国际眼科时讯
编者按：目前，尚无标准化的治疗方法来预防白内障术后发生黄斑水肿。此外，也无任何设计良好的随机对照试验可以证明哪种方式疗效最好。对此，预防白内障术后黄斑水肿（PREMED）研究将对比数种现有治疗药物与方式，包括抗VEGF 药物、糖皮质激素、NSAIDs 以及联合用药，以期为白内障术后黄斑水肿的预防提供指导方针。2013 年ESCRS 会议的东道主Prof. Rudy M. Nuijts 偕同Dr. Jan Schoutan 和Dr. Laura Wielders 介绍了PREMED 研究的进展情况。
手术增加黄斑水肿的危险
对于糖尿病患者，糖尿病本身是术后黄斑水肿的一个主要危险因素，但是手术创伤仍是最大的影响因素。这意味着复杂的白内障手术会增加额外的风险。对于糖尿病黄斑水肿的患者，视网膜的状况很重要，医师需要在手术之前采取适合的治疗。重点是目前是否存在大量的白内障患者以及是否都需要手术治疗，手术会增加黄斑水肿的风险，因此需要术后密切随访。目前我们的优势是有很多的干预措施，例如抗VEGF 药物、糖皮质激素以及二者的联合应用，这些是在十年前所没有的。但手术后发生糖尿病黄斑水肿的风险已经增加到10%，特别是在某些病例中可以出现难治性黄斑水肿。
In the case of diabetes, diabetes itself is the major risk factor, but on top of that it is the trauma of the cataract surgery. That implies that if you have a complicated cataract surgery, the additional risk factors increases. In diabetic macular edema, the state of the retina is important. People need to be treated properly for their diabetic macular edema before they go to surgery. The main point is that if there is a great amount of cataract and the decision needs to be made to go for cataract surgery, then you take the risk that the macular edema will increase. Therefore, a close follow-up is necessary. The advantage we have now, is that we have several interventions which we didn’t have ten years ago - the anti-VEGFs, corticosteroids or their combination, for example. The risk of having an increase in diabetic macular edema after surgery is in the tens of percentages. It is not a small risk; it is quite substantial. It may also lead in some cases to refractory macular edema which is very difficult to treat.
OCT 是诊断黄斑水肿的金标准
在临床中，对白内障患者进行术后随访时如果发现其视力低于预期，首先应检查黄斑，再进行OCT 检查，因为只观察黄斑不足以确定视力低于预期是黄斑水肿引起的。如果患者视力是1.0，而这正是我们所期望达到的，那就没必要做OCT。
使用检眼镜观察视网膜之后再做OCT 检查对于检测黄斑水肿非常重要。进行OCT 检查可以获得黄斑水肿客观的定量信息，OCT 是金标准。在一些病例中可联合应用FA 和OCT。本次会议上有讨论会推荐ERG，但这不是常规检查手段，因为它是主观检查，并且不能提供定量信息。另外，ERG 耗时而且枯燥，其额外价值有限。
In daily practice, when you do a follow-up on a cataract patient and visual acuity is not as you would expect, the first thing you look at is the macula. Then you do your OCT because just looking at the macula does not give you the details that you need to decide if it is the macula edema that is causing the lower than expected visual acuity. If visual acuity is at 1.0 then that is what you wanted to achieve and you don’t do an OCT. It is crucial in the detection of macular edema after first examining the retina by ophthalmoscopy. We back that up with OCT to get an objective measurement to obtain quantitative information on the amount of macular edema. OCT is the gold standard for that. In certain cases, fluorescein angiography can add to the data you obtain from the OCT, so that is present in our armamentarium of diagnostic methodologies. After that, it was suggested in the symposium this morning that ERGs could be helpful. However, that would not be routine, as ERGs are subjective and don’t provide any quantitative information. Additionally, the ERG is time-consuming and bothersome and its additional value is limited. But it is OCT that gives us the data that we need.
