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中心性浆液性脉络膜视网膜病变

简介:

? ? ? ?中心性浆液性脉络膜视网膜病变(central serous chorioretinopathy,CSC)是以黄斑部及其附近局限性浆液性神经上皮脱离为特征的常见眼底病变,国内临床上常简称“中浆”。1866年Von Graefe首先描述了该病,并命名为“复发性中心性视网膜炎”。到1965年,Maumenee通过荧光造影观察到该病变是由色素上皮渗漏引起的。1967年Gass详细描述了该病的病理和临床特征,对其神经上皮层盘状脱离的机制做了详尽的论述,并将其命名为“特发性中心性浆液性脉络膜炎”(idiopathic central serous choroidopathy)。

分类

根据临床不同的征候特点,本病属中医学“目妄见”、“视瞻昏渺”、“视瞻有色”、“视直如曲”、“视正反斜”、“视惑”等病症。

病因病理:

一 西医病因病理 本病的发病与年龄、性别、血型、气候、全身情况、妊娠、精神紧张、情绪异常、过敏、感冒、过度疲劳 和烟酒刺激等有关。常见的诱因有睡眠不足、紧张、劳累和情绪波动等。发病机制尚不清楚,有缺血、感染、炎症、免疫反应及代谢障碍等学说。但都缺乏有力的证据 二、中医病因病机 1.目为肝窍,瞳神属肾,肝身同源,脾主运化,黄斑属脾,肝郁脾虚,脾失健运,清阳不升,浊阴不降,痰湿阻络,血流不畅而发病。 2.感受湿热之邪,湿热内蕴,熏蒸清窍,或痰湿化热,上泛于目也可导致黄斑部渗出、水肿。 3.肝肾不足,精血亏损,精不上承,目失濡养引起脉络膜视网膜水肿,渗出等病变。 故本病的发生与肝、肾、脾的功能失调有关。痰湿,气郁,精亏是本病的主要病因。

临床表现

1、自觉症状:视物模糊,眼前有灰黄色暗影遮挡,视物变形,视大如小,视直为曲或视正反斜等。 2、体征 (1)黄斑部视网膜水肿环,点状黄白色渗出,中心凹光反射消失。 (2)荧光素眼底血管造影黄斑部及附近可见神经上皮脱离,或色素上皮脱离,或色素上皮脱失等典型的荧光形态。(3)发病人群多为健康成年人,骤然发觉视物模糊,视野中心似有淡影阻挡,视物可有变形、变小的感觉。视力障碍程度不一,远视力检查从1.0到0.1。用Amsler方格表检查常有变形或暗点。 3、眼底检查在病变轻者仅见后极部视网膜呈闪烁不定的反光,中心凹光反射略为弥散。重者可见黄斑区视网膜有圆形隆起的盘状脱离,其边缘有反光轮。数周后盘状脱离区有黄白色渗出点。裂隙灯接触镜检查,从光学切面显示神经上皮层与色素上皮层分离,神经层向前隆起,脱离腔的后壁有黄白色点状物,腔内积液可透明或略现混浊。个别极重病例,视网膜下液体过多,因重力作用而向下方流动,使周边视网膜脱离。液体吸收后,常在眼底下半留下液体流经区域的色素上皮萎缩条带,清楚地显示当初视网膜下液体通道的痕迹与范围。对于复发病例或在隐匿进行的患者,检眼镜下所见,除严重渗液者可再现盘状脱离外,大多数只表现黄斑区色素紊乱,或中心凹反射异常。仅从眼底表现不能判定是否病情复发或是隐匿进行。并且患者视力好坏也常与病变进展并不平行。对于疑为慢性进行病变的患眼应当再行荧光血管造影检查,因为造影图像所见与眼底表现有很大的不同。造影图片可以具体显示色素上皮的损害程度和病变范围,了解病情究竟是复发活跃还是萎缩稳定。本病虽有较大程度的自限性,经过垂直追踪观察发现有的病例可以延续多年,时显时隐,病变范围也逐渐扩大,色素上皮萎缩也严重。据统计约1/3或半数病眼可以复发,10%病例可多次复发,50%病例复发期在1年左右,而顽固病例可长达10年。少数病眼经多次发作后,最终可使中心视力蒙受永久性损害。

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