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医药导报, 2019, 38(1): 62-65
doi: 10.3870/j.issn.1004-0781.2019.01.014
玻璃体腔内注射曲安奈德联合激光光凝治疗糖尿病性黄斑水肿32例*
Effect of Intravitreal Injection of Triamcinolone Acetonide Combined with Laser Photocoagulation in Treatment of 32 Cases of Diabetic Macular Edema
吕旭东, 龚兰兰, 柴基桥

摘要:

目的 探讨玻璃体腔内注射曲安奈德(IVTA)联合激光光凝治疗糖尿病性黄斑水肿(DME)的临床疗效。方法 DME患者64例87眼,采取随机数字表分成2组,治疗组32例46眼,对照组32例41眼。对照组给予激光光凝治疗,治疗组联合IVTA治疗,比较两组治疗效果。结果 治疗组和对照组的有效率分别为95.65%,80.49%(P<0.05),治疗组II期DME患者的疗效优于对照组Ⅱ期DME患者。两组Ⅲ期及Ⅳ期患者的有效率差异无统计学意义(P>0.05);两组患者术后1,3,6个月黄斑区视网膜厚度(MRT)及平均视网膜神经纤维层厚度(ARNFLT)均较术前显著下降,且治疗组术后1,3,6个月MRT、ARNFLT均显著低于同期对照组(P<0.05)。结论 激光光凝联合IVTA治疗DME疗效比单一激光光凝治疗效果显著,尤其对早期DME患者,治疗效果更明显,值得临床推广应用。

关键词: 曲安奈德 ; 激光光凝 ; 黄斑水肿 ; 视网膜病变 ; 糖尿病

Abstract:

Objective To investigate the clinical efficacy of vitreous cavity injection of triamcinolone acetonide (IVTA) combined with laser photocoagulation in the treatment of diabetic macular edema (DME). Methods 87 eyes from 64 patients with DME were enrolled in this study. They were divided into two groups by random number table. The treatment group consisted of 32 cases (46 eyes), and the control group consisted of 32 cases (41 eyes). The control group was treated with laser photocoagulation, and the treatment group was treated with laser photocoagulation and IVTA treatment. Then the therapeutic effects were compared between the two groups Results The effective rate of the treatment group and the control group was 95.65% and 80.49%, respectively (P<0.05), and the efficacy of the treatment group stage II DME patients was better than that of the control group stage II DME patients. There was no significant difference in efficiency between the two groups in stage III and IV (P>0.05). The retinal thickness and average retinal nerve fiber layer thickness of the macular area were significantly decreased in the two groups at 1, 3 and 6 months after operation. The thickness of the retina and average retinal nerve fiber layer in the macular area at 1, 3 and 6 months after operation were significantly lower than the control group (P<0.05). Conclusion Laser photocoagulation combined with IVTA is more effective than single laser photocoagulation in the treatment of DME, especially for early DME patients, the treatment effect is more obvious and worthy of clinical application.

Key words: Triamcinolone acetonide ; Laser photocoagulation ; Macular edema ; Retinopathy ; diabetic

糖尿病性黄斑水肿(diabetic macular edema,DME)是造成糖尿病视网膜病变及视力衰退或视力丧失的主要原因,水肿多来源于黄斑区局部扩张的毛细血管或个别微动脉瘤,表现为视网膜增厚或视网膜硬性渗出,长期黄斑水肿可致视力出现不可逆性损伤[1]。近年来,尽管对于DME的病因及发病机制有了更深入的研究,但其治疗仍较棘手。激光光凝是DME常用的治疗方法,一定程度上有助于缓解部分水肿,抑制视力进一步减退[2]。曲安奈德作为一种长效糖皮质激素,在缓解黄斑水肿方面具有较好的疗效[3]。本研究将这两种方法联合起来用于DME的治疗,旨在观察联合治疗的效果,为DME的治疗提供更多的优选手段。

