1、.Wills手冊 第十一章 視網膜 第十三節 玻璃體積血 郝曉軍整理 打雜組出品 2014.10.2211.13 Vitreous Hemorrhage第十三節  玻璃體積血Symptoms【癥狀】Sudden, painless loss of vision or sudden appearance of black spots, cobwebs, or haze in the vision.突然出現無痛性視力喪失，或突然出現眼前黑點、蜘蛛網或煙霧。Signs   【體征】(See Figure 11.13.1.)   &

2、#160;見圖11.13.1Critical. In a severe vitreous hemorrhage (VH), the red fundus reflex may be absent, and there may be no view to the fundus. Red blood cells may be seen in the anterior vitreous. In a mild VH, there may be a partially obscured view to the fundus. Chronic vitreous hemorrhage has a

3、yellow ochre appearance from hemoglobin breakdown.【主要體征】    1、嚴重的玻璃體積血  眼底紅光反射消失無法看到眼底。裂隙燈下可見前玻璃體紅細胞。   2、輕度玻璃體積血   可見出血遮擋部分視網膜或視網膜血管。  3、慢性玻璃體積血   因血紅蛋白降解而呈赭黃色玻璃體混濁。Other. A mild RAPD is possible. Depending on the etiol

4、ogy, there may be other fundus abnormalities.【其他體征】可能出現輕度的相對性傳入性瞳孔障礙。由于致病病因不同，也可見其他的眼底異常。Differential Diagnosis【鑒別診斷】       Vitritis (white blood cells in the vitreous): Usually not sudden onset; anterior or posterior uveitis may also be present. No red blood cells are

5、seen in the vitreous. See 12.3, Posterior Uveitis.   1、玻璃體炎  玻璃體內出現白細胞。非突然發病，而伴有前葡萄膜炎或后葡萄膜炎，玻璃體內無紅細胞，參見第十二章第三節后葡萄膜炎。       Retinal detachment: May occur without a VH, but the symptoms may be identical. In VH due to RD, the peripheral retina is o

6、ften obscured on indirect ophthalmoscopy. See 11.3, Retinal Detachment.   2、視網膜脫離   可不伴有玻璃體積血。癥狀典型。視網膜脫離造成的玻璃體積血病例，間接檢眼鏡下無法看清其周邊部視網膜。參見本章第三節視網膜脫離。Etiology    【病因學】       Diabetic retinopathy: Usually history of diabetes

7、and usually diabetic retinopathy. Diabetic retinopathy is usually evident in the contralateral eye. In VH due to PDR, the peripheral retina is often visible on indirect ophthalmoscopy. See 11.12, Diabetic Retinopathy.   1、糖尿病性視網膜病變   通常有明確的糖尿病病史和糖尿病性視網膜病變病史。對側眼常有顯著的糖尿病性

8、視網膜病變。由于增殖型糖尿病性視網膜病變造成的玻璃體積血病例，間接檢眼鏡下通常可看清其周邊部視網膜。參見本章第十二節糖尿病性視網膜病變。       PVD: Common in middle-aged or elderly patients. Usually patients note floaters and flashing lights. See 11.1, Posterior Vitreous Detachment.   2、玻璃體后脫離（PVD）   常見于中老年

9、患者，自述眼前有漂浮物或閃光感。參見本章第一節玻璃體后脫離。       Retinal break: Commonly superior in cases of dense vitreous hemorrhage. This may be demonstrated by scleral depression and, if poor view, US. See 11.2, Retinal Break.   3、視網膜裂孔    玻璃體嚴重積血的患眼，裂孔常見于視網

10、膜上方。可通過鞏膜壓迫檢查發現，如果窺不清眼底，行眼部B超。參見本章第二節視網膜裂孔。       Retinal detachment: May be diagnosed by US if the retina cannot be viewed on clinical examination. See 11.3, Retinal Detachment.4、視網膜脫離   如果臨床檢查看不清眼底時，可行眼科B超檢查。參見本章第三節視網膜脫離。      &

