糖尿病黄斑水肿的临床诊断方法比较
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摘要
目的：对比分析糖尿病视网膜病变黄斑水肿患者光学相干断层扫描(OCT)、眼底荧光血管造影(FA)及裂隙灯显微镜下+90D非接触镜检查所观察到的黄斑区的图像特征，探讨三者对糖尿病性黄斑水肿的诊断价值。
方法：收集51例94眼临床确诊为糖尿病视网膜病变(DR)的患者光学相干断层扫描、眼底荧光血管造影及裂隙灯显微镜下+90D非接触镜检查所观察到的资料，分析三者对糖尿病性黄斑水肿的检出率，将所得的裂隙灯显微镜下+90D非接触镜及光学相干断层扫描的检查结果分别与眼底荧光血管造影的检查结果进行一致性比较；观察分析光学相干断层扫描与眼底荧光血管造影图像分类的关系，并将结果进行统计学分析；将黄斑中心凹厚度与最佳矫正视力进行相关性分析。
结果：裂隙灯显微镜下+90D非接触镜、眼底荧光血管造影及光学相干断层扫描对糖尿病视网膜病变黄斑水肿的检出率分别是63％、87％及89％。光学相干断层扫描与眼底荧光血管造影、裂隙灯显微镜下+90D非接触镜检查与眼底荧光血管造影结果有较好的一致性。符合率分别为88.3％、69.1％。光学相干断层扫描测得对照组正常人的黄斑中心凹厚度为140±6.17μm。经光学相干断层扫描检查诊断海绵样水肿的为45眼(47.9％)；黄斑囊样水肿为12眼(12.8％)；中心性浆液性脱离视网膜水肿的为22眼(23.4％)；中心性浆液性脱离视网膜水肿伴玻璃体黄斑部牵拉2眼(2.1％)。光学相干断层扫描所测得的黄斑中心凹平均视网膜厚度值在无渗漏组最低，并按着局限性渗漏、弥漫性渗漏、局限合并弥漫性渗漏、黄斑囊样水肿依次增加。统计学分析显示各组间的差异具有显著性：ANOVA；F=40；P＜0.05。黄斑中心凹厚度与最佳矫正视力之间有明确的相关性。
结论：光学相干断层扫描能客观的提供糖尿病患者黄斑区结构的变化，尤其在观察黄斑区脱离、玻璃体黄斑部牵拉及CME等的结构变化方面更为明确，对临床检查及眼底荧光血管造影还没有明确变化的早期黄斑水肿诊断更为敏感。但光学相干断层扫描不能取代眼底荧光血管造影在黄斑水肿诊断中的作用：眼底荧光血管造影能提供黄斑区灌注情况，其对视网膜渗漏的判断非常敏感。这是光学相干断层扫描所不能做到的。裂隙灯显微镜下非接触镜检查价格低廉，简单易行，应用方便，易于普及。三者的联合应用可为揭示糖尿病病理机制，临床诊断DME、判断DME的类型及其最佳治疗方案提供参考依据。
Objective: To compare the optical coherence tomographic (OCT) features with clinical and fluorescein angiographic (FA) findings in patients with diabetic retinopathy. And to evaluate the result for diagnosis ofmacular edema.
Methods: Ninety-four eyes of 51 DR patients were diagnosed with fundus fluorescein angiography, the clinical examination ( the slit-lamp biomicoscopy with a+90D noncontact lens) and OCT. The detection rate was analyzed by these three methods. OCT was used to measure the retina thickness in the fovea, the results were compared with FA. ANOVA was used for the statistic comparison between the groups. The results of the clinical examination with +90D noncontact lens were also compared with FA. The correlation between retinal thickness at the central fovea and the best corrected visual acuity was analyzed.
