本文關(guān)鍵詞： 新生血管性青光眼 眼壓 虹膜新生血管 雷珠單抗 綜合治療　出處：《鄭州大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景新生血管性青光眼(neovascular glaucoma,NVG)被認(rèn)為是一種具有高致盲率的眼部疾患,為難治性青光眼。其主要繼發(fā)于糖尿病視網(wǎng)膜病變、視網(wǎng)膜中央靜脈阻、眼缺血綜合征等疾病,同時眼外傷、眼部腫瘤等疾病亦可引起新生血管性青光眼的發(fā)生。NVG的發(fā)生是由于各種原因?qū)е乱暰W(wǎng)膜血流供應(yīng)減少,引起視網(wǎng)膜缺血缺氧,導(dǎo)致視網(wǎng)膜產(chǎn)生血管內(nèi)皮生長因子(Vascular endothelial growth factor,VEGF)產(chǎn)生增加,導(dǎo)致虹膜、房角及小梁網(wǎng)大量新生血管形成,引起小梁網(wǎng)的阻塞和房角的進行性的關(guān)閉從而阻止了房水的正常流出通道,使眼壓不斷升高,進而引起眼部疼痛。同時隨著眼壓的不斷升高,眼部缺血缺氧未得到控制,進而造成視神經(jīng)的損害,造成視力的損害。然而對于NVG的治療有很多種方法,主要是通過應(yīng)用降低眼壓的藥物和手術(shù)治療為主,但是這兩種方法的效果卻不明顯。隨著抗VEGF的藥物研發(fā)和臨床上的使用,為NVG的治療又提出了新的理念。在手術(shù)治療NVG之前,予以抗VEGF藥物的注射,待虹膜和小梁網(wǎng)表面完全消退或大部分消退后再進行手術(shù)治療。由于患者就診時病情及家庭經(jīng)濟情況的不同,應(yīng)從多方面考慮,予以一個更加合理的治療方案。所以根據(jù)患者的實際情況選擇合理的個體化的綜合治療為治療NVG的提出了新的理念。目的本研究通過對NVG患者進行的綜合治療來客觀評估和探討個體化綜合治療的效果,并為臨床治療NVG提供一個依據(jù)。材料和方法選取2014年10月至2016年1月在鄭州大學(xué)人民醫(yī)院(河南省人民醫(yī)院)就診并接受治療的NVG患者67例共70只眼進行回顧性分析,其中男性患者30例32只眼,女性患者37例38只眼,年齡29~76歲,平均年齡(57.9±12.2)歲,其中糖尿病視網(wǎng)膜病變繼發(fā)NVG的患者32例34只眼,視網(wǎng)膜中央靜脈阻塞繼發(fā)NVG患者29例30眼,其他疾病引起的NVG患者6例6只眼。其中眼壓≤21mmHg但有虹膜新生血管即虹膜紅變的患者共19例20只眼,眼壓21mmHg的患者共48例50只眼。排除既往患有青光眼患者、既往行眼部手術(shù)和接受視網(wǎng)膜激光光凝的患者、無視力患者。其中眼壓≤21mmHg(虹膜紅變)的20只眼接受了單純的PRP治療,眼壓21mmHg的患者在先完成雷珠單抗0.05ml注射后,根據(jù)患者3~7天內(nèi)虹膜新生血管消退情況、眼壓以及眼部屈光間質(zhì)情況接受了不同的治療方案:(1)經(jīng)注藥治療后眼壓≤21mmHg的18只眼予以PRP治療其中10眼因玻璃體積血另外進行了玻璃體手術(shù)來改善屈光間質(zhì);(2)經(jīng)注藥治療后眼壓21mmHg的19只眼予以復(fù)合式小梁切除術(shù)+PRP治療,13只眼予以復(fù)合式小梁切除術(shù)+玻璃體切割+PRP治療。對于眼壓≤21mmHg的患者記錄治療前和治療后1周、1個月、3個月、6個月的眼壓;對于眼壓21mmHg的患者記錄注藥前和接受個體化綜合治療后1周、1個月、3個月、6個月的眼壓;同時記錄接受個體化總綜合治療前眼壓。應(yīng)用SPSS 24.0統(tǒng)計學(xué)軟件進行統(tǒng)計學(xué)分析,對于治療前和治療后各個時間點的眼壓情況應(yīng)用單因素重復(fù)測量方差分析,對注藥前與手術(shù)前眼壓對比進行配對t檢驗分析,對于治療前與注藥后結(jié)果以P0.05為差異具有統(tǒng)計學(xué)意義。結(jié)果(1)對于眼壓≤21mmHg(虹膜紅變)的20只眼在隨訪期間有14只眼在完成PRP治療后虹膜新生血管完全消退,有6只眼在隨訪過程中接受玻璃體腔注射雷珠單抗后虹膜新生血管消退。對于眼壓21mmHg的50只眼在接受玻璃體腔注射雷珠單抗后有22只眼在3天內(nèi)虹膜新生血管完全消退,在注藥后1周有45只眼虹膜新生血管完全消退,5只眼虹膜新生血管大部分消退,該5只眼于注藥后9天完全消退。在接受個體化治療后有5例患者出現(xiàn)虹膜新生血管復(fù)發(fā),在再次接受雷珠單抗注射后消退。(2)眼壓≤21mmHg(虹膜紅變)的20只眼在末次隨訪時有7只眼視力有不同程度的提高,11只眼視力保持原狀,2眼視力較之前下降。眼壓21mmHg的50只眼在末次隨訪時有20只眼視力有不同程度的提高,21只眼視力維持原狀,9只眼視力較之前下降。(3)對于眼壓≤21mmHg(虹膜紅變)的20只眼激光治療前眼壓、治療后1周、1個月、3個月、6個月眼壓分別為:(18.35±1.04)mmHg;(18.25±1.58)mmHg;(17.80±1.79)mmHg;(17.85±1.53)mmHg;(17.95±1.53)mmHg。與治療前對差異無統(tǒng)計學(xué)意義P0.05。對于眼壓21mmHg的50只眼在注藥前的眼壓為(47.60±6.46)mmHg,接受個體化治療后1周、1個月、3個月、6個月的眼壓分別為:(17.62±5.12)mmHg;(17.40±4.91)mmHg;(17.34±4.20)mmHg;(17.02±4.47)mmHg。進行個體化綜合治療后各個時間點的眼壓于注藥前相比均具有統(tǒng)計學(xué)意義P0.05。(4)所有接受復(fù)合式小梁切除術(shù)的32只眼中,在末次隨訪時維持有功能濾泡的有20只眼,12只眼為瘢痕型濾過泡。(5)所有手術(shù)患者均未出現(xiàn)視網(wǎng)膜脫離、脈絡(luò)膜脫離等手術(shù)并發(fā)癥,個體化綜合治療后有3例患者出現(xiàn)淺前房,予以阿托品散瞳加壓包扎后3天恢復(fù)正常,有6只眼出前房積血,于術(shù)后3~7天內(nèi)消失。結(jié)論1.單純的PRP治療可以有效的消退虹膜紅變患者的虹膜新生血管。2.玻璃體腔注射雷珠單抗聯(lián)合PRP可以有效的消退虹膜新生血管,降低眼內(nèi)壓。3.復(fù)合式小梁切除術(shù)聯(lián)合改善屈光間質(zhì)手術(shù)可以安全有效的治療NVG。4.根據(jù)患者的不同情況選擇合理的個體化綜合治療對于NVG的治療安全、有效,能夠安全有效的控制眼內(nèi)壓。
