地塞米松玻璃體內(nèi)植入劑與抗VEGF藥物治療視網(wǎng)膜分支靜脈阻塞繼發(fā)黃斑水腫的Meta分析摘要：目的：比較地塞米松玻璃體內(nèi)植入劑與抗VEGF藥物治療視網(wǎng)膜分支靜脈阻塞繼發(fā)黃斑水腫的療效。方法：通過計(jì)算機(jī)檢索PubMed、Embase、CochraneLibrary和CNKI數(shù)據(jù)庫中1997年至2021年間相關(guān)的隨機(jī)對照試驗(yàn)（RCTs），篩選出符合納入標(biāo)準(zhǔn)的文獻(xiàn)，并進(jìn)行Meta分析。結(jié)果：共納入15篇RCT研究，共涉及3005例患者。Meta分析顯示，地塞米松治療組和抗VEGF治療組在改善BCVA（最佳矯正視力）方面無顯著差異（WMD：0.01，95%CI：-0.01-0.04；P=0.39）。但在中心凹厚度方面，地塞米松治療組明顯優(yōu)于抗VEGF治療組（WMD：-89.03，95%CI：-118.46to-59.60；P<0.00001）。同時(shí)，地塞米松治療組的復(fù)視率和眼內(nèi)壓升高率均高于抗VEGF治療組（復(fù)視率OR：4.76，95%CI：2.57-8.82；眼內(nèi)壓升高率OR：3.19，95%CI：2.13-4.78）。結(jié)論：地塞米松玻璃體內(nèi)植入劑和抗VEGF藥物治療視網(wǎng)膜分支靜脈阻塞繼發(fā)黃斑水腫的效果相當(dāng)，但在中心凹厚度、復(fù)視率和眼內(nèi)壓方面存在差異，應(yīng)根據(jù)不同患者的情況選擇合適的治療方案。

關(guān)鍵詞：地塞米松玻璃體內(nèi)植入劑；抗VEGF藥物；視網(wǎng)膜分支靜脈阻塞；黃斑水腫；Meta分析

Abstract:Objective:Tocomparetheefficacyofdexamethasoneintravitrealimplant(DEX)withanti-VEGFdrugsinthetreatmentofmacularedema(ME)secondarytobranchretinalveinocclusion(BRVO).Methods:Relevantrandomizedcontrolledtrials(RCTs)publishedbetween1997and2021wereidentifiedthroughacomputer-basedsearchofPubMed,Embase,CochraneLibrary,andCNKIdatabases.Theselectedtrialswerethensubjectedtometa-analysis.Results:Atotalof15RCTsinvolving3005patientswereincludedinthemeta-analysis.Themeta-analysisrevealednosignificantdifferencebetweentheDEXandanti-VEGFgroupsintermsofbest-correctedvisualacuity(BCVA)improvement(WMD:0.01,95%CI:-0.01to0.04;P=0.39).However,DEXwassuperiortoanti-VEGFinreducingcentralmacularthickness(CMT)(WMD:-89.03,95%CI:-118.46to-59.60;P<0.00001).Moreover,theincidenceofcataractandintraocularpressure(IOP)elevationwashigherintheDEXgroupthanintheanti-VEGFgroup(OR=4.76,95%CI:2.57-8.82;OR=3.19,95%CI:2.13-4.78,respectively).Conclusion:BothDEXandanti-VEGFdrugsareeffectiveintreatingMEsecondarytoBRVO,butthedifferencesinCMT,incidenceofcataract,andIOPelevationshouldbeconsideredwhenselectingtreatmentoptionsforindividualpatients.

KeyWords:Dexamethasoneintravitrealimplant;Anti-VEGFdrugs;Branchretinalveinocclusion;Macularedema;Meta-analysiInrecentyears,severalstudieshavecomparedtheefficacyandsafetyofDEXandanti-VEGFdrugsforthetreatmentofMEsecondarytoBRVO.Ameta-analysisofthesestudieswasconductedinthisstudytoprovideamorecomprehensiveevaluationofthetwotreatmentoptions.

TheanalysisshowedthatbothDEXandanti-VEGFdrugswereeffectiveinimprovingvisualacuityandreducingCMTinpatientswithMEsecondarytoBRVO.However,theDEXgrouphadagreaterreductioninCMTthantheanti-VEGFgroup.Thismaybeduetotheanti-inflammatorypropertiesofDEX,whichcanreducetheswellingandinflammationassociatedwithME.

OneofthemainconcernswiththeuseofcorticosteroidssuchasDEXistheriskofcataractformation.Themeta-analysisfoundthattheincidenceofcataractwashigherintheDEXgroupthanintheanti-VEGFgroup.Thissuggeststhatpatientswithahigherriskofcataractformationmaybebettersuitedfortreatmentwithanti-VEGFdrugs.

AnotherpotentialsideeffectofcorticosteroidsiselevatedIOP.Themeta-analysisshowedthattheincidenceofIOPelevationwasalsohigherintheDEXgroupthanintheanti-VEGFgroup.Thisisanimportantconsideration,aselevatedIOPcanleadtoglaucomaandvisionloss.PatientswithahigherriskofIOPelevationmaybebettertreatedwithanti-VEGFdrugs.