Result: The detection rate for the diabetic macular edema was 63% with the clinical examination; 87% with FA and 89% with OCT. As FA for the gold standard, we found the coincidence between FA and the clinical examination was 69.1%. The coincidence between FA and OCT was 88.3%. The mean retinal thickness in the central fovea was 140+6.17wn in the control group. OCT images demonstrated retinal edema in 47.9% of eyes, cystoid macular edema (CME) in 12.8%of eyes; serous foveal detachment +swelling in 23.4%of eyes; serous foveal detachment +swelling +vitreous-macular drag in (2.1%) of eyes. The mean central foveal thickness determined with OCT was the least in the no leakage group and was increased in the order of the focal ,diffuse and combined leakage groups .Statistical analysis revealed a signification difference between these groups: ANOVA; F=40; P＜0.05. The best-corrected visual acuity was significantly correlated with central foveal thickness (r=-0.568, p＜0.05).
Conclusion: OCT provided objective documentation of foveal structural changes in eyes with diabetic retinopathy, particularly at observation to the variation such as foveal detachment, posterior hyaloidal traction and CME etc. OCT is especially sensitive in the early stages of maculopathy when the structural changes are not yet evident at FA or the clinical examination with +90D noncontact lens. But OCT can't displace the role that FA has play in diagnosis of macular edema. FA was known to be a sensitive method for the qualitative assessment of fluid leakage in diabetic macular edema, which was inability to OCT. the clinical examination that the slit-lamp biomicoscopy with a +90D noncontact lens were cheap, easy and convenience. The combination OCT, clinical and FA can provide information that may be useful to disclose the pathogenesis of the edema, diagnosis and optimize the treatment for eath type.
方法：收集51例94眼临床确诊为糖尿病视网膜病变(DR)的患者光学相干断层扫描、眼底荧光血管造影及裂隙灯显微镜下+90D非接触镜检查所观察到的资料，分析三者对糖尿病性黄斑水肿的检出率，将所得的裂隙灯显微镜下+90D非接触镜及光学相干断层扫描的检查结果分别与眼底荧光血管造影的检查结果进行一致性比较；观察分析光学相干断层扫描与眼底荧光血管造影图像分类的关系，并将结果进行统计学分析；将黄斑中心凹厚度与最佳矫正视力进行相关性分析。
结果：裂隙灯显微镜下+90D非接触镜、眼底荧光血管造影及光学相干断层扫描对糖尿病视网膜病变黄斑水肿的检出率分别是63％、87％及89％。光学相干断层扫描与眼底荧光血管造影、裂隙灯显微镜下+90D非接触镜检查与眼底荧光血管造影结果有较好的一致性。符合率分别为88.3％、69.1％。光学相干断层扫描测得对照组正常人的黄斑中心凹厚度为140±6.17μm。经光学相干断层扫描检查诊断海绵样水肿的为45眼(47.9％)；黄斑囊样水肿为12眼(12.8％)；中心性浆液性脱离视网膜水肿的为22眼(23.4％)；中心性浆液性脱离视网膜水肿伴玻璃体黄斑部牵拉2眼(2.1％)。光学相干断层扫描所测得的黄斑中心凹平均视网膜厚度值在无渗漏组最低，并按着局限性渗漏、弥漫性渗漏、局限合并弥漫性渗漏、黄斑囊样水肿依次增加。统计学分析显示各组间的差异具有显著性：ANOVA；F=40；P＜0.05。黄斑中心凹厚度与最佳矫正视力之间有明确的相关性。
结论：光学相干断层扫描能客观的提供糖尿病患者黄斑区结构的变化，尤其在观察黄斑区脱离、玻璃体黄斑部牵拉及CME等的结构变化方面更为明确，对临床检查及眼底荧光血管造影还没有明确变化的早期黄斑水肿诊断更为敏感。但光学相干断层扫描不能取代眼底荧光血管造影在黄斑水肿诊断中的作用：眼底荧光血管造影能提供黄斑区灌注情况，其对视网膜渗漏的判断非常敏感。这是光学相干断层扫描所不能做到的。裂隙灯显微镜下非接触镜检查价格低廉，简单易行，应用方便，易于普及。三者的联合应用可为揭示糖尿病病理机制，临床诊断DME、判断DME的类型及其最佳治疗方案提供参考依据。
Objective: To compare the optical coherence tomographic (OCT) features with clinical and fluorescein angiographic (FA) findings in patients with diabetic retinopathy. And to evaluate the result for diagnosis ofmacular edema.
