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1、糖尿病性视网膜病变,病因 确切发病机制尚不十分明了.高血糖症 多种生化和生理改变毛细血管内皮细胞损伤(周细胞减少,基底膜增厚,毛细血管腔减小,毛细血管内皮屏障失代偿),诊断,1.全身有多饮,多食,多尿和消瘦,疲乏等症状.2.视力减退,决定于黄斑区是否受累,以及出血渗出的数量和范围.,3.临床分期,非增殖期糖尿病视网膜病变,也称单纯性糖尿病视网膜病变眼底表现:微血管瘤,出血斑,硬性渗出,棉絮斑及血管改变等.,微血管瘤,其发生与局部组织缺氧有关,是毛细血管的囊样膨出和/或毛细血管内皮增殖所致.眼底镜下为边界清晰的红色或暗红色斑点,位于末梢的小动脉或小静脉上.FFA:点状强荧光.,出血,视网膜出血在
2、深层多为小点状或圆形出血,出血位于视网膜浅层者表现为条状火焰状出血亦可为网膜下或网膜前出血.FFA呈遮蔽荧光.,硬性渗出,为黄白色边界清楚的蜡样斑点.是血浆渗漏到视网膜外丛状层,水及一些小分子物质被吸收而脂类及蛋白大分子物质残留形成的.FFA不显荧光亦不遮蔽荧光.,棉絮斑,边界不清的灰白斑.由于血管闭塞缺血,视网膜神经纤维轴浆流阻滞及细胞内水肿所致.通常棉绒斑消退后形成毛细血管的无灌注区.FFA呈弱荧光区.棉绒斑表现视网膜病变较重.,视网膜血管病变,小动脉闭塞 小动脉分支变细,严重时较大动脉可有白鞘或呈白线状.小动脉硬化 动脉壁反光增宽,动静脉交叉压迫征.视网膜静脉 呈管径不均匀,菱形,串珠状
3、或球状扩张,局部管径变窄伴有白鞘或部分或全部闭塞呈血管白线.视网膜毛细血管 视网膜毛细血管闭塞,扩张,糖尿病视网膜病变 单纯型期：视网膜静脉充盈，颞上视网膜有数个微动脉瘤,糖尿病视网膜病变 单纯型期：后极部视网膜微动脉瘤增多，不易数,糖尿病视网膜病变 单纯型期：微动脉瘤，并有小出血斑,糖尿病视网膜病变 单纯型期：视网膜出血增多，并有黄白色硬性渗出,糖尿病视网膜病变 单纯型期：视网膜出血斑及“硬性渗出”增多（不易数）,糖尿病视网膜病变 单纯型期：出血及“硬性渗出”增多（不易数）,糖尿病视网膜病变 单纯型期：有白色“棉絮斑”及出血斑（棉絮斑易数）,糖尿病视网膜病变 单纯型期：棉絮斑较多，出血多,糖
4、尿病视网膜病变 单纯型期：视网膜弥漫“硬性渗出”及出血斑,糖尿病视网膜病变 单纯型期：硬性渗出和出血累及黄斑区,增殖性糖尿病视网膜病变,新生血管增殖 表现为毛细血管芽或直接从视网膜静脉上萌发.开始新生血管位于视网膜平面内,以后穿过视网膜的内界膜,在视网膜和玻璃体的内界膜之间.FFA呈荧光渗漏.新生血管可伸入玻璃体内,出现玻璃体积血.,增殖性糖尿病视网膜病变的并发症,玻璃体积血牵拉性视网膜脱离虹膜红变及新生血管性青光眼,糖尿病黄斑病变,黄斑水肿 局限性水肿:局部视网膜内微循环异常,微血管瘤及毛细血管扩张,渗漏所致.黄斑光反射消失,视网膜厚度增加,微血管周围有硬性渗出环.弥漫性水肿:为弥漫性扩张的
5、毛细血管渗漏所致.常见硬性渗出,网膜增厚,FFA见花瓣样强荧光.囊样变性:长期黄斑水肿,视网膜外丛状层液体积存而形成.黄斑区呈蜂窝样改变,FFA广泛荧光渗漏,花瓣状或环形强荧光.,糖尿病黄斑病变,黄斑缺血 黄斑区棉绒斑,小动脉呈白线状,严重的视网膜内循环异常.FFA轻者表现为黄斑区拱环扩大,毛细血管闭塞,严重者小动脉闭塞形成黄斑区无灌注区.增殖性玻璃体视网膜病变对黄斑的影响 视网膜纤维组织增厚牵拉可使黄斑形成皱褶,黄斑视网膜前膜,引起视力下降及视物变形.,糖尿病视网膜病变 颞侧周边视网膜毛细血管闭锁，闭锁血管的后缘有新生血管芽出现,糖尿病视网膜病变 增殖型期：视网膜有新生血管形成,糖尿病视网膜
6、病变 增殖型期：颞侧视网膜有新生血管及玻璃体出血,糖尿病视网膜病变 增殖型期：视盘鼻侧视网膜新生血管及视网膜前出血,糖尿病视网膜病变 增殖型期：视盘周围新生血管及鼻下视网膜前出血，黄斑区水肿,糖尿病视网膜病变 增殖型期：视盘出现新生血管，下方纤维增殖，上方视网膜前出血,糖尿病视网膜病变 视网膜水肿，出血及视网膜前“舟样”出血,糖尿病视网膜病变 增殖型期：视盘颞下视网膜新生血管网，上方及鼻侧纤维增殖,糖尿病视网膜病变 增殖型期：视盘上方视网膜新生血管和纤维增殖，黄斑区水肿,糖尿病视网膜病变 增殖型期：视网膜新生血管和纤维增殖，视乳头水肿，黄斑区水肿,糖尿病视网膜病变 增殖型期：视网膜新生血管,糖
7、尿病视网膜病变 增殖型期：眼底新生血管，纤维增殖,糖尿病视网膜病变 增殖型期：视网膜新生血管，纤维增生，并发视网膜脱离,糖尿病视网膜病变 增殖型期：眼底新生血管，纤维增殖，并发视网膜脱离,Diabetic Retinopathy,Nonproliferative(#1,1)Comment:Many red dots,microaneurysms,are seen together with hard exudates in a circinate pattern.,Diabetic Retinopathy,Nonproliferative(#1,2),AngiogramComment:The
8、angiogram reveals even more bright spots than the clinical picture suggests with subtle staining of the retina surrounding these areas.In addition,there is a lack of capillaries where there are no aneurysms.,Diabetic Retinopathy,Nonproliferative(#2)Comment:Many superficial,intraretinal hemorrhages.T
9、he fluffy,white spots,cotton wool spots,are microinfarcts.,Diabetic Retinopathy,Nonproliferative(#3),HistologyComment:A trypsin digest of a diabetic retina shows capillaries with loss of pericytes,condensation of endothelial nuclei,and formation of little aneurysmatic dilatations of the capillaries.
