#46
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Êîëëåãè, ìîæíî ìíå âåðíóòüñÿ ê äàìå ñ ïðåäïîëàãàåìîé âàìè ãåìàíãèîìîé ëåâîãî ãëàçà (ïîñò ¹ 34). Ïðîøëî 2 ñ ïîëîâèíîé ìåñÿöà- è îíà ïðèøëà ê ñâîåìó äîêòîðó îïÿòü. ß íå ìîãó âûëîæèòü ÔÀà è ôîòî ïî òåõíè÷åñêèì ïðè÷èíàì. Íî íà ýòîò ðàç ÿ ìîãó âûëîæèòü âàì ñäåëàííûå 29 àïðåëÿ ÎÊÒ îáîèõ ãëàç. Âèçóñ ñïðàâà 0,4 ñ êîðð. 0,8; ñëåâà 0,02 ñ êîðð. 0,1.
Êëèíè÷åñêè äîêòîð, äåëàâøàÿ ÔÀÃ, ãîâîðèò î ìíîæåñòâå ñóáðåòèíàëüíûõ åìîððàãèé, ïîÿâèâøèõñÿ â çàäíåì ïîëþñå îáîèõ ãëàç. Ïåðâûå òðè ÎÊÒ ïðåäñòàâëÿþò ëåâûé ãëàç, äâå ïîñëåäíèõ- ïðàâûé. Îñòà¸òåñü ëè âû ïðè ñâî¸ì ìíåíèè îòíîñèòåëüíî ãåìàíãèîìû? Åù¸ ñêàæèòå: âàì êàæåòñÿ, ÷òî èçìåíåíèÿ â ÏÝ ñîîòâåòñòâóþò åãî ïðåäïîëàãàåìûì ãåìîððàãè÷åñêèì îòñëîéêàì èëè ýòî îïòè÷åñêèé ýââåêò çà ñ÷¸ò ïðîìèíåíöèè? È ïîñëåäíåå: ÷òî çà îïòè÷åñêè ïëîòíûé ñóáñòðàò ïåðåä ïèãìåíòíûì ýïèòåëèåì â íàðóæíûõ ñëîÿõ ñåò÷àòêè íà ëåâîì ãëàçó? ôèáðîç çà ñ÷¸ò ñäàâëåíèÿ íîâîîáðàçîâàíèåì èëè êðîâüþ? íî âåäü îíè âíèçó, à íå ââåðõó... ñàìî íîâîîáðàçîâàíèå? íî âåäü îíî ïðèíàäëåæèò õîðèîèäåå, à íå ñåò÷àòêå... êðîâü? íî îòêóäà îíà âçÿëàñü èìåííî â íàðêæíûõ îòäåëàõ ñåò÷àòêè íàä ïèãìåíòíûì ýïèòåëèåì?.. Ñïàñèáî çà âíèìàíèå. Íàäåþñü íà ìíåíèÿ. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#47
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Äîêòîðà!
Íåäàâíî íàì äîâåëîñü äåëàòü ÔÀà îäíîìó ïàðíþ, íàïðàâëåííîìó ê íàì ñ ïðåäâàðèòåëüíûì äèàãíîçîì "çàñòîéíûé äèñê". ß íå ìîãó Âàì ïîêàçàòü ñíèìêè, äà è íå â íèõ äåëî. Íà îñíîâàíèè àíàìíåçà è êëèíèêè ìû äîâîëüíî óâåðåííî èñêëþ÷èë "ÇÑ" è ïîñòàâèë ïàïèëëèò ñ ÿâëåíèÿìè àíãèèòà. Îäíàêî, ìû çàäóìàëèñü. Ñóùåñòâóþò ëè ÷èñòî àíãèîãðàôè÷åñêèå (à íå êëèíè÷åñêèå, âðåìåííûå, âîçðàñòíûå, èììóíîëîãè÷åñêèå è ïðî÷èå) êðèòåðèè äèôôåðåíöèàöèè çàñòîéíîãî äèñêà, ïàïèëëèòà è ïåðåäíåé îïò. íåéðîïàòèè? Áóäó ðàä ìíåíèÿì. Ñïàñèáî. |
#48
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×òîáû äîïîëíèòü îáñóæäåíèå ðàçðåøèòå ñïðîñèòü: ñêîëüêî ëåò ïàöèåíòó, êàêîå íåâðîëîãè÷åñêîå è íåéðîâèçóàëèçàöèîííîå îáñëåäîâàíèå áûëî ïðîâåäåíî?