11、#160;Retinal vein occlusion (usually a BRVO): Commonly occurs in older patients with a history of high blood pressure. See 11.9, Branch Retinal Vein Occlusion.   5、視網膜靜脈阻塞    通常為視網膜分支靜脈阻塞。好發于有高血壓病史的老年人。數月或數年前該眼有視網膜靜脈阻塞史或視力突然喪失史。參見本章第九節視網膜分支靜脈阻塞。    &

12、#160;  Exudative Age-Related Macular Degeneration (ARMD): Usually with a disciform scar or advanced choroidal neovascular membrane (CNVM). Poor vision before the VH as a result of their underlying disease. Macular drusen or other findings of ARMD or both are found in the contralateral eye.

13、 B-scan US may aid in the diagnosis. See 11.17, Neovascular or Exudative (Wet) Age-Related Macular Degeneration.   6、滲出性年齡相關黃斑變性(ARMD)    通常合并盤狀瘢痕或晚期脈絡膜新生血管(CNV)。由于原發病，患者在玻璃體積血前就有視力低下。可在對側眼發現黃斑玻璃膜疣或年齡相關黃斑變性的其他表現。眼科B超可幫助診斷。參見本章第十七節新生血管性或滲出性(濕性)年齡相關性黃斑變性。  

14、     Sickle cell disease: May have peripheral retinal neovascularization in the contralateral eye, typically in a “sea fan” configuration and salmon color. See 11.20, Sickle Cell Disease (Including Sickle Cell, Sickle Trait).   7、鐮狀細胞病   &#

15、160;對側眼周邊視網膜可見新生血管，呈“海扇”狀，三文魚色。參見本章第二十節鐮狀細胞病(包括鐮狀細胞病和鐮狀細胞素質)。       Trauma: By history.   8、外傷      有外傷史。       Intraocular tumor: May be visible on ophthalmoscopy or B-scan US. See 5.13, Maligna

16、nt Melanoma of the Iris, and 11.35, Choroidal Nevus/Malignant Melanoma of the Choroid.   9、眼內腫瘤   檢眼鏡下或眼科B超可查見。參見第五章第十三節虹膜惡性黑色素瘤和本章第三十五節脈絡膜痣/脈絡膜惡性黑色素瘤。       Subarachnoid or subdural hemorrhage (Terson syndrome): Frequently bilateral preret

17、inal or vitreous hemorrhages may occur. A severe headache usually precedes the fundus findings. Coma may occur.   10、蛛網膜下或硬腦膜下出血(Terson綜合征)    常可出現雙眼視網膜前或玻璃體積血，在眼底改變出現之前常有嚴重的頭痛，可出現昏迷。       Eales disease: Usually occurs in men aged 20

18、to 30 years with peripheral retinal ischemia and neovascularization of unknown etiology. Decreased vision as a result of vitreous hemorrhage is frequently the presenting sign. Typically bilateral. Diagnosis of exclusion.   11、視網膜靜脈周圍炎（Eales病）  多發于2030歲男性，不明原因的周邊視網膜缺血和新生血管膜形成

19、。常見的體征是由玻璃體積血引起的視力下降，常發生于雙眼。排除性診斷。       Others: e.g., Coats disease, retinopathy of prematurity, retinal capillary angiomas of von HippelLindau syndrome, congenital prepapillary vascular loop, retinal cavernous hemangioma, hypertension, radiation retinopathy, anterior

20、segment hemorrhage because of an intraocular lens, bleeding diathesis. See specific sections.   12、其他    外層滲出性脈絡膜炎(Coats病)，早產兒視網膜病變(ROP),腦一視網膜血管瘤病(Von Hippel-Lindau病)的視網膜毛細血管瘤，先天性視盤前血管袢，視網膜海綿狀血管瘤，高血壓，放射性視網膜病變，人工晶狀體引起的眼前節出血，出血素質等。參見相關章節。NoteIn infancy and childhood

