病例17　58岁中年男性主诉左眼视力下降、眼痛1周

CASE 17　A 58-year-old male complaining of left eye blurred vision and pain for 1 week

见图1-27。See Fig. 1-27.

鉴别诊断

Differential Diagnosis

◎ 真菌性角膜炎：通常有植物接触史或外伤史，病灶隆起、菌丝苔被、不规则羽毛状边缘、质地干燥粗糙和卫星灶等特征性表现。

◎ Fungal keratitis: It is usually caused by trauma with plants, especially by crops. Clinical f indings such as elevated areas, hyphae (branching) ulcers, irregular feathery margins,a dry rough texture, and satellite lesions, are suggestive of filamentous fungal keratitis.

◎ 细菌性角膜炎：细菌性角膜炎发生速度快，进展迅速，一般发生在角膜外伤或角膜异物取出术后。

◎ Bacterial keratitis: Bacterial keratitis always progressed rapidly. Trauma, contact lens and surgery are risk factors.

◎ 棘阿米巴性角膜炎：通常有接触镜配戴史及污水接触史。眼痛剧烈。

◎ Acanthamoeba keratitis: Usually with contact lens wearing history and sewage exposure history. The eye pain is severe.

◎ 病毒性角膜炎：可伴感冒、发热等症状，常反复发作。

◎ Virus keratitis: Usually accompanied by cold and fever,repeated attacks.

病史询问

Asking History

◎ 是否有过植物、农作物接触史，是否有外伤史，是否有角膜接触镜配戴史。

◎ History of eye trauma, especially with plants trauma,history of wearing of contact lens.

◎ 是否有污水接触史，肿瘤或手术史、类固醇或抗生素滴眼液使用史、HSV感染史，既往有哪些眼部疾病，有哪些伴眼部症状的全身疾病史，有无免疫性疾病。

◎ History of contact with contaminated water, tumor or surgery, long term usage of steroid or antibiotic eye drops,HSV infection history, other eye disorders, systemic diseases with ocular manifestations, immune system diseases.

眼部检查

Examination

◎ 视力、眼压。

◎ Visual acuity, IOP.

◎ 裂隙灯检查：使用荧光素染色辅助观察角膜病灶是否隆起，苔被是否致密，刮除苔被后基质床是否致密，溃疡边缘界限是否清楚，有无卫星灶、免疫环等。

◎ Slit lamp examination: To check the size, location,depth and margin of the lesion. Fluorescein staining is mandatory to check the elevated corneal lesion, rough texture, clear margin of the ulcer, satellite lesions, immune ring, etc.

◎ 共聚焦显微镜检查：是快速诊断真菌性角膜炎的一种直观方法。须在角膜刮片及培养前进行（图1-28，共聚焦显微镜显示大量菌丝）。

◎ Confocal microscope is a visualized diagnostic approach for fungal keratitis. (Added picture Fig. 1-28 shows a mass of mycelium.) It should be performed before corneal scraping and culture.

◎ B超检查，以排除眼内炎及视网膜脱离。

◎ In addition, if there is no view of fundus, B-scan ultrasound should be performed to eliminate endo p h t h a lmitis and retinal detachment.

◎ 前节OCT来确定角膜最薄点的厚度，是否有穿孔的风险。

◎ Anterior segment-OCT could be used to identify and quantify the thinnest point in the presence of corneal thinning.

实验室检查

Lab

◎ 从角膜溃疡灶与正常角膜交界处进行角膜刮片可以提高病原体的检出率，将标本进行涂片镜检和真菌培养。样品制备通常采用10%氢氧化钾(KOH)和革兰氏染色。真菌培养是真菌性角膜炎诊断的金标准。

◎ Cornea scraping specimen from the base and edges of the corneal lesion, specimen should be subjected for microscopic examination and culture. 10% pota s s ium hydroxide (KOH)and Gram staining was nor m ally utilized for sample preparation. Culture is the golden standard of diagnosis.

诊断

Diagnosis

真菌性角膜炎。

Fungal keratitis.

治疗

Management

真菌性角膜炎诊疗复杂，周期较长（数周或数月）。

Medical management of fungal keratitis is problematic. There are no standard guidlines for selecting and adm in istering current antifungals.

◎ 药物治疗

◎ Topical drugs

常用的抗真菌药物有那他霉素、伏立康唑、两性霉素B，初始给药频次可为每1小时1次或每2小时1次，根据病情和患者对药物的反应也可选择结膜下注射、基质注药或全身给药。

Common anti-fungal agents include natamycin,voriconazole and amphotericin B, initially given from Q1H to Q2H. Subconjunctival injection, intrastromal injection or systemic administration are optional according to medication response.

严禁使用局部类固醇类药物。

Topical steroids are strictly forbidden.

前房积脓阳性时使用阿托品或托吡卡胺解除睫状肌痉挛，非甾体抗炎药可减轻前节炎症反应。

Using atropine or tropicamide when hypopyon was present.

Non-steroid eye drops could be used to reduce anterior segment inf lammation.

◎ 手术治疗

◎ Surgery

由于抗真菌类药物对角膜基质的穿透性差，须辅以角膜清创，清除角膜溃疡灶，改善药物穿透力，以提高治疗效果，但不建议频繁做。

To improve therapeutic effect and poor drug penetration through the corneal stroma, debridement of cornea epithelium and ulceration are needed. But it’s not recommended to do it frequently.

当患者对药物不敏感时可行角膜基质注药术。

Corneal stromal injection is performed when drug reaction is poor.

结膜瓣覆盖手术通常在对药物反应良好，但有角膜穿孔倾向或已经穿孔又不具备角膜移植条件时进行。

Conjunctival f lap surgery is used when there’s some tendency for cornea perforation however medication is valid,or the perforation already happened however penetration keratoplasty is not available.

中浅层角膜溃疡，且对药物反应不佳时可采用板层角膜移植。

Lamellar corneal transplantation is applied in the middleshallow layer corneal ulceration where drug treatment is ineffective.

当患者对药物反应不佳，角膜溃疡扩大或角膜穿孔形成时，应行穿透性角膜移植术。

Penetration keratoplasty is an effective approach when poor response to medication, ulceration is consistently enlarged or perforation is existed.

患者教育和预后

Patient Education & Prognosis

◎ 病程长、预后差：通常需要几个月的时间，即使角膜溃疡灶完全愈合，大多数角膜溃疡患者将会遗留角膜瘢痕，并伴不同程度视力下降。

◎ Longer course, poor prognosis: The patient should be acknowledged that the treatment course is relatively long,it would take months before the keratohelcosis healing.Most cases like these would lead to cornea scar and decreased vision.

◎ 如真菌感染不能控制或发生角膜穿孔时，须立即行角膜移植术或结膜瓣覆盖术。

◎ The patient should be monitored daily and kept an eye on the thinnest point. Explain to the patient in case of cornea perforation, conjunctival f lap or keratoplasty are needed immediately.

◎ 如手术不能控制感染，可能发展为真菌性眼内炎时须行眼球摘除，严重者可致颅脑感染。

◎ If the operation can not control the infection, it may develop into fungal endophthalmitis when ophthalmectomy is needed, severe cases can lead to craniocerebral infection.