Wills手册 第十一章 视网膜 第十三节 玻璃体积血 郝晓军整理 打杂组出品

1、.Wills手册 第十一章 视网膜 第十三节 玻璃体积血 郝晓军整理 打杂组出品 2014.10.2211.13 Vitreous Hemorrhage第十三节  玻璃体积血Symptoms【症状】Sudden, painless loss of vision or sudden appearance of black spots, cobwebs, or haze in the vision.突然出现无痛性视力丧失，或突然出现眼前黑点、蜘蛛网或烟雾。Signs   【体征】(See Figure 11.13.1.)   &

2、#160;见图11.13.1Critical. In a severe vitreous hemorrhage (VH), the red fundus reflex may be absent, and there may be no view to the fundus. Red blood cells may be seen in the anterior vitreous. In a mild VH, there may be a partially obscured view to the fundus. Chronic vitreous hemorrhage has a

3、yellow ochre appearance from hemoglobin breakdown.【主要体征】    1、严重的玻璃体积血  眼底红光反射消失无法看到眼底。裂隙灯下可见前玻璃体红细胞。   2、轻度玻璃体积血   可见出血遮挡部分视网膜或视网膜血管。  3、慢性玻璃体积血   因血红蛋白降解而呈赭黄色玻璃体混浊。Other. A mild RAPD is possible. Depending on the etiol

4、ogy, there may be other fundus abnormalities.【其他体征】可能出现轻度的相对性传入性瞳孔障碍。由于致病病因不同，也可见其他的眼底异常。Differential Diagnosis【鉴别诊断】       Vitritis (white blood cells in the vitreous): Usually not sudden onset; anterior or posterior uveitis may also be present. No red blood cells are

5、seen in the vitreous. See 12.3, Posterior Uveitis.   1、玻璃体炎  玻璃体内出现白细胞。非突然发病，而伴有前葡萄膜炎或后葡萄膜炎，玻璃体内无红细胞，参见第十二章第三节后葡萄膜炎。       Retinal detachment: May occur without a VH, but the symptoms may be identical. In VH due to RD, the peripheral retina is o

6、ften obscured on indirect ophthalmoscopy. See 11.3, Retinal Detachment.   2、视网膜脱离   可不伴有玻璃体积血。症状典型。视网膜脱离造成的玻璃体积血病例，间接检眼镜下无法看清其周边部视网膜。参见本章第三节视网膜脱离。Etiology    【病因学】       Diabetic retinopathy: Usually history of diabetes

7、and usually diabetic retinopathy. Diabetic retinopathy is usually evident in the contralateral eye. In VH due to PDR, the peripheral retina is often visible on indirect ophthalmoscopy. See 11.12, Diabetic Retinopathy.   1、糖尿病性视网膜病变   通常有明确的糖尿病病史和糖尿病性视网膜病变病史。对侧眼常有显著的糖尿病性

8、视网膜病变。由于增殖型糖尿病性视网膜病变造成的玻璃体积血病例，间接检眼镜下通常可看清其周边部视网膜。参见本章第十二节糖尿病性视网膜病变。       PVD: Common in middle-aged or elderly patients. Usually patients note floaters and flashing lights. See 11.1, Posterior Vitreous Detachment.   2、玻璃体后脱离（PVD）   常见于中老年

9、患者，自述眼前有漂浮物或闪光感。参见本章第一节玻璃体后脱离。       Retinal break: Commonly superior in cases of dense vitreous hemorrhage. This may be demonstrated by scleral depression and, if poor view, US. See 11.2, Retinal Break.   3、视网膜裂孔    玻璃体严重积血的患眼，裂孔常见于视网

10、膜上方。可通过巩膜压迫检查发现，如果窥不清眼底，行眼部B超。参见本章第二节视网膜裂孔。       Retinal detachment: May be diagnosed by US if the retina cannot be viewed on clinical examination. See 11.3, Retinal Detachment.4、视网膜脱离   如果临床检查看不清眼底时，可行眼科B超检查。参见本章第三节视网膜脱离。      &