21、consider birth trauma, shaken baby syndrome, traumatic child abuse, congenital X-linked retinoschisis, and pars planitis.注：  在嬰兒和兒童，應考慮產傷，嬰兒搖晃綜合征，外傷性兒童受虐待，先天性X-性連鎖性視網膜劈裂癥和睫狀體平部炎。Work-Up    【檢查】   1    History: Any ocular or systemic diseases, sp

22、ecifically the ones mentioned previously? Trauma?   1、病史   是否有眼病或全身性疾病，特別是前而提到的疾病?有無外傷史？   2    Complete ocular examination, including slit-lamp examination with undilated pupils to check for iris neovascularization, IOP measurement, and dilated

23、 fundus examination of both eyes by using indirect ophthalmoscopy. In cases of spontaneous vitreous hemorrhage, scleral depression is performed if a retinal view can be obtained.2、全面的眼科檢查    包括裂隙燈檢查有無虹膜新生血管，眼壓測量，散瞳間接檢眼鏡下檢查雙眼眼底。在自發性玻璃體積血的患眼，如果能看見眼底，應行鞏膜壓迫檢查。   3 

24、60;  When no retinal view can be obtained, B-scan US is performed to detect an associated RD or intraocular tumor. Flap retinal tears may be detected with scleral depression and sometimes can be seen on B-scan US (elevated flap).   3、眼底看不到的病例給以眼科B超檢查   以觀察是否合并視網膜脫離

25、或眼內腫瘤，有蓋的視網膜裂孔可通過鞏膜壓迫發現。有時眼科B超也可發現(隆起的瓣膜)。   4    IVFA may aid in defining the etiology, although the quality of the angiogram depends on the density of the hemorrhage.4、眼底熒光血管造影(FFA)  可有助于確定病因，但成像的質量取決于出血的嚴重程度。NoteWe do not usually depress eyes until 2 weeks after

26、 traumatic hyphema/microhyphema. 注：  在外傷性前房積血或前房微量積血的病例，通常傷后2周內不要對患者施壓。Treatment   【治療】   1    If the etiology of the vitreous hemorrhage is not known and a retinal break or a RD or both cannot be ruled out (i.e., there is no known history of on

27、e of the diseases mentioned previously, there are no changes in the contralateral eye, and the fundus is obscured by a total vitreous hemorrhage), the patient is monitored closely as an outpatient.    1、如果玻璃體積血的病因不明，且不能排除視網膜脫離或裂孔，或二者均可能存在。即沒有前述的任何一種疾病的病史，對側眼未見異常，患眼由于全玻璃積血，無法看清眼底。

28、無需住院，密切觀察。   2    Bed rest with the head of the bed elevated for 2 to 3 days. This reduces the chance of recurrent bleeding and allows the blood to settle inferiorly, permitting a view of the superior peripheral fundus, a common site for responsible retinal breaks. 

29、0; 2、高枕位臥床休息23d，以減少再次出血的機會，并使積血下沉。上方周邊部視網膜是視網膜裂孔的好發部位。   3    Eliminate aspirin, nonsteroidal antiinflammatory drugs, and other anticlotting agents unless they are medically necessary.   3、如果不是內科治療所必需，停用非甾體類抗炎藥、阿斯匹林和其他抗凝藥物。   4   

30、 The underlying etiology is treated as soon as possible (e.g., retinal breaks are sealed with cryotherapy or laser photocoagulation, detached retinas are repaired, and proliferative retinal vascular diseases are treated with laser photocoagulation).   4、盡可能治療原發病，如冷凝或激光封閉視網膜裂孔，手術復位脫離的視

31、網膜，激光光凝增殖性視網膜血管性疾病。   5    Surgical removal of the blood (vitrectomy) is usually performed for:   5、下列情況常行玻璃體切除以清除積血:                Vitreous hemorrhage accompanied by RD or break seen

32、on B-scan US.   (1)眼科B超顯示玻璃體積血合并有視網膜脫離或視網膜裂孔。                Nonclearing vitreous hemorrhage, usually persisting >3 to 6 months. However, two-thirds of patients with an idiopathic, fundus-obscuring hemorrhage will have retinal tears or a retinal detachment. Thus, early