【作者】 刘涛；

【导师】 肖骏；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2023， 硕士

【摘要】 目的:通过对眼缺血综合征(Ocular ischemic syndrome,OIS)患者临床特征的回顾性分析,探究OIS患者最佳矫正视力(Best-corrected visual acuity,BCVA)、眼压的影响因素以及患者视觉症状持续时间与眼部临床特征的相关性。分析患者行颈动脉手术前后眼底、BCVA和眼压的改变。方法:回顾性分析2020年6月至2022年10月于我院确诊的41例OIS患者(50眼)。观察并记录患者的性别、年龄、BCVA、眼压、眼前节及相关影像学表现。采用卡方检验、Mann-Whitney U检验等统计学方法进行分析,P<0.05有统计学差异。结果:1.一般资料本研究纳入患者41例(50眼),平均年龄65.61±6.39岁,男女比例30:11,单眼32例,双眼9例。视力下降46眼(92.0%),一过性黑矇4眼(8.0%),眼部疼痛5眼(10.0%),视野缺损2眼(4.0%)。平均Log MAR视力为1.67±0.96。眼压正常34眼(68.0%),眼压>21mm Hg16眼(32.0%),平均眼压为21.34±9.28mm Hg。视觉症状持续时间≤1个月30眼(60.0%),视觉症状持续时间>1个月20眼(40.0%)。合并糖尿病19例(46.3%),合并高血压11例(26.8%),合并脑梗11例(26.8%)。2.眼部特征的分析(1)眼底表现视网膜出血27眼(54.0%),微血管瘤31眼(62.0%),棉绒斑13眼(26.0%)。(2)根据OIS患者的眼底荧光素血管造影(Fluorescein fundus angiography,FFA)是否存在无灌注(non-perfusion,NP)区,分为NP区(图1)和无NP区(图2)两组。FFA表现为NP区22眼(48.9%),无NP区23眼(51.1%)。采用卡方检验,分析两种造影特征与视觉症状持续时间、虹膜新生血管(neovascularization of the iris,NVI)和新生血管性青光眼(neovascular glaucoma,NVG)的相关性。结果显示,两种造影特征与视觉症状持续时间、NVI和NVG均不存在相关性(P>0.05)。(3)根据有无虹膜新生血管,将OIS患者分为NVI和无NVI两组,NVI组36眼(72.0%),无NVI组14眼(28.0%)。采用Mann-Whitney U检验,比较两组的视力和眼压。结果显示,NVI组较无NVI视力差,有统计学差异(P<0.05),两组间眼压不存在统计学差异(P>0.05)。采用卡方检验,分析NVI组和无NVI组与视觉症状持续时间之间的相关性。结果显示,有无NVI与视觉症状持续时间不存在相关性(P>0.05)。(4)根据超声生物显微镜检查结果,房角360°关闭定义为房角完全关闭,房角关闭范围小于360°定义为部分关闭,房角没有关闭定义为开放。将OIS患者的房角分为完全关闭、部分关闭和开放三组。房角完全关闭组12眼(48.0%),房角部分关闭组6眼(24.0%),房角开放组7眼(28.0%)。采用Kruskal-Wallis检验,比较三组的视力和眼压。结果显示,三组患者的视力存在统计学差异(P<0.05),三组患者的眼压存在统计学差异(P<0.05)。(5)对合并NVI的病例,根据首诊眼压检查结果,IOP>21mm Hg定义为NVG。NVG组14眼(28.0%),非NVG组36眼(72.0%)。采用卡方检验分析两组患者与视觉症状持续时间的相关性。采用Mann-Whitney U检验,分析两组患者视力的差异。结果显示,是否存在NVG与视觉症状持续时间不存在相关性(P>0.05),两组患者的视力不存在统计学差异(P>0.05)。3.颈动脉手术前后患者视力、眼压的比较及眼底改变本组病例中,颈动脉手术治疗6例,均合并NVI,房角完全关闭或部分关闭。其中1例行颈动脉内膜切除术,5例行颈动脉支架置入术。颈动脉手术术后与术前相比,2例眼底棉绒斑消失,3例眼底出血点减少,2例臂-视网膜时间缩短,3例血管渗漏减轻。采用配对样本t检验和Wilcoxon符号秩检验,比较患者行颈动脉手术术前和术后1周的视力和眼压。结果显示,NVI的患者术前术后的视力有统计学差异(P<0.05),术后视力下降。房角关闭的患者术前术后的眼压有统计学差异(P<0.05),术后眼压增高。4.OIS患者颈动脉狭窄部位分析本组病例均首诊于眼科,疑诊OIS后,经颈部动脉血管彩超检测到颈内动脉颅外段狭窄或闭塞44例(88.0%),其中颈动脉狭窄70-99%16眼(36.4%),颈动脉闭塞28眼(63.6%)。6例(12.0%)患者眼底疑似OIS改变,颈部动脉血管彩超未见狭窄或闭塞,行头颈部计算机断层血管造影(Computed tomographic angiography,CTA)或磁共振血管造影(Magnetic resonance angiography,MRA)检测到颈内动脉颅内段重度狭窄或闭塞,诊断为OIS。结论:1.存在NP区和无NP区两种FFA特征与视觉症状持续时间、NVI和NVG的发生不存在相关性。2.NVI是患者视力不佳的标志,有无NVI与眼压不存在相关性,有无NVI与视觉症状持续时间不存在相关性。3.房角开放状态与视力有关,房角完全关闭可能是患者视力差的标志。4.OIS患者是否存在NVG与视觉症状持续时间不存在相关性,患者的视力与NVG的发生不存在相关性。5.NVI的患者行颈动脉术后1周,视力较术前下降;房角关闭的患者行颈动脉术后1周,眼压较术前升高。6.对于OIS的诊断,眼底存在缺血改变怀疑OIS,颈部动脉血管彩超未见明确狭窄时,需要考虑颈内动脉颅内段狭窄的可能,进一步行CTA或MRA检查,以免漏诊。更多还原

【Abstract】 Objective:A retrospective analysis of the clinical characteristics of patients with ocular ischemic syndrome(OIS)was conducted to investigate the factors influencing the best corrected visual acuity(BCVA)and intraocular pressure in patients with OIS,as well as the correlation between the duration of visual symptoms and the ocular clinical characteristics of patients.The changes of fundus,BCVA and intraocular pressure before and after carotid artery surgery were analyzed.Methods:41 patients(50 eyes)with OIS diagnosed in our hospital from June 2020 to October 2022 were analyzed retrospectively.Patients’ gender,age,BCVA,intraocular pressure,anterior segment and related imaging manifestations were observed and recorded.Statistical methods such as chi-square test and Mann-Whitney U test were used for