玻璃体视网膜病PPT课件

VITROUS & RETINAL DISEASE,EYE & ENT HOSPITAL,1,玻璃体视网膜疾病,飞蚊症视网膜血管阻塞玻璃体积血糖尿病视网膜病变 COATS病中浆年龄相关性黄斑变性视网膜色素变性视网膜脱离视网膜母细胞瘤,2,玻璃体病,组成99水1胶原和透明质酸解剖占眼球体积4/5玻璃体皮质与基底部、视乳头、黄斑和大血管粘连功能维持形状、缓存外力、视觉通路、物质代谢,3,飞蚊症（floaters),症状黑影飘动，白色明亮背景明显闪光感病因玻璃体液化玻璃体后脱离,4,5,飞蚊症,临床表现玻璃体腔内光学空隙点状混浊或膜状物Weiss 环*视网膜裂孔*玻璃体出血*,6,飞蚊症,治疗随访，无需特殊治疗药物治疗平地木散冲剂、碘剂等激光治疗视网膜裂孔,7,玻璃体积血(vitreous hemorrhage),症状急性无痛性视力下降突然出现的眼前黑点,8,玻璃体积血(vitreous hemorrhage),病因视网膜血管病DR, RVO, Eales, 玻璃体后脱离伴或不伴视网膜裂孔外伤眼外伤、内眼手术、蛛网膜下腔或硬膜下出血 (Tersons syndrome)年龄相关性黄斑变性其他,9,玻璃体积血(vitreous hemorrhage),诊断病史：眼部和全身疾病，外伤？完全的眼部检查：裂隙灯，眼压，强调双眼扩瞳眼底镜检查B超,10,玻璃体积血(vitreous hemorrhage),治疗药物治疗止血药、碘制剂等手术治疗玻璃体积血伴视网膜脱离或裂孔36月积血未吸收玻璃体积血伴虹膜红变,11,视网膜病,概述视网膜水肿细胞性水肿：视网膜动脉阻塞细胞外水肿：毛细血管的内皮细胞受损 黄斑囊样水肿（CME）,12,视网膜渗出硬性渗出（hard exudates)视网膜毛细血管病变，慢性缺氧视网膜外丛状层的脂质沉着视网膜内黄白色小点和斑块，边界清晰棉绒斑 (cotton-wool spot)毛细血管前小动脉阻塞神经纤维层的梗塞视网膜内边界不清的灰白色棉花或绒毛状斑块,13,视网膜出血深层出血 外丛状层和内核层圆点状出血，色暗红浅层出血神经纤维层线状、条状、火焰状，色较鲜红视网膜前出血视网膜内界膜和玻璃体后界膜，半月形玻璃体出血,14,视网膜新生血管NVD、NVE脉络膜新生血管 ( CNV )色素改变色素脱失、增生、化生,15,视网膜动脉阻塞,CRAO,BRAO,16,CRAO,病因粥样硬化栓塞拴子系统性病因巨细胞动脉炎、凝血障碍、外伤、炎症或感染性病等,17,CRAO,临床表现一眼突发无痛性失明患眼瞳孔直接光反射消失视网膜混浊水肿，视网膜动脉变细，黄斑樱桃红数周后，水肿消退，视盘苍白，血管变细呈白线,18,CRAO,治疗降眼压吸入95氧及5二氧化碳舌下含服硝酸甘油或亚硝酸异戊酯,19,BRAO,病因栓塞最常见，拴子来源：胆固醇拴子、血小板纤维蛋白拴子、钙化拴子、粘液瘤拴子、脂肪拴子、菌拴临床表现受累动脉供应区视网膜灰白色水肿混浊遗留永久性视野缺损治疗对因治疗,20,视网膜静脉阻塞,视网膜中央静脉阻塞( central retinal vein occlusion, CRVO),21,CRVO,病因血栓形成，与视网膜中央动脉粥样硬化压迫有关高血压、糖尿病、动脉硬化、高血粘滞炎症远视、小视盘好发,22,CRVO,临床表现视力下降，眼底静脉扩张、迂曲，视网膜出血、水肿，视盘水肿分非缺血性和缺血性,23,CRVO,治疗病因治疗激光治疗全视网膜光凝 ( PRP )虹膜红变黄斑格栅样光凝黄斑水肿手术治疗放射状视神经切开*,24,视网膜分支静脉阻塞( branch retinal vein occlusion, BRVO ),25,BRVO,病因动静脉交叉处，动脉壁增厚压迫静脉临床表现视力视黄斑受累，呈不同程度下降阻塞静脉扩张、迂曲，相应区域内视网膜出血、水肿、棉毛斑视网膜新生血管致玻璃体出血,26,BRVO,治疗病因治疗激光光凝黄斑水肿广泛毛细血管无灌注或新生血管手术玻璃体切割动静脉鞘膜切开术*,27,BRVO,3M POST LASER,28,COATS 病,病因不明，无遗传性，与系统性血管异常无关临床表现男性儿童，单眼视力障碍眼底毛细血管扩张，微动脉瘤，大片硬性渗出，胆固醇结晶，渗出性视网膜脱离,29,COATS病,30,COATS病,治疗早期激光光凝或冷凝晚期玻璃体手术治疗，视力预后差多次治疗，长期随访,31,糖尿病视网膜病变( diabetic