中心性漿液性脈絡膜視網膜病變

簡介:

       中心性漿液性脈絡膜視網膜病變(central serous chorioretinopathy,CSC)是以黃斑部及其附近局限性漿液性神經上皮脫離為特征的常見眼底病變,國內臨床上常簡稱“中漿”。1866年Von Graefe首先描述了該病,并命名為“復發性中心性視網膜炎”。到1965年,Maumenee通過熒光造影觀察到該病變是由色素上皮滲漏引起的。1967年Gass詳細描述了該病的病理和臨床特征,對其神經上皮層盤狀脫離的機制做了詳盡的論述,并將其命名為“特發性中心性漿液性脈絡膜炎”(idiopathic central serous choroidopathy)。

分類

根據臨床不同的征候特點,本病屬中醫學“目妄見”、“視瞻昏渺”、“視瞻有色”、“視直如曲”、“視正反斜”、“視惑”等病癥。

病因病理:

一 西醫病因病理

本病的發病與年齡、性別、血型、氣候、全身情況、妊娠、精神緊張、情緒異常、過敏、感冒、過度疲勞

和煙酒刺激等有關。常見的誘因有睡眠不足、緊張、勞累和情緒波動等。發病機制尚不清楚,有缺血、感染、炎癥、免疫反應及代謝障礙等學說。但都缺乏有力的證據

二、中醫病因病機

1.目為肝竅,瞳神屬腎,肝身同源,脾主運化,黃斑屬脾,肝郁脾虛,脾失健運,清陽不升,濁陰不降,痰濕阻絡,血流不暢而發病。

2.感受濕熱之邪,濕熱內蘊,熏蒸清竅,或痰濕化熱,上泛于目也可導致黃斑部滲出、水腫。

3.肝腎不足,精血虧損,精不上承,目失濡養引起脈絡膜視網膜水腫,滲出等病變。

故本病的發生與肝、腎、脾的功能失調有關。痰濕,氣郁,精虧是本病的主要病因。

臨床表現

1、自覺癥狀:視物模糊,眼前有灰黃色暗影遮擋,視物變形,視大如小,視直為曲或視正反斜等。 2、體征

(1)黃斑部視網膜水腫環,點狀黃白色滲出,中心凹光反射消失。 (2)熒光素眼底血管造影黃斑部及附近可見神經上皮脫離,或色素上皮脫離,或色素上皮脫失等典型的熒光形態。(3)發病人群多為健康成年人,驟然發覺視物模糊,視野中心似有淡影阻擋,視物可有變形、變小的感覺。視力障礙程度不一,遠視力檢查從1.0到0.1。用Amsler方格表檢查常有變形或暗點。 3、眼底檢查在病變輕者僅見后極部視網膜呈閃爍不定的反光,中心凹光反射略為彌散。重者可見黃斑區視網膜有圓形隆起的盤狀脫離,其邊緣有反光輪。數周后盤狀脫離區有黃白色滲出點。裂隙燈接觸鏡檢查,從光學切面顯示神經上皮層與色素上皮層分離,神經層向前隆起,脫離腔的后壁有黃白色點狀物,腔內積液可透明或略現混濁。個別極重病例,視網膜下液體過多,因重力作用而向下方流動,使周邊視網膜脫離。液體吸收后,常在眼底下半留下液體流經區域的色素上皮萎縮條帶,清楚地顯示當初視網膜下液體通道的痕跡與范圍。

對于復發病例或在隱匿進行的患者,檢眼鏡下所見,除嚴重滲液者可再現盤狀脫離外,大多數只表現黃斑區色素紊亂,或中心凹反射異常。僅從眼底表現不能判定是否病情復發或是隱匿進行。并且患者視力好壞也常與病變進展并不平行。對于疑為慢性進行病變的患眼應當再行熒光血管造影檢查,因為造影圖像所見與眼底表現有很大的不同。造影圖片可以具體顯示色素上皮的損害程度和病變范圍,了解病情究竟是復發活躍還是萎縮穩定。

本病雖有較大程度的自限性,經過垂直追蹤觀察發現有的病例可以延續多年,時顯時隱,病變范圍也逐漸擴大,色素上皮萎縮也嚴重。據統計約1/3或半數病眼可以復發,10%病例可多次復發,50%病例復發期在1年左右,而頑固病例可長達10年。少數病眼經多次發作后,最終可使中心視力蒙受永久性損害。

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