analysis,and P<0.05 was statistically different.Result:1.General information41 patients(50 eyes)were included in this study,the average age was 65.61±6.39 years old,the ratio of male to female was 30:11,monocular in 32 cases,binocular in 9 cases.Visual acuity decreased in 46 eyes(92.0%),transient amaurosis in 4 eyes(8.0%),eye pain in 5 eyes(10.0%),and visual field defect in 2 eyes(4.0%).The average Log MAR visual acuity was 1.67 ±0.96.The mean intraocular pressure was 21.34 ±9.28 mm Hg.The duration of visual symptoms was less than 1 month in 30eyes(60.0%)and > 1 month in 20 eyes(40.0%).There were 19 cases(46.3%)with diabetes,11 cases(26.8%)with hypertension and 11 cases(26.8%)with cerebral infarction.2.Analysis of ocular features(1)Fundus manifestationRetinal hemorrhage in 27 eyes(54.0%),microaneurysm in 31 eyes(62.0%),cotton-wool spot in 13 eyes(26.0%).(2)The fluorescein fundus angiography(FFA)findings of OIS were divided into two groups: non-perfusion(NP)area(figure 1)and non-NP area(figure 2).FFA showed NP area in 22 eyes(48.9%)and no NP area in 23 eyes(51.1%).Chi-square test was used to analyze the correlation between the two angiographic features and duration of visual symptoms,neovascularization of the iris(NVI)and neovascular glaucoma(NVG).The results showed no correlation between the two angiographic features and the duration of visual symptoms,NVI and NVG(P>0.05).(3)Depending on the presence or absence of NVI,Patients with OIS were divided into two groups: NVI group and non-NVI group,36 eyes(72.0%)in NVI group and 14 eyes(28.0%)in non-NVI group.Mann-Whitney U test was used to compare the visual acuity and intraocular pressure between the two groups.The results showed that the visual acuity of the NVI group was worse than that of the non-NVI group,and there was a statistical difference(P < 0.05).There was no significant difference in IOP between the two groups(P>0.05).Chi-square test was used to analyze the association between the NVI and non-NVI groups and the duration of visual symptoms.The result showed that there was no correlation between NVI and the duration of visual symptoms(P>0.05).(4)According to the ultrasound biomicroscope findings,360°closure of the angle was defined as complete closure of the angle,less than 360° closure of the angle was defined as partial closure,and no closure of the angle was defined as open.The angles of OIS patients were divided into three groups: completely closed,partially closed and open.12 eyes(48.0%)in the group with completely closed angles,6 eyes(24.0%)in the group with partially closed angles,and 7 eyes(28.0%)in the group with open angles.The Kruskal-Wallis test was used to compare the visual acuity and intraocular pressure of the three groups.The results showed that there was a statistical difference in visual acuity(P<0.05)and a statistical difference in IOP(P< 0.05)between the three groups of patients.