2014-04-30 陈松 尖峰眼科

Wills 手册 第十一章 视网膜 第十二节 糖尿病 性视网膜病变 郝晓军整理 打杂组出品 2014.10.19 11.12 Diabetic Retinopathy 第十二节 糖尿病性视网膜病变 Diabetic Retinopathy Disease Severity Scale 【糖尿病性视网膜病变分级】 No apparent retinopathy. 1、无显著的视网膜病变。 Mild nonproliferative diabetic retinopathy (NPDR): Microaneurysms only. 2、轻度非增殖型糖尿病性视网膜病变(NPDR) 仅有微血管瘤。 Moderate NPDR: More than mild NPDR, but less than severe NPDR. See Figure 11.12.1. 3、中度非增殖型糖尿病视网膜病变(NPDR) 介于轻度和重度非增殖型糖尿病视网膜病变 之间。见图 11.12.1。 Severe NPDR: Any of the following in the absence of proliferative diabetic retinopathy: 20 intraretinal hemorrhages in each quadrant, two quadrants of venous beading, or one quadrant of prominent intraretinal microvasclar abnormalities (IRMA). See Figure 11.12.2. 4、重度非增殖型糖尿病视网膜病变(NPDR) 无增殖型糖尿病视网膜病变表现，出现以下体征之一:4 个象限的视网膜内出血，每一个象 限均超过 20 处，2 个象限的静脉串珠样改变，或 1 个象限的显著的视网膜内微血管异常 （IRMA ）。见图 11.12.2。 Proliferative diabetic retinopathy (PDR): One or more of: neovascularization (i.e., of the iris, angle, optic disc, or elsewhere), or vitreous/preretinal hemorrhage. See Figures 11.12.3 and 11.12.4. 5、增殖型糖尿病视网膜病变(PDR) 以下一项或多项：视盘上或距离 1 个视盘直径的范围 内出现新生血管(NVD)，视网膜其他部位出现新生血管(NVE)，虹膜表面出现新生血管(NV I），前房角新生血管(NVA）；玻璃体积血或视网膜前出血。见图 11. 12.3 和图 11 .12.4 。 Diabetic macular edema (DME): May be present in any of thestages list ed above. Clinically significant macular edema (CSME) requires treatment and is defined as any one of the following (see Figures 11.12.5 and11.12.6): 6、糖尿病性黄斑水肿（DME） 上述各期均可出现。有临床意义的黄斑水肿(CSME）需 要治疗。出现以下情况之一，即可定义为有临床意义的黄斑水肿。见图 11.12.5 和图 11.1 2.6。 1 Retinal thickening within 500 m (one-third of disc diameter) of the foveal center. (1)黄斑中心凹视网膜增厚1 视盘直径(PD),且部分位于距黄斑中心凹 1PD 内。 Differential Diagnosis for Nonproliferative Diabetic Retinopathy 【非增殖型糖尿病视网膜病变的鉴别诊断】 Central retinal vein occlusion (CRVO): Optic disc swelling, veins are more dilated and tortuous, hard exudates usually not found, hemorrhages are nearly always in the nerve fiber layer (“splinter hem orrhages”). CRVO is generally unilateral and of more sudden onset. See 11.8, Central Retinal Vein Occlusion. 1、视网膜中央静脉阻塞(CRVO) 视盘水肿，静脉明显迂曲扩张，通常无硬性渗出，出血几乎均位于神经纤维层(裂片形出血) 。 视网膜中央静脉阻塞常为单侧发病，起病突然。参见本章第八节视网膜中央静脉阻塞。 Branch retinal vein occlusion (BRVO): Hemorrhages are distributed along a vein, and do not cross the horizontal ra phe (midline). See 11.9, Branch Retinal Vein Occlusion. 2、视网膜分支静脉阻塞(BRVO) 出血沿静脉分支的走行分布，不越过水平中线。参见本章第九节视网膜分支静脉阻塞。 Ocular ischemic syndrome: Hemorrhages mostly in the midperiphery and l arger; exudate is absent. Usually accompanied by pain; mild anterior chamber reaction; corneal edema; episcleral vascular congestion; a mid-dilated, poorly reactive pupil; iris neovascularization. See 11.11, Ocular Ischemic Syndrome. 3、眼缺血综合征 出血斑较大，大多位于中周部视网膜，无渗出；通常伴有眼部疼痛； 前房轻度炎症反应，角膜水肿，表层巩膜充血；瞳孔轻度散大，对光反应迟钝；虹膜新生 血管。参见本章第十一节眼缺血综合征。 Hypertensive retinopathy: Hemorrhages fewer and typically flame-shaped, microaneurysms rare, and the arteriolar narrowing. See 11.10, Hypertensive Retinopathy. 4、高血压性视网膜病变 出血较多，呈火焰状，微血管瘤少见，视网膜动脉狭窄，常双 眼发病。参见本章第十节高血压性视网膜病变。 Radiation retinopathy: Usually develops within a few years of radiation. Microaneurysms are rarely present. See 11.5, Cotton Wool Spot: Differential Diagnosis. 5、放射性视网膜病变 放疗后任何时间均可发病，多在头几年之内。