11、#160;Retinal vein occlusion (usually a BRVO): Commonly occurs in older patients with a history of high blood pressure. See 11.9, Branch Retinal Vein Occlusion.   5、视网膜静脉阻塞    通常为视网膜分支静脉阻塞。好发于有高血压病史的老年人。数月或数年前该眼有视网膜静脉阻塞史或视力突然丧失史。参见本章第九节视网膜分支静脉阻塞。    &

12、#160;  Exudative Age-Related Macular Degeneration (ARMD): Usually with a disciform scar or advanced choroidal neovascular membrane (CNVM). Poor vision before the VH as a result of their underlying disease. Macular drusen or other findings of ARMD or both are found in the contralateral eye.

13、 B-scan US may aid in the diagnosis. See 11.17, Neovascular or Exudative (Wet) Age-Related Macular Degeneration.   6、渗出性年龄相关黄斑变性(ARMD)    通常合并盘状瘢痕或晚期脉络膜新生血管(CNV)。由于原发病，患者在玻璃体积血前就有视力低下。可在对侧眼发现黄斑玻璃膜疣或年龄相关黄斑变性的其他表现。眼科B超可帮助诊断。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。  

14、     Sickle cell disease: May have peripheral retinal neovascularization in the contralateral eye, typically in a “sea fan” configuration and salmon color. See 11.20, Sickle Cell Disease (Including Sickle Cell, Sickle Trait).   7、镰状细胞病   &#

15、160;对侧眼周边视网膜可见新生血管，呈“海扇”状，三文鱼色。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)。       Trauma: By history.   8、外伤      有外伤史。       Intraocular tumor: May be visible on ophthalmoscopy or B-scan US. See 5.13, Maligna

16、nt Melanoma of the Iris, and 11.35, Choroidal Nevus/Malignant Melanoma of the Choroid.   9、眼内肿瘤   检眼镜下或眼科B超可查见。参见第五章第十三节虹膜恶性黑色素瘤和本章第三十五节脉络膜痣/脉络膜恶性黑色素瘤。       Subarachnoid or subdural hemorrhage (Terson syndrome): Frequently bilateral preret

17、inal or vitreous hemorrhages may occur. A severe headache usually precedes the fundus findings. Coma may occur.   10、蛛网膜下或硬脑膜下出血(Terson综合征)    常可出现双眼视网膜前或玻璃体积血，在眼底改变出现之前常有严重的头痛，可出现昏迷。       Eales disease: Usually occurs in men aged 20

18、to 30 years with peripheral retinal ischemia and neovascularization of unknown etiology. Decreased vision as a result of vitreous hemorrhage is frequently the presenting sign. Typically bilateral. Diagnosis of exclusion.   11、视网膜静脉周围炎（Eales病）  多发于2030岁男性，不明原因的周边视网膜缺血和新生血管膜形成

19、。常见的体征是由玻璃体积血引起的视力下降，常发生于双眼。排除性诊断。       Others: e.g., Coats disease, retinopathy of prematurity, retinal capillary angiomas of von HippelLindau syndrome, congenital prepapillary vascular loop, retinal cavernous hemangioma, hypertension, radiation retinopathy, anterior

20、segment hemorrhage because of an intraocular lens, bleeding diathesis. See specific sections.   12、其他    外层渗出性脉络膜炎(Coats病)，早产儿视网膜病变(ROP),脑一视网膜血管瘤病(Von Hippel-Lindau病)的视网膜毛细血管瘤，先天性视盘前血管袢，视网膜海绵状血管瘤，高血压，放射性视网膜病变，人工晶状体引起的眼前节出血，出血素质等。参见相关章节。NoteIn infancy and childhood

