更昔洛韦玻璃体内注射治疗新生儿巨细胞病毒性视网膜炎的效果观察

Observation on the efficacy of intravitreal injection of ganciclovir in the treatment for neonatal cytomegalovirus retinitis

目的观察玻璃体内注射更昔洛韦治疗新生儿巨细胞病毒性视网膜炎(CMVR)的效果。方法回顾性病例系列研究。分析郑州大学附属儿童医院2020年11月至2022年4月更昔洛韦玻璃体内注射治疗的患儿8例(16只眼)的临床资料。所有患儿均接受更昔洛韦玻璃体内注射及全身应用更昔洛韦治疗。记录玻璃体内注射更昔洛韦的次数,观察治疗后眼底照像、眼底荧光血管造影(FFA)结果、血巨细胞病毒(CMV)-IgG、血CMV-DNA、尿CMV-DNA水平、中性粒细胞数量以及肝肾功能等全身体征变化和不良反应。随访6个月。结果患儿初诊时房水CMV-IgG、血CMV-IgG、血CMV-DNA、尿CMV-DNA水平均高于正常值。所有患儿接受玻璃体内注射更昔洛韦次数为1~6次。治疗前眼底检查:3例可见沿血管分布的黄白色渗出病灶,周边视网膜可见无血管区。1例可见黄白色渗出病灶,部分血管呈白线状改变。4例可见大片出血,血管呈白线状。治疗后,3例眼底黄白色渗出病灶较前明显减少。1例血管白线较前好转。4例出血较前吸收,血管白线较前好转。FFA检查:治疗前,3例造影晚期可见荧光渗漏着染,可见大片状无灌注区。1例造影显示血管充盈延迟,可见大片无灌注区。4例造影显示大片荧光遮蔽,血管充盈延迟,可见大片无灌注区。治疗后,3例晚期血管荧光渗漏明显减少,但是仍可见无灌注区。1例血管充盈延迟较前好转。4例荧光遮蔽减少,血管充盈延迟明显好转。治疗后8例血CMV-IgG、血CMV-DNA、尿CMV-DNA均恢复正常水平,均未发生眼内炎、视网膜脱离、中性粒细胞数量持续下降及肝肾功能异常等并发症。结论玻璃体内注射更昔洛韦是新生儿CMVR的有效治疗方式,术后视网膜病灶能够明显改善,且并发症较少。

Objective To investigate the efficacy of intravitreal injection of ganciclovir in the treatment for neonatal cytomegalovirus retinitis(CMVR).Methods This was a retrospective case series study.The clinical data of 16 eyes of 8 children treated with intravitreal ganciclovir from Nov.2020 to Apr.2022 at Children’s Hospital affiliated to Zhengzhou University were analyzed.All children were treated with intravitreal ganciclovir and systemic application of ganciclovir.The number of intravitreal ganciclovir injections was counted,and fundus photography,fundus fluorescence angiography(FFA)results,changes in systemic signs such as blood cytomegalovirus(CMV)-IgG,blood CMV-DNA,urinary CMV-DNA levels,neutrophil counts,hepatorenal function and adverse effects were observed after treatment.The follow-up time was 6 months.Results Aqueous CMV-IgG,blood CMV-IgG,blood CMV-DNA,and urinary CMV-DNA were higher than normal at the time of initial ophthalmologic consultation.The number of intravitreal ganciclovir injections in this study ranged from 1 to 6.Before treatment fundus examination showed yellowish-white exudative lesions distributed along blood vessels in 3 cases,and avascular areas in the peripheral retina.Yellowish-white exudative lesions with some blood vessels showing white-linear changes were seen in 1 case,and large hemorrhages with white-linear blood vessels were seen in 4 cases.After treatment,the yellowish-white exudate lesions significantly reduced in 3 cases,the white line of blood vessels was better in 1 case,and the hemorrhage was absorbed and the white line of blood vessels was better in 4 cases.FFA showed before treatment,late fluorescence leakage staining and large non-perfused areas.One case showed delayed vascular filling and large non-perfused areas in 3 cases.Four cases showed large fluorescence masking,delayed vascular filling and large non-perfused areas.After treatment,the late fluorescence leakage significantly reduced in 3 cases,but the non-perfused area was still visible;1 case showed better delayed vascular filling than before;4 cases showed reduced fluorescence masking and significantly better delayed vascular filling.After treatment,blood CMV-IgG,blood CMV-DNA and urinary CMV-DNA returned to normal levels in all 8 cases,and no complications such as endophthalmitis,retinal detachment,persistent decrease in neutrophil count,abnormal liver or kidney function occurred in any of them.Conclusion Intravitreal injection of genciclovir is an effective treatment for neonatal CMVR,with significant postoperative improvement of retinal lesions and less complications.