(5)In cases of combined NVI,IOP > 21 mm Hg was defined as NVG based on the first IOP examination result.Patients with OIS were divided into NVG group and non-NVG group,14 eyes(28.0%)in NVG group and 36 eyes(72.0%)in non-NVG group.The correlation between the two groups of patients and the duration of visual symptoms was analyzed using the chi-square test.The Mann-Whitney U test was used to analyze the difference in visual acuity between the two groups of patients.The results showed that there was no correlation between the presence of NVG and the duration of visual symptoms(P > 0.05),and there was no significant difference in visual acuity between the two groups(P>0.05).3.Comparison of visual acuity,intraocular pressure and fundus changes in patients before and after carotid artery surgeryIn our group,six cases were treated for carotid artery surgery,all with combined NVI and complete or partial closure of the angle.Among them,1 case underwent carotid endarterectomy,and 5 cases underwent carotid artery stenting.After carotid artery surgery,compared with the preoperative period,two cases of fundus cotton-wool spot disappeared,three cases of retinal hemorrhage were reduced,two cases of arm-retinal time were shortened,and three cases of vascular leakage were reduced.Paired sample t test and Wilcoxon symbolic rank test were used to compare the visual acuity and intraocular pressure of the patients before and 1 week after carotid artery operation.The results showed that there was a statistical difference(P<0.05)between preoperative and postoperative visual acuity in patients with NVI,and postoperative visual acuity was decreased.There was a statistically significant difference(P<0.05)in the preoperative and postoperative IOP in patients with closed angles and increased postoperative IOP.4.Analysis of carotid artery stenosis sites in OIS patientsAll cases in this group were first diagnosed in ophthalmology,and after suspected OIS,stenosis or occlusion of the extracranial segment of the internal carotid artery was detected by carotid artery ultrasound in 44 cases(88.0%),including 16eyes(36.4%)with 70-99% carotid stenosis and 28 eyes(63.6%)with carotid occlusion.Six patients(12.0%)had suspected OIS changes,and no stenosis or occlusion was found by carotid artery ultrasound.Severe stenosis or occlusion of the intracranial segment of the internal carotid artery was detected by head and neck computed tomographic angiography(CTA)or magnetic resonance angiography(MRA),which was diagnosed as OIS.Conclusion:1.There was no correlation between the two FFA features with and without NP area and the duration of visual symptoms,NVI and NVG.2.NVI is a sign of poor vision,there is no correlation between NVI and intraocular pressure,and there is no correlation between NVI and the duration of visual symptoms.3.The open status of the angle is associated with visual acuity,and complete closure of the angle may be a sign that the patient has poor vision.4.There is no correlation between the existence of NVG and the duration of visual symptoms in patients with OIS,and there is no correlation between visual acuity and the occurrence of NVG.5.Patients with NVI had decreased visual acuity 1 week after carotid artery surgery compared to preoperative.Patients with angle closure had increased IOP 1week after carotid artery surgery compared to preoperative.6.For the diagnosis of OIS,when there are ischemic changes in the fundus suspicious of OIS and no clear stenosis is seen on carotid artery ultrasound,the possibility of stenosis in the intracranial segment of the internal carotid artery needs to be considered and further CTA or MRA should be performed to avoid missing the diagnosis.更多还原