中心性滲出性脈絡膜視網膜病變

簡介:

       該病發病年齡為20-50歲的青壯年,亦多為單眼發病,男女發病率相等,但視力損害嚴重,一般低于0.2,眼底黃斑部有滲出、出血等炎性病灶,癥狀視力下降,視物變形,視野中心暗點。中心性滲出性脈絡膜視網膜病變(central exudative chorioretinopathy)簡稱“中滲”,1939年Rieger首次報告。多單眼發病。眼底表現類似老年黃斑變性,但病灶較老年性黃斑變性者為小。多為孤立的滲出灶,伴有出血。本病曾有青年性黃斑變性或出血性黃斑病變之稱,其致病為不同原因的炎癥,引起視網膜下新生血管膜形成,發生漿液性和(或)出血性色素上皮和(或)神經上皮脫離。

臨床癥狀體征 患者多為中青年,單眼發病居多,但少數病例亦有雙眼患病者。自覺中心視力障礙,視物變形或小視癥。眼底檢查有以下典型征候:

1.病變中心為灰白色深層浸潤性病灶,略呈圓形,稍隆起,邊緣模糊,大小約1/4盤徑,很少超過1個盤徑。

2.周圍可有出血,常在病灶邊緣處出現,呈點狀、片狀、弧形或環形,圍繞著灰白色浸潤損害。

3.視網膜下可能有滲液而使病灶周圍有盤狀脫離,尤其在急性階段。

4.病情持續較久者,病灶附近可能有亮白色的硬性脂類沉著。

       本病病程持久,常呈間歇性發作,持續一二年甚至更長時間,最后進入瘢痕形成階段。此時由色素上皮細胞化生或膠質細胞進行修復,形成機化瘢痕。眼底可見原來的病變部位已由灰白色,境界清晰,被有色素堆積的瘢痕所代替。患者留有濃厚的中心暗點,視力蒙受永久性的損害。如果病灶位于旁中心區,中心凹未受累,則患者常可保留相當的中心視力。極少數病例過數年后病情可復發,復發的滲出灶常在原來瘢痕的邊緣出現。

飲食保健:

       日常飲食應以清淡易消化的飲食為主,宜多食富含維生素C、礦物質及植物蛋白的食物,增加粗纖維食物的攝入量,多吃新鮮蔬菜、水果及適量的肉類。忌吸煙,禁飲酒,少吃或不吃刺激性食物。

并發癥

       視網膜出血甚至玻璃體積血等。預后與出血的量及次數密切相關。

發病機制

炎癥原發于脈絡膜,肉芽腫性炎癥易于誘發新生血管,來源于脈絡膜毛細血管層的新生血管,經被損害的Bruch膜及色素上皮侵入視網膜神經上皮層下,形成新生血管膜及隨之而來的滲出、出血、機化等一系列病理改變。

檢查方法

1、血象檢查、結核菌素皮內試驗、組織胞質菌素皮內試驗以及弓形蟲紅細胞凝聚反應、梅毒VORL及TPHA等血液檢查是必要的,但多數病例可能仍無法確定病因而只能給予對癥治療。

2、其他輔助檢查:1.胸部X射線攝片。2.眼底及熒光造影所見 本病整個病程可分為3期:

(1)活動期:裂隙燈顯微鏡加前置鏡或接觸鏡檢查后部玻璃體,部分病例在檢查者經暗適應后可見極其輕微的塵埃狀或線結狀灰白色混濁。檢眼鏡下,在黃斑中央或其附近有灰白色圓形或類圓形滲出性病灶,大小為1/2~1PD,微微隆起,境界欠清。滲出病灶周圍有鋸齒形的環狀或眉月狀出血(圖1)。FFA可見灰白色滲出病灶內在動脈期開始已顯熒光,呈輻射狀或顆粒狀,并迅速擴大增強成強熒光斑,直至造影晚期仍持續不退,提示視網膜神經上皮層下有新生血管存在。病灶周圍出血處熒光遮蔽(圖2A,B)。

(2)恢復期:滲出病灶處視網膜水腫減退,境界比活動期略感清晰,周緣出血消失。出現色素脫失及色素增生(圖3)。FFA動脈期出現與灰白色病灶及其周圍脫色素區大小一致的熒光,逐漸增強并略有擴大。

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