微血管瘤极少见。 曾行眼及其周围组织如脑、筛窦、鼻咽部放疗，眼睛受到辐射。即使放疗时有眼罩保护， 也要高度警惕，一般放疗量 3000cGY 即可致病，但有放疗量 1500cGY 致病的报道。参见 本章第五节棉绒斑的鉴别诊断。 Differential Diagnosis For Proliferative Diabetic Retinopathy 【增殖型糖尿病性视网膜病变的鉴别诊断】 Neovascular complications of CRAO, CRVO, or BRVO: See 11.6, Central Retinal Artery Occlusion, 11.8, Central Retinal Vein Occlusion, 11.9, Branch Retinal Vein Occlusion. 1、视网膜中央动脉阻塞、视网膜中央静脉阻塞或视网膜分支静脉阻塞引起的新生血管。 参见本章第六节视网膜中央动脉阻塞，第八节视网膜中央静脉阻塞，第九节视网膜分支静 脉阻塞。 Sickle cell retinopathy: Peripheral retinal neovascularization. “Sea fans” of neovascularization present. See 11.20, Sickl e Cell Disease (Including Sickle Cell, Sickle Trait). 2、镰状红细胞性视网膜病变 视网膜新生血管位于周边部，呈 “海扇”形，黄斑一般 不受累。参见本章第二十节镰状细胞病(包括镰状细胞病和镰状细胞素质 )。 Embolization from i.v. drug abuse (e.g., talc retinopathy): History of i.v. dr ug abuse, peripheral retinal neovascularization, may see particles of talc in ma cular vessels. See 11.33, Crystalline Retinopathy. 3、静脉吸毒性血管栓塞（滑石粉性视网膜病变） 有经静脉吸毒史，周边视网膜新生血 管、黄斑区血管可见滑石粉颗粒。参见本章第三十三节结晶样视网膜病变。 Sarcoidosis: May have uveitis, exudates around veins (“candle-wax drippings”), NVE,or systemic findings. See 12.6, Sarcoidosis. 4、结节病 可有葡萄膜炎、静脉旁渗出(蜡样小滴)、视网膜其他部位新生血管（NVE） 或全身表现。参见第十二章第六节结节病。 Ocular ischemic syndrome: See above. 5、眼缺血综合征 如前所述。 Radiation retinopathy: See above. 6、放射性视网膜病变 如前所述。 Work-Up 【检查】 1 Slit- lamp examination with gonioscopy with careful attention for NVI and NVA, prefer ably before pharmacologic dilation. 1、在药物散瞳前行裂隙灯联合前房角镜检查，仔细检查有无虹膜新生血管(NVI ）和前房 角新生血管(NVA)。 2 Dilated fundus examination by using a 90- or 60- diopter or fundus contact lens with a slit lamp to rule out neovascularization and macular edema. Use indirect ophthalmoscopy to examine the retinal periphery. 2、散瞳后用 90D 或 60D 透镜或三面镜联合裂隙灯查眼底，以排除新生血管和黄斑水肿， 用间接检眼镜检查周边部视网膜。 3 Fasting blood sugar, glycosylated hemoglobin, and, if necessary, a glucos e tolerance test if the diagnosis is not established. 3、检查空腹血糖、糖化血红蛋白，若不能确诊，可行糖耐量试验。 4 Check the blood pressure. 4、测血压。 5 Consider IVFA to determine areas of perfusion abnormalities, foveal ische mia, microaneurysms, and subclinical neovascularization, especially if considering f ocal macular laser therapy. 5、行眼底荧光血管造影（FFA）检查，确定异常灌注区、中心凹缺血、微血管瘤、亚临床 新生血管，尤其是准备行黄斑区局限性激光治疗的患者。 6 Consider blood tests for hyperlipidemia if extensive exudate is present. 6、若视网膜有大量渗出，需行高脂血症相关的血液检查。 Treatment 【治疗】 Clinically Significant Macular Edema 1、有临床意义的黄斑水肿（CSME） 1 Focal or grid laser treatment should be considered in patients with clinica lly significant macular edema (CSME). Patients with enlarged foveal avascular zone s on IVFA are treated lightly, away from the regions of foveal ischemia, if they are t reated at all. Patients with extensive foveal ischemia are poor laser candidates. Yo unger patients and diet- controlled diabetic patients tend to have a better response. （1）有临床意义的黄斑水肿(CSME)必须采用局限性或格栅样激光治疗。眼底荧光血管造 影（FFA）显示黄斑无血管区扩大者，如果采取治疗，应轻度治疗，远离中心凹缺血区。 中心凹严重缺血的激光治疗效果欠佳。年轻患者和饮食控制治疗糖尿病的患者激光疗效较 好。 2 Patients with diffuse/extensive macular edema may benefit from combini ng laser treatment with intravitreal injection of triamcinolone acetonide (currently an off-label indication). （2）黄斑弥漫性水肿或广泛性水肿的患者，激光联合玻璃体腔内注射曲安奈德(没被临床 试验认可的药物使用指征)效果更佳。 