山东大学耳鼻喉眼学报 ›› 2020, Vol. 34 ›› Issue (4): 28-34.doi: 10.6040/j.issn.1673-3770.1.2020.057

• 眼缺血综合征多学科精准诊疗 临床研究 • 上一篇    下一篇

动脉溶栓治疗视网膜中央动脉阻塞Meta分析

陈曦,李珊珊,赵露,尤冉,王艳玲   

  1. 陈曦, 李珊珊, 赵露, 尤冉, 王艳玲首都医科大学附属北京友谊医院 眼科, 北京 100050
  • 收稿日期:2020-06-01 出版日期:2020-07-20 发布日期:2020-08-28
  • 基金资助:
    国家自然科学基金资助(81870686);北京市自然科学基金资助(7184201);首都卫生发展科研专项资助(编号:首发2018-1-2021)

Intra-arterial thrombolysis for central retinal artery occlusion: a Meta-analysisCHEN Xi, LI Shanshan, ZHAO Lu, YOU Ran, WANG Yanling Department of Ophthalmology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, ChinaAbstract:

ObjectiveTo compare the effects of intra-arterial thrombolysis and traditional treatment in central retinal artery occlusion(CRAO). MethodsWe searched the Pubmed, Embase, Clinical.gov, CNKI, and Wan Fang databases for related studies that were published up to May 14, 2020. We included clinical controls that compared intra-arterial thrombolysis and conventional treatment in CRAO. The random effect model and R software were used for data analysis. ResultsWe identified seven studies including 563 CRAO patients. Meta-analysis results of two randomized controlled trials(RCTs)showed that there was no significant difference in visual acuity improvement between CRAO patients treated with arterial thrombolysis therapy and those with conventional therapy(RR: 1.17, 95% confidence interval 0.80-1.72, P=0.409). Meta-analysis results of five cohort studies indicated that compared with conventional therapy, arterial thrombolysis therapy significantly improved visual acuity(RR: 1.86, 95% confidence interval 1.43-2.41, P<0.001). The difference between thrombolysis therapy and conventional therapy may be caused by the different treatment time windows in patients. Concerning the adverse reactions after treatment, two RCTs and five cohort studies showed that the adverse reactions in the thrombolysis group are significantly higher than those in the conventional treatment group. ConclusionAlthough intra-arterial thrombolysis therapy has therapeutic potential in CRAO patients, there is still insufficient clinical evidence to prove its effectiveness and safety. Further studies with a large sample and high quality RCTs are required.   

  1. Key words: Central retinal artery occlusion;
    Intra-arterial thrombolysis;
    Systematic review;
    Meta-analysis视网膜中央动脉阻塞(central retinal artery occlusion, CRAO)常常迅速导致严重的视力损害甚至完全丧失[1], 病理过程为视网膜中央动脉阻塞导致视网膜急性缺血缺氧[2], 是缺血性卒中的眼部表现形式之一[1-3]。早期治疗对于挽救CRAO患者视功能十分关键[4], 直接影响此类患者的视功能预后[5]。CRAO治疗的目的是尽快恢复视网膜血液循环及其功能[6]。现有对CRAO传统治疗的方法主要包括有扩张血管、解除痉挛及吸氧治疗, 增加视网膜血供, 改善组织缺血缺氧[7];
    降眼压治疗, 增加视网膜血液灌注[8];
    按摩眼球, 驱使栓子进入小支血管。
  • Received:2020-06-01 Online:2020-07-20 Published:2020-08-28

