匍行性脉络膜炎不同亚型眼底病灶演变的临床观察

Clinical observation on the evolution of fundus lesions in different subtypes of serpiginous choroiditis

目的观察匍行性脉络膜炎(SC)不同亚型的脉络膜病灶临床演变过程及影像学特征,探讨亚型分类的临床意义。方法回顾性、无对照、观察性研究。2009年5月至2021年9月于云南省眼科医院确诊的SC患者25例45只眼纳入研究。根据病灶初发部位和眼底彩色照相、荧光素眼底血管造影(FFA)、光相干断层扫描(OCT)等检查结果,将SC分为视盘周围型(盘周型)、黄斑型、急性多灶型;根据首诊时病灶形态分为仅有浸润水肿表现的新发病灶、仅有萎缩表现的陈旧性病灶和水肿与萎缩表现并存的复发性病灶。观察不同亚型患眼病灶的影像特征、演变过程和并发症发生情况。结果25例45只眼中,男性15例,女性10例;双眼、单眼发病分别为20、5例;年龄(42.3±5.7)岁。活动性病灶21只眼,其中新发病灶、复发病灶分别为5、16只眼;陈旧性病灶24只眼。并发视盘水肿3只眼;轻度玻璃体炎5只眼;视网膜血管炎3只眼;脉络膜新生血管3只眼。盘周型16例30只眼(64%,16/25),包括单眼2例2只眼,双眼14例28只眼。活动性病灶16只眼,其中双眼患者仅单眼存在活动性病灶。脉络膜病灶紧邻视盘一侧或围绕视盘,随病程延长离心向外扩展,可进展至黄斑区。病灶边缘曲折,呈"地图样"、"阿米巴样"及"指状"、息肉状或"螺旋翼样"。FFA显示活动性病灶早期呈弱荧光,晚期呈强荧光;陈旧性病灶早期中心呈弱荧光,晚期呈斑驳状荧光,其边缘多为强荧光。OCT显示活动性病灶病变区增厚,陈旧性病灶病变区变薄。黄斑型4例6只眼(16.0%,4/25),其中单眼2例2只眼,均为活动性病灶;双眼2例4只眼,其中陈旧性病灶1例2只眼,双眼相续呈活动性病灶1例2只眼。初发病灶均位于黄斑区偏中心,多呈"盘状"并离心性向周围进展,反复复发的病灶可波及视盘并向周边部扩展。其FFA、OCT影像表现与盘周型相似。急性多灶型5例9只眼(20.0%,5/25),包括单眼1例1只眼,双眼4例8只眼。均为后极部多发性大小不等、灰白色伴色素沉着、边缘清晰的陈旧性病灶,其中陈旧性病灶附近出现多个新的活动性病灶4只眼。陈旧性病灶呈边界清晰的弱荧光,晚期边缘荧光素渗漏形成强荧光环;活动性病灶呈边缘模糊的弱荧光斑,晚期荧光略增强。陈旧性病灶光感受器层、视网膜色素上皮层及脉络膜萎缩,部分区域视网膜色素上皮增生。结论SC亚型是对首发病灶出现部位的分类,但本病反复发作的特性,可导致各亚型特征因病灶不断扩展的演变而湮灭。眼底活动性病灶仅单眼发作的现象,可解释双眼病灶形态不对称的临床表现。双眼亚型同一性的特点,可警示临床对单眼患者随访时应关注其健康眼的好发部位。

Objective:To observe the clinical evolution process and imaging characteristics of choroidal lesions in different subtypes of serpiginous choroiditis(SC),and to explore the clinical significance of subtype classification.Methods:A retrospective,uncontrolled and observational study.A total of 45 eyes of 25 SC patients diagnosed in Yunnan Eye Hospital from May 2009 to September 2021 were included in the study.According to the initial location of the lesion and fundus images,including fundus color photography,fundus fluorescein angiography(FFA),optical coherence tomography(OCT)and other examination results.SC was divided into peripapillary serpiginous choroiditis,macular serpiginous choroiditis and ampiginous choroiditis.According to the shape of the lesions at the first diagnosis,it can be divided into new lesions with only infiltrating edema,old lesions with only atrophy and recurrent lesions with coexistence of edema and atrophy.the imaging features,development and complications of different subtypes of ocular lesion were observed.Results:Among the 45 eyes of 25 cases,15 cases were male and 10 cases were female,20 cases of binocular and 5 cases of monocular,age was 42.3±5.7 years old.There were 21 eyes with active lesions,of which 5 eyes were new lesions and 16 eyes with recurrent lesions;24 eyes were old lesions.Concurrent optic disc edema occurred in 3 eyes;mild vitreitis occurred in 5 eyes;retinal occurred vasculitis in 3 eyes;choroidal neovascularization occurred in 3 eyes.Among the 16 cases(64%,16/25)of the peripapillary serpiginous choroiditis,2 cases(2 eyes)were monocular,and 14 cases(28 eyes)were binocular.Active lesions were found in 16 eyes,of which patients with binocular lesions only one had active lesions.The choroidal lesions that were close to the optic disc or around the optic disc,expanded outwards centrifugally with the prolongation of the disease course,and can progress to the macula.The edge of the lesion was tortuous,with a geographic-like,amoeboid-like and finger-like,polypoid or propeller-like shape.Active lesions in FFA showed weak fluorescence in the early stage and strong fluorescence in the late stage;the old lesions showed weak fluorescence in the early stage and mottled fluorescence in the late stage,and mostly strong fluorescence on the edge.OCT showed thickening of active lesions and thinning of old lesions.Among the 4 cases(16.0%,4/25)of macular type,2 cases(2 monocular eyes)had active lesions;2 cases(4 eyes)had lesion in both eyes,among them,1 case(2 eyes)had old lesion,and the other case had alternate active lesions.The initial lesions were all located in the off-center of the macula,and most of them were disk-shaped and progressing centrifugally to the periphery.The FFA and OCT imaging findings of the lesions were similar to those of the peridisc type.Among the 5 cases(20.0%,5/25)of ampiginous choroiditis,1 case(1 eye)was monocular and 4 cases(8 eyes)were binocular.These lesions were multiple old lesions of varying sizes,gray-white with pigmentation,with clear borders in the posterior pole.Among them 4 eyes have new active lesions appeared near the old lesions.The old lesions showed weak fluorescence with clear borders,and the fluorescein leakage at the late edge formed a strong fluorescence ring;the active lesions showed weak fluorescent spots with blurred edges,and the fluorescence was slightly enhanced in the late stage.In old lesions,atrophy of the photoreceptor layer,RPE and choroid can be seen,and RPE hyperplasia in some areas.Conclusions:SC subtype is a classification of the location of the first lesion,but the characteristics of the repeated attack of this disease can lead to the annihilation of each subtype due to the continuous expansion of the lesion.The phenomenon that the fundus active lesions only occur in one eye that can explain the clinical manifestations of asymmetric morphology of binocular lesions.The characteristics of binocular subtype warn that the predilection site of the healthy eye should be paid attention to.