Methods: Ninety-four eyes of 51 DR patients were diagnosed with fundus fluorescein angiography, the clinical examination ( the slit-lamp biomicoscopy with a+90D noncontact lens) and OCT. The detection rate was analyzed by these three methods. OCT was used to measure the retina thickness in the fovea, the results were compared with FA. ANOVA was used for the statistic comparison between the groups. The results of the clinical examination with +90D noncontact lens were also compared with FA. The correlation between retinal thickness at the central fovea and the best corrected visual acuity was analyzed.
Result: The detection rate for the diabetic macular edema was 63% with the clinical examination; 87% with FA and 89% with OCT. As FA for the gold standard, we found the coincidence between FA and the clinical examination was 69.1%. The coincidence between FA and OCT was 88.3%. The mean retinal thickness in the central fovea was 140+6.17wn in the control group. OCT images demonstrated retinal edema in 47.9% of eyes, cystoid macular edema (CME) in 12.8%of eyes; serous foveal detachment +swelling in 23.4%of eyes; serous foveal detachment +swelling +vitreous-macular drag in (2.1%) of eyes. The mean central foveal thickness determined with OCT was the least in the no leakage group and was increased in the order of the focal ,diffuse and combined leakage groups .Statistical analysis revealed a signification difference between these groups: ANOVA; F=40; P＜0.05. The best-corrected visual acuity was significantly correlated with central foveal thickness (r=-0.568, p＜0.05).
Conclusion: OCT provided objective documentation of foveal structural changes in eyes with diabetic retinopathy, particularly at observation to the variation such as foveal detachment, posterior hyaloidal traction and CME etc. OCT is especially sensitive in the early stages of maculopathy when the structural changes are not yet evident at FA or the clinical examination with +90D noncontact lens. But OCT can't displace the role that FA has play in diagnosis of macular edema. FA was known to be a sensitive method for the qualitative assessment of fluid leakage in diabetic macular edema, which was inability to OCT. the clinical examination that the slit-lamp biomicoscopy with a +90D noncontact lens were cheap, easy and convenience. The combination OCT, clinical and FA can provide information that may be useful to disclose the pathogenesis of the edema, diagnosis and optimize the treatment for eath type.
引文
1 Suguru K, Masumi T, Norikhko Y, et al. Three-dimensional analysis of macular diseases with a scanning retina thickness analyzer and a confocal scanning laser ophthalmoscope. Ophthalmic Surg Laser. 2001, 32: 95～98.
2 Early treatment diabetic retinopathy study research group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Ophthalmology. 1987, 94: 761～774.
3 Kang SW, Park CY, Ham D. The correlation between fluorescein angiographic and the optical coherence tomographic features in clinically significant diabetic edema. Am J Ophthalmol. 2004, 137: 313～322.
4 Hee MR, Puliaflto CA, Weng C, et al. Quantitative assessment of macular edema with optical coherence tomography. Arch Ophthalmol. 1995, 113: 1019～1039.
5 He MR, Puliaflto CA, Duker JS. et al. Tomography of diabetic macular edema with optical coherence tomography. (J) Ophthalmology. 1996, 105: 360～370.
6 Otani T, Knishes, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. (J) Am J Ophthalmol. 1999, 127:588～593
7 师自安，龙力等．糖尿病黄斑水肿的光学相干断层扫描与多焦视网膜电图的改变(J)中国实用眼科杂志．2001，16(2)：87～90．
8 Browning DJ, McOwen MD, Bowen RM Jr. O' Marah TL. Comparison of the clinical diagnosis of diabetic macular edema wish diagnosis by optical coherence tomography. Ophthalmology. 2004; 111: 712～715.
