首诊眼科与非首诊眼科的获得性免疫缺陷综合征合并巨细胞病毒视网膜炎的眼底特征对比分析

Comparative analysis for the fundus characteristics of acquired immune deficiency syndrome with cytomegalovirus retinitis between fir st-visit and non-first-visit in ophthalmology

目的对比分析首诊眼科与非首诊眼科的获得性免疫缺陷综合征(AIDS)合并巨细胞病毒视网膜炎(CMVR)的眼底特征。方法回顾性系列病例研究。2004年7月至2017年9月在徐州医科大学附属徐州市立医院眼科确诊的AIDS合并CMVR患者22例41只眼纳入研究。因眼部症状来眼科就诊后发现AIDS者7例14只眼(FVO组),已知患有AIDS后发生眼底病变者15例27只眼(FVNO组)。所有患者行视力、眼压、裂隙灯显微镜、间接检眼镜检查;屈光间质清晰者21例39只眼均行眼底彩色照相检查,其中5例行FFA检查;5例行OCT和眼部B型超声检查。将CMVR分为暴发型及懒惰型。除2例4只眼外,其余20例37只眼均进行了高效抗逆转录病毒治疗。所有患者均接受静脉滴注更昔洛韦治疗。41只眼中,行玻璃体腔注入更昔洛韦治疗12只眼;因视网膜脱离行25G玻璃体切割联合硅油填充手术10只眼;因广泛视网膜脱离,患者放弃手术治疗7只眼;未接受任何眼科治疗12只眼。治疗后平均随访时间(23±39)个月。对比分析两组患者暴发型、懒惰型CMVR的发生率及各自眼底特征。两组患者初诊及末次随访时的视力差异以及CD4+T细胞计数比较采用t检验;两组患者病灶是否累及黄斑以及病灶波及范围比较采用χ^2检验。结果暴发型CMVR表现为沿大血管分布的浓密的黄白色坏死灶伴出血以及伴或不伴卫星灶;懒惰型CMVR表现为稀疏的黄白色颗粒状外观病灶伴少许出血。伴随体征包括霜样树枝样血管鞘、视网膜动脉闭塞及视盘水肿等。FVO组7例14只眼均为暴发型。其中,伴视网膜动脉闭塞2例2只眼;伴视盘水肿1例2只眼,为双眼发病者。FVNO组15例27只眼中,暴发型13例21只眼,懒惰型4例6只眼。暴发型患者中,伴霜样树枝样血管鞘4例6只眼,伴视网膜动脉闭塞10例12只眼,伴视盘水肿4例4只眼。FVO组与FVNO组初诊视力比较,差异无统计学意义(t=-1.534,P=0.133);末次随访视力比较,差异有统计学意义(t=-3.420,P=0.001);初诊时CD4^+T细胞计数比较,差异无统计学意义(t=-0.902,P=0.378)。FVO组病灶累及黄斑和病灶范围波及3~4个象限的患眼数高于FNVO组,差异均有统计学意义(χ^2=7.552、7.865,P=0.006、0.005)。结论AIDS合并CMVR首诊眼科者较非首诊眼科者眼底浓密的坏死病灶累及黄斑更多,病灶范围更广。

Objective To comparatively analyze for the fundus characteristics of acquired immune deficiency syndrome(AIDS)with cytomegalovirus retinitis(CMVR)between first-visit and non-first-visit in ophthalmology.Methods A retrospective study was performed for 22 patients(41 eyes)diagnosed as CMVR with AIDS by ophthalmology in the Affiliated Municipal Hospital of Xuzhou Medical University from July 2004 to September 2017.The patients were divided into two groups:one with the first-visit in ophthalmology(FVO)and the other with the first-visit in non-ophthalmology(FVNO).All patients underwent visual acuity,intraocular pressure,slit lamp microscope and indirect ophthalmoscope examinations.Thirty-nine eyes of 21 patients with clear refractive media were examined by color fundus photography,of which 5 patients were examined by FFA.Five patients examined by OCT and B-mode ultrasound.The CMVR were characterized as fulminant type or indolent type.All the 22 patients(41 eyes)except 2 patients(4 eyes)accepted highly active antiroviral therapy,and all patients were treated with ganciclovir intravenously.Nine patients(12 eyes)received intravitreal injection of ganciclovir,7 patients(10 eyes)underwent vitrectomy because of retinal detachment,6 patients(7 eyes)gave up surgery because of extensive retinal detachment,and the other 12 eyes did not undergo any eye surgery.All patients were followed for 6-58 months(average 23±39 months).The incidences and fundus characteristics of the patients with fulminant or indolent CMVR were compared and analyzed.Between the two groups,the difference of visual acuity and CD4^+T cell count at the first vist and the last follow-up were analyzed by a z-test,and the macular involvement and spread of the two groups were compared by a chi-square test.Results Fulminant CMVR showed dense yellow-white necrotic lesions along the great vessels with or without satellite lesions,while indolent CMVR showed sparse yellow-white granular lesions with a little bleeding.The concomitant signs included frost-like dendritic vascular sheath,retinal artery occlusion and optic disc edema.Fourteen eyes of 7 patients in FVO group were fulminant,including 2 patients(2 eyes)with retinal artery occlusion and 1 patient(two eyes)with optic disc edema.In FVNO group,there were 27 eyes of 15 patients,including 21 eyes of 13 cases identified as fulminant type and 6 eyes of 4 patients as indolent type.In the fulminant type,there were 4 patients(6 eyes)with frost-like dendritic vascular sheath,10 patients(12 eyes)with retinal artery occlusion and 4 patients(4 eyes)with optic disc edema.There was no significant difference in initial visual acuity(t=-1.534,P=0.133),but there was a significant difference in visual acuity at the last follow-up(t=-3.420,P=0.001).There was no significant difference in CD4^+T cells between the two groups at the first visit(t=-0.902,P=0.378).The proportions of macular involvement and 3-4 quadrant involvement in FVO group were significantly higher than those in FVNO group(χ^2=7.552,7.865;P=0.006,0.005).Conclusion For AIDS patients with CMVR,the first-visit in ophthalmology showed more dense necrotic lesions involving macular and a wider range of lesions than the first-visit in non-ophthalmology.