[Abstract]:The research background of neovascular glaucoma (neovascular glaucoma NVG) is considered to be a high rate of blindness eye disease, refractory glaucoma. The main secondary to diabetic retinopathy, retinal vein obstruction, ocular ischemic syndrome and other diseases, and ocular trauma, tumor and other diseases can also cause ocular neovascular glaucoma the occurrence of.NVG occurs due to retinal blood flow to reduce the supply of a variety of reasons, cause retinal ischemia and hypoxia, leading to retinal vascular endothelial growth factor (Vascular endothelial, growth factor, VEGF) have led to increased iris angle and trabecular meshwork abundant neovascularization caused by obstruction of the trabecular meshwork and angle of the closed so as to prevent the normal aqueous outflow channel, so that the pressure rising, causing eye pain. At the same time as the eye pressure increasing, eye Hypoxia ischemia has not been controlled, thereby causing damage to the optic nerve, cause vision damage. However, there are many methods for the treatment of NVG, mainly through the application of reducing drug and surgical treatment of intraocular pressure, but the effect of these two methods is not obvious. With the use of drug development and clinical anti VEGF. For the treatment of NVG and puts forward a new concept. Before surgical treatment of NVG, treated with anti VEGF drugs, the iris and trabecular surface disappeared completely or mostly subsided after surgery. Patients due to illness and family economic situation is different, we should consider many aspects to a more reasonable treatment. So according to the actual situation of patients to choose reasonable individualized comprehensive treatment for the treatment of NVG put forward a new concept. The objective of comprehensive treatment for NVG patients with the view of visitors through the study To evaluate the effect of individualized and comprehensive treatment, and provide a basis for clinical treatment of NVG. Materials and methods from October 2014 to January 2016 in the people's Hospital of Zhengzhou University (Henan Province People's Hospital) patients and NVG patients treated 67 cases of 70 eyes were retrospectively analyzed, including 30 cases of male patients 32 eyes, 37 cases of female patients 38 eyes, age 29~76 years old, average age (57.9 + 12.2) years old, the diabetic retinopathy secondary NVG patients 32 cases 34 