急性视网膜坏死综合征患者继发视网膜脱离影响因素分析

Influencing factors of retinal detachment in acute retinal necrosis

目的分析急性视网膜坏死综合征(ARN)患者继发视网膜脱离(RD)的影响因素。方法采用病例对照研究方法,收集2013年3月至2021年4月于山东第一医科大学附属青岛眼科医院收治的首诊为ARN且未伴有RD患者57例64眼,其中男36例40眼,女21例24眼;平均年龄(51.72±9.73)岁。所有患者均行抗病毒药物及抗炎药物的局部点眼及全身静脉滴注和口服,并根据患者病情及意愿行玻璃体腔注射更昔洛韦注射剂。根据1年随访过程中是否发生RD分为RD组和无RD组,其中RD组23例23眼,占35.94%,发生时间为发病后27~160 d,平均45(30,83)d。评估前房炎症反应程度并分级,通过九方位彩色眼底照相拼图或免扩瞳超广角激光扫描检眼镜检查并结合荧光素眼底造影评估视网膜坏死灶累及范围,将视网膜出血形态分为无或仅有少许散在小片状出血、范围>1个视盘直径(PD)的视网膜片状出血和霜枝样视网膜出血3种类型。纳入基线因素包括性别、年龄、病程等;纳入眼部因素包括视力、眼压、眼前节炎症反应、视网膜出血、视网膜坏死灶侵袭程度与范围等,治疗因素包括全身抗病毒药物治疗时间,玻璃体腔注射抗病毒药物与否和频次作为自变量,RD是否发生作为因变量进行多因素Logistic回归分析。结果排除严重玻璃体混浊4眼,在其余60眼眼底图像分析中,坏死灶累及视网膜范围达到1~4个象限的眼数分别为14、9、17和20眼,坏死灶侵袭仅累及3区、2区和1区眼数分别为13、23和24眼;治疗前,26眼有霜枝样视网膜出血,占43.33%;25眼存在范围>1 PD视网膜片状出血,占41.67%。与无RD组相比,RD组病程更长,基线视力更差,坏死灶范围更大,侵袭区域接近黄斑区患眼更多,出现霜枝样视网膜出血患眼更多,差异均有统计学意义(均P<0.05)。2个组初诊时年龄、眼压、眼前节炎症反应、静脉注射抗病毒药物治疗时间,玻璃体腔注射抗病毒药物与否及频次等指标比较差异均无统计学意义(均P>0.05)。多因素Logistic回归分析显示,霜枝样视网膜出血是RD的危险因素(比值比=9.14,95%置信区间:1.10~82.44,P=0.049)。结论霜枝样视网膜出血是ARN患眼继发RD的危险因素。

Objective To investigate the influencing factors of secondary retinal detachment(RD)in patients with acute retinal necrosis syndrome(ARN).Methods A case control study was conducted.A total of 57 patients(64 eyes)with initial diagnosis of ARN not accompanied by RD were enrolled in Qingdao Eye Hospital of Shandong First Medical University from March 2013 to April 2021.Among them,36 cases(40 eyes)were male and 21 cases(24 eyes)were female,with an average age of(51.72±9.73)years.All patients received topical ophthalmic,systemic intravenous and oral antiviral and anti-inflammatory medications,as well as intravitreal injection of ganciclovir according to the patient's condition and willingness.The RD group was divided into RD group and RD-free group according to whether RD occurred during the 1-year follow-up,of which 23 cases and 23 eyes(35.94%)in the RD group occurred from 27 to 160 days after the onset of the disease,with a mean of 45(30,83)days.The degree of anterior chamber inflammation was evaluated and graded.The scope of retinal necrosis was evaluated by nine-directional fundus color photographs or ultra-wide angle laser scanning ophthalmoscopy without pupil dilation combined with fundus fluorescein angiography.Retinal hemorrhage was divided into three types,no or little scattered patchy hemorrhage,patchy retinal hemorrhage with>1 papillary diameter(PD)and frost-branch retinal hemorrhage.Baseline systemic parameters included sex,age,course of disease,etc.Ocular parameters included best corrected visual acuity,intraocular pressure,anterior segment inflammatory response,retinal hemorrhage,as well as invasion degree and scope of retinal necrosis.Therapy parameters included duration of systemic antiviral drug treatment,with or without intravitreal injection of ganciclovir and the injection frequency as independent variables,and RD occurred whether or not as dependent variables for multivariate logistic regression analysis.This study adhered to the Declaration of Helsinki.The study protocol was approved by the Ethics Committee of Qingdao Eye Hospital(No.2020-15).Results Four eyes with severe vitreous opacity were excluded.In the fundus image analysis of the other 60 eyes,the necrotic lesion involved retina reaching 1 to 4 quadrants were in 14,9,17 and 20 eyes,respectively.Necrotic lesion affected 13,23 and 24 eyes in zone 3,zone 2 and zone 1,respectively.Before treatment,frost-like retinal hemorrhage occurred in 26 eyes(43.33%),retinal hemorrhage with>1 PD in 25 eyes(41.67%).Compared with RD-free group,the RD group had a longer course of disease,worse baseline visual acuity,larger necrotic lesions,more eyes with more invasion areas close to the macular area,and more eyes with frost-branch retinal hemorrhage,with statistically significant differences(all at P<0.05).There were no significant differences in age,intraocular pressure,anterior segment inflammatory response,duration of intravenous antiviral drug injection,with or without intrvitreal injection of antiviral drug and injection frequency between the two groups(all at P>0.05).Multivariate logistic regression analysis showed that the occurrence of frost branch-retinal hemorrhage was a high risk factor for RD(odds ratio=9.14,95%confidence interval:1.10-82.44,P=0.049).There were no significant differences between the two groups in age,intraocular pressure,anterior inflammatory response,time of intravenous antiviral drug injection,whether or not antiviral drug was injected into vitreous cavity and frequency at the time of initial diagnosis(all at P>0.05).Conclusions Frost-branch retinal hemorrhage is a risk factor for retinal detachment in ARN.