1 资料与方法
1.1 临床资料

研究对象选择为我院2013年8月—2015年8月收治的DME患者64例87眼,所有患者均经眼底检查及眼底荧光血管造影检查(fundus fluorescein angiography,FFA)等明确诊断为DME,且均为2型糖尿病,所有糖尿病视网膜病变按程度为Ⅱ~Ⅳ期,以病变远离黄斑中心为轻度Ⅱ期,病变接近但未累及黄斑中心为中度Ⅲ期,病变累及黄斑中心为重度Ⅳ期;FFA可见黄斑区荧光素渗漏;光学相干断层扫描(optical coherence tomography,OCT)检查显示黄斑厚度超过250 μm;餐前血糖低于8 mmol·L-1。患者入院时主诉有视力减退、视物遮挡、视物变形等。采取随机数字表法将其分成两组,其中治疗组32例46眼,对照组32例41眼。治疗组男18例,女14例,年龄34~70岁,平均(52.6±6.3)岁,术前最佳矫正视力(best corrected visual acuity,BCVA)0.01~0.3,平均0.13±0.08,黄斑区视网膜厚度(macular retinal thickness,MRT)428~855 μm,平均(602.5±91.5) μm,平均视网膜神经纤维层厚度(average retinal nerve fiber layer thickness,ARNFLT)219~405 μm,平均(322.3±75.6)μm,糖尿病病程6~28年,平均(11.63±4.56)年;对照组男17例,女15例,年龄32~68岁,平均(51.8±7.7)岁,术前最佳矫正视力0.01~0.3,平均0.15±0.10,MRT 433~842 μm,平均(593.2±86.5)μm,ARNFLT 226~423 μm,平均(326.9±82.5) μm,糖尿病病程6~29年,平均(12.04±3.75)年。手术前,两组患者一般资料差异无统计学意义(P>0.05),具有可比性。排除条件:①排除青光眼、白内障、屈光不正等引起视力下降的其他因素;②排除合并患有难以控制的糖尿病、高血压患者;③排除严重心、肺、肝、肾功能障碍的患者;④排除研究者认为不适合参与本研究的患者。

1.2 治疗方法

治疗组采取玻璃体腔注射曲安奈德(intravitreal triamcinolone acetonide,IVTA)联合激光光凝治疗,先给予IVTA治疗,常规消毒,眼球后麻醉,在颞下方角膜缘后约4 mm处穿刺进入玻璃体腔内,抽取玻璃体约0.1 mL,再将曲安奈德(TA)注射液加入9 g·L-1氯化钠溶液中稀释至20 g·L-1,抽取0.1 mL稀释后的溶液,将内含0.1 mL玻璃体的针管拔出,并将装有TA的针管再接到穿刺入玻璃体腔内的针头上,将TA推入玻璃体腔后将针头拔出。包扎术眼,静坐2 h即可。术后1,3,7 d及1个月检查视力、眼压等。IVTA治疗后1个月再行激光光凝治疗,对弥漫性水肿与囊样水肿采取格栅样光凝治疗,对局限性黄斑水肿采取局灶光凝治疗。激光光凝治疗采取美国科医人公司激光机,波长532 nm,能量250~350 mW,近黄斑血管弓的后极部光斑直径20 μm,中周边部300 μm,曝光时间0.2 s,光斑强度3级,光凝范围为视盘上、下、鼻侧1 PD以外,颞侧上、下血管弓及黄斑中心凹颞侧2 PD以外至赤道部区域,以出现明显灰白色的III级轻中度光斑为准,每2个光斑之间间隔1个光斑直径,患者每次光凝500点,总光凝1200~1500点,分2或3次完成,每次光凝间隔2周,3个月为一个疗程。激光光凝治疗一个疗程后1,3,6个月分别进行眼压、视力、OCT等检查。而对照组仅采用激光光凝治疗,治疗后检测方法同治疗组。两组患者均治疗1个疗程,至本研究结束前,无患者补治。

1.3 疗效判定标准

显效:FFA渗漏消失,术后视力提高至少3行,黄斑水肿基本消失或明显缓解,眼底出血与渗出吸收;有效:FFA渗漏明显减轻,术后视力提高,但低于3行,黄斑水肿有所缓解,眼底出血与渗出明显吸收;无效:视力、黄斑水肿、眼底出血与渗出、FFA均无改善或加重。总有效率=(显效例数+有效例数)/总例数×100%。

1.4 观察指标

比较两组患者治疗总有效率,并根据DME的不同分期比较两组患者有效率差异,观察手术前及手术后1,3,6个月两组患者MRT、ARNFLT变化情况。

1.5 统计学方法

采用SPSS 19.0版统计学软件处理数据,计数资料以百分率(%)表示,数据比较采取χ2检验;计量资料均采用均数±标准差( x ¯ ±s)表示,两组间均数比较采取t检验,以 P<0.05为差异有统计学意义。

2 结果
2.1 临床疗效

治疗组有效率明显高于对照组(P<0.05),见表1。

表1 两组患者临床疗效比较
Tab.1 Comparison of clinical efficacy between two groups of patients 眼
组别 眼数 显效 有效 无效 有效
%
对照组 41 12 21 8 33 80.49
治疗组 46 19 25 2 44 95.65*1

与对照组比较,χ2=4.900,*1P<0.05

Compared with control group, χ2=4.900,*1P<0.05

表1 两组患者临床疗效比较

Tab.1 Comparison of clinical efficacy between two groups of patients 眼

2.2 两组不同临床分期DME患者临床疗效比较

治疗组和对照组Ⅱ期DME患者治疗有效率分别为100.00%,84.21%,治疗组Ⅱ期DME患者有效率显著高于对照组Ⅱ期DME患者(P<0.05);两组Ⅲ期和Ⅳ期DME患者的治疗有效率差异无统计学意义(均P>0.05)。见表2。

