病例5　85歲女性，右眼間斷性異物感、眼痛、流淚伴視物模糊半年余

CASE 5　A 85-year-old female complaining of right eye blurry vision with intermittent foreign body sensation, pain and tearing for more than half a year

見圖1-7。See Fig. 1-7.

鑒別診斷

Differential Diagnosis

◎ 大泡性角膜病變：患者多有內(nèi)眼手術(shù)史（最多見于白內(nèi)障術(shù)后人工晶狀體眼或無晶狀體眼伴玻璃體疝接觸角膜內(nèi)皮）、Fuchs角膜內(nèi)皮營(yíng)養(yǎng)不良（圖1-8）、青光眼病史等。角膜內(nèi)皮細(xì)胞數(shù)量明顯降低或內(nèi)皮功能下降致失代償。視力下降，角膜上皮霧狀水腫，單個(gè)或多發(fā)大泡，大泡易破裂導(dǎo)致突發(fā)的異物感、疼痛、畏光、流淚等癥狀，隨著上皮修復(fù)，癥狀可緩解，該病可反復(fù)發(fā)生。

◎ Bullous keratopathy: Most of the patients with bullous keratopathy have the histories of intraocular surgery(IOL eye or aphakic eye with vitreous hernia contacting endothelium), or Fuchs corneal endothelial dystrophy(Fig. 1-8), or glaucoma, etc. The quantity of corneal endothelial cells signif icantly decreased led to endothelium dysfunction and severe cornea edema. The cornea appears hazy or opaque which also reduces vision. Single or multiple bullae in the corneal epithelium rupture easily which trigger sudden foreign body sensation, eye pain,photophobia and tearing. The symptom can be improved with the epithelium repaired. But the process occurs repeatedly.

◎ 角膜上皮剝脫：角膜上皮剝脫通常與外傷、嚴(yán)重干眼有關(guān)，患者多眼疼、流淚及睜眼困難，裂隙燈顯示局部上皮缺損。

◎ Corneal epithelial exfoliation: This disease is usually related to trauma and severe dry eye. The patient complains of painful, tearing and difficulty opening eyes. Certain part of epithelium defect can be examined using a slitlamp.

◎ 角膜內(nèi)皮炎：角膜內(nèi)皮炎是原發(fā)于角膜內(nèi)皮的炎癥導(dǎo)致角膜功能障礙，病毒感染及自身免疫反應(yīng)是主要發(fā)病原因，裂隙燈可見角膜水腫、角膜后沉著物以及輕度前房反應(yīng)。

◎ Corneal endotheliitis: The inf lammation originates from endothelium and can lead to corneal endothelium dysfunction. Virus infection such as herpes, and autoimmune reaction are the main causes. Corneal edema, keratic precipitates and mild anterior chamber reaction can be observed by a slitlamp.

病史詢問

Asking History

◎ 疾病出現(xiàn)的時(shí)間、是否反復(fù)、是否患有其他眼部疾病（青光眼、慢性葡萄膜炎、Fuchs角膜內(nèi)皮營(yíng)養(yǎng)不良等）。

◎ Asking the duration of disease, similar episodes, other eye diseases (glaucoma, chronic uveitis, Fuchs endothelial dystrophy, etc).

◎ 是否有眼部手術(shù)史（白內(nèi)障手術(shù)或其他眼內(nèi)手術(shù)）及家族病史（Fuchs角膜內(nèi)皮營(yíng)養(yǎng)不良有家族遺傳傾向）。

◎ The history of eye surgery (cataract surgery or other intraocular surgery), the family medical history (Fuchs endothelial dystrophy).

檢查

Examination

◎ 視力：霧視，一般晨起重，下午可以改善。嚴(yán)重患者刺激癥狀明顯，難以睜開眼睛。病程較長(zhǎng)者，基質(zhì)層混濁明顯，視力顯著降低。

◎ Visual acuity: Foggy vision is the most severe in the morning in mild cases and can be improved in the afternoon. In severe cases, the irritation symptoms are obvious and it is difficult to open eyes. In cases with a long course of disease, the stromal layer is turbid and the visual acuity is signif icantly reduced.

