光相干断层扫描血管成像评估视网膜中央静脉阻塞继发黄斑水肿雷珠单抗治疗后复发的作用

The role of optical coherence tomography angiography in evaluating recurrent macular edema secondary to central retinal vein occlusion after intravitreal injection of ranibizumab

目的观察视网膜中央静脉阻塞(CRVO)继发黄斑水肿(ME)患眼玻璃体腔注射雷珠单抗(IVR)治疗后,复发与非复发者黄斑区微血管结构差异,初步分析其与ME复发之间的相关性。方法前瞻性临床观察性研究。2020年1月至2021年12月于天津医科大学眼科医院检查确诊的CRVO继发ME(CRVO-ME)患者45例45只眼纳入研究。其中,男性22例22只眼,女性23例23只眼;年龄(61.11±10.88)岁;均为单眼发病。所有患眼均接受IVR治疗,每一个月1次,连续3个月;并于初始3次治疗后ME消退。根据治疗后6个月时是否再次出现ME将患者分为复发组、非复发组,分别为21例21只眼、24例24只眼。患眼均行最佳矫正视力(BCVA)、眼压、光相干断层扫描血管成像(OCTA)检查。采用OCTA仪对黄斑区3 mm×3 mm范围进行扫描,测量治疗前后视网膜浅层毛细血管丛(SCP)、深层毛细血管丛(DCP)、中心凹、旁中心凹的血流密度(VD)以及黄斑中心凹视网膜厚度、中心凹无血管区(FAZ)面积、FAZ周长(PERIM)、非圆度指数(AI)、FAZ范围300μm宽度内VD(FD-300)。中心凹VD包括浅层、深层视网膜VD(SFVD、DFVD);旁中心凹VD包括浅层、深层视网膜VD(SPFVD、DPFVD)。以初始3次治疗后为观察时间点,对比观察两组患眼各参数变化情况。复发组、非复发组间各参数比较采用两独立样本t检验。采用受试者工作特征(ROC)曲线分析各参数预测ME复发的曲线下面积(AUC),确定预测ME复发的临界值。结果复发组与非复发组患者年龄(t=1.350)、眼压(t=1.929)、SFVD(t=-1.716)、DFVD(t=-1.143)、CRT(t=-1.207)、AI(t=1.387)比较,差异均无统计学意义(P>0.05);IVR治疗次数(t=5.912)、BCVA(t=5.003)、SVD(t=-4.617)、SPFVD(t=-4.110)、DVD(t=-5.503)、DPFVD(t=-4.772)、FAZ面积(t=2.172)、PERIM(t=2.606)、FD-300(t=-3.501)比较,差异有统计学意义(P<0.05)。ROC曲线分析结果显示,DVD预测CRVO-ME复发的AUC最大,为0.921;DVD预测ME复发的最佳临界值为37.65%,灵敏度、特异性分别为91.7%、85.7%。结论与非复发者比较,复发者SVD、SPFVD、DVD、DPFVD、FD-300降低,FAZ面积和PERIM增加。DVD≤37.65%是预测ME复发的最佳临界值。

Objective To observe the differences of macular microvascular structure between recurrent and non-recurrent macular edema(ME)secondary to central retinal vein occlusion(CRVO)after intravitreal injection of ranibizumab(IVR),and to preliminarily analyze the correlation between recurrence and ME.Methods A prospective clinical observational study.Forty-five patients(45 eyes)diagnosed as CRVO with ME were included in this study in Tianjin Medical University Eye Hospital from January 2020 to December 2021.There were 22 males(22 eyes)and 23 females(23 eyes).All cases were unilateral.The average age was 61.11±10.88 years old.All patients received IVR treatment once a month for 3 consecutive months.ME were regressive after the initial three treatments.The patients were divided into recurrent group(21 cases,21 eyes)and non-recurrent group(24 cases,24 eyes)based on ME recurrence at 6 months after ME resolution.All patients underwent best corrected visual acuity(BCVA),intraocular pressure,and optical coherence tomography angiography(OCTA).OCTA was used to scan the macula in the area of 3 mm×3 mm,and the vessel density(VD)of superficial capillary plexus(SCP),deep capillary plexus(DCP),fovea and parafovea before and after treatment was measured.Foveal retinal thickness,foveal avascular zone(FAZ)area,perimeter of FAZ(PERIM),avascular index of FAZ(AI),VD within 300μm width of FAZ range(FD-300).Foveal VD included superficial and deep retinal VD(SFVD,DFVD);parafoveal VD included superficial and deep retinal VD(SPFVD,DPFVD).Taking the initial three treatments as the observation time point,the changes of the parameters of the two groups were compared.Comparison between the recurrent and non-recurrent group was performed by two independent sample t-tests.Receiver operating characteristic(ROC)curve analysis was used to measure the area under the curve(AUC)of VD for predicting the recurrence of ME.Results There were no significant differences in age(t=1.350),IOP(t=1.929),SFVD(t=-1.716),DFVD(t=-1.143),CRT(t=-1.207)and AI(t=1.387)between the recurrent and non-recurrent group(P>0.05).There were significant differences in times of anti-VEGF therapy(t=5.912),BCVA(t=5.003),SVD(t=-4.617),SPFVD(t=-4.110),DVD(t=-5.503),DPFVD(t=-4.772),FAZ area(t=2.172),PERIM(t=2.606)and FD-300(t=-3.501)between the recurrent and non-recurrent group(P<0.05).ROC curve analysis showed that the AUC of DVD in predicting the recurrence of ME was highest,with 0.921,and the threshold was 37.65%.The sensitivity and specificity were 91.7%and 85.7%,respectively.Conclusions The SVD,SPFVD,DVD,DPFVD and FD-300 in the recurrence group are significantly lower than those in the non-recurrence group,while the FAZ area and PERIM are significantly higher than those in the non-recurrence group.DVD≤37.65%can be used as the best threshold for predicting the recurrence of ME.