息肉样脉络膜血管病变患眼脉络膜特征对抗血管内皮生长因子药物治疗应答的预测作用分析

Choroidal characteristics to predict the therapeutic response of anti-vascular endothelial growth factor drugs in polypoidal choroidal vasculopathy

目的观察息肉样脉络膜血管病变(PCV)患眼玻璃体腔注射抗VEGF药物治疗后的脉络膜特征变化,初步评估其对PCV抗VEGF药物治疗应答的预测作用。方法回顾性临床研究。2015年1月至2020年5月于南京医科大学附属眼科医院检查确诊的PCV患者63例63只眼纳入研究。其中,男性39例39只眼,女性24例24只眼;平均年龄(62.53±6.05)岁;均为单眼发病。患眼均行玻璃体腔注射雷珠单抗治疗,治疗后应答不佳者再行光动力疗法(PDT)联合抗VEGF药物治疗。63只眼中,治疗后无应答或应答不佳38只眼,应答良好25只眼,并据此分为应答不佳组、应答良好组。采用德国Herdelberg公司共焦激光同步血管造影系统(HRA+OCT)增强深度扫描技术测量黄斑中心凹脉络膜厚度(SFCT)、脉络膜大血管层厚度(LCVT)。依据ICGA检查结果对脉络膜高通透性(CVH)进行判定。CVH:中晚期(吲哚青绿注射后10~15 min)后极部脉络膜可见边缘模糊的多灶性强荧光。对比观察两组患眼治疗前以及应答良好组治疗后6个月、应答不佳组联合PDT治疗后6个月患眼SFCT、LVCT变化。治疗前后SFCT、LCVT比较行t检验。结果治疗前,63只眼中,伴有CVH表现38只眼(60.3%),其中应答良好组、应答不佳组患眼分别为5(20.0%,5/25)、33(86.8%,33/38)只眼。应答良好组、应答不佳组患眼SFCT、LCVT分别为(244.16±23.74)、(152.76±22.70)μm和(367.34±35.21)、(271.84±35.42)μm。两组患眼治疗前SFCT、LVCT比较,差异均有统计学意义(t=7.24、6.87,P=0.01、0.01)。治疗后6个月,应答良好组患眼SFCT、LVCT分别为(241.04±32.56)、(150.44±23.45)μm;与治疗前比较,差异无统计学意义(t=5.35、8.64,P=0.08、0.07)。应答不佳组患眼联合PDT治疗后6个月,SFCT、LCVT分别为(311.63±25.36)、(220.11±41.30)μm;与治疗前比较,差异有统计学意义(t=6.84、9.23,P=0.02、0.01)。治疗后,所有患眼CVH表现无明显改变,但应答不佳组患眼联合PDT治疗后,多灶性强荧光明显减弱。结论PCV厚脉络膜多以脉络膜大血管异常增厚为主;具有厚脉络膜和CVH表现的患眼单纯抗VEGF药物治疗应答不佳,联合PDT治疗可能更适用于该类患者。

Objective To observe the changes in choroidal characteristics of polypoid choroidal vascular disease(PCV)eyes after intravitreal injection of anti-VEGF drugs,and to preliminarily evaluate its predictive effect on the response of PCV anti-VEGF drugs.Methods A retrospective clinical study.From January 2015 to May 2020,63 eyes(63 PCV patients)diagnosed in NanJing Medical University Eye Hospital were included in the study.There were 39 eyes(39 males)and 24 eyes(24 females);all were monocular,with the average age of 62.53±6.05 years old.All eyes were treated with intravitreal injection of ranibizumab,and those with poor response after treatment were treated with photodynamic therapy(PDT)combined with anti-VEGF drugs.Among the 63 eyes,38 eyes did not respond or responded poorly after treatment,and 25 eyes responded well.Based on response results,patients were divided into the poor response group and the good response group.The confocal laser synchronous angiography system(HRA+OCT)enhanced depth scanning technology of Herdelberg(Germany)was used to measure the foveal choroid thickness(SFCT)and the choroidal large vessel thickness(LCVT).The choroidal hyperpermeability(CVH)was judged based on the ICGA inspection results.CVH:In the middle and late stages(10-15 min after indocyanine green injection),the choroid of the posterior pole can be seen with multifocal strong fluorescence with blurred edges.The SFCT and LVCT changes of the two groups of eyes before treatment and 6 months after treatment in the good response group,and 6 months after the treatment of the poor response group combined with PDT were observed.SFCT and LCVT were compared with t test before and after treatment.Results Before treatment,of the 63 eyes,38 eyes(60.3%)with CVH manifestations,of which 5 eyes(20.0%,5/25)and 33 eyes(86.8%,33/38).The SFCT and LCVT of the good response group and the poor response group were 244.16±23.74,152.76±22.70μm and 367.34±35.21,271.84±35.42μm,respectively.The comparison of SFCT and LVCT between the two groups of eyes before treatment showed statistically significant differences(t=7.24,6.87;P=0.01,0.01).Six months after treatment,the SFCT and LVCT of the eyes in the good response group were 241.04±32.56 and 150.44±23.45μm,respectively;compared with those before treatment,the difference was not statistically significant(t=5.35,8.64;P=0.08,0.07).Six months after the poor response group combined with PDT treatment,SFCT and LCVT were 311.63±25.36 and 220.11±41.30μm respectively;compared with those before treatment,the difference was statistically significant(t=6.84,9.23;P=0.02,0.01).After treatment,the CVH manifestations of all the eyes did not change significantly,but the eyes of the poor response group were treated with PDT,and the multifocal strong fluorescence was significantly weakened.Conclusions PCV thick choroid is mostly caused by abnormal thickening of choroidal large vessels.Eyes with thick choroid and CVH have poor response to anti-VEGF drug therapy alone,and combined PDT therapy may be more suitable for this type of patients.