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中心性渗出性脉络膜视网膜病变

简介:

? ? ? ?该病发病年龄为20-50岁的青壮年,亦多为单眼发病,男女发病率相等,但视力损害严重,一般低于0.2,眼底黄斑部有渗出、出血等炎性病灶,症状视力下降,视物变形,视野中心暗点。中心性渗出性脉络膜视网膜病变(central exudative chorioretinopathy)简称“中渗”,1939年Rieger首次报告。多单眼发病。眼底表现类似老年黄斑变性,但病灶较老年性黄斑变性者为小。多为孤立的渗出灶,伴有出血。本病曾有青年性黄斑变性或出血性黄斑病变之称,其致病为不同原因的炎症,引起视网膜下新生血管膜形成,发生浆液性和(或)出血性色素上皮和(或)神经上皮脱离。

临床症状体征 患者多为中青年,单眼发病居多,但少数病例亦有双眼患病者。自觉中心视力障碍,视物变形或小视症。眼底检查有以下典型征候:

1.病变中心为灰白色深层浸润性病灶,略呈圆形,稍隆起,边缘模糊,大小约1/4盘径,很少超过1个盘径。 2.周围可有出血,常在病灶边缘处出现,呈点状、片状、弧形或环形,围绕着灰白色浸润损害。 3.视网膜下可能有渗液而使病灶周围有盘状脱离,尤其在急性阶段。 4.病情持续较久者,病灶附近可能有亮白色的硬性脂类沉着。 ? ? ? ?本病病程持久,常呈间歇性发作,持续一二年甚至更长时间,最后进入瘢痕形成阶段。此时由色素上皮细胞化生或胶质细胞进行修复,形成机化瘢痕。眼底可见原来的病变部位已由灰白色,境界清晰,被有色素堆积的瘢痕所代替。患者留有浓厚的中心暗点,视力蒙受永久性的损害。如果病灶位于旁中心区,中心凹未受累,则患者常可保留相当的中心视力。极少数病例过数年后病情可复发,复发的渗出灶常在原来瘢痕的边缘出现。

饮食保健:

? ? ? ?日常饮食应以清淡易消化的饮食为主,宜多食富含维生素C、矿物质及植物蛋白的食物,增加粗纤维食物的摄入量,多吃新鲜蔬菜、水果及适量的肉类。忌吸烟,禁饮酒,少吃或不吃刺激性食物。

并发症

? ? ? ?视网膜出血甚至玻璃体积血等。预后与出血的量及次数密切相关。

发病机制

炎症原发于脉络膜,肉芽肿性炎症易于诱发新生血管,来源于脉络膜毛细血管层的新生血管,经被损害的Bruch膜及色素上皮侵入视网膜神经上皮层下,形成新生血管膜及随之而来的渗出、出血、机化等一系列病理改变。

检查方法

1、血象检查、结核菌素皮内试验、组织胞质菌素皮内试验以及弓形虫红细胞凝聚反应、梅毒VORL及TPHA等血液检查是必要的,但多数病例可能仍无法确定病因而只能给予对症治疗。 2、其他辅助检查:1.胸部X射线摄片。2.眼底及荧光造影所见 本病整个病程可分为3期: (1)活动期:裂隙灯显微镜加前置镜或接触镜检查后部玻璃体,部分病例在检查者经暗适应后可见极其轻微的尘埃状或线结状灰白色混浊。检眼镜下,在黄斑中央或其附近有灰白色圆形或类圆形渗出性病灶,大小为1/2~1PD,微微隆起,境界欠清。渗出病灶周围有锯齿形的环状或眉月状出血(图1)。FFA可见灰白色渗出病灶内在动脉期开始已显荧光,呈辐射状或颗粒状,并迅速扩大增强成强荧光斑,直至造影晚期仍持续不退,提示视网膜神经上皮层下有新生血管存在。病灶周围出血处荧光遮蔽(图2A,B)。 (2)恢复期:渗出病灶处视网膜水肿减退,境界比活动期略感清晰,周缘出血消失。出现色素脱失及色素增生(图3)。FFA动脉期出现与灰白色病灶及其周围脱色素区大小一致的荧光,逐渐增强并略有扩大。

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