摘要
35岁男性,因“双眼视力下降半年,加重1个月”就诊。患者既往曾于当地医院诊断为“双眼慢性中心性浆液性脉络膜视网膜病变(简称中浆)”行4次抗血管内皮生长因子(VEGF)治疗。初诊查体:右眼最佳矫正视力0.3,左眼最佳矫正视力0.5,双眼角膜清,可见白色尘状KP,余前节正常。双眼玻璃体混浊,可见炎性细胞,左眼较右眼明显。光学相干层析成像(OCT):右眼黄斑中心凹下合并少量视网膜下液,脉络膜厚度321μm,左眼脉络膜厚度357μm。荧光素眼底血管造影(FFA):双眼视盘晚期强荧光伴渗漏,右眼黄斑区及左眼视网膜血管晚期荧光渗漏。初步诊断为双眼葡萄膜炎,为查找病因行全身检查未发现结节病、感染、自身免疫系统等指标异常。眼内液检查仅提示轻度眼内炎症反应。予以试验性口服激素治疗,2周后双眼炎症反应消失,双眼玻璃体腔清亮,右眼黄斑区视网膜下液吸收,鉴于激素治疗有效,且未造成中浆病情复发或进展,考虑患者既往“慢性中浆”的诊断可能为误诊。通过反复询问既往病史及追踪既往病例资料,发现患者半年前于当地医院初诊时眼底照显示双眼黄斑区环形点状黄白色病灶,OCT图像显示双眼对称性视网膜下液,并合并少量高反射物质堆积。且患者为体检发现双眼黄斑区异常,但患者无任何自觉症状。考虑患者可能为Best病,行基因检查及眼电图(EOG)检查确诊,更正诊断为常染色体隐性遗传的Best病。而患者于当地医院行4次抗VEGF治疗后病情并未好转,并且在末次治疗后1周出现双眼玻璃体混浊,考虑为和抗VEGF治疗相关的迟发性葡萄膜炎反应。讨论体会:对于病情复杂,病程较长的患者,在检查结果和诊断有矛盾之处要保持怀疑,详细询问既往病史,积极追踪原始资料,寻找诊疗过程中的“蛛丝马迹”对于正确的诊断和治疗极为重要。
A 35-year-old male presented with bilateral vision blurred for half a year,and worsened for 1 month.The patient had previously been diagnosed with“bilateral chronic central serous choroiretinopathy”in local hospital and received anti-vascular endothelial growth factor(VEGF)treatments 4 times.Initial examination showed that the BCVA was 0.3 in the right eye and 0.5 in the left.The corneas of both eyes were clear,and KP could be seen.Besides,the other anterior segments were normal.Vitreous opacity and inflammatory cells can be seen in both eyes,which was more obvious in the left eye.Optical coherence tomography(OCT)showed subretinal fluid in the right eye,with a choroidal thickness of 321μm,while that of the left eye was 357μm.FFA showed lately hyperfluorescence with fluorescein leakage from the optic disc of both eyes,the macular of the right eye and retinal vessels of the left eye.Systemic examinations were performed and sarcoidosis,infection,and autoimmune disorder were all excluded.Intraocular fluid test indicated only mild intraocular inflammation.The patient was preliminarily diagnosed with bilateral uveitis.After 2 weeks of experimental oral prednisone treatment,the inflammation of both eyes disappeared and the macular subretinal fluid of the right eye was absorbed.Because the prednisone worked effectively,the previous“chronic central serous choroiretinopathy”might be misdiagnosed.By inquiring the past medical history in detail and tracking the previous examinations from local hospital,we found that the fundus photo of half a year ago showed ring-like yellowish lesions in the macular area of both eyes,and the OCT showed symmetrical subretinal fluid of both eyes,combined with hyperreflective material accumulation.The patient didn’t have any visual symptoms and was diagnosed by routine physical examination.The patient further received a genetic examination and electronic oculogram,and the diagnosis was then corrected as autosomal recessive bestrophinopathy.Furthermore,the bilateral uveitis that occ
作者
姚昱欧
赵明威
YAO Yuou;ZHAO Mingwei(Department of Ophthalmology,Peking University People’s Hospital,Beijing 100044,China)
出处
《中国眼耳鼻喉科杂志》
2022年第S01期16-23,共8页
Chinese Journal of Ophthalmology and Otorhinolaryngology
