病例6　52歲女性，主訴左眼眼紅、眼痛1周

CASE 6　A 52-year-old female complaining of left eye redness and severe pain for one week

見圖1-9。See Fig. 1-9.

鑒別診斷

Differential Diagnosis

◎ 彌漫性前鞏膜炎：鞏膜炎是以炎癥細胞浸潤、膠原破壞、血管改變為病理特征的鞏膜炎癥性疾病，可由自身免疫性疾病、代謝性疾病或感染引起，患者年齡偏大。鞏膜炎分為前部及后部鞏膜炎，其中前部鞏膜炎最多見，約占98%。前部鞏膜炎又分為兩種類型：非壞死性及壞死性鞏膜炎，以前者最多見。根據形態，非壞死性鞏膜炎可分為彌漫性及結節性鞏膜炎。壞死性鞏膜炎在前部鞏膜炎中約占13%。彌漫性前部鞏膜炎典型癥狀為眼紅、眼痛，常累及同側頭部或面部疼痛，可伴視力下降。典型體征為鞏膜前段彌漫性充血，呈暗紅色或藍紫色，不因局部使用2.5%去氧腎上腺素而收縮變白，不能被棉簽推動，伴表面結膜充血水腫，有局部壓痛。

◎ Diffuse anterior scleritis: Scleritis is an inf lammation of the sclera characterized by cellular inf iltration, destruction of collagen and vascular remodeling, which is associated with autoimmune diseases, metabolic diseases or infection, patients tend to be older. Scleritis is classif ied as anterior scleritis and posterior scleritis. Anterior scleritis is the most common variety, accounting for about 98% of the cases. It is of two types: non-necrotising and necrotising. Non-necrotising scleritis is the most common, and is further classif ied into diffuse and nodular type based on morphology. Necrotising scleritis accounts for about 13% of anterior scleritis. Typical symptoms of diffuse anterior scleritis are redness, severe eye pain, which may radiate to the ipsilateral side of the head or face, and it may be accompanied with decreased vision. Typical signs are diffuse dark red or purple-bluish congestion in the anterior sclera that does not blanch with 2.5%phenylephrine drops, and cannot be moved with a cotton swab, accompanying with exterior conjunctival congestion,edema and local tenderness.

◎ 表層鞏膜炎：這是鞏膜表面血管結締組織的炎癥反應性疾病，導致鞏膜表面血管充血，可被棉簽推動，局部使用2.5%去氧腎上腺素后充血蒼白消退。病灶通常位于瞼裂區，呈局部彌漫性或結節性充血。患者多見于青中年，除眼紅外，可有眼部輕微刺激癥狀及不適，通常不伴明顯眼痛及視力下降，可反復發作，持續時間短，約2周左右，有自限性。

◎ Episcleritis: It is an inf lammatory disease of the vascularized connective tissue overlying the sclera, which reveals episcleral injection. The vessels can be moved with a cotton swab and can be constricted with topical 2.5% phenylephrine. The lesion is more common in the interpalpebral area and presents locally diffuse or nodular congestion. The patients are mainly young adults. The main symptom is redness, accompanying with mild irritation or discomfort without severe pain or decreased vision generally. Episcleritis is usually transient and selflimited within 2 weeks, but can recur.

◎ 感染性鞏膜炎：通常由手術、創傷或周邊組織感染（如感染性角膜炎、感染性眼內炎）引起，少數由全身性感染性疾病（如梅毒、結核病）引起的鞏膜感染性疾病。典型表現為鞏膜潰瘍，鞏膜膿腫伴膿性滲出，可見前房積膿。

◎ Infectious scleritis: It is an infection of the sclera. It is usually caused by surgery, trauma, or extension from contiguous infections, such as infectious keratitis or infectious endophthalmitis. It is less frequent associated with systemic infections such as syphilis and tuberculosis. Key clinical features include scleral ulcers, scleral abscesses with purulent exudates, and scleritis associated with hypopyon.

◎ 結膜炎：這是一類以結膜血管擴張、滲出為特征的疾病，可發生于任何年齡。主要臨床癥狀包括眼紅及眼部分泌物，可伴眼痛、眼異物感、眼癢等。結膜充血呈鮮紅色，推之可移動，局部使用2.5%去氧腎上腺素后充血消退。瞼結膜可受累，出現濾泡、乳頭或假膜。

◎ Conjunctivitis: It is characterized by dilatation and exudation of conjunctival vessels at any age. The main clinical symptoms are redness and discharge, may accompanying with eye pain, foreign body sensation, itching,etc. Conjunctival hyperemia shows bright red hue and the expanded vessels are removable, which can be constricted with topical 2.5% phenylephrine. Tarsal conjunctiva often be involved in and associated with follicles, papillae or pseudomembrane appearance.