3 Anti- VEGF agents have been used for refractory CSME with some success. The role of t hese agents in CSME requires further study. See 11.17, Neovascular or Exudative ( Wet) Age-Related Macular Degeneration for a more detailed discussion. (3)抗血管内皮生长因子（VEGF）已用于顽固性的有临床意义的黄斑水（CSME），并取得 一些成功。这些因子针对有临床意义的黄斑水肿的作用还有待于进一步的研究。详细的讨 论参见本章第十七节新生血管性或渗出性(湿性)年龄相关性黄斑变性。 Proliferative Diabetic Retinopathy 2、增殖型糖尿病性视网膜病变 Panretinal laser photocoagulation is indicated for any one of the following high- risk characteristics (see Figure 11.12.7): 出现以下高危情况的任何一项，即应行全视网膜光凝(见图 11.12.7） 1 NVD greater than one-fourth to one-third of the disc area in size. (1)视盘新生血管(NVD)的范围大于视盘表面面积的 1/41/3。 2 Any degree of NVD when associated with preretinal or vitreous hemorrhage. (2)不同程度的视盘新生血管(NVD)合并视网膜前出血或玻璃体积血。 3 NVE greater than one half of the disc area in size when associat ed with a preretinal or vitreous hemorrhage. (3)视网膜其他部位新生血管(NVE)的范围视盘表面面积的 1/2，并有视网膜前出血或玻 璃体积血。 4 Any NVI or neovascularization of the angle. (4)虹膜新生血管(NVI)或前房角新生血管 (NVA）。 Note Some physicians treat NVE or any degree of NVD without preretinal or vitreous he morrhage, especially in unreliable patients. If the ocular media are too hazy for an adequate fundus view, yet one of these crit eria is met, pars plana vitrectomy and endolaser therapy with or without lensecto my and posterior chamber intraocular lens is another option. 注： 有人主张对视网膜其他部位新生血管(NVE ）或所有的不伴有视网膜前出血或玻璃 体积血的视盘新生血管(NVD)进行治疗，特别是一些不能按时复诊的患者; 如患眼具有上述体征，而屈光间质混浊，眼底看不清，选择玻璃体切除及眼内激光治疗 ，可同时切除晶状体或保留晶状体，可选择植入或不植入后房型人工晶体。 Indications for Vitrectomy 3、玻璃体切除术的适应证 Vitrectomy may be indicated for any one of the following conditions: 出现以下任一种情况均应行玻璃体切除术。 1 Dense vitreous hemorrhage causing decreased vision, especially when present for several months. (1)浓密的玻璃体积血引起视力下降，特别是已持续数月者。 2 Traction retinal detachment involving and progressing within th e macula. (2)牵引性视膜网脱离累及黄斑，并且病情持续进展。 3 Macular epiretinal membranes or recent-onset displacement of the macula. (3)黄斑前膜或新近发生的黄斑脱离。 4 Severe retinal neovascularization and fibrous proliferation that i s unresponsive to laser photocoagulation. (4)激光光凝治疗无效的严重的视网膜新生血管和纤维增殖。 5 Dense premacular hemorrhage. (5)浓密的黄斑前出血。 Note Young patients with juvenile type 1 diabetes are known to have more aggressive P DR and therefore may benefit from earlier vitrectomy and laser photocoagulation. B-scan US may be required to rule out tractional detachment of the macula in eye s with dense vitreous hemorrhage obscuring a fundus view. 注： 青少年的 l 型糖尿病患者的增殖型糖尿病性视网膜病变更为严重，尽早行玻璃体切除 和激光治疗对患者有益。对于玻璃体积血浓密，影响观察眼底的患者应做 B 超检查，以排 除牵引性黄斑脱离。 Follow-Up 【随访】 1 Diabetes without retinopathy. Annual dilated examination. 1、未出现视网膜病变的糖尿病 每年 1 次散瞳检查眼底。 2 Mild NPDR. Dilated examination every 6 to 9 months. 2、轻度非增殖型糖尿病性视网膜病变 每 69 个月散瞳检查 1 次。 3 Moderate to severe NPDR. Dilated examination every 4 to 6 mo nths. 3、中、重度非增殖型糖尿病性视网膜病变 每 46 个月散瞳检查 1 次。 4 PDR (not meeting high-risk criteria). Dilated examination every 2 to 3 months. 4、增殖型糖尿病性视网膜病变(未达到高危标准者) 每 23 个月散瞳检查 1 次。 5 Diabetes and pregnancy. Changes that occur during pregnancy have a high likelihood of postpartum regression. See Table 11.12.1 for follow-up r ecommendations. 5、糖尿病和妊娠 妊娠期发生的病变于产后消退可能性很大。随访 Note T