病例23　36岁男性，眼红、畏光，伴视力下降2天（角膜移植术后2年）

CASE 23　A 36-year-old male with penetrating keratoplasty for 2 years complaining of eye redness, photophobia and vision decreased for 2 days

见图1-38。See Fig. 1-38.

鉴别诊断

Differential Diagnosis

◎ 角膜植片排斥：可以发生在角膜移植术后任何时间，患眼突然充血，疼痛畏光伴视力下降，角膜植片水肿，植片出现上皮排斥线，或基质浸润，或内皮排斥线及角膜后沉着物。

◎ Corneal endothelial graft rejection: It can occur at any time post keratoplasty. The affected eyes presented with suddenly congestion, pain and phot o p h obia combined with vision loss. The grafts are edema with epithelial rejection line, or stromal inf ilt r ation, or endothelial rejection line and keratic precipitates.

◎ 角膜植片慢性失功：一般发生在角膜移植术后1年以上，出现无症状的视力下降，角膜植片全层水肿，无排斥迹象。

◎ Graft dysfunction: After one year of operation, there is no special reason for graft function prog r e s sive decline,which eventually leads to the opacity of the grafts, also known as “graft failure” (no infla m m a t ion).

◎ 病毒性角膜炎：患者多有前驱感冒症状，角膜可以显示小的凸起的透明的囊泡，树枝状溃疡。神经营养性角膜病变的早期症状包括角膜表面不规则和点状上皮糜烂。坏死性角膜基质炎的特征是角膜基质浸润、溃疡和坏死。免疫性角膜基质炎(ISK)临床上可表现为局限性、多灶性或弥漫性细胞浸润、免疫环、新生血管或角膜血管影。结膜充血伴水样分泌物增多，眼压升高，需要联合全身抗病毒治疗。

◎ Viral keratitis: Most patients have precursor sym p t oms such as cold. The cornea could show small, raised, clear vesicles, dendritic ulcers. The earliest signs of neurotrophic keratopathy include an irregular corneal surface and punctate epithelial erosions. Ne c r otizing stromal keratitis is characterized by dense stromal inf iltrate, ulceration,and necrosis. Immune stromal keratitis (ISK) may present clinically with focal, multifocal, or diffuse cellular inf iltrates; imm u ne rings; neovascularization; or ghost vessels at any level of the cornea. Conjunctival congestion with the increase of aqueous secretion can be found. The IOP may be elevated. The treatment needs to be combined with systemic antiviral drug.

病史询问

Asking History

◎ 角膜移植的手术时间及原发病。

◎ Asking original disease and the operation of corneal transplantation.

◎ 术后抗排斥用药是否规律及症状出现时间。

◎ Asking the usage of anti-rejection drugs post operation and onset of the symptoms.

◎ 近期是否有发烧、不适和上呼吸道症状。

◎ Asking fever, malaise and upper respiratory tract symptoms.

检查

Examination

◎ 视力、眼压。

◎ Vision, IOP.

◎ 裂隙灯检查：结膜充血，角膜植片增厚，角膜基质浸润、血管化以及缝线的完整性。可发现上皮排斥反应线或内皮排斥反应线以及角膜后沉着物。

◎ Slit lamp examination: Conjuctiva congestion, corneal graft thickening, transparency, inf iltration, neovasculization,intact suture and exposure. Epithelial rejection line,endothelial rejection line or keratic precipitates may be found.

实验室检查

Lab

◎ 结膜囊取分泌物镜检及培养。

◎ Microbiologic examination and culture of conjun c tival sac secretion.

诊断

Diagnosis

角膜移植术后排斥（内皮型）。

Corneal endothelial graft rejection.

治疗（图1-39）

Management (Fig. 1-39)

◎ 激素冲击治疗，糖皮质激素滴眼液频点，每1小时1次持续1天，之后每2小时1次，持续3天，口服泼尼松每天40~80mg或全身静脉滴注甲泼尼龙500mg，必要时联合结膜下注射地塞米松3mg。同时可联合使用环孢素或他克莫司。局部预防性应用抗生素。如伴随眼压升高，须联合抗青光眼滴眼液。

◎ The frequency of glucocorticoid eye drops is 1 hour for 1 day, and then every 2 hours for 3 days. Oral take prednisone 40 to 80 mg per day or systemic intravenous methylprednisolone 500 mg. If necessary, combined with subconjunctival dexamethasone 3 mg. At the same time,cyclosporine or tacrolimus can be used in combination. If IOP increase, add anti-glaucoma drops.

患者教育和预后

Patient Education & Prognosis

◎ 角膜移植较其他器官移植排斥发生概率低，但高危患者术后依然可以出现排斥反应，角膜移植术后需要长期规律用药。

◎ The rejection rate of keratoplasty is lower than that of other organ transplantation, but rejection can still occur in high-risk patients, and regular medication is needed for a long time after keratoplasty.

◎ 出现眼红、畏光、视力下降、眼痛的情况，要及时就诊。就诊及时预后很好，若延迟1~2周预后较差。

◎ Educate patients to recognize symptoms of rejection and to seek treatment. The prognosis was good for patients who get an in-time treatment, but poor if delayed for 1 to 2 weeks.