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#49
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Ýòî ïðî èøåìè÷åñêóþ íåéðîïàòèþ, ñêîïèðîâàë èç êíèãè, ïåðåâîäèòü íå ñòàë (ëåíü ñòîëüêî íàáèðàòü áûëî )
There are three angiographic features that are well studied in NAION: 1. Peripapillary choroidal delay or choroidal dye filling delay: Early reports on angiography in NAION emphasized delayed filling of the disc and peripapillary choroid. However, recent angiographic studies have revealed a generalized choroidal filling delay only in arteritic disease. Patients with nonarteritic disease demonstrate only a focal delay (with filling times similar to those of controls). Hayreh described massive choroidal nonperfusion in patients with arteritic anterior ischemic optic neuropathy (AAION). He suggested that such choroidal abnormalities are extremely rare in NAION. Similarly, comparative analysis from ICGV and FA techniques did not show a statistically significant increase in the frequency of the peripapillary choroidal watershed zone filling delay in NAION. 2. Leakage from the disc: FA can show hyperfluorescence due to diffuse or focal leakage from the disc. ICGV is unable to demonstrate optic disc leakage. 3. Disc filling defects: FA demonstrates hypofluorescent areas encircled by hyperfluorescence. The hypofluorescence is due to segmental optic disc ischemia. Hyperfluorescence occurs secondary to leakage from the edematous disc. À ýòî ïðî îòåê äèñêà: The difference between normal and abnormal leakage at the disc may be subtle. In both papilledema and optic disc edema, the capillaries of the optic nerve are dilated and leak fluorescein. Because the fluorescein picture is not specific to these conditions, the diagnosis is made by the clinical history and ophthalmoscopic findings. The angiogram is similar in each case, demonstrating leakage associated with swelling of the optic nerve head. In the early phases of the angiogram, dilation of the capillaries on the optic nerve head may be seen. In the late phases of the angiogram, the dilated vessels leak, resulting in a fuzzy fluorescence of the disc margin. |
#50
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Retinal Angiography and Optical Coherence Tomography - J. Fernando Arevalo
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#51
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Êîëëåãè, ìîæíî ñ Âàìè îáñóäèòü èíòåðåñíûé ñëó÷àé?
Ïàðåíü ïðèø¸ë íà ïðè¸ì ê êîëëåãå. Îñòðîòà çðåíèÿ íà ïðàâûé ãëàç= 0,3 í.ê. Ó îôòàëüìîëîãà ïðàêòè÷åñêè íå íàáëþäàëñÿ. Îñòðîòà çðåíèÿ ìîæåò áûòü ñíèæåíà àïðèîðè èç- çà âîçìîæíîé àìáëèîïèè (ìèîïèÿ è ðîãîâè÷íûé àñòèãìàòèçì- ïðàâäà, óìåðåííûå). Ñíèæåíèå çðåíèÿ íà ïðàâûé ãëàç îòìåòèë îêîëî 3 ìåñÿöåâ íàçàä. Òîìîãðàììó ïðåäëàãàþ. Âàøåìó âíèìàíèþ. Îáðàùàþ âíèìàíèå, ÷òî äåñòðóêòèâíûå èçìåíåíèÿ â ñòåêëîâèäíîì òåëå ïðèñóòñòâóþò è íà ïàðíîì ãëàçó. Íàçâàòü èõ âîñïàëèòåëüíûìè íå ìîãó, ïîñêîëüêó è ñåò÷àòêà, è çðèòåëüíûé íåðâ â öåëîì âûãëÿäÿò áåçìÿòåæíî. Äåôåêò â ïðîåêöèè ôîòîðåöåïòîðîâ ïðåêðàñíî âèäåí êëèíè÷åñêè, îñîáåííî â áåñêðàñíîì ñâåòå (ââèäó ïðîáëåì ñ ôóíäóñ- êàìåðîé íå ìîãó Âàì ïîêàçàòü). Âïðî÷åì, ïàðåíü óòâåðæäàåò, ÷òî "ïëàâàþùèå ìóøêè" ïîÿâèëèñü èìåííî íåäàâíî, îäíîâðåìåííî ñî ñíèæåíèåì çðåíèÿ íà ïðàâîì ãëàçó. Ëåâûé ãëàç âèäèò õîðîøî. Ñêîòîìû íå ÷óâñòâóåò. Ïåðèìåòðèÿ èíòàêòíà (ïðàâäà, ìèêðîñôåðîïåðèìåòðà ó íàñ íåò). Âñÿ÷åñêèå òîêñè÷åñêèå óâëå÷åíèÿ ñ íåãîäîâàíèåì îòðèöàåò. Çàòìåíèåì íå ëþáîâàëñÿ, ëàçåðíûõ øîó íå ïîñåùàë. È âñ¸ ðàâíî ÿ ïðåæäå âñåãî äóìàþ î ôîòîòðàâìàòèçìå. À âû, ãëóáîêîóâàæàåìûå êîëëåãè? [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#52
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ÿ åù¸ äîáàâëþ, ÷òî îí ïðèíèìàë â òå÷åíèå 3 ìåñÿöåâ ðîàêêóòàí (èçîòðåòèíîèí)- áèîëîãè÷åñêè àêòèâíóþ ôîðìó âèòàìèíà À, è õðîíîëîãè÷åñêè æàëîáû âîçíèêëè íà ôîíå ïðè¸ìà ýòîãî ëåêàðñòâà.