9 Gass DM. Stereoscopicatlas of macular diseases diagnosis and treatment (M) 3rd ed. St Louis: The CV Mosby Company. 1987, 398～402.
10 Lewis H, Abram GW, Blumenkranz MS. Campo RV: Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology. 1992, 99: 753～759.
11 Massin P, Duguid G, Erginay A, Haouchine B. Gaudric A: Optical coherence tomography for evaluating diabetic macular edema before and after vitrectomy. Am J Ophthalmol. 2003, 135: 169～177.
1 The diabetic retinopathy study research group Ophthalmology. 1981, 88: 583.
2 Early Treatment Diabetic Retinopathy Stud Research Group. Early photoagulation for diabetic retinopathy. ETDRS report number9 Ophthalmology. 1991, 98: 766-785.
3 Fuksam. Classification and treatment of diabetic retinopathy. Diabetic Res Clin-Pract, 1994, 24(Supple): 171-176.
4 Huang D , Swanson EA , lin CP , et al. Optical coherence tomography, Science. 1991,254(5035): 1178-1181.
5 Puliafito CA , Duker JS , Reichel E , Coker JG , Wilking JR , et al. Topography of diabetic macular edema with optical coherence tomography. Ophthalmology. 1998, 105: 360-370.
6 Otain T , Kishi S , Maruyama Y . Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmology. 1999, 127: 688-693.
7 Sanchez-Tocino H , Alvarez-vidal A , Mandonado MJ , Moreno-Montanes J, et al. Retinal thickness study with optical coherence tomography in patients with diabetes. Invest Ophthalmol Vis Sci. 2002, 43: 1588-1594.
8 Lattanzio R , Brancato Rapiers L , et al. Macular thickness measured by optical coherence tomography in diabetic patients. Eur J Ophthalmology. 2002, 12: 482-487.
9 Hee MR , Puiafito CA , Wong C , et al. Quantitative assessment of Inacular edelna with optical coherence tomography Arch Ophthalmology. 1995, 113:1019-1029.
10 Groebel W, Kretzchmar Gross T. Retinal thickness in diabetic. 2002, 22: 759-767.
11 Dubois A , Grietre K , Moneron G , et al. Ultrahigh-resolution full field optical coherence tomography. Appl Opt. 2004, 43: 2874-2883.
12 Jaffe GJ , Caprioli J . OPtical coherence tomography to detect and manage retinal disease and glaucoma . Am J ophthalmology. 2004, 137: 156-169.
13 Landau D , Schneidman EM ,Jacobovitz T , et al. Quantitative in vivo retinal thickness measurements in healthy subjects. Ophthalmology. 1997, 104: 63-642.
14 Polito A , Shah SM , Haller JA, et al. Comparison between retinal thickness analyzer and optical coherence tomography for assessment of foveal thickness in eyes with macular disease. Am, J Ophthalmology. 2002, 134: 240-251.
15 Pires I , Beruardes RC , Lobo CL , et al. Retinal thickness in eyes with mild nonproliferative retinopathy in patients with type 2 diabetes mellitus: comparison of measurements obtained by retinal thickness analysis and optical coherence tomography. Arch Ophthalmology. 2002, 120: 1301-1306.
16 Zambarakji HJ , Amoaku WM , Vernon SA . Volumetric analysis of early macular edema with the Heidelberg Retina Tomography in diabetic retinopathy. Ophthalmology. 1998, 105: 1051-1059.
17 Guan K , Hudson C , Flanagan JG . Comparison of Heidelberg Retina To mography 11 and Retinal Thickness Analyzer in the assessment of diabetic macular edema. Invest Ophthalmol Vis Sci. 2004, 45: 610-616.
18 Ang A , Tong L . Vernon SA Improvement of reproment of reproducibility of macular volume measurement using the Heidelberg retinal tomography. Br J Ophthalmology. 2000, 84: 1194-1197.