21、consider birth trauma, shaken baby syndrome, traumatic child abuse, congenital X-linked retinoschisis, and pars planitis.注：  在婴儿和儿童，应考虑产伤，婴儿摇晃综合征，外伤性儿童受虐待，先天性X-性连锁性视网膜劈裂症和睫状体平部炎。Work-Up    【检查】   1    History: Any ocular or systemic diseases, sp

22、ecifically the ones mentioned previously? Trauma?   1、病史   是否有眼病或全身性疾病，特别是前而提到的疾病?有无外伤史？   2    Complete ocular examination, including slit-lamp examination with undilated pupils to check for iris neovascularization, IOP measurement, and dilated

23、 fundus examination of both eyes by using indirect ophthalmoscopy. In cases of spontaneous vitreous hemorrhage, scleral depression is performed if a retinal view can be obtained.2、全面的眼科检查    包括裂隙灯检查有无虹膜新生血管，眼压测量，散瞳间接检眼镜下检查双眼眼底。在自发性玻璃体积血的患眼，如果能看见眼底，应行巩膜压迫检查。   3 

24、60;  When no retinal view can be obtained, B-scan US is performed to detect an associated RD or intraocular tumor. Flap retinal tears may be detected with scleral depression and sometimes can be seen on B-scan US (elevated flap).   3、眼底看不到的病例给以眼科B超检查   以观察是否合并视网膜脱离

25、或眼内肿瘤，有盖的视网膜裂孔可通过巩膜压迫发现。有时眼科B超也可发现(隆起的瓣膜)。   4    IVFA may aid in defining the etiology, although the quality of the angiogram depends on the density of the hemorrhage.4、眼底荧光血管造影(FFA)  可有助于确定病因，但成像的质量取决于出血的严重程度。NoteWe do not usually depress eyes until 2 weeks after

26、 traumatic hyphema/microhyphema. 注：  在外伤性前房积血或前房微量积血的病例，通常伤后2周内不要对患者施压。Treatment   【治疗】   1    If the etiology of the vitreous hemorrhage is not known and a retinal break or a RD or both cannot be ruled out (i.e., there is no known history of on

27、e of the diseases mentioned previously, there are no changes in the contralateral eye, and the fundus is obscured by a total vitreous hemorrhage), the patient is monitored closely as an outpatient.    1、如果玻璃体积血的病因不明，且不能排除视网膜脱离或裂孔，或二者均可能存在。即没有前述的任何一种疾病的病史，对侧眼未见异常，患眼由于全玻璃积血，无法看清眼底。

28、无需住院，密切观察。   2    Bed rest with the head of the bed elevated for 2 to 3 days. This reduces the chance of recurrent bleeding and allows the blood to settle inferiorly, permitting a view of the superior peripheral fundus, a common site for responsible retinal breaks. 

29、0; 2、高枕位卧床休息23d，以减少再次出血的机会，并使积血下沉。上方周边部视网膜是视网膜裂孔的好发部位。   3    Eliminate aspirin, nonsteroidal antiinflammatory drugs, and other anticlotting agents unless they are medically necessary.   3、如果不是内科治疗所必需，停用非甾体类抗炎药、阿斯匹林和其他抗凝药物。   4   

30、 The underlying etiology is treated as soon as possible (e.g., retinal breaks are sealed with cryotherapy or laser photocoagulation, detached retinas are repaired, and proliferative retinal vascular diseases are treated with laser photocoagulation).   4、尽可能治疗原发病，如冷凝或激光封闭视网膜裂孔，手术复位脱离的视

31、网膜，激光光凝增殖性视网膜血管性疾病。   5    Surgical removal of the blood (vitrectomy) is usually performed for:   5、下列情况常行玻璃体切除以清除积血:                Vitreous hemorrhage accompanied by RD or break seen

32、on B-scan US.   (1)眼科B超显示玻璃体积血合并有视网膜脱离或视网膜裂孔。                Nonclearing vitreous hemorrhage, usually persisting >3 to 6 months. However, two-thirds of patients with an idiopathic, fundus-obscuring hemorrhage will have retinal tears or a retinal detachment. Thus, early