retinopathy,DR),糖尿病的严重并发症发生率与糖尿病病程、发病年龄、血糖控制情况有关高血压、肾病、怀孕等可加重DR,32,DR分期,单纯性或背景性DR微动脉瘤、出血、硬性渗出,33,DR分期,增殖性DR (PDR)标志为新生血管形成玻璃体出血、牵引性视网膜脱离,34,DR,治疗控制血糖和合并症定期眼科检查激光玻璃体手术,35,中心性浆液性脉络膜视网膜病变( central serous chorioretinopathy,CSC),病因RPE屏障功能损害临床表现视物变形、视力下降眼底黄斑中心凹反光消失，圆盘状脱离区FA荧光素渗漏点,36,CSC,黄斑中心凹反光消失，圆盘状脱离区,37,CSC,FA荧光素渗漏点,38,CSC,治疗自限性疾病无特殊药物治疗禁用糖皮质激素激光封闭渗漏点,39,年龄相关性黄斑变性( age-related macular degeneration, AMD),病因与黄斑长期慢性光损伤、遗传、代谢、营养等有关临床分型干性湿性 CNV形成,40,Photoreceptors,Choroid,RPE,Normal Retina,41,Cross Section of Macula with Dry AMD,Age-related effects in choroid and Bruchs MembraneImpaired transport of O2 in and of waste materials/fluids outReduced RPE phagocytosis and accumulation of drusen,Choroid,RPE,Retina,Bruchs Membrane,Healthy Fovea,42,AMD: Development of Large Drusen,Bruchs membrane thickens and large drusenbecome apparent (intermediate stage of AMD),43,AMD dry form,44,Development of Subfoveal Wet AMD,New vessels grow into and break through Bruchs Membrane,45,Progression of Neovascular AMD:Formation of New Vessels,New abnormal blood vessels (CNV) proliferate and penetrate Bruchs membrane in setting of large-sized drusen,46,Wet AMD - Subfoveal Classic CNV,Type II CNV develops which typically shows classic components or remains occult to FA depending on activity of RPE cells,Healthy Fovea,47,Progression of Neovascular AMD:Leakage of Fluid and Blood from CNV,New blood vessels (CNV) leak blood and fluid contributing to symptoms of metamorphopsia or scotoma,48,Progression of Neovascular AMD:Fibrovascular Scar,Without treatment, CNV is accompanied by fibrous tissue, often with permanent destruction of outer retina,49,Wet AMD - Disciform Scar,Disciform scar - end-stage of wet AMDSevere irreversible vision lossAccounts for 80% of SVL in AMD,50,Neovascular(choroidal neovascularization),Non-neovascular(geographic atrophy),Two Forms of Advanced AMD That Can Cause Severe Loss of Central