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#53
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Öèòàòà:
Äåôåêò òåìíåå èëè ñâåòëåå ôîíà ïðè îôòàëüìîñêîïèè? |
#54
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òåìíåå. Íî ìíå êàæóòñÿ íàðóæíàÿ ïîãðàíè÷íàÿ ìåìáðàíà è ïèãìåíòíûé ýïèòåëèé íåïîâðåæä¸ííûìè (âåðîÿòíî, ïîâðåæäåíà ìåìáðàíà Âåðõãîôà). Ñïàñèáî çà îòçûâ.
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#55
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"Ìåìáðàíà" Âåðõîôôà - ýòî êîíöû íàðóæíûõ ñåãìåíòîâ ôîòîðåöåïòîðîâ.
Ìîæåò áûòü ýòî Occult Macular Dystrophy, ïî êðàéíåé ìåðå íåìíîãî ïîõîæå. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Åñëè íå÷åì îöåíèòü öåíòðàëüíîå ïîëå çðåíèÿ - åñòü òåñò 9 òî÷åê èëè ðåøåòêà Àìñëåðà. |
#56
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ãäå òî÷êà ôèêñàöèè? Ïîïðîáóéòå ìàëåíüêóþ ïðèçìó - ÷òî áóäåò?
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#57
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Âîîáùå âûãëÿäèò êàê ñîëÿðíàÿ ìàêóëîïàòèÿ.
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#58
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Ïåðâîå îáðàùåíèå ãîä íàçàä OS Òîò æå ãëàç 22.05.  îäíîé âûïèñêå íàïèñàíî, ÷òî áûëà èíúåêöèÿ àâàñòèíà, íî îíà ýòîãî íå ïîäòâåðæäàåò. OD- ïåðâûé ñêàí ãîä íàçàä - íîðìà. Ñëåäóþùèå 2 ñêàíà ñîñòîÿíèå íà 22.05 Äîðîãèå äðóçüÿ, êîëëåãè! Îáðàòèëàñü ïàöèåíòêà, âûïîëíèë òîëüêî ÎÑÒ, îáùåãî îñìîòðà íå äåëàë.  ïðîøëîì ãîäó ÿ ñòàâèë DS: ÑÍÌ è åãî ïîäòâåðäèëè íà ÔÀÃ. ×òî ñ ïðàâûì ãëàçîì? Íà÷èíàåòñÿ ÕÍÂ? Ìîëîäîé âîçðàñò, îáà ãëàçà... Ñïàñèáî! |
#59
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íà ëåâîì ãëàçó ïðîöåññ â õîðèîèäåå, íà ïðàâîì â ñåò÷àòêå - íàäî ïîäóìàòü... Íàïîìíèòå, ïëèç, êóäà ñìîòðåòü - ãäå áûëî ïåðâîå îïèñàíèå -æàëîáû è ò.ä.?
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#60
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ÈÌÕÎ äà. Íà÷èíàåòñÿ. Êàêîé vis? ß áû íàâåðíîå íàáëþäàë ïîêà åæåìåñÿ÷íî ïðè âîçíèêíîâåíèè îò¸êà èëè ëàçåð èëè a/VEGF. Íàâåðíîå ïðè ëîêàëüíîé ÕÍ ñêîðåå ëàçåð. Õîðîøèå ðåçóëüòàòû ïîëó÷àþòñÿ. È çðåíèå ëèáî âûøå ëèáî òî æå ÷òî è äî ëàçåðà. Íèæå íè ðàçó íå áûëî.
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