表2 两组不同临床分期DME患者临床疗效比较
Tab.2 Comparison of clinical efficacy between two groups of DME patients with different clinical stages 眼
组别与分期 眼数 显效 有效 无效 有效
%
对照组
Ⅱ期 19 6 10 3 16 84.21
Ⅲ期 14 5 7 2 12 85.71
Ⅳ期 8 1 4 3 5 62.50
治疗组
Ⅱ期 26 12 14 0 26 100.00*1
Ⅲ期 13 4 8 1 12 92.31
Ⅳ期 7 3 3 1 6 85.71

与对照组同期比较,χ2=4.398,*1P<0.05

Compared with control group at the same time, χ2=4.398,*1P<0.05

表2 两组不同临床分期DME患者临床疗效比较

Tab.2 Comparison of clinical efficacy between two groups of DME patients with different clinical stages 眼

2.3 MRT变化

两组患者术后1,3,6个月MRT均较术前显著下降,治疗组患者术后1,3,6个月MRT均显著低于同期对照组患者(P均<0.05)。见表3。

表3 两组患者黄斑区视网膜厚度变化情况
Tab.3 Comparison of retina thickness change in macular area between two groups of patients μm,x¯±s
组别 眼数 治疗前 术后1个月 术后3个月 术后6个月
对照组 41 593.2±86.5 368.6±107.3*1 315.3±85.3*1 281.5±78.3*1
治疗组 46 602.5±91.5 323.4±99.2*1*2 280.5±67.4*1*2 242.6±77.5*1*2

与同组治疗前比较,*1P<0.05;与对照组同时间点比较,*2P<0.05

Compared with the same group before treatment,*1P<0.05;compared with control group at the same time point,*2P<0.05

表3 两组患者黄斑区视网膜厚度变化情况

Tab.3 Comparison of retina thickness change in macular area between two groups of patients μm,x¯±s

2.4 ARNFLT变化

两组患者术后1,3,6个月ARNFLT均较术前均显著下降,治疗组患者术后1,3,6个月ARNFLT均显著低于同期对照组患者(均P<0.05)。见表4。

表4 两组患者平均视网膜纤维层厚度变化情况
Tab.4 Changes of average thickness pf retinal nerve fiber layer in two groups of patients μm,x¯±s
组别 眼数 治疗前 术后1个月 术后3个月 术后6个月
对照组 41 326.9±82.5 244.0±102.2*1 132.5±88.9*1 95.3±89.5*1
治疗组 46 322.3±75.6 223.2±79.5*1*2 113.6±75.6*1*2 88.6±69.8*1*2

与同组治疗前比较,*1P<0.05;与对照组同时间点比较,*2P<0.05

Compared with the same group before treatment, *1P<0.05;compared with control group at the same time point,*2P<0.05

表4 两组患者平均视网膜纤维层厚度变化情况

Tab.4 Changes of average thickness pf retinal nerve fiber layer in two groups of patients μm,x¯±s

3 讨论

DME是糖尿病常见并发症之一,其产生与糖尿病病程、血糖控制程度密切相关,其组织病理学改变主要为细胞外液异常集聚在视网膜Henle纤维以及内颗粒中,导致黄斑区视网膜增厚或出现硬性渗出,并伴有视网膜神经纤维层病变[4]。近年来,通过对DME深入研究发现,DME主要和视网膜外屏障及内屏障受损密切相关,血管内屏障是通过视网膜神经胶质细胞及血管内皮细胞间紧密连接而成的,主要由不透水蛋白组成。而视网膜外屏障则是由色素上皮细胞组成。其中内屏障功能受损是引发DME的主要原因[5]

激光目前已成为视网膜病变内科治疗的主要手段之一。激光光凝治疗DME的作用机制主要是,激光光凝可破坏外层视网膜,改善内层视网膜缺血状况;通过使微血管瘤与毛细血管封闭进而减少渗漏;通过促使视网膜色素上皮及神经上皮与Bruch膜发生粘连,进而促使视网膜下液的吸收,缓解黄斑水肿[6]。TA为一种人工合成的长效肾上腺糖皮质激素,可通过减少炎症血管的渗透,对上皮细胞增生以及新生血管生成产生抑制作用[7]。TA还可非特异性对花生四烯酸通路形成抑制,抑制血-视网膜屏障进一步破坏,并通过下调血管内皮生长因子的表达,进而起到有效治疗黄斑水肿的作用[8]。近年来,大量研究显示,IVTA对各种原因引起的黄斑水肿均具有显著疗效,但也存在一定不良反应,如眼压升高、视网膜毒性反应等,且对于TA剂量选择、适应证、给药方式、远期疗效等也存在一定争议[9]。以往,对于DME,激光光凝作为一种单一治疗手段,疗效并不十分理想。近年来,临床开始将其与其他药物联合使用,并取得满意效果[10]。例如,李琴等[11]采用532激光联合卵磷脂络合碘片治疗中心性浆液性脉络膜视网膜病变,取得了良好的临床效果。高瑞新等[12]的研究显示,通过对比激光光凝、IVTA单用治疗以及联合使用激光光凝与IVTA治疗DME发现,单独采用激光光凝或IVTA治疗后,两组在视力及黄斑中心凹厚度的改善效果方面差异无统计学意义,但二者联合治疗组患者的视力及黄斑中心凹厚度改善效果要显著优于单用激光光凝或IVTA治疗组患者。王博等[13]采用玻璃体内注射曲安奈德治疗糖尿病黄斑水肿的研究结果显示,治疗后患者视力出现明显回升,黄斑中心凹视网膜厚度较治疗前有显著降低,说明有效控制糖尿病视网膜病变患者病情发展并能改善视力。在本研究中,治疗组患者在联合使用激光光凝及IVTA治疗后,临床有效率显著高于单用激光光凝治疗对照组,且术后1,3,6个月MRT、ARNFLT均显著低于同期对照组,进一步证明了IVTA联合激光光凝治疗DME的可行性及优势。