Vision,51,AMD,治疗抗氧化剂、Zn激光PDTTTT手术：黄斑转位手术、黄斑下手术其他：放疗等,52,Step 1,Step 2,Photodynamic therapy, PDT,53,Wet AMD - PDT Treatment of Subfoveal Classic CNV,Pre-treatment,One day post-treatment,54,Wet AMD - TTT Treatment of Subfoveal Occult CNV,Principles of Treatment,55,Wet AMD - TTT Treatment of Subfoveal Occult CNV,VA 20/100Retinal thickening, subretinal fluid, and an RPE detachment,Optical Coherence Tomography (OCT)Pretreatment,56,Wet AMD - TTT Treatment of Subfoveal Occult CNV,VA 20/100At 1 month follow-up, there is still subretinal fluid and less thickening of retina,OCT1 month follow-up,57,Wet AMD - TTT Treatment of Subfoveal Occult CNV,VA 20/50At 2 months follow-up, subretinal fluid has further diminished,OCT2 months follow-up,58,Wet AMD - TTT Treatment of Subfoveal Occult CNV,VA 20/40At 3 months follow-up, there is no subretinal fluidCentral foveal depression can be observed,OCT3 months follow-up,59,2m Post-injection，Vos 0.1,近视性黄斑变性,60,62F，高度近视，左眼视力下降2M，Vos 0.01,61,视网膜色素变性( retinitis pigmentosa, RP),一组遗传性视网膜疾病感光细胞进行性退化，同时累及视网膜其他层主要累及视杆细胞，视锥细胞受累程度较轻视功能改变夜盲视野丧失中心视力减退起病年龄及进展速度随RP的类型而异，从婴儿期开始到各个年龄段,62,视网膜色素变性（RP),每4000人中有1个，分布于世界各地中国人口: 13 亿中国的RP患者 : 325,000 例全世界有140万。,63,RP分类,基于遗传方式常染色体隐性遗传 (ARRP) - 41%常染色体显性遗传 (ADRP) - 16%X-伴性遗传 (XLRP) -9%散发病例 无特定遗传方式 - 44%,64,Attenuation of retinal vesselsBone spicule pigment in retinal peripheryWaxy palor of optic disc,65,诊断,视野环形暗点- 早期严重的视野缩窄- 晚期视网膜电图（ERG)杆细胞和锥细胞信号减弱b-波潜伏期显著延迟*,66,RP的治疗,尚无有效疗法以下两种药物有证据证实可延缓RP的自然病程软脂酸维生素A 二十二碳六烯酸 (DHA),67,视网膜脱离(retinal detachment, RD),裂孔性视网膜脱离 （RRD）牵拉性视网膜脱离（TRD）渗出性视网膜脱离 （ERD）,68,RRD,视网膜感觉层与RPE之间脱离多见于老年人、高度近视、眼外伤无晶体眼和人工晶体眼一眼有视网膜脱离史或有家族史,69,RRD,不同形状的视网膜裂孔,70,RRD,临床表现飞蚊、闪光、眼前黑影遮挡累及黄斑视力明显减退眼底脱离的视网膜兰灰色，波浪状术前多可找到红色裂孔,71,摘要幻灯片,主题 1,72,单个裂孔象限脱离或全脱离,73,矩齿缘截离视网膜脱离,74,黄斑裂孔和巨大裂孔视网膜脱离,75,黄斑裂孔,76,RRD,治疗封闭裂孔解除牵引,77,RRD,78,Surgical Technique,79,RRD,预后90可手术成功失败主要原因为PVR形成,80,视网膜母细胞瘤( Retinoblastoma, RB ),一般情况儿童最常见的原发性眼内恶性肿瘤发病年龄