摘要: 目的 动脉溶栓治疗与传统方法治疗视网膜中央动脉阻塞(CRAO)疗效对比分析。 方法 检索Pubmed、Embase、Clinical.gov、中国知网以及万方数据库,纳入动脉溶栓治疗与传统方法治疗CRAO的临床对照研究,文献发表的时间截止为2020年5月14日。采用随机效应模型并使用R软件进行数据分析。 结果 共纳入7篇文献,入组563例CRAO患者。2篇随机对照试验的Meta分析结果显示经动脉溶栓治疗的CRAO患者与传统的治疗方法相比视力提高并无统计学差异(RR: 1.17,95%CI 0.80~1.72,P=0.409),5篇队列研究的Meta分析结果显示动脉溶栓治疗较传统治疗患者视力明显提高(RR: 1.86,95%CI 1.43~2.41,P<0.001)。引起两者不同的原因可能为动脉溶栓治疗和传统治疗纳入患者治疗时间窗不同。治疗后的不良反应方面,2篇随机对照试验研究和5篇队列研究的Meta分析结果均显示溶栓组不良反应发生率明显高于传统治疗。 结论 虽然动脉溶栓治疗对CRAO的患者表现出一定的应用前景,但是尚缺乏足够的临床证据证明其有效性和安全性,今后还需要大样本高质量的随机对照研究来验证。

关键词: 视网膜中央动脉阻塞, 动脉溶栓, 系统评价, Meta分析

Abstract: Objective To compare the effects of intra-arterial thrombolysis and traditional treatment in central retinal artery occlusion(CRAO). Methods We searched the Pubmed, Embase, Clinical.gov, CNKI, and Wan Fang databases for related studies that were published up to May 14, 2020. We included clinical controls that compared intra-arterial thrombolysis and conventional treatment in CRAO. The random effect model and R software were used for data analysis. Results We identified seven studies including 563 CRAO patients. Meta-analysis results of two randomized controlled trials(RCTs)showed that there was no significant difference in visual acuity improvement between CRAO patients treated with arterial thrombolysis therapy and those with conventional therapy(RR: 1.17, 95% confidence interval 0.80-1.72, P=0.409). Meta-analysis results of five cohort studies indicated that compared with conventional therapy, arterial thrombolysis therapy significantly improved visual acuity(RR: 1.86, 95% confidence interval 1.43-2.41, P<0.001). The difference between thrombolysis therapy and conventional therapy may be caused by the different treatment time windows in patients. Concerning the adverse reactions after treatment, two RCTs and five cohort studies showed that the adverse reactions in the thrombolysis group are significantly higher than those in the conventional treatment group. Conclusion Although intra-arterial thrombolysis therapy has therapeutic potential in CRAO patients, there is still insufficient clinical evidence to prove its effectiveness and safety. Further studies with a large sample and high quality RCTs are required.

Key words: Central retinal artery occlusion, Intra-arterial thrombolysis, Systematic review, Meta-analysis

中图分类号: 