◎ 裂隙燈檢查：角膜上皮呈霧狀，可伴單發(fā)或多發(fā)大小不等的上皮水泡，角膜基質(zhì)增厚水腫，后部角膜不清或混濁。病程持續(xù)者，角膜基質(zhì)新生血管長(zhǎng)入，基質(zhì)層逐漸混濁。

◎ Slitlamp examination: The corneal epithelium is foggy,with single or multiple epithelial vesicles of different size,stroma edema and thickening. The deep layer of cornea unclear or opacity. As the course of the disease continues,some signs occur including neovascularization into stroma and stromal layer opacity gradually.

實(shí)驗(yàn)室檢查

Lab

◎ 角膜共聚焦顯微鏡：角膜內(nèi)皮細(xì)胞計(jì)數(shù)通常低于500個(gè) /mm²，共聚焦顯微鏡顯示角膜內(nèi)皮細(xì)胞異常增大，如伴Fuchs角膜內(nèi)皮營(yíng)養(yǎng)不良可見角膜內(nèi)皮細(xì)胞間大小不一、類圓形高反光贅疣，大量贅疣可融合，內(nèi)皮細(xì)胞增大、失去多邊形結(jié)構(gòu)，甚至結(jié)構(gòu)不清。

◎ Confocal microscope: Endothelial cell density usually less than 500/mm², abnormal endothelial cells enlargement.The patient with Fuchs endothelial dystrophy has some special signs including different sizes of corneal endothelial cells, round-like highly ref lective excrescence, a large number of verruca can be fused, abnormal endothelial cell swell, lose polygonal structure or even unclear structure.

◎ 基因檢測(cè)：Fuchs角膜內(nèi)皮營(yíng)養(yǎng)不良的患者可行基因檢測(cè)。

◎ Gene detection: It is available for Fuchs endothelial dystrophy patient.

診斷

Diagnosis

大泡性角膜病變。

Bullous keratopathy.

治療

Treatment

◎ 高滲劑：50%葡萄糖溶液或5%鹽水局部滴用可減輕角膜水腫。

◎ Hypertonic solution(50% hypertonic glucose, 5%normal saline)can reduce corneal edema.

◎ 抗生素眼藥水或眼藥膏可預(yù)防感染。

◎ Antibiotic eye drops or ointment to prevent infection.

◎ 人工淚液、角膜營(yíng)養(yǎng)類滴眼液及角膜繃帶鏡可緩解眼部刺激癥狀，促進(jìn)上皮愈合。

◎ Artif icial tears, corneal nutrition eye drops and bandage contact lens can relieve eye irritation symptoms and pr om ote epithelial healing.

◎ 手術(shù)治療包括角膜內(nèi)皮移植術(shù)、穿透性角膜移植術(shù)、角膜層間燒灼術(shù)以及結(jié)膜瓣覆蓋術(shù)。

◎ Surgical treatment includes corneal endothelial transp l antation, penetrating keratoplasty, corneal lamellar cauterization and conjunctival f lap covering.

患者教育和預(yù)后

Patient Education & Prognosis

◎ 該疾病病因是各種原因?qū)е碌慕悄?nèi)皮細(xì)胞數(shù)量降低或功能下降致角膜內(nèi)皮失代償。疾病不可逆，非手術(shù)治療只可緩解癥狀，不能提高角膜內(nèi)皮細(xì)胞數(shù)量或提高視力。

◎ The etiology of this disease is corneal decom p e n s ation caused by the decrease of corneal endothelial cells number or function. The disease is irreversible, non-surgical treatment can only alleviate symptoms, can not increase the number of corneal endothelium cells, or improve vision.

◎ 疾病最終為角膜混濁并形成瘢痕，癥狀或可減輕。對(duì)仍有潛在視力的患者，可選擇角膜內(nèi)皮移植手術(shù)緩解癥狀并提高視力。但對(duì)于因青光眼等嚴(yán)重疾病導(dǎo)致的角膜內(nèi)皮失代償，提高視力的可能性較小。

◎ The outcome of the disease may be corneal op a cif ica tion and scarring, the symptoms may be reli ev ed. For patients who still have potential vision, cor neal endothelial transplantation can be selected to relie ve symptoms and improve vision. But for end ot helial decompensation caused by serious diseases such as glaucoma, it is less likely to improve vision.