综上所述,与单独给予激光光凝治疗相比,IVTA联合激光光凝治疗DME疗效显著,患者MRT、ARNFLT下降更为明显,值得临床推广应用。

The authors have declared that no competing interests exist.

参考文献

[1] 董明霞,王林洪,李冬育,.PASCAL激光联合玻璃体腔注药治疗糖尿病性黄斑水肿的短期疗效观察[J].眼科,2015,24(5):332-336.
目的观察Pattern Scan Laser(PASCAL)模式扫描激光联合玻璃体腔注药治疗糖尿病性黄斑水肿(DME)的短期疗效。设计回顾性比较性病例系列。研究对象2012年12 月至2014年2月唐山市眼科医院收治的重度非增生性糖尿病视网膜病变(NPDR)及增生性糖尿病视网膜病变(PDR)合并DME患者80例(135 眼)。方法 40例(70眼)采用PASCAL激光联合玻璃体腔注射曲安奈德(IVTA)2 mg,为治疗组;40例(65眼)采用传统多波长氪离子激光治疗,为对照组。两组患者术前DME病变程度无明显差异。通过诊断验光、相干光断层扫描 (OCT)及微视野计(SLO)检查随访患者治疗前及治疗后3个月最佳矫正视力(BCVA)、黄斑中心厚度(CMT)及黄斑中心10°范围内平均光敏感度 变化情况。主要指标BCVA(logMAR)、CMT及黄斑中心10°范围内平均光敏感度。结果治疗组治疗后3个月BCVA、CMT、黄斑区10°范围平 均光敏感度的治疗有效及显效眼数总和较对照组多(治疗组分别为62眼、64眼、60眼,对照组分别为42眼、47眼、30眼)两组比较差异有统计学差异 (χ~2=10.60、8.42、38.83,P=0.010、0.005、0.023)。治疗组总有效率(分别为88.57%、91.40%、 85.70%)均高于对照组(分别为64.30%、72.30%、46.15%)。治疗后3个月治疗组BCVA(logMAR)及黄斑区10°范围平均光 敏感度分别为0.400±0.700、16.000±13.500,好于对照组(0.600±0.900、12.500±10.000),两组比较差异有 统计学意义(t=0.612、0.695,P=0.010、0.005)。治疗组CMT(325±125)μm,与对照组(350±125)μm比较,差 异无统计学意义(t=0.520,P=0.223)。结论 PASCAL激光联合IVTA治疗DME的疗效明显优于传统氪离子激光治疗模式,具有治疗后可快速提高中心视力,降低黄斑中心厚度,明显降低激光对黄斑区 视敏度损害的优势。
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[2] 宗巧梅. 激光联合玻璃体腔注射小剂量曲安奈德治疗视网膜分支静脉阻塞合并黄斑水肿21例[J].陕西医学杂志,2015,44(3):334-335.
目的:观察激光联合玻璃体腔注射小剂量曲安奈德(TA)治疗视网 膜分支静脉阻塞(BRVO)合并黄斑水肿(ME)的疗效和安全性。方法:据荧光素眼底血管造影(FFA)对BRVO合并ME患者38例38眼随机分为两 组:对照组(17眼)单纯行黄斑区格栅样光凝,治疗组(21眼)玻璃体腔注射1次TA0.05ml(2mg),1~2周后行黄斑区格栅样光凝;随访3个 月,观察最佳矫正视力及光学相干断层扫描(OCT)检查黄斑中央厚度。结果:治疗组临床疗效总有效率95.2%,对照组总有效率64.7%,治疗组总有效 率显著高于对照组,差异有统计学意义。观察期间未发生眼压升高、并发性白内障、玻璃体出血、眼内炎等并发症。结论:激光联合玻璃体腔注射小剂量曲安奈德治 疗视网膜分支静脉阻塞合并黄斑水肿,是一种安全、有效、经济的治疗方法。
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[3] 杨波,宋艳.超声乳化联合曲安奈德玻璃体腔内注射治疗白内障合并糖尿病黄斑水肿[J].国际眼科杂志,2015,15(9):1532-1535.
目的:观察超声乳化联合曲安奈德玻璃体腔内注射(IVTA)对白内障合并糖尿病黄斑水肿患者的临床疗效。方法:将白内障合并糖尿病黄斑水肿患者44例52眼随机分为两组:对照组行白内障超声乳化联合人工晶状体植入手术;IVTA组在对照组手术的基础上,联合IVTA治疗。所有患眼均接受裂隙灯显微镜、光相干断层(OCT)、最佳矫正视力(BCVA)及间接检眼镜检查。比较各组治疗前后平均最小分辨角对数(Log MAR BCVA)及黄斑中心凹厚度(CMT)变化。并对手术治疗6mo后平均Log MAR BCVA和各因素进行相关性分析。采用多因素线性回归分析法分析术后6mo视力恢复的影响因素。结果:各组治疗1、3、6mo后Log MAR BCVA均明显改善,差异具有统计学意义(F=3.351、4.588,P=0.022、0.005),但两组间无统计学差异(P0.05)。手术后1、3mo后,IVTA组CMT显著低于对照组(t=3.402、2.083,P=0.001、0.042),手术后6mo时无明显差别。手术后6mo平均Log MAR BCVA与ELM(中心凹外界膜)状态负相关(r=-0.611,P=0.006)。多因素线性回归分析结果显示,手术后6mo视力恢复与中心凹外界膜ELM状态(B=0.333,P=0.030)和糖尿病病程(B=-0.307,P=0.005)具有相关性。结论:超声乳化手术联合IVTA治疗白内障合并糖尿病黄斑水肿,可在短期内减轻黄斑水肿,改善视力。IVTA对改善黄斑水肿的作用更为明显。
DOI:10.3980/j.issn.1672-5123.2015.9.10      Magsci     URL    
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[4] 杨杰,彭振宇,黄慧,.激光联合曲安奈德治疗糖尿病黄斑水肿的疗效[J].国际眼科杂志,2013,13(5):960-962.