  • R774.1
[1] Nicholson P, Margolin E, Krings T. Letter by Nicholson et al regarding article, “thrombolytic therapy for acute central retinal artery occlusion”[J]. Stroke, 2020, 51(5): e95.doi: 10.1161/STROKEAHA.120.029552.
[2] Matthe E, Eulitz P, Furashova O. Acute retinal ischemia in central versus branch retinal artery occlusion: changes in retinal layers' thickness on spectral-domain optical coherence tomography in different grades of retinal ischemia[J]. Retina, 2020, 40(6): 1118-1123. doi: 10.1097/IAE.0000000000002527.
[3] Ferreira D, Soares C, Tavares-Ferreira J, et al. Acute phase treatment in central retinal artery occlusion: thrombolysis, hyperbaric oxygen therapy or both[J]. J Thromb Thrombolysis, 2020. doi: 10.1007/s11239-020-02072-0.
[4] Mathew B, Chennakesavalu M, Sharma M, et al. Autophagy and post-ischemic conditioning in retinal ischemia[J]. Autophagy, 2020:1-21. doi: 10.1080/15548627.2020.1767371.
[5] Shah SM, Khanna CL. Ophthalmic emergencies for the clinician[J]. Mayo Clin Proc, 2020, 95(5): 1050-1058. doi: 10.1016/j.mayocp.2020.03.018.
[6] Miao Na, Fan Wei. Clinical research status and progress of central retinal artery occlusion[J]. Chinese Journal of Ocular Fundus Diseases, 2018, 34(3): 296-299. doi: 10.3760/cma.j.issn.1005-1015.2018.03.023.
[7] Duker JS, Brown GC. Recovery following acute obstruction of the retinal and choroidal circulations. A case history[J]. Retina, 1988, 8(4): 257-260. doi: 10.1097/00006982-198808040-00007.
[8] Dattilo M, Biousse V, Newman NJ. Update on the management of central retinal artery occlusion[J]. Neurol Clin, 2017, 35(1): 83-100. doi: 10.1016/j.ncl.2016.08.013.
[9] Schultheiss M, Hartig F, Spitzer MS, et al. Intravenous thrombolysis in acute central retinal artery occlusion—a prospective interventional case series[J]. PLoS One, 2018, 13(5): e0198114. doi: 10.1371/journal.pone.0198114.
[10] Schrag M, Youn T, Schindler J, et al. Intravenous fibrinolytic therapy in central retinal artery occlusion: a patient-level meta-analysis[J]. JAMA Neurol, 2015, 72(10): 1148-1154. doi: 10.1001/jamaneurol.2015.1578.
[11] Raber FP, Reinking K, Schmitz-Valckenberg S, et al. Successful systemic lysis therapy in acute retinal arterial occlusions[J]. Klin Monbl Augenheilkd, 2020, 237(6): 772-779. doi: 10.1055/a-1079-5635.
[12] Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience[J]. Stroke, 2008, 39(6): 1746-1750. doi: 10.1161/STROKEAHA.107.505404.
[13] Schmidt DP, Schulte-Monting J, Schumacher M. Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment[J]. AJNR Am J Neuroradiol, 2002, 23(8): 1301-1307.
[14] Schumacher M, Schmidt D, Jurklies B, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial[J]. Ophthalmology, 2010, 117(7): 1367-1375. doi: 10.1016/j.ophtha.2010.03.061.
[15] Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses[J]. Eur J Epidemiol, 2010, 25(9): 603-605. doi: 10.1007/s10654-010-9491-z.