19 Greenstein VC , Holopigan K , Serple W , et al. AiyPical multifocal ERG responses in patients with diseases affecting the photoreceptors. Vision Res. 2004, 44: 2867-2874.
20 Jonas JB , Kreissig I, sofker A, et al. Intravitreal injection of triamci-nolone for diffuse diabetic macular edema. Arch Ophthalmology. 2003, 121: 57-61.
21 Morse PA. Appleton Century Crofts. 1985, 75: 1349-1355.
22 Kishi S , Kamei Y , Shimizu K . Tractional elevation of Henle's fiber layer in idiopathic macular holes. Am, J Ophthalmology. 1995, 120: 486-496.
23 Lewis H , Abrams CW , Blumenkranz MS , et al. Vitrectomy for dia-betic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology. 1992, 99: 753-759.
24 Harbour JW , Smiddy WE , Flynn H W Jr , et al. Vitrectomy for dia- betic macular edema associated with a thickened and taut posterior hyaloid membrane. Am, J Ophthalmology. 1996, 121:405-413.
25 Gandorder A , messmer FM , Ulbig MW , et al. Resolution of diabetic macular edema after surgical removal of the posterior hyaoid and the inner limiting membrance. Retina. 2000, 20: 120-133.
26 Yang CM . Surgical treatment for severe diabetic macular edema with massive hard exudates. Retina. 2000, 20: 121-123.
2 Early treatment diabetic retinopathy study research group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Ophthalmology. 1987, 94: 761～774.
3 Kang SW, Park CY, Ham D. The correlation between fluorescein angiographic and the optical coherence tomographic features in clinically significant diabetic edema. Am J Ophthalmol. 2004, 137: 313～322.
4 Hee MR, Puliaflto CA, Weng C, et al. Quantitative assessment of macular edema with optical coherence tomography. Arch Ophthalmol. 1995, 113: 1019～1039.
5 He MR, Puliaflto CA, Duker JS. et al. Tomography of diabetic macular edema with optical coherence tomography. (J) Ophthalmology. 1996, 105: 360～370.
6 Otani T, Knishes, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. (J) Am J Ophthalmol. 1999, 127:588～593
7 师自安，龙力等．糖尿病黄斑水肿的光学相干断层扫描与多焦视网膜电图的改变(J)中国实用眼科杂志．2001，16(2)：87～90．
8 Browning DJ, McOwen MD, Bowen RM Jr. O' Marah TL. Comparison of the clinical diagnosis of diabetic macular edema wish diagnosis by optical coherence tomography. Ophthalmology. 2004; 111: 712～715.
9 Gass DM. Stereoscopicatlas of macular diseases diagnosis and treatment (M) 3rd ed. St Louis: The CV Mosby Company. 1987, 398～402.
10 Lewis H, Abram GW, Blumenkranz MS. Campo RV: Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology. 1992, 99: 753～759.
11 Massin P, Duguid G, Erginay A, Haouchine B. Gaudric A: Optical coherence tomography for evaluating diabetic macular edema before and after vitrectomy. Am J Ophthalmol. 2003, 135: 169～177.
1 The diabetic retinopathy study research group Ophthalmology. 1981, 88: 583.
2 Early Treatment Diabetic Retinopathy Stud Research Group. Early photoagulation for diabetic retinopathy. ETDRS report number9 Ophthalmology. 1991, 98: 766-785.
3 Fuksam. Classification and treatment of diabetic retinopathy. Diabetic Res Clin-Pract, 1994, 24(Supple): 171-176.
4 Huang D , Swanson EA , lin CP , et al. Optical coherence tomography, Science. 1991,254(5035): 1178-1181.
5 Puliafito CA , Duker JS , Reichel E , Coker JG , Wilking JR , et al. Topography of diabetic macular edema with optical coherence tomography. Ophthalmology. 1998, 105: 360-370.