目的:评价激光联合曲安奈德玻璃体腔注射治疗黄斑水肿的疗效及安全性.方法:对37例55眼糖尿病黄斑水肿(diabetic macular edema,DME)患者首先采用玻璃体腔注射曲安奈德4mg,术后3wk采用眼底激光对黄斑水肿进行局部直接光凝或格栅样光凝,分别在激光治疗术后1,3,6mo行最佳矫正视力、眼压、眼底检查,术后3mo行光学相干断层扫描(OCT)、荧光素眼底血管造影(FFA)检查,术后6mo行OCT检查,将术后各时间点检测结果与术前值进行比较,做出客观评价.结果:与治疗前相比,术后3wk,激光治疗后1mo,术后3mo,术后6mo视力提高者分别占34.2%,84.6%,87.9%,79.6%;术前、术后3mo和术后6mo平均视力分别为0.1627±0.1016,0.2743±0.1617,0.2615±0.1833,术前视力与术后3mo和6mo视力有显著统计学差异(P<0.01),术后3mo视力提高有效率为83.6%.OCT测量黄斑区视网膜厚度显示,术前、术后3mo和术后6mo黄斑区平均视网膜厚度分别为467.5±150.9,272.7±120.1,308.1±136.2μm,术前黄斑区厚度与术后3mo及6mo有显著统计学差异(P<0.01).治疗前后FFA显示黄斑区及相关血管的荧光素渗漏较术前明显减少.结论:激光联合曲安奈德玻璃体腔注射治疗黄斑水肿疗效好,并发症少,术后3mo效果最为显著.
DOI:10.3980/j.issn.1672-5123.2013.05.36      Magsci     URL    
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[5] 许立帅,杨小丽,兰长骏.不同方法注射曲安奈德联合光凝治疗糖尿病性黄斑水肿[J].国际眼科杂志,2014,14(3):435-437.
目的:评估曲安奈德(triamcinolone acetonide,TA)玻璃体腔和球后注射联合黄斑部格栅样光凝治疗糖尿病性黄斑水肿的临床疗效和安全性。方法:将52例62眼糖尿病性黄斑水肿患者随机分为璃体腔(0.1mL/4mg)注射TA组31眼和球后(1mL/40mg)注射TA组31眼,注药1mo后行黄斑部格栅样光凝,随访9mo观察视力、黄斑水肿情况及并发症。结果:两组患者治疗后1,3,6,9mo 4个随访时间点平均最佳矫正视力提高、黄斑水肿减轻,同治疗前比较均有统计学差异(P0.05),组间差异均无统计学意义(P0.05)。球后注射组并发症低于玻璃体腔注射组,组间差异有统计学意义(P0.05)。结论:TA球后注射联合黄斑部格栅样光凝治疗糖尿病性黄斑水肿,同玻璃体腔注射的疗效无明显差异,且更安全。
DOI:10.3980/j.issn.1672-5123.2014.03.14      Magsci     URL    
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[6] 毕苗苗,洪森,周鸿雁,.曲安奈德玻璃体腔注射联合全视网膜光凝治疗老年糖尿病黄斑水肿的疗效[J].中国老年学杂志,2013,33(6):1377-1379.
糖尿病是发生于老年人中最常见的慢性内分泌代谢疾病,而黄斑水肿 是导致糖尿病患者中心视力严重受损的主要原因之一.近年来众多医生们不断探索治疗糖尿病黄斑水肿(DME)的方法,包括激光治疗、药物治疗及手术等治疗方 法.但经过多年的临床观察表明,上述各种传统的治疗方法均有一定的局限性.我院采用IVTA 4 mg/0.1 ml治疗老年DME,并根据FFA进行PRP预防其向增生性糖尿病视网膜病变发展,取得良好的治疗效果.
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[7] MARTIDIS A,DUKER J S,GREENBERG P B,et al.Intravitreal triamcinolone for refractory diabetic macular edema[J].Ophthalmology,2006,113(9):1533-1538.
To report 2-year safety and efficacy outcomes from a trial of intravitreal triamcinolone acetonide (TA) injections (4 mg) in eyes with diabetic macular edema and impaired vision that persisted or recurred after laser treatment. Prospective, double-masked, placebo-controlled, randomized clinical trial. Sixty-nine eyes of 43 patients were entered into the study, with 34 eyes randomized to receive active treatment and 35 placebo. Two-year data were available for 60 of 69 (87%) eyes of 35 of 41 (85%) patients; 9 eyes of 6 patients were lost to follow-up, of which 6 received a placebo and 3 received intravitreal TA. Triamcinolone acetonide (0.1 ml) was injected through the pars plana using a 27-gauge needle. Eyes randomized to placebo received a subconjunctival injection of saline. Improvement of best-corrected logarithm of the minimum angle of resolution visual acuity (VA) by ≥5 letters after 2 years and incidence of moderate or severe adverse events. Improvement of ≥5 letters’ best-corrected VA was found in 19 of 34 (56%) eyes treated with intravitreal TA, compared with 9 of 35 (26%) eyes treated with the placebo ( z generalized estimating equation = 2.73, P = 0.006). The mean improvement in VA was 5.7 letters (95% confidence interval, 1.4–9.9) more in the intravitreal TA–treated eyes than in those treated with the placebo. An increase of intraocular pressure (IOP) of ≥5 mmHg was observed in 23 of 34 (68%) treated versus 3 of 30 (10%) untreated eyes ( P<0.0001). Glaucoma medication was required in 15 of 34 (44%) treated versus 1 of 30 (3%) untreated eyes ( P = 0.0002). Cataract surgery was performed in 15 of 28 (54%) treated versus 0 of 21 (0%) untreated eyes ( P<0.0001). Two eyes in the intravitreal TA–treated group required trabeculectomy. There was one case of infectious endophthalmitis in the treatment group. Intravitreal TA improves vision and reduces macular thickness in eyes with refractory diabetic macular edema. This beneficial effect persists for up to 2 years with repeated treatment. Progression of cataract and elevation of IOP commonly occur but appear manageable. Spontaneous improvement over years can still occur in eyes that are apparently severely affected by diabetic macular edema.
DOI:10.1016/j.ophtha.2006.02.065      PMID:16828501      URL    
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[8] JONAS J B,KREISSIG I,DEGENRING R.Intraocular pres-sure after intravitreal injection of triamcinolone acetonide[J].Br J Ophthalm,2003,87(1):24-27.
AIM: To investigate the intraocular pressure (IOP) response after intravitreal injections of triamcinolone acetonide as treatment of intraocular neovascular or oedematous diseases. METHODS: The prospective consecutive non-comparative interventional case series study included 71 patients (75 eyes) with progressive exudative age related macular degeneration (n = 64 eyes) or diffuse diabetic macular oedema (n = 11 eyes), who received an intravitreal injection of 25 mg triamcinolone acetonide. Mean follow up time was 6.86 (SD 2.52) months (range 3.1-14.47 months). RESULTS: IOP increased significantly (p<0.001) from 15.43 (3.26) mm Hg preoperatively to a mean maximum of 23.38 (8.37) mm Hg (range 13-64 mm Hg) postoperatively. An IOP rise to values higher than 21 mm Hg was observed in 39 (52%) eyes. Elevation of IOP occurred about 2 months after the injection. Preoperative predictive factor for the rise in IOP was younger age (p=0.013). It was statistically independent of refractive error, presence of diabetes mellitus, and indication for the injection. In all but one eye, IOP could be lowered to the normal range with topical medication, without development of glaucomatous optic nerve head changes. In the eyes with an elevation of IOP, IOP normalised about 6 months after the injection, without further medication. Eyes undergoing repeatedly intravitreal injections of triamcinolone