视网膜皱褶1例

A case of retinal folds

41岁男性,因“左眼视力下降1月余”就诊,患者除偶有眼胀外,无其他不适。初诊查体:最佳矫正视力右眼1.2,左眼0.9;眼压右眼14 mmHg(1 mmHg=0.133 kPa),左眼13 mmHg;裂隙灯检查除左眼眼底视网膜皱褶外,余眼部结构均未见异常。进一步行光学相干层析成像(OCT)、荧光素眼底血管成像(FFA)、全视野闪光视网膜电图(ffERG)等专科检查,除左眼视网膜和脉络膜皱褶外,余未见明显异常。患者血常规、糖化血红蛋白、肝肾功能、结核感染T细胞、乙肝两对半、术前四项(乙肝表面抗原、丙肝抗体、梅毒螺旋体抗体、人免疫缺陷病毒抗原抗体)、自身抗体、HLA-B27、肿瘤标记物等均未见明显异常,仅尿液中β2-微球蛋白、α1-微球蛋白及转铁蛋白偏高。初步诊断为左眼视网膜皱褶,考虑左眼巩膜炎可能性大,予球周注射激素治疗1次后,视力恢复到1.0,但仅持续1 d。行眼眶磁共振成像(MRI)可见左眼视神经鞘稍有增宽;检查颅脑MRI、脑动脉磁共振静脉成像(MRV)、双侧颈动脉及椎动脉彩色多普勒超声等检查,均未见明显异常。予患者球周注射激素及全身激素治疗,未见明显效果。行腰椎穿刺,测得脑脊液压力185 mmH_(2)O(正常参考值80~180 mmH_(2)O),脑脊液的化验结果未见明显异常。患者发病3个月后,右眼开始出现相似症状,影像学检查发现右眼视盘周围视网膜开始出现皱褶。追问病史,患者诉夜间打鼾且经常梦见坐过山车的场景,所以对患者进行了夜间睡眠监测,结果显示患者符合重度阻塞型睡眠呼吸暂停低通气综合征,因工作及疫情原因,患者未佩戴呼吸机进一步治疗。定期随访过程中发现,患者的双眼视网膜及脉络膜皱褶逐渐加重,考虑可能是间断性夜间特发性高颅压引起的视网膜及脉络膜皱褶,目前口服醋甲唑胺片(尼目克司)治疗,建议呼吸机治疗,并追踪治疗效果分析病因。讨论体会:此患者高度怀疑是由于睡眠过程中呼吸暂停时存在颅内压大幅上升的情况,从而引起了视网膜及脉络膜的皱褶。

A 41-year-old male present with blurred vision in the left eye for more than one month,with swelling pain sometimes.The best corrected visual acuity were 1.2 in the right eye,and 0.9 in the left.The intraocular pressure were 14mmHg in the right eye,and 13mmhg in the left.The patient underwent further ocular examinations such as OCT,FFA,and ffERG.No obvious abnormality was found except for the retinal and choroidal folds of the left eye.There was no obvious abnormality in the blood test,including blood routine test,HbA1C,liver and kidney function,T-spot,HBV test,autoantibodies,HLA-B27,tumor markers,and other preoperative blood tests.There is a mild elevation in theβ2-microglobulin,α1-microglobulin,and transferrin of his urine.Primary diagnosis is scleritis on the left eye,after a periorbital injection of steroid,his visual acuity recovered significantly,but only maintained for one day.Orbital MRI showed a slight widening of the optic nerve sheath in the left eye.There was no positive finding in the examination of cranial MRI,cerebral artery MRV,bilateral carotid artery or vertebral artery color Doppler ultrasound.The patient received topical and systemic steroid therapy again,but no obvious effect was found.A lumbar puncture showed the cerebrospinal fluid pressure was 185 mmH_(2)O.The biochemistry test of cerebrospinal fluid appeared normal.Three months later,similar symptoms appeared in his right eye,and ocular images revealed the retinal fold around the right optic disc.Based on his medical history,the patient complained of snoring at night and dreamed of frequent roller coaster rides.Therefore,the patient was referred for sleep monitoring at night,and the results showed that the patient had severe obstructive sleep apnea syndrome.Due to his busy work and COVID-19 pandemic,the patient did not wear any ventilator.During the regular follow-up,his retinal and choroid folds gradually increased.Considering that the retinal and choroidal folds may be caused by intermittent idiopathic intracranial hypertension,he received oral methazolamide therapy currently,and was advised to use ventilator.Further follow-up is needed to analyze the etiology.This retinal fold was highly suspected to be caused by intracranial pressure rises sharply during sleep,which resulted from severe obstructive sleep apnea syndrome.