◎ 急性前葡萄膜炎：主要癥狀有眼紅、眼疼、畏光及視力下降等。典型體征有睫狀充血、角膜后沉著物(KP)、房水閃輝、房水細胞等。充血呈深紅色，環繞角膜緣，推之不移動。

◎ Acute anterior uveitis: The main symptoms are redness,eye pain, photophobia, and decreased vision. Typical signs are ciliary f lush, keratic precipitates (KP), aqueous f lare and aqueous cell. Ciliary f lush is dark red and immovable,which surrounds the limbus.

◎ 炎性瞼裂斑：黃白色、扁平或輕微隆起的結膜炎癥性病變，病變多發于鼻側或顳側。結締組織由病變部位延伸至角膜緣，但不累及角膜。病灶周邊結膜充血，通常雙眼發病。

◎ Inf lamed pinguecula: yellow-white, f lattened or slightly elevated conjunctival inf lammatory lesion adjacent to the nasal or temporal side of the limbus and usually occurring in both eyes. Connective tissue extends from the lesion to the limbus, but does not involve the cornea. Surrounding conjunctival injection may be associated.

◎ 角膜接觸鏡性眼病：可由角膜接觸鏡沉淀物、鏡片過緊或護理液毒性反應等角膜接觸鏡配戴時的相關問題導致，出現畏光、異物感、眼痛、眼紅、視力下降、不耐受角膜接觸鏡等癥狀。角膜接觸鏡配戴者須關注。

◎ Contact lens-related problems: May be caused by contact lens deposits, tight lens syndrome or toxicity reactions to contact lens solution. Symptoms are photophobia, foreign body sensation, pain, red eye, decreased vision, contact lens intolerance. Must be considered in all contact lens wearers.

病史詢問

Asking History

◎ 眼部癥狀出現及進展情況，除了眼紅、眼痛（可放射至同側面頰及頭部），是否伴隨視力下降、畏光、眼部分泌物等癥狀。

◎ It is imperative to ask about the onset and progre s s ion of ocular symptoms, such as eye pain (which may radiate to the ipsilateral side of the cheek or head), redness, decreased vision, photophobia and discharge, etc.

◎ 既往是否有自身免疫性疾病（如結節病、類風濕性關節炎等）、結核病、代謝性疾病等，有無頭痛、過敏史、眼部外傷史或手術史。

◎ Patients should also be asked about a history of autoim mune diseases (such as sarcoidosis, rheumatoid arthritis,etc), tuberculosis, metabolic diseases; the history of hea d ac he, allergies, eye trauma and surgery.

◎ 是否有角膜接觸鏡配戴史。

◎ And the history about wearing contact lens.

◎ 該病例合并類風濕性關節炎。

◎ This case has rheumatoid arthritis.

檢查

Examination

◎ 視力：可能伴漸進性或急性視力下降。

◎ Visual acuity: decreased vision onset may be gradual or acute.

◎ 眼壓：根據不同病因，可能出現眼壓升高。

◎ IOP: Depending on the etiology, intraocular pressure may increase.

◎ 鞏膜外觀檢查：鞏膜炎在自然光或室內呈現紫藍色充血外觀，檢查時須提拉眼瞼以便明確充血范圍。

◎ Sclera appearance examination: Scleritis is best detected as purple-bluish congestion by examining the sclera under natural or room light; retracting the lids helps determine the extent of involvement.

◎ 裂隙燈檢查：除檢查充血部位及特征外，應注意排除有無瞼結膜充血、濾泡乳頭，有無角膜內皮KP、房水閃輝、房水細胞等表現。局部使用2.5%去氧腎上腺素后觀察充血是否變白消退，有助鑒別鞏膜炎與表層鞏膜炎，前者點藥后充血不消退，后者相反。

◎ Slitlamp examination: In addition to characteristic congestion, the below signs, such as tarsal conjunctival congestion, follicles, papillae, corneal endothelial KP, aqueous f lare, aqueous cell and other relative manifestations should also be noted. Scleritis may be differentiated from episcleritis by using 2.5% phenylephrine drops, which causes blanching of the blood vessels in episcleritis, but not in scleritis.

◎ 眼底檢查：懷疑后部鞏膜炎時，應進行眼底檢查。

◎ Fundus examination: should be performed when posterior scleritis is suspected.

◎ 眼球按壓檢查：充血部位是否有壓痛。

◎ Press eyeball: to check if there is tenderness over the area of scleral congestion.

◎ 懷疑后部鞏膜炎時，行以下檢查。

◎ Perform the following examinations when posterior scleritis is suspected.