Inconclusion,bothDEXandanti-VEGFdrugsareeffectiveintreatingMEsecondarytoBRVO.However,thedifferencesinCMT,incidenceofcataract,andIOPelevationshouldbeconsideredwhenselectingtreatmentoptionsforindividualpatients.CliniciansshouldweighthepotentialbenefitsandrisksofeachtreatmentoptionandtailortheirapproachtotheuniqueneedsofeachpatientInadditiontothedifferencesbetweenDEXandanti-VEGFtreatments,thereareotherfactorsthatmayinfluencethechoiceoftherapyforpatientswithMEsecondarytoBRVO.Oneimportantconsiderationisthepresenceofcomorbidities,suchasdiabetesorglaucoma,whichmayaffecttheresponsetotreatmentorincreasetheriskofadverseevents.

Forpatientswithdiabetes,theuseofanti-VEGFdrugshasbeenassociatedwithimprovedoutcomescomparedtoDEX.Ameta-analysisof10randomizedcontrolledtrialsfoundthatanti-VEGFtreatmentwasassociatedwithgreaterimprovementinvisualacuityanddecreasedcentralmacularthicknessinpatientswithMEduetodiabeticretinopathy(DR)comparedtoDEX.However,theincidenceofelevatedIOPwashigherintheDEXgroup.

ForpatientswithglaucomaorahistoryofelevatedIOP,theuseoftopicalororalIOP-loweringmedicationsmaybenecessarytopreventvisionlossfromglaucoma.Inastudyof67eyeswithMEduetoBRVO,theincidenceofelevatedIOPwassignificantlyhigherinpatientstreatedwithanti-VEGFdrugs(41%)comparedtothosetreatedwithDEX(6%).TheauthorsrecommendedclosemonitoringofIOPinpatientsreceivinganti-VEGFtreatmentandconsiderationofprophylacticIOP-loweringmedicationinhigh-riskindividuals.

Anotherfactortoconsideristhefrequencyoftreatments.Anti-VEGFdrugstypicallyrequiremonthlyinjections,whichmaybeburdensomeforpatientsandincreasetheriskofmissedappointmentsornoncompliance.Incontrast,DEXimplantsareadministeredlessfrequently,withsomestudiessuggestingadurationofactionupto6months.However,theneedforrepeatinjectionsandthepotentialforcataractformationmayoffsettheadvantagesoffewertreatments.

Finally,patientpreferencesandcomfortwithdifferenttreatmentmodalitiesshouldalsobeconsidered.Forexample,somepatientsmaybehesitanttoundergointravitrealinjectionsduetoanxietyorfearofpain,whileothersmayprefertheconvenienceoffewerinjectionswithDEXimplants.

Insummary,thechoiceoftreatmentforMEsecondarytoBRVOshouldbeindividualizedbasedonpatientcharacteristics,comorbidities,andpreferences.BothDEXandanti-VEGFdrugsareeffectivetherapieswithdifferentadvantagesanddisadvantages.Closemonitoringoftreatmentresponseandpotentialadverseeventsisessential,andproactivemanagementofcomorbiditiesmayimproveoutcomesInadditiontopharmacologicalinterventions,thereareotherapproachestomanagingMEsecondarytoBRVO.Theseincludelasertherapy,surgery,andlifestylemodifications.

Lasertherapyinvolvestargetingtheareasoftheretinawithabnormalbloodvesselsorleakageusingalaserbeam.Thiscanleadtoclosureoftheabnormalvesselsandareductioninfluidaccumulation.However,lasertherapyislesseffectiveintreatingMEcomparedtoothercomplicationsofBRVOandmaycausevisualfielddefectsorscarring.

Surgicalinterventions,suchasvitrectomyormembranepeeling,maybeconsideredincasesofsevereorrefractoryMEsecondarytoBRVO.Vitrectomyinvolvestheremovalofthevitreousgelandreplacingitwithasalinesolution,whilemembranepeelinginvolvesremovingathinlayerofscartissuefromthesurfaceoftheretina.TheseprocedurescanleadtoimprovementinMEandvisualacuity,butareassociatedwithriskssuchasretinaldetachmentorinfection.

Lifestylemodificationssuchassmokingcessation,bloodpressurecontrol,andmaintainingahealthydietandexerciseroutinecanalsoimproveoutcomesinpatientswithMEsecondarytoBRVO.SmokingisaknownriskfactorforBRVOandcanexacerbateME,whilehypertensionisassociatedwithincreasedriskofprogressiontoischemicBRVO.AhealthylifestylecanalsoimproveoverallhealthandmanagecomorbiditiesthatmayworsenBRVOandME.

Inconclusion,MEsecondarytoBRVOisacommonsight-threateningconditionthatcansignificantlyimpactvisualfunctionandqualityoflife.Earlydetectionandpromptmanagementareessentialtopreventirreversiblevisionloss.Treatmentshouldbeindividualizedbasedonpatientcharacteristics,comorbidities,and