10、,Diabetic Retinopathy(#1,1),Proliferative(PDR)Comment:One has to look carefully to see the heavy neovascularization that extends along the posterior surface of vitreous which is adherent to the disc but detached elsewhere.,Diabetic Retinopathy(#1,2),Proliferative(PDR),AngiogramComment:The angiogram
11、reveals the many new vessels which leak flurescein.,Diabetic Retinopathy(#2),Proliferative(PDR)Comment:There are multiple signs of diabetic retinopathy:venous beading,hemorrhages,cotton-wool spots,intraretinal vascular abnormalities(IRMA),but most important for the prognosis is the neovascularizatio
12、n of the disc(NVD).,Diabetic Retinopathy(#3),Proliferative,(PDR)Comment:Severe macular edema with hard exudates.Neovascularization above the disc.,Diabetic Retinopathy(#4),Proliferative(PDR)Comment:Massive neovascularization along the retinal surface(this indicates that the vitreous is not detached)
13、.,Diabetic Retinopathy(#5),Proliferative(PDR)Comment:Preretinal hemorrhages occur after traction on new vessels.They can be suspected to be located at the proliferation of the 6 oclock vein and at 7 oclock.The hemorrhagic streaks toward the macula indicate a subhyaloid connection to this area.,Diabe
14、tic Retinopathy(#6),Proliferative(PDR)Comment:Proliferations typically occur at the disc and along the arcades.Despite photocoaculation there is still active neovascularization.The vitreous is not detached as indicated by the preretinal location of the neovascularization.,Diabetic Retinopathy(#7),Pr
15、oliferative(PDR),OCTComment:OCT shows a preretinal membrane that is not everywhere attached to the retina.,Diabetic Retinopathy(#8),Proliferative(PDR)Comment:Neovascularization of the iris,iris bomb閑,occurring in eyes with active diabetic proliferative retinopathy.,Diabetic Retinopathy(#9),Prolifera
16、tive(PDR)Comment:Severe neovascularization with hemorrhage and proliferation that has detached the retina.,Diabetic Retinopathy,Proliferative(#1,1),(PDR),HistologyComment:Neovascularization is on the surface of the retina(although it originates from a retinal vein).,Diabetic Retinopathy,Proliferativ
17、e(#1,2),(PDR),HistologyComment:Contracting preretinal tissue partially folds the inner retinal surface and partially pulls itself loose from the retinal surface.,Diabetic Retinopathy(#1,1),Proliferative after VitrectomyComment:Rarely,despite successful vitreous surgery,small convoluted new vessels d
18、o develop.They grow very little and may bleed.,Diabetic Retinopathy(#1,2),Proliferative after Vitrectomy,AngiogramComment:In the arterio-venous phase several grape-like lesions light up,only one of which is visible on the fundus photograph.This may indicate that the new vessels initially are intrare
19、tinal and only later break through the internal lamina.,Diabetic Retinopathy(#1,3),Proliferative,after Vitrectomy,AngiogramComment:There is extensive leakage from the lesions with so called smoke-stack formation,a sign of of a preretinal upward current.,治 疗,治疗原则:非增殖性糖尿病视网膜病变主要为全身治疗,旨在延缓视网膜病变的进展或使病变有所退行.增殖性糖尿病视网膜病变激光治疗或玻璃体切割.,