6 Otain T , Kishi S , Maruyama Y . Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmology. 1999, 127: 688-693.
7 Sanchez-Tocino H , Alvarez-vidal A , Mandonado MJ , Moreno-Montanes J, et al. Retinal thickness study with optical coherence tomography in patients with diabetes. Invest Ophthalmol Vis Sci. 2002, 43: 1588-1594.
8 Lattanzio R , Brancato Rapiers L , et al. Macular thickness measured by optical coherence tomography in diabetic patients. Eur J Ophthalmology. 2002, 12: 482-487.
9 Hee MR , Puiafito CA , Wong C , et al. Quantitative assessment of Inacular edelna with optical coherence tomography Arch Ophthalmology. 1995, 113:1019-1029.
10 Groebel W, Kretzchmar Gross T. Retinal thickness in diabetic. 2002, 22: 759-767.
11 Dubois A , Grietre K , Moneron G , et al. Ultrahigh-resolution full field optical coherence tomography. Appl Opt. 2004, 43: 2874-2883.
12 Jaffe GJ , Caprioli J . OPtical coherence tomography to detect and manage retinal disease and glaucoma . Am J ophthalmology. 2004, 137: 156-169.
13 Landau D , Schneidman EM ,Jacobovitz T , et al. Quantitative in vivo retinal thickness measurements in healthy subjects. Ophthalmology. 1997, 104: 63-642.
14 Polito A , Shah SM , Haller JA, et al. Comparison between retinal thickness analyzer and optical coherence tomography for assessment of foveal thickness in eyes with macular disease. Am, J Ophthalmology. 2002, 134: 240-251.
15 Pires I , Beruardes RC , Lobo CL , et al. Retinal thickness in eyes with mild nonproliferative retinopathy in patients with type 2 diabetes mellitus: comparison of measurements obtained by retinal thickness analysis and optical coherence tomography. Arch Ophthalmology. 2002, 120: 1301-1306.
16 Zambarakji HJ , Amoaku WM , Vernon SA . Volumetric analysis of early macular edema with the Heidelberg Retina Tomography in diabetic retinopathy. Ophthalmology. 1998, 105: 1051-1059.
17 Guan K , Hudson C , Flanagan JG . Comparison of Heidelberg Retina To mography 11 and Retinal Thickness Analyzer in the assessment of diabetic macular edema. Invest Ophthalmol Vis Sci. 2004, 45: 610-616.
18 Ang A , Tong L . Vernon SA Improvement of reproment of reproducibility of macular volume measurement using the Heidelberg retinal tomography. Br J Ophthalmology. 2000, 84: 1194-1197.
19 Greenstein VC , Holopigan K , Serple W , et al. AiyPical multifocal ERG responses in patients with diseases affecting the photoreceptors. Vision Res. 2004, 44: 2867-2874.
20 Jonas JB , Kreissig I, sofker A, et al. Intravitreal injection of triamci-nolone for diffuse diabetic macular edema. Arch Ophthalmology. 2003, 121: 57-61.
21 Morse PA. Appleton Century Crofts. 1985, 75: 1349-1355.
22 Kishi S , Kamei Y , Shimizu K . Tractional elevation of Henle's fiber layer in idiopathic macular holes. Am, J Ophthalmology. 1995, 120: 486-496.
23 Lewis H , Abrams CW , Blumenkranz MS , et al. Vitrectomy for dia-betic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology. 1992, 99: 753-759.
24 Harbour JW , Smiddy WE , Flynn H W Jr , et al. Vitrectomy for dia- betic macular edema associated with a thickened and taut posterior hyaloid membrane. Am, J Ophthalmology. 1996, 121:405-413.
25 Gandorder A , messmer FM , Ulbig MW , et al. Resolution of diabetic macular edema after surgical removal of the posterior hyaoid and the inner limiting membrance. Retina. 2000, 20: 120-133.
26 Yang CM . Surgical treatment for severe diabetic macular edema with massive hard exudates. Retina. 2000, 20: 121-123.