal detachment. Five eyes presented with retinal hemorrhage. Baseline visual acuity ranged from hand motion to 0.5. In FFA,2 eyes demonstrated hypofluorescence in the early stage and hyperfluorescence in the late stage,while 5 eyes revealed hyperfluorescence in the early stage and fluorescence leakage in the late stage. Needle-like high fluorescein spots were found in the margins of the lesions in 4 cases. ICGA revealed hypofluorescentce in the early phase and hyperfluorescence with obscure boundary in the late phase. After standard anti-tuberculosis treatment(the course of treatment was 6 to 18 months),inflammation was controlled at the end of follow-up in all cases. Conclusion Choroidal tuberculoma can associate with active or inactive pulmonary tuberculosis, or latent tuberculosis infection. The main presentations of choroidal tuberculoma are subretinal yellow-white lesions at the posterior pole, and exudative retinal detachment. Standard anti-tuberculosis treatment can improve ocular inflammation.