acetonide showed only an elevation of IOP, if after the first injection a rise of IOP had occurred. CONCLUSIONS: After intravitreal injections of 25 mg of triamcinolone acetonide, an IOP elevation can develop in about 50% of eyes, starting about 1-2 months after the injection. In the vast majority, IOP can be normalised by topical medication, and returns to normal values without further medication about 6 months after the injection.
DOI:10.1136/bjo.87.1.24      PMID:1771462      URL    
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[9] YAMASHITA T,UEMURA A,KITA H,et al.Intraocular pressure after intravitreal injection of triamcinolone acetonide following vitrectomy for macular edema[J].J Glaucoma,2007,16(2):220-224.
Abstract PURPOSE: To evaluate long-term intraocular pressure (IOP) response after intravitreal injections of different doses of triamcinolone acetonide (TA) upon completion of pars plana vitrectomy (PPV) for macular edema secondary to diabetic retinopathy or retinal vein occlusion. PATIENTS AND METHODS: Retrospective, consecutive, comparative, interventional case series. Twenty-seven eyes of 25 consecutive patients with macular edema associated with diabetic retinopathy (n=18) or retinal vein occlusion (n=9), who underwent PPV for the treatment of macular edema between January 2003 and December 2003, were included. Upon completion of vitrectomy, different doses of TA were injected into the vitreous cavity: 14 eyes with 5 mg of TA (group 1) and 13 eyes with 10 mg of TA (group 2). The main outcome measure was IOP. RESULTS: All patients were followed up for at least 12 months. Preoperative IOP was 12.6+/-2.6 mm Hg (mean+/-standard deviation) in group 1 and 13.2+/-2.1 mm Hg in group 2. Postoperatively, IOP increased to a mean maximum of 20.6+/-5.5 mm Hg in group 1 and 31.5+/-3.5 mm Hg in group 2 (P<0.01 for both groups). The difference between groups was also significant (P<0.05). Five of 14 eyes (36%) in group 1 and 10 of 13 eyes (77%) in group 2 had an elevation of IOP exceeding 21 mm Hg (P=0.03). The median interval from surgery to reach maximal IOP was 7 days in both groups. The significant IOP elevation lasted for 3 months in group 1 and 6 months in group 2. CONCLUSIONS: After injecting of TA into the vitreous cavity upon completion of PPV for macular edema, a dose-dependent IOP elevation was observed, starting from early postoperative days and returning to normal values after several months. These results show that intravitreal TA injection in the vitrectomized eyes might have different IOP changes from in the nonvitrectomized eyes.
DOI:10.1021/cm048105e      PMID:17473734      URL    
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[10] 孙莉,张文芳,王玉萍,.玻璃体腔分别注射雷珠单抗与曲安耐德并联合黄斑格栅光凝治疗黄斑水肿的临床分析[J].兰州大学学报(医学版),2014,40(3):38-40.
