髓鞘少突胶质细胞糖蛋白抗体阳性视神经炎糖皮质激素冲击治疗后视力预后的影响因素分析

Analysis of influencing factors related to the prognosis of visual acuity on myelin oligodendrocyte glycoprotein antibody positive optic neuritis after methylprednisolone pulse

目的分析髓鞘少突胶质细胞糖蛋白(MOG)抗体阳性视神经炎(ON)(MOG-ON)糖皮质激素冲击治疗后视力预后的影响因素。方法临床观察性研究。2019年3月至2022年1月于首都医科大学附属北京同仁医院眼科及其医联体北京市普仁医院眼科诊治的MOG-ON患者32例47只眼纳入研究。患眼均行最佳矫正视力(BCVA)、眼眶核磁共振成像检查。BCVA检查采用Snellen对数视力表进行,统计分析时转换为最小分辨角对数(logMAR)视力。32例47只眼中,影像资料完整者22例38只眼。患者均行静脉糖皮质激素冲击(IVMP)治疗3~5 d。根据发病至糖皮质激素干预的时间(干预时机)将患者分为干预时机<7 d组、7~14 d组、>14 d组,分别为16、13、11只眼。治疗后随访时间中位数28个月。治疗后1周,1、3、6个月采用治疗前相同设备和方法行相关检查。观察IVMP治疗后患眼视力变化情况。采用logistic回归及线性回归分析法分析影响视力预后的相关因素。采用受试者工作特征(ROC)曲线确定干预时机的临界值。结果患者中,男性、女性各16例;中位年龄26岁。发病时间5~60 d。血清免疫指标异常18例(56.3%,18/32)。均以单眼或双眼视力下降为首发症状。单眼、双眼发病分别为17(53.1%,17/32)、15(46.9%,15/32)例。视盘水肿36只眼(76.6%,36/47),其中伴眼球转动痛37只眼(78.7%,37/47)。发病时平均logMAR BCVA 1.69±0.13。视神经眶内段呈纡曲、节段性增粗的长T2WI信号27只眼(71.1%,27/38);伴视神经及鞘膜强化24只眼(63.2%,24/38)。随访期间复发ON 10例(31.3%,10/32)。IVMP治疗后1周以及1、3、6个月,患眼logMAR BCVA分别为0.52±0.09、0.22±0.06、0.12±0.06、0.10±0.06;治疗后1周BCVA提高最快,3个月时BCVA恢复稳定。Logistic回归分析结果显示,首次发病者干预时机与视力预后明显相关(比值比=12.17,P=0.006),两者呈负线性回归关系(r=-0.48,95%可信区间-0.71~-0.17,P=0.008)。干预时机>14 d组与<7 d组、7~14 d组患眼logMAR BCVA比较,差异均有统计学意义(P=0.017、0.037)。ROC曲线预测最佳干预时机的临界值为13.5 d。性别、年龄、诱因、转眼痛、视盘水肿、双侧ON、影像学、自身免疫指标异常等因素均与视力预后无关。结论MOG-ON首次发病者干预时机是影响视力预后的重要因素,IVMP治疗的最佳时间窗为2周。

Objective To analyze the prognostic factors of vision of myelin oligodendrocyte glycoprotein(MOG)antibody positive associated optic neuritis(ON)after methylprednisolone pulse therapy.Methods A clinical observational study.A total of 32 patients(47 eyes)with MOG antibody positive ON were observed and followed up in the ophthalmology department of Beijing Tongren Hospital Affiliated to Capital Medical University and Beijing Puren Hospital from March 2019 to January 2022.Clinical data including the best corrected visual acuity(BCVA)and orbital magnetic resonance imaging were recorded.The BCVA was examined by Snellen visual acuity chart,which was finally converted into the logarithm of the minimal angle of resolution(logMAR)for statistical analysis.There were 22 case(38 eyes)with complete image data.All patients were treated with intravenous methylprednisolone pulse(IVMP)for 3-5 days.According to the intervention time(from onset to glucocorticoid treatment),the patients were divided into three groups:<7 d group,7-14 d and>14 d group,with 16,13,11 eyes,respectively.The median follow-up time was 28 months.After 1 week,1,3 and 6 months treatment,the same equipment and methods were used for relevant examinations to observe the changes of visual acuity and the factors influencing the prognosis of visual acuity after IVMP treatment.Logistic regression and linear regression were used to analyze the prognostic correlation factors.Receiver operating characteristic(ROC)curve was used to determine the critical cut-off point of intervention timing.Results Among the patients,16 were male and 16 were female.The median onset age was 26 years.The onset duration time was 5-60 days.There were 18 cases(56.3%,18/32)with abnormal serum immune indexes.The initial symptom was decreased vision with unilateral or bilateral ON.Seventeen(53.1%,17/32)cases had unilateral ON and 15(46.9%,15/32)cases with bilateral ON.Thirty-six eyes(76.6%,36/47)got optic disc edema,37 eyes(78.7%,37/47)accompanied by pain of ocular movement.The nadir logMAR BCVA was mean 1.69±0.13.Long T2WI signals with segmental thickening in the orbital segment of the optic nerve were obtained in 27 eyes(71.1%,27/38)and in 24 eyes(63.2%,24/38)with optic nerve and sheath enhancement.During the follow-up period,there were 10 cases of relapse(31.3%,10/32).The logMAR BCVA of attacked eyes were 0.52±0.09,0.22±0.06,0.12±0.06,0.10±0.06 at 1 week and 1,3 and 6 months after IVMP treatment,respectively.The rate of BCVA improvement was the fastest at 1 week after treatment,and BCVA returned to stability at 3 months.Logistic regression analysis showed that the timing of intervention was significantly correlated with the prognosis of vision in primary onset patients(odds ratio=12.17,P=0.006),with a negative linear regression relationship(r=-0.48,95%confidence interval-0.71--0.17,P=0.008).Comparing the logMAR BCVA between the intervention time>14 group with the<7 group and the 7-14 group,there were statistically significant difference(P=0.017,0.037),respectively.The cut-off point of ROC curve to predict the optimal intervention time was 13.5 days.Other factors such as:gender,age,predisposing factor,pain of eye motion,edema of optic disc,bilateral ON,imaging changes,abnormal autoimmune indicators were not associated with the prognosis of visual acuity.Conclusion The timing of hormone intervention in primary onset patients is an important factor affecting the prognosis of vision and the optimal intervention time window of IVMP is two weeks.