eyes, 29 eyes of 30 cases patients with NVG secondary to central retinal vein occlusion and other diseases caused by NVG in 6 cases of 6 eyes. The intraocular pressure is less than 21mmHg but is rubeosis of iris neovascularization a total of 19 patients 20 eyes, intraocular pressure in 21mmHg patients with a total of 48 eyes of 50 cases who suffered from glaucoma patients. Excluded, patients undergoing eye surgery and underwent laser photocoagulation in patients without visual acuity. The intraocular pressure is less than or equal to 21mmHg (rubeosis) 20 eyes received PRP treatment alone, intraocular pressure with 21mmHg prior to complete ranibizumab after 0.05ml injection, according to the patients within 3~7 days of iris neovascularization, intraocular pressure and ocular refractive interstitial received different treatment regimens: (1) to PRP treatment the 10 eyes with vitreous hemorrhage in the vitreous body surgery to improve the refractive interstitial injection for the treatment of 18 eyes after intraocular pressure less than 21mmHg; (2) to be combined trabeculectomy in 19 eyes treated by +PRP injection for the treatment of IOP after 21mmHg, 13 eyes of compound trabeculectomy + vitreous body cutting +PRP = 21mmHg for treatment. The intraocular pressure were recorded before and after treatment for 1 weeks, 1 months, 3 months, 6 months for intraocular pressure; intraocular pressure 21mmHg were recorded before injection and receive individualized comprehensive treatment after 1 weeks, 1 months, 3 months, 6 months Intraocular pressure; records of individual total IOP before treatment at the same time. The application of SPSS 24 statistical software for statistical analysis, for the treatment of intraocular pressure before and after treatment application each time point of the single factor analysis of variance of repeated measurement, of before injection and preoperative intraocular pressure compared with paired t test analysis for before treatment and drug injection results after P0.05 the difference was statistically significant. Results (1) for intraocular pressure less than 21mmHg (rubeosis) 20 eyes have 14 eyes and iris neovascularization disappeared completely in PRP after treatment during the follow-up period, 6 eyes received intravitreal injection of ranibizumab during follow-up after neovascularization of iris for. 50 eyes IOP in 21mmHg received intravitreal ranibizumab injection after 22 eyes in iris neovascularization within 3 days completely disappeared in 1 weeks after injection, 45 eyes with iris neovascularization disappeared completely, 5 鍙溂铏硅啘鏂扮敓琛，

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