目的观察分析玻璃体腔分别注射 雷珠单抗与曲安奈德并联合黄斑格栅光凝治疗黄斑水肿的临床疗效。方法黄斑水肿患者共83例102眼,其中单眼64例,双眼19例。随机选取单、双眼42例 共53眼行玻璃体腔注射雷珠单抗,3周后行黄斑格栅光凝治疗;选取单眼33例、双眼8例共49眼行玻璃体腔内注射曲安奈德,3周后黄斑格栅光凝治疗。治疗 后3~12个月通过荧光素眼底血管造影、眼底、视力、光学相干断层扫描等检查来观察疗效。结果玻璃体腔注射雷珠单抗联合黄斑格栅光凝治疗黄斑水肿,有效率 为83.01%,较对黄斑水肿行玻璃体腔注射曲安奈德联合黄斑格栅光凝治疗有效率54.24%明显增高(P0.05)。结论玻璃体腔注射雷珠单抗联合黄斑 格栅光凝治疗黄斑水肿较为安全、有效且并发症少。
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[11] 李琴,黄毅,张少维.532激光联合卵磷脂络合碘治疗中心性浆液性脉络膜视网膜病变32例[J].医药导报,2017,36(2):178-180.
目的 应用光学相干断层扫描(OCT)评价532激光联合卵磷脂络合碘片治疗中心性浆液性脉络膜视网膜病变(CSC)的临床疗效.方法 将CSC患者60例(62眼)随机分为治疗组32例(32眼)和对照组28例(30眼).对照组仅进行532激光光凝治疗,治疗组532激光治疗后口服卵磷脂络合碘片治疗,每次3 mg,tid,po,2个月后停药,少数患者服用3个月.比较两组患者治疗前后视力变化,治疗前后眼底OCT及平均光敏感度检查结果.结果 治疗组治疗后2,4周后,最佳矫正视力、眼底OCT以及平均光敏感度的恢复均高于对照组,差异有统计学意义(P<0.05).治疗12周后,治疗组和对照组最佳矫正视力分别为(0.92±0.12),(0.88±0.16),眼底OCT恢复(神经上皮脱离高度)分别为(18,14±11.15),(23.76±10.20) μm,差异均无统计学意义(均P>0.05),平均光敏感度分别为(27.32±2.61),(25.25±2.55) dB,差异有统计学意义(P<0.05).结论 激光联合卵磷脂络合碘治疗CSC能快速消退黄斑水肿,与单纯激光治疗比较,缩短病程,加快视力恢复,能保护黄斑的视功能,并且安全有效.
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[12] 高瑞新,范玉香,李朝霞.黄斑格栅样激光光凝联合玻璃体腔注射曲安奈德治疗糖尿病性黄斑水肿的疗效分析[J].中国眼耳鼻喉科杂志,2014,14(2):92-95.
目的评价黄斑格栅样激光光凝联合玻璃体腔注射曲安奈德(IVTA)对糖尿病性黄斑水肿(DME)的治疗效果。方法将DME患者48例(60眼)分成A、B、C组,每组20眼,A组行单纯黄斑区格栅样激光光凝治疗,B组行单纯IVTA治疗,C组在IVTA 4 mg后2周行黄斑区格栅样激光光凝。观察3组治疗前及治疗后1、3、6个月的视力,黄斑中心凹厚度。结果 3组患者治疗前视力、黄斑中心凹厚度差异均无统计学意义(P0.05),3组治疗后1、3、6个月,视力、黄斑中心凹厚度比较:A组与B组差异无统计学意义(P0.05),A、B组分别与C组比较差异有统计学意义(P0.05)。结论黄斑格栅样激光光凝联合IVTA优于单纯激光及单纯玻璃体腔注药。(中国眼耳鼻喉科杂志,2014,14:92-95)
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[13] 王博,吴京,马明,.玻璃体内注射雷珠单抗与曲安奈德治疗糖尿病黄斑水肿的疗效对比分析[J].眼科新进展,2015,35(3):246-249.
目的 对比分析玻璃体内注射雷珠单抗与曲安奈德治疗糖尿病黄斑水肿的临床疗效.方法 选取就诊于我院眼科的糖尿病黄斑水肿患者47例(48眼),病程6 ~14个月;分为雷珠单抗组24例24眼,曲安奈德组23例24眼;分别给予玻璃体内注射雷珠单抗0.05 mL与曲安奈德0.05 mg,比较两组治疗1周、1个月、3个月、6个月患眼的最佳矫正视力、黄斑中心凹视网膜厚度、眼压及眼底黄斑区荧光素渗漏情况,观察治疗后的效果.结果 雷珠单抗组与曲安奈德组治疗后1周、1个月、3个月患眼的最佳矫正视力均得到提高,分别为0.08±0.02与0.06±0.03、0.21±0.03与 0.17±0.05、0.29±0.07与0.27±0.04,治疗后短期内两组间差异无统计学意义(P值分别为0.082、0.092、0.320); 治疗6个月后,曲安奈德组患眼的最佳矫正视力(0.18±0.03)有5例出现回降现象;而雷珠单抗组患眼的最佳矫正视力(0.28±0.09)变化趋于 稳定,两组间的差异有统计学意义(P=0.003).治疗后1周、1个月、3个月、6个月雷珠单抗组与曲安奈德组患眼的黄斑中心凹视网膜厚度分别为 (336.00±94.71) μm与(378.00±89.74) μm、(251.00±63.55)μm与(273.00±81.29) μm、(263.00±59.42)μm与(267.00±49.32)μm、(238.00±42.61) μm与(298.00±33.27) μm,治疗后各时间点两组间的差异均无统计学意义(P =0.127、0.071、0.053、0.058).另外,治疗后各时间点两组的眼压均在正常范围内,并且黄斑区荧光渗漏均无明显增强现象.结论 玻璃体内注射雷珠单抗和曲安奈德治疗糖尿病黄斑水肿,均能有效控制糖尿病视网膜病变患者病情发展并能改善视力.两种疗法的疗效在短期内差异无统计学意义, 治疗6个月后,雷珠单抗疗效的稳定性优于曲安奈德.
DOI:10.13389/j.cnki.rao.2015.0066      URL    
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关键词(key words)
曲安奈德
激光光凝
黄斑水肿
视网膜病变
糖尿病

Triamcinolone acetonide
Laser photocoagulation
Macular edema
Retinopathy
diabetic

作者
吕旭东
龚兰兰
柴基桥

LYU Xudong
GONG Lanlan
CHAI Jiqiao