视网膜血管增生性肿瘤的治疗分析和探讨

Treatment of vasoproliferative tumors of the retina

目的探讨视网膜血管增生性肿瘤(VPTR)的治疗方法。方法回顾性病例系列研究。收集2006至2017年在北京大学人民医院眼科确诊的VPTR的患者20例(20只眼),其中男性13例,女性7例,年龄(40.05±14.28)岁。其中2只眼单独行冷冻疗法,1只眼单独行视网膜激光治疗,1只眼单独行巩膜外敷贴治疗,余16只眼根据病情分别选择了巩膜外放射敷贴疗法、光动力疗法(PDT)、玻璃体腔注射抗新生血管药物、视网膜激光光凝和冷冻疗法的联合治疗。其中9只眼因视网膜脱离、玻璃体积血等并发症行玻璃体切除术(PPV)。以肿瘤缩小、渗出吸收、异常血管萎缩、视网膜脱离减轻为治疗有效的观察指标。结果20例患者中眼底检查均可见视网膜上单个或多个黄白色或橙红色,富含血管的瘤体。20只眼均同时伴有并发症,其中并发视网膜内(下)渗出20只眼(100%);黄斑水肿19只眼(95%),黄斑前膜4只眼(20%);视网膜脱离8只眼(40%);玻璃体积血6只眼(30%);异常血管16只眼(80%)和增生膜7只眼(35%)。长期随访中,单独行巩膜外敷贴治疗的1只眼肿瘤萎缩,视力提高。单独行冷冻疗法的2只眼:1只眼黄斑水肿减轻,异常血管减少,视力提高;1只眼无明显变化。单独行视网膜激光治疗的1只眼渗出增加,视力下降;行联合治疗的16只眼中9只眼并发症减轻,视力提高;3只眼无明显变化;4只眼并发症加重,视力下降。结论VPTR的病情复杂,治疗棘手。临床上应根据具体病情选择合适的治疗方法,不同的治疗方法也可联合应用。对于以异常血管为主要并发症的小肿瘤可选择激光光凝和(或)冷冻治疗。肿瘤较大并伴有渗出性视网膜脱离的可选择巩膜外放射敷贴治疗,出现玻璃体积血和牵拉性视网膜脱离的可选择PPV。抗新生血管治疗对并发黄斑水肿治疗切实有效。

Objective To evaluate the treatment of vasoproliferative tumors of the retina(VPTR).Methods Retrospective case series study.The clinical data of 20 VPTR patients(20 eyes)were retrospectively analyzed,including 2 eyes only treated by cryotherapy,1 eye only treated by photocoagulation and 1 eye only treated by ruthenium-106 brachytherapy.The remaining 16 eyes had combined treatment of ruthenium-106 brachytherapy,photodynamic therapy,anti-VEGF therapy,photocoagulation and cryotherapy.Nine eyes were also treated by vitrectomy because of complications such as retinal detachment and vitreous hemorrhage.Results Single or multiple yellow white or orange red,highly vascular tumor lesions were found in ocular fundi of the 20 eyes.All eyes were accompanied by complications,including intraretinal and subretinal exudations(100%),macular edema(n=19,95%),epiretinal membrane(n=4,20%),retinal detachment(n=8,40%),vitreous hemorrhage(n=6,30%),abnormal blood vessels(n=16,80%)and proliferative membrane(n=7,35%).In the follow-up,the tumor in the eye treated by ruthenium-106 brachytherapy alone was atrophied and the vision improved.Regarding the 2 eyes treated by cryotherapy alone,macular edema and abnormal blood vessels decreased and visual acuity improved in 1 eye,and visual acuity did not change significantly in another eye.More leakages and increased visual acuity were found in the eye treated by photocoagulation alone.Among the 16 eyes treated with combined therapy,9 eyes had decreased complications and improved visual acuity,3 eyes did not change significantly,and 2 eyes had increased complications and decreased visual acuity.Conclusions The conditions of VPTR are complex and difficult to treat.According to the specific conditions,clinicians should choose appropriate treatment methods;different treatment methods can be combined.Laser photocoagulation and cryotherapy may be chosen to treat small tumors complicated with abnormal blood vessels.Ruthenium-106 brachytherapy could treat big tumors complicated with exudative retinal detachment.Vitreous surgery can be used in hemorrhage and tractional retinal detachment.Anti-VEGF therapy is effective in the treatment of macular edema.(Chin J Ophthalmol,2020,56:272-278)