慢性中心性浆液性脉络膜视网膜病变所致黄斑囊样变性的临床观察

Clinical observation of cystoid macular degeneration in chronic central serous chorioretinopathy

目的观察分析慢性中心性浆液性脉络膜视网膜病变(cCSC)继发黄斑囊样变性(CMD)患眼的临床及影像学特征。方法回顾性临床研究。2018年2月至2023年6月于云南大学附属医院眼科检查确诊的cCSC继发CMD患者9例15只眼纳入研究。患者均为男性;年龄(53.67±3.83)岁。双眼、单眼发病分别为6、3例。患眼视力0.02~0.1,均不能矫正。视力下降、眼前阴影遮挡感持续时间>1年。行半剂量光动力疗法(PDT)治疗8只眼。患眼均行最佳矫正视力、散瞳后眼底彩色照相、红外眼底照相(IR)、眼底自发荧光(AF)、荧光素眼底血管造影(FFA)、光相干断层扫描(OCT)、多波长炫彩成像(MC)检查。行半剂量PDT治疗者随访观察至治疗后3个月;未行治疗者随访观察至首诊后2年。结果所有患眼黄斑区反光减弱或消失,其中可见黄斑区异常色素沉着12只眼。IR检查,所有患眼均可见黄斑区弥漫性斑片样弱荧光,周边散在点状强荧光。眼底AF检查,黄斑区盘状弱AF,中间及边缘可见散在少量强AF,其中可见黄斑区向下分布的视网膜色素上皮(RPE)萎缩轨迹7只眼。MC检查,所有患眼后极部黄斑区绿色信号不均匀呈斑驳样改变。FFA检查,15只眼中,未见明显异常荧光素渗漏8只眼,表现为弥漫透见荧光所致强荧光;其内可见少量活动性荧光素渗漏7只眼。OCT检查,所有患眼可见数个大小不一的囊腔,RPE不同程度萎缩,其中可见RPE细胞代偿的隆起病灶及视网膜外层管状结构6只眼;CMD与活动性荧光素渗漏并存的7只眼,可见神经上皮层下积液征。所有患眼均可见脉络膜肥厚,大血管层扩张明显,挤压中血管层及毛细血管层。行半剂量PDT治疗的8只眼中,治疗后3个月时,治疗无效6只眼;治疗有效2只眼。未行半剂量PDT治疗的7只眼,随访2年时,CMD结构无明显改善;随病程延长,视力呈下降趋势。结论CMD多见于病程较长的cCSC,其对视力影响显著且预后不良;眼底彩色照相显示后极部黄斑区反光减弱或消失,可合并黄斑异常色素沉着。IR、眼底AF检查均可见黄斑区不均匀的强弱荧光。MC检查可见黄斑区绿色信号不均匀。FFA检查表现为弥漫透见荧光所致强荧光,合并活动性病灶可见荧光素渗漏。OCT检查可见多个小囊腔或囊腔之间连接断裂消失融合、RPE不同程度萎缩。

Objective To observe and analyze the clinical and imaging features of eyes with cystoid macular degeneration(CMD)secondary to chronic central serous chorioretinopathy(cCSC).Methods A retrospective clinical study.From February 2018 to June 2023,9 patients of 15 eyes with cCSC secondary CMD diagnosed by ophthalmology examination in Yunnan University Affiliated Hospital were included in the study.All patients were male.The age was(53.67±3.83)years.The cases of binocular and monocular were 6 and 3 respectively.The visual acuity of the affected eye ranges from 0.02 to 0.1,which cannot be corrected.Visual acuity decreased and the duration of shadow occlusion was>1 year.Half dose photodynamic therapy(PDT)was performed on 8 eyes.All the patients underwent the best corrected visual acuity,posterior mydriatic fundus color photography,infrared fundus photography(IR),fundus autofluorescence(AF),fluorescein fundus angiography(FFA),optical coherence tomography(OCT),and multi-wavelength dazzling imaging(MC).The patients who received half dose PDT were followed up until 3 months after treatment.Patients who did not receive treatment were followed up to 2 years after the first diagnosis.Results The light reflection in macular area decreased or disappeared in all eyes,and abnormal macular pigmentation was observed in 12 eyes.IR examination showed diffuse patchy weak fluorescence in the macular area in all affected eyes,and dotted strong fluorescence in the periphery.Fundus AF examination showed disc-like weak AF in the macular area,and scattered small amounts of strong AF in the middle and margins,among which the retinal pigment epithelium(RPE)atrophy trace in the macular area was observed in 7 eyes.By MC examination,the green signal in the macular area of the posterior pole of all affected eyes was uneven and mottled.FFA examination showed that no abnormal fluorescein leakage was observed in 15 eyes and 8 eyes showed strong fluorescence caused by diffuse permeation fluorescence.A small amount of active fluorescein was found in 7 eyes.OCT examination showed that there were several cystic cavities of different sizes in all the affected eyes,RPE atrophied to different degrees,and RPE cell compensatory ridges and tubular structures in the outer retina were seen in 6 eyes;7 eyes with CMD and active leakage showed signs of subcortical fluid accumulation.Choroidal hypertrophy was seen in all affected eyes,with significant expansion of the great vascular layer and compression of the middle vascular layer and capillary layer.In 8 eyes treated with half-dose PDT,6 eyes were ineffective at 3 months after treatment.The treatment was effective in 2 eyes.In 7 eyes that did not receive half-dose PDT,CMD structure did not improve significantly after 2 years of follow-up.The visual acuity decreased with the prolongation of the disease.Conclusions CMD is more common in cCSC with a long course of disease,which has significant effects on vision and poor prognosis.Fundus color photography shows that the reflection in the macular area of the pole is weakened or disappeared,which may be combined with macular abnormal pigmentation.IR and AF examination show uneven fluorescence in macular area.The green signal in macular area is not uniform according to MC inspection.FFA shows strong fluorescence caused by diffuse permeable fluorescence and fluorescein leakage in active lesions.OCT examination shows that multiple small sacs or connections between sacs were broken and fused,and RPE atrophied to varying degrees.