合并慢性粒细胞白血病的增生型糖尿病视网膜病变患者五例

Clinical observations of proliferative diabetic retinopathy with chronic myeloid leukemia of five cases

目的观察5例合并慢性粒细胞白血病(CML)的增生型糖尿病视网膜病变(PDR)患者的临床特征及治疗预后。方法回顾性研究。2011年5月至2020年12月在复旦大学附属眼耳鼻喉科医院住院治疗的合并CML的PDR患者5例10只眼纳入研究。收集患者的年龄、性别、糖尿病病史及CML病史等基本信息。检测其内分泌、血液学指标以评估患者全身情况。所有患者均行视力、眼压、裂隙灯显微镜、超广角眼底照相等检查以评估患者的眼部情况。患者接受的眼科治疗包括全视网膜激光光凝(PRP)、玻璃体腔注射抗血管内皮生长因子药物、玻璃体切割手术(PPV)等。治疗后随访时间6个月〜6年。随访观察患者视力、眼压、眼前节及视网膜状态。结果5例患者中,男性4例,女性1例;年龄27〜49岁,平均年龄39岁。均为双眼发病。均患有2型糖尿病,糖尿病病程为3个月〜13年。4例患者在眼科就诊前均已确诊CML,1例患者因视力下降首诊于眼科而后确诊CML。患者治疗前视力为光感〜0.4,6只眼的初始视力<0.1。除静脉纡曲扩张、渗出、微动脉瘤以及新生血管等糖尿病视网膜病变的典型表现之外,患者还出现了罗斯斑等白血病眼底表现。所有患者双眼均发展至PDR,易在视网膜下方出现异常增厚的视网膜前增生膜并继发严重的牵引性视网膜脱离。所有患眼均接受了RPR治疗,9只眼接受PPV治疗。经治疗后,8只眼视网膜复位,最佳矫正视力为无光感〜1.0,其中4只眼最佳矫正视力达到0.2以上,1只眼因继发新生血管性青光眼视力丧失。结论合并CML的PDR患者眼底不仅具有静脉纡曲扩张、渗出、微动脉瘤、新生血管等糖尿病视网膜病变的典型表现,同时还出现了罗斯斑等白血病的眼底表现。其视网膜病变迅速进展,加重的增生膜、玻璃体积血、牵引性视网膜脱离等并发症会导致视力预后不良,早期筛查和治疗有助于提升患者的预后。

Objective To observe and analyze the clinical features and prognosis of proliferative diabetic retinopathy(PDR)with chronic myeloid leukemia.Methods A retrospective case series study.From May 2011 to December 2020,5 patients(10 eyes)were included in this study in Eye-ENT Hospital of Fudan University.Basic information about the patient's age,gender,diabetes history and CML history were collected.The endocrine and hematological indexes of all patients were evaluated.All the patients were undertaken visual acuity,intraocular pressure,slit lamp and fundus examination and other examinations to observe the eye conditions.Ophthalmic treatments included panretinal laser photocoagulation,intravitreal injection of antivascular endothelial growth factor,vitrectomy.During the follow up period from 5 months to 6 years,prognosis was observed at each office visit.During the follow up period,patients'vision,intraocular pressure,anterior segment and retinal status were observed.Results There were 4 males and a female in 5 patients.The ages were from 27 to 49 years,with the mean age of 39 years.All patients were bilateral.All patients suffered type 2 diabetes for 3 months to 13 years.Four of them were diagnosed as chronic myeloid leukemia before visiting to ophthalmologists,while the other visited to ophthalmology first due to poor vision.The initial visual acuity ranged from light perception to 0.4 and 6 eyes were less than 0.1.In addition to the typical manifestations of diabetic retinopathy,such as venous tortuous dilation,exudation,microaneurysm and neovascularization,patients also presented with Roth spot as leukemic fundus manifestations.All eyes developed to PDR stage.Abnormal thickening of the neovascular membranes may occur in the lower part of the retina,with secondary traction retinal detachment.All the eyes were treated with pan retinal photocoagulation and 9 eyes underwent pars plana vitrectomy.After treatment,retina of 8 eyes kept flat.The best corrected visual acuity ranged from no light perception to 1.0,and only 4 eyes reached more than 0.2.Unfortunately,one eye lost vision because of secondary neovascular glaucoma.Conclusions PDR patients with CML of fundus not only have venous tortuous dilation,exudation,microaneurysm and neovascularization,also present with Roth spot as leukemic fundus manifestations.Diabetic retinopathy combined with CML could progress rapidly,and its aggravating complications such as hyperplastic membrane,vitreous hemorrhage and traction retinal detachment may result in poor visual prognosis.Early screening and treatment can help improve the prognosis of patients.