[16] Ahn SJ, Kim JM, Hong JH, et al. Efficacy and safety of intra-arterial thrombolysis in central retinal artery occlusion[J]. Invest Ophthalmol Vis Sci, 2013, 54(12): 7746-7755. doi: 10.1167/iovs.13-12952.
[17] Arnold M, Koerner U, Remonda L, et al. Comparison of intra-arterial thrombolysis with conventional treatment in patients with acute central retinal artery occlusion[J]. J Neurol Neurosurg Psychiatry, 2005, 76(2): 196-199. doi: 10.1136/jnnp.2004.037135.
[18] Weber J, Remonda L, Mattle HP, et al. Selective intra-arterial fibrinolysis of acute central retinal artery occlusion[J]. Stroke, 1998, 29(10): 2076-2079. doi: 10.1161/01.str.29.10.2076.
[19] 王志扬, 韩爱敏, 刘影,等. 尿激酶溶栓介入治疗视网膜中央动脉阻塞的疗效观察[J]. 临床医学研究与实践, 2016, 1(16): 53.
[20] Motoyama Y, Hayashi H, Kawanishi H, et al. Ocular blood flow by laser speckle flowgraphy to detect cerebral ischemia during carotid endarterectomy[J]. J Clin Monit Comput, 2020. doi: 10.1007/s10877-020-00475-1.
[21] Mac Grory B, Lavin P, Kirshner H, et al. Thrombolytic therapy for acute central retinal artery occlusion[J]. Stroke, 2020, 51(2): 687-695. doi: 10.1161/STROKEAHA.119.027478.
[22] Sharma RA, Newman NJ and Biousse V. New concepts on acute ocular ischemia[J]. Curr Opin Neurol, 2019, 32(1): 19-24. doi: 10.1097/WCO.0000000000000634.
[23] Chronopoulos A and Schutz JS. Central retinal artery occlusion—A new, provisional treatment approach[J]. Surv Ophthalmol, 2019, 64(4): 443-451. doi: 10.1016/j.survophthal.2019.01.011.
[24] Ishida M, Abe S, Nakagawa T, et al. Short-term results of endovascular surgery with tissue plasminogen activator injection for central retinal vein occlusion[J]. Graefes Arch Clin Exp Ophthalmol, 2017, 255(11): 2135-2140. doi: 10.1007/s00417-017-3763-1.
[25] Hayreh SS. Ocular vascular occlusive disorders: natural history of visual outcome[J]. Prog Retin Eye Res, 2014, 41: 1-25. doi: 10.1016/j.preteyeres.2014.04.001.
[26] Limaye K, Adams HP, Jr. Is management of central retinal artery occlusion the next frontier in cerebrovascular diseases[J]. J Stroke Cerebrovasc Dis, 2019, 28(2): 521. doi: 10.1016/j.jstrokecerebrovasdis. 2018.09.044.
[27] He YD, Guo ZN, Qin C, et al. Remote ischemic conditioning combined with intravenous thrombolysis for acute ischemic stroke[J]. Ann Clin Transl Neurol, 2020, Online ahead of print. doi: 10.1002/acn3.51063.
[28] Mac Grory B, Yaghi S, Flood S, et al. Competing embolic mechanisms in acute central retinal artery occlusion[J]. Stroke, 2019, 50(9): e253-e256. doi: 10.1161/STROKEAHA.119.026209.
[29] Wang R, Qian L, Wang Y, et al. Evaluation of ophthalmic artery branch retrograde intervention in the treatment of central retinal artery occlusion(CRAO)[J]. Med Sci Monit, 2017, 23: 114-120. doi: 10.12659/msm.898-352.
[30] Kaburaki T, Fukunaga H, Tanaka R, et al. Retinal vascular inflammatory and occlusive changes in infectious and non-infectious uveitis[J]. Jpn J Ophthalmol, 2020, 64(2): 150-159. doi: 10.1007/s10384-020-00717-4.