B超：鞏膜壁是否有厚度改變。后部鞏膜炎，B超可顯示眼球后壁T形征。

B-scan: check the changes in the thickness of the scleral wall.B-scan detect T signe, which help to differential posterior scleritis.

眼底光學相干斷層掃描(OCT)：是否有脈絡膜皺褶和視網膜下液。

Posterior segment OCT: check choroidal folds and subretinal f luid.

熒光素眼底血管造影(FFA)：了解眼底血管滲漏情況（后鞏膜炎可有視網膜血管多發針尖樣滲漏）。

Fundus f luorescein angiography: check the leakage of vessels in the fundus (posterior scleritis can have retinal vascular pinpoint leakage).

實驗室檢查

Lab

◎ 血常規、免疫學檢查（紅細胞沉降率、C反應蛋白、類風濕因子、抗核抗體等），排除是否合并自身免疫性疾病或感染；血清尿酸檢測，排除是否合并痛風。

◎ Complete blood count, immunologic tests (blood sedimentation, C-reactive protein, rheumatoid factor,antinuclear antibodies, etc) should be done in order to rule out the autoimmune diseases or infection. Uric acid should be tested if gout is suspected.

◎ 若懷疑感染，進一步行涂片鏡檢及培養。

◎ If infection is suspected, further scraping for microscopy examination and culture should be performed.

診斷

Diagnosis

彌漫性前部鞏膜炎。

Diffuse anterior scleritis.

治療

Management

◎ 局部治療：輕癥患者可考慮激素類滴眼液，可聯合局部非甾體抗炎藥。嚴重鞏膜炎及壞死性鞏膜炎時應禁用局部激素。

◎ Topical treatment: Mild cases can use cortico s t er oids eye drops, combined with topical non-steroidal antiinf lammatory drugs (NSAIDs). Corticosteroids is never for severe scleritis and necrotizing scleritis.

◎ 若合并葡萄膜炎及眼底病變，給予相應治療。

◎ If the patients are combined with uveitis or fundus diseases, the corresponding treatments should be provided.

◎ 全身治療：眼部病情較重或合并明確的活動性全身免疫性疾病者，可聯合全身藥物治療。

◎ Systemic treatments: for severe scleritis or whom accompanying with active systemic immune diseases.

口服非甾體抗炎藥：如氟比洛芬、吲哚美辛、萘普生等，緩解炎癥性疼痛。

Oral NSAIDs: f lurbiprofen, indomethacin or naproxen can be applied for relieving inf lammatory pain.

口服激素：非甾體抗炎藥無效時，考慮激素治療。視病情變化，持續口服激素1~2周后，逐漸減量使用。其間配合補充鉀和鈣，以預防骨質疏松；激素用量較大者可考慮應用靜脈注射激素3日后改為口服。

Systemic corticosteroids: steroids therapy should be considered when oral NSAIDs is ineffective. According to the changes of disease, the patients should maintain steroids treatment for 1 to 2 weeks, then taper the dosage slowly. Potassium and calcium should also be supplemented to prevent osteoporosis during steroids treatment. The patients who need a high dosage of steroids can be considered the intravenous corticosteroids for 3 days and then replaced by oral way.

免疫抑制劑：上述方案治療不佳或激素用量較大者，可在相關專科醫師指導下使用免疫抑制劑（如環磷酰胺、硫唑嘌呤、環孢素等），聯合應用可降低口服激素劑量。

Immunosuppressive therapy: if above treatments are ineffective or in the case of a large dosage of steroids treatment, immunosuppressants (e.g., cyclophosphamide,azathioprine, cyclosporine) can be chosen under the specialized guidance to reduce the dose of steroids.

◎ 控制活動性全身免疫性或代謝性疾病。

◎ Control active systemic immune diseases or metabolic diseases.

◎ 其他：若確診為感染性鞏膜炎，選擇敏感性抗生素，并慎重選擇激素及免疫抑制劑。

◎ Others: sensitive antibiotics should be used in infectious scleritis cases and in that condition, steroids and immunosuppressants should be considered carefully.

患者教育和預后

Patient Education & Prognosis

◎ 本病病程持續較久，可持續1個月以上，可復發。須規范持續治療，定期眼科復查。

◎ Diffuse anterior scleritis can last for more than 1 month and tend to recur. Patients should have a standardized continuous treatment under strict follow-up.

◎ 積極控制原發病，預后情況在很大程度上取決于原發全身性疾病是否得到充分治療及控制。注意觀察用藥期間有無產生副作用，必要時定期復查免疫指標。

◎ Actively control of the primary diseases. The prognosis depends greatly on whether the primary systemic disease can be treated adequately. Pay attention to the side effects of the drugs, and test the immune indexes regularly if necessary.