| The choroidal neovscullarization(CNV),also called subretrinal neovascallarization. Many reasons can lead CNV permeate the Brush member, and come to retinal pigment epithelium or neuroepithelium of retinal, proliferated, and cause the hemorrhage, exudation, edema and scars, this can affect the persons quality of daily life and central vision. Many diseases can cause the CNV, most common to see are Age related macular degeneration (AMD), Pathological myopia (PM), others are Central exudation retino-choroiditis, Choroiditis, Choroidal rupture et al.The question of what reason form the CNV is not. Clear, many people believed two reseans: Hypoxia and Inflammation. The process of CNV formation contains activation of vascular endothelial cell (EC), extracellular matrix degrdned, proliferation of EC and formation of vessel. So, in this procession, many cell factors, cells and ECM joined .The therapy of CNV are radiation therapy, operation and laser therapy. Because of radiation therapy have many complication and not very safe, it is just used in research. The operation is based on consummate microsurgery, and have two types, one is move the fovel from abnormal pigment epithelium to the normal place, and the other is take out the CNV. This two types make serious damaged and after operation, it have more compilation, patients do not have good vision. so it have more time to estimate the therapeutic effect.The laser is the mainly therapy of CNV, It has three types: Photocoagulation, Transpupillary thermotherapy (TTT), Photodynamic therapy (PDT). hotocoagulation is used to deal with the CNV, which is 500μm away from fovel and have clear boundary, the photocoagulation can release a great heat at the time it comes to affection, block the vessel, cure the CNV. But it has some fault, it can damage the normal retina, and have high rate of recurrence. TTT is 810nm laser, used low power, big spot, raise the temperature of the retinal structure, lead the thrombus in the CNV, it can save some retina function, and theoretically, it can block all the CNV types. But it can't block CNV completely and long time, research also showed it can damaged the normal retina. PDT is acknowledged as the most useful therapy on CNV. It intravenous some photosesitizer, and then give the laser raying (689nm), the drug will activated, and lead thrombus, block the CNV. The effect is identify, and don't damage normal retina, it safe and can give many times, but it expensive and also can recurred.]Now we know all the laser therapy have fault and forte, and different laser have different use, If we can integrated the different laser's forte, we can find a way to use less cost and have best result. In this imagination, we used TTT and PDT to have a research.Objective:1. Evaluate the effective of used TTT combined with PDT to deal with CNV.2. Comparied effective with receptive PDT and TTT combined with PDT, and investigate the feasibility of the combined therapy.Methods:1. Retrospected the patients from 2006 to 2008, which were diagnosed have CNV. Two teams, all the patients were AMD or PM, the fundus fluorescein angiography (FFA) combined with indocyanine green angiography(ICGA) showed the subfovel CNV or parafovea CNV.2. One team were deal with PDT, from 55 patients (87 eyes ), 61 AMD eyes, 26 PM eyes. All the patients were received vision test (Snell Vision table), FFA&ICGA, optic coherent tomography (OCT) after PDT 1 month and 3 months. If fund CNV were recur or not block, then give PDT again. All the patients were followed 6.8months; anther team were give TTT, after 3 months, FFA&ICGA fund CNV were not block, then give PDT, The data from 25 patients (34 eyes ), 24 AMD eyes and 10 PM eyes. All the patients were received vision test, FFA&ICGA, OCT after PDT 1 month and 3 months. All the patient were followed 5.2months.3. PDT method: The photosesitizer is Visudyne. 6mg/m~2 every body surface area, and then the drug was diluted to 20ml.Use semiconductor laser, the wave is 689nm. The drug was intravenous in 15 minutes in dark room. The therapy area is based on the CNV, and each therapy spot will add 1000μm on the each side of CNV. Power is 600mw/cm~2, time is 83s, total light flow is 50J/cm~2. After therapy, patient will keep away from light for 48 hours. The indication of repetitive PDT: 3 months after PDT, FFA&ICGA, OCT find CNV remained or recurred, the leakage area is bigger than half, or find new CNV; Have no complication of PDT; The patient's family member agreed. TTT method: Used semiconductor with waves 810nm. The therapy spot and power is based on CNV, spot is bigger than CNV, and if necessary, it can use several spot. Spot diameter is 3mm,number is 1-2, power is 180-300mJ. On therapy process, we can't see the retina changed color, if it happened, the therapy should stop.4. Compared Vision, FFA&ICGA, OCT result between before therapy and after therapy. Evaluated the effect of two therapy, and find if it have statistics significance.5. The standard of evaluate effect: In two way, Vision and Image processing. Used Snell vision table to exam vision. If corrected vision raised 2 lines, it shows vision improved, if corrected vision waved in 1 line, it shows vision remain; if corrected vision decreased in 2 lines, it shows vision decreased. The image processing is based on FFA&ICGA test, if it shows no leakage of CNV, it means leakage stop, if leakage is less than 50% before, it means leakage decrease, if leakage is more than 50% before, it means leakage remain, if leakage is more than before, no matter how serious it is, it means leakage increase, after laser therapy, leakage stopped, then it leakage again or have new CNV, it means CNV recurred. OCT showed edema alleviated means improved, no change means remained, aggravated means get worse. Compared two team used chi-square test, and the statistic software is SPSS11.5.Results:1. PDT team :In the final follow-up examination, compared with the condition before PDT, the visual acuity increased>2 lines in 32 eyes (36.78%), changed士1 line in 35 eyes (40.23%), and decreased> 2 lines in 20 eyes (22.99%); The results of fundus fluorescein angiography (FFA) combined with indocyanine green angiography (ICGA) showed that the leakage of choroidal nevoscularization (CNV) stopped in 23 eyes (26.44), reduced in 51 eyes (58.62%), and remained in 13 eyes (14.94%). The result of optic coherent tomography (OCT) showed that the edema were alleviated 35 eyes, remained 36 eyes, aggravated 16 eyes.2. TTT combined PDT team: In the final follow-up examination, compared with the condition before TTT, the visual acuity increased>2 lines in 12 eyes (35.29%), changed士1 line in 18 eyes (52.94%), and decreased> 2 lines in 4 eyes (11.76%); The results of fundus fluorescein angiography(FFA) combined with indocyanine green angiography(ICGA) showed that the leakage of choroidal nevoscularization (CNV) stopped in 14 eyes (41.18%), reduced in 17 eyes (50.00%), remained in 2 eyes(5.88%), and 1 eye (2.94%) has new CNV. The result of optic coherent tomography(OCT) showed that the edema were alleviated 15 eyes, remained 18 eyes, aggravated 1 eyes.3. The comparison of vision in two teams has no difference, no statistic significance (Z= -1.386 P=0.166) ; The comparison of block CNV showed in FFA&ICGA in two teams has no difference, no statistic significance (Z= -0.899 P=0.374); The comparison showed OCT in two teams has difference, statistic significance (Z= -2.189 P=0.029). The TTT combined PDT team is better than PDT team. We also compared the different disease with two therapies, in disease of AMD, the comparison of vision in two team has no difference, no statistic significance (Z= -1.221 P=0.222), The comparison of block CNV showed in FFA&ICGA in two teams has no difference, no statistic significance (Z= -0.612 P=0.540), The comparison showed OCT in two teams has no difference, no statistic significance (Z= -1.643 P=0.100); in disease of PM, the two team showed no different in vision comparison (Z= -0.656 P=0.512), no different in leakage of FFA&ICGA (Z=-0.656 P=0.512), and no different in OCT (Z= -1.474 P=0.141). |
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