[31] Takata Y, Nitta Y, Miyakoshi A, et al. Retinal endovascular surgery with tissue plasminogen activator injection for central retinal artery occlusion[J]. Case Rep Ophthalmol, 2018, 9(2): 327-332. doi: 10.1159/00048-9696.
[32] Kadonosono K, Yamane S, Inoue M, et al. Intra-retinal arterial cannulation using a microneedle for central retinal artery occlusion[J]. Sci Rep, 2018, 8(1): 1360. doi: 10.1038/s41598-018-19747-7.
[33] Ishida M, Abe S, Nakagawa T, et al. Short-term results of endovascular surgery with tissue plasminogen activator injection for central retinal vein occlusion[J]. Graefes Arch Clin Exp Ophthalmol, 2017, 255(11): 2135-2140. doi: 10.1007/s00417-017-3763-1.
[1] 杨明综述魏文斌审校. 溶栓治疗在视网膜动脉阻塞中的应用进展[J]. 山东大学耳鼻喉眼学报, 2020, 34(4): 5-10.
[2] 韩书婧,鲁洁,初平,唐力行,郑惠文,杨小健,张薇,王蓬鹏,张杰,郭永丽,葛文彤. 慢性鼻-鼻窦炎的微生态Meta分析[J]. 山东大学耳鼻喉眼学报, 2019, 33(5): 132-138.
[3] 刘琳,郑华,谌绍林,段宣初. 干细胞移植对大鼠青光眼模型视神经保护作用及安全性的Meta分析[J]. 山东大学耳鼻喉眼学报, 2019, 33(4): 138-144.
[4] 林兴,林宗通,沈翎. 鼻窦球囊扩张治疗儿童慢性鼻窦炎的系统评价及Meta分析[J]. 山东大学耳鼻喉眼学报, 2017, 31(6): 79-86.
[5] 张杰,陈雪梅,许安廷. 超声刀扁桃体切除术与低温等离子扁桃体切除术的对比研究[J]. 山东大学耳鼻喉眼学报, 2017, 31(5): 95-100.
[6] 王越,柯敏,韩芳芳,王文欢,翁鸿. EX-PRESS引流器植入术与小梁切除术治疗开角型青光眼有效性和安全性的Meta分析[J]. 山东大学耳鼻喉眼学报, 2017, 31(2): 104-111.
[7] 谢邵兵,张燕妮,徐震航,张建辉,吴学文,孙虹. 外伤性面神经麻痹手术时机的系统评价[J]. 山东大学耳鼻喉眼学报, 2016, 30(6): 18-21.
[8] 于青青,唐隽,王跃建. 建立扁桃体腺样体不同手术方式对儿童阻塞性睡眠呼吸暂停低通气综合征疗效的系统评价体系[J]. 山东大学耳鼻喉眼学报, 2016, 30(5): 42-48.
[9] 李泽文,郭俊宇,周洁,严福波,杨志敏,丁珠华. 胃食管反流病与喉癌关系的Meta分析[J]. 山东大学耳鼻喉眼学报, 2016, 30(3): 40-46.
[10] 陈曦, 李进让. 鼻用激素治疗儿童阻塞性睡眠呼吸暂停低通气综合征疗效的Meta分析[J]. 山东大学耳鼻喉眼学报, 2015, 29(2): 9-11.
[11] 徐媛媛,曾泉,洪苏玲,胡国华. 新辅助化疗联合同期放化疗与同期放化疗单独治疗鼻咽癌疗效及安全性的Meta分析[J]. 山东大学耳鼻喉眼学报, 2013, 27(5): 8-14.
[12] 侯森1,杨海珍2. 低温等离子射频消融术治疗慢性肥厚性鼻炎有效率的Meta分析[J]. 山东大学耳鼻喉眼学报, 2013, 27(1): 51-53.
[13] 于晓明,吴欣怡. 角膜缘干细胞移植与羊膜移植治疗翼状胬肉的Meta分析[J]. 山东大学耳鼻喉眼学报, 2013, 27(1): 66-71.
[14] 侯森1,杨海珍2. 盐酸氨溴索治疗分泌性中耳炎疗效的Meta分析[J]. 山东大学耳鼻喉眼学报, 2012, 26(3): 10-12.
[15] 徐志华,王继群,张 涛,贾海英,孙 瑾,山艳春 . VEGF在喉癌中表达的Meta分析[J]. 山东大学耳鼻喉眼学报, 2008, 22(1): 32-34 .
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed   
[1] 周斌,李滨 . 鼻内窥镜下鼻窦鼻息肉手术75例疗效观察[J]. 山东大学耳鼻喉眼学报, 2006, 20(1): 24 -26 .
[2] 张玉光,韩旭光,张华,王旭,徐湘辉 . 改良穿透性角膜移植术治疗真菌性角膜炎[J]. 山东大学耳鼻喉眼学报, 2006, 20(1): 94 -95 .
[3] 隆梅辉,何明强,牟艳云,田利健 . 上颌窦炎性肌纤维母细胞瘤1例并文献复习[J]. 山东大学耳鼻喉眼学报, 2008, 22(4): 329 -330 .
[4] 邹 俊,卢 奕,褚仁远 . 体外培养人胚晶状体上皮细胞生长特性的研究[J]. 山东大学耳鼻喉眼学报, 2008, 22(5): 453 -456 .
[5] 夏文清,郑 敏,满晓飞,李建平 . 手法劈核治疗老年性白内障[J]. 山东大学耳鼻喉眼学报, 2008, 22(5): 467 -469 .
[6] 杜晓东 . 码摄录像系统在耳鼻咽喉科医教研中的应用[J]. 山东大学耳鼻喉眼学报, 2006, 20(3): 287 -287 .
[7] 李学昌,王金磊,张玉莉,董文汇,韩在文 . 中药冲洗对鼻黏膜纤毛超微结构的影响[J]. 山东大学耳鼻喉眼学报, 2006, 20(6): 522 -524 .
[8] 康宏建,李晓红,王保安,周 涛 . 重型颅脑损伤患者行气管切开术的意义[J]. 山东大学耳鼻喉眼学报, 2007, 21(3): 234 -236 .
[9] 闫 蕊,朱淋洁 . 翼状胬肉显微手术切除后角膜干细胞移植[J]. 山东大学耳鼻喉眼学报, 2007, 21(3): 243 -244 .
[10] 黄 方,朱从月 . p21、p73及PTEN在头颈部多原发癌中的表达及意义[J]. 山东大学耳鼻喉眼学报, 2007, 21(5): 388 -392 .