病例10　72歲女性，右眼紅痛20天。患者既往類(lèi)風(fēng)濕性關(guān)節(jié)炎病史

CASE 10　A 72-year-old female, with right eye redness and pain for 20 days. The patient has the history of rheumatoid arthritis

見(jiàn)圖1-15。See Fig. 1-15.

鑒別診斷

Differential Diagnosis

◎ 邊緣性角膜潰瘍：是指近角膜緣處角膜基質(zhì)的半月形炎癥性病變，伴隨角膜上皮缺損以及基質(zhì)炎癥浸潤(rùn)。多伴有全身免疫性疾病。

◎ Peripheral ulcerative keratitis (PUK): PUK is a type of crescent-shaped inf lammatory damage that occurs in the cornea limbus, always combined with an epithelial defect and the destruction of the peripheral corneal stroma. PUK may have a connection with systemic immune disease.

◎ 蠶食性角膜潰瘍：是一種慢性疼痛性周邊角膜潰瘍性疾病，原因不明。潰瘍起始于角膜緣，向周邊及中央?yún)^(qū)進(jìn)展，呈潛掘狀。最后大部分角膜被血管化混濁的組織替代，殘余角膜中央島。

◎ Mooren ulcer: Mooren ulcer is characterized by painful peripheral corneal ulceration of unknown etiology. The ulcer extends circumferentially and centrally with a leading undermined edge. Cornea is replaced by a vascularized,opaque thinned tissue leaving behind a central island of cornea.

◎ Terrien角膜邊緣變性：是一種少見(jiàn)的特發(fā)性的角膜周邊變薄，通常雙眼發(fā)病。

◎ Terrien marginal degeneration: Terrien marginal degeneration is a rare idiopathic peripheral corneal thinning that usually occurs in both eyes.

◎ 泡性角結(jié)膜炎：為眼部的非感染性疾病，是微生物抗原引起的免疫反應(yīng)，引起角膜和結(jié)膜的結(jié)節(jié)樣病變。

◎ Phlyctenular keratoconjunctivitis: It is an immune respond to microbial antigens to cause the corneal and conjunctival nodular lesions.

◎ 透明邊緣性角膜變性：是一種非炎癥性的擴(kuò)張性角膜疾病，表現(xiàn)為周邊角膜窄帶樣變薄，與角膜緣間隔1~2mm，是一種罕見(jiàn)的角膜疾病。

◎ Pellucid marginal degeneration: Pellucid marginal degeneration (PMD) is a non-inf lammatory ectatic corneal disease characterized by a narrow band of corneal thinning separated from the limbus by a relatively uninvolved area 1 to 2 mm in width. It is a rare corneal disorder.

病史詢(xún)問(wèn)

Asking History

◎ 詢(xún)問(wèn)是否有類(lèi)風(fēng)濕性關(guān)節(jié)炎、Wegener肉芽腫、復(fù)發(fā)性多軟骨炎等全身免疫相關(guān)疾病。

◎ Asking the history of systemic diseases such as rheu ma toid arthritis, Wegener’s granuloma and recurrent polychondritis.

檢查

Examination

◎ 視力下降。

◎ Visual acuity is decreased.

◎ 裂隙燈檢查：角膜緣處角膜基質(zhì)的新月形炎性浸潤(rùn)，伴隨角膜上皮缺損和基質(zhì)變薄。

◎ Slit-lamp examination: crescent-shaped inf la mmatory inf iltration that occurs in the limbal region of the cornea,combined with an epithelial defect and thinning of the peripheral corneal stroma.

實(shí)驗(yàn)室檢查

Lab

◎ 全身自身免疫性疾病檢查包括：全血細(xì)胞計(jì)數(shù)(CBC)、尿液鏡檢、抗核抗體(ANA)、抗中性粒細(xì)胞胞漿抗體(ANCA)、類(lèi)風(fēng)濕因子(RF)、抗環(huán)瓜氨酸肽(anti-CCP)、快速血漿反應(yīng)素試驗(yàn)(RPR)、熒光密螺旋體抗體(FTAAbs)、胸部X線、結(jié)核菌素純蛋白衍化物實(shí)驗(yàn)(PPD)、骶髂關(guān)節(jié)X線、鼻竇CAT掃描、乙肝及丙肝病毒檢查。

◎ Systemic evaluation for underlying autoimmune dise ases may include: Complete blood count (CBC), urinalysis with microscopic analysis (UA&micro), antinuclear antibody (ANA), anti-neutrophil cytopl asm ic antibody(ANCA), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), rapid plas ma reagin (RPR), f luorescent treponemal ant ibody (FTA-Abs), chest X-ray, tuberculin purif ied protein derivative (PPD), sacroiliac joint X-ray,CAT scan of sinuses, hepatitis B virus, hepatitis C virus.

◎ 角膜微生物培養(yǎng)。

◎ Corneal microbial culture.

診斷

Diagnosis

邊緣性角膜潰瘍。

Peripheral ulcerative keratitis.

治療

Management

◎ 無(wú)防腐劑的人工淚液，淚點(diǎn)塞或者淚點(diǎn)燒灼，角膜繃帶鏡可用于治療干眼，促進(jìn)角膜上皮化。

◎ Preservative free artif icial tears, closure of puncta with plugs or cautery, and bandage soft contact lens are used to treat associated dry eye and promote epithelialization of the ulcer.

◎ 氰基丙烯酸鹽黏合劑可用于有穿孔風(fēng)險(xiǎn)的角膜潰瘍。

◎ Cyanoacrylate adhesive may be applied to the ulcer bed to limit ulceration in cases of impending perforation.

◎ 局部抗生素用于預(yù)防細(xì)菌感染。

◎ Topical antibiotics are used to prevent bacterial sup erinfection.

◎ 局部使用免疫抑制劑和膠原酶抑制劑。

◎ Local immunosuppression, collagenase inhibitors.

◎ 全身免疫抑制劑。

◎ Systemic immunosuppression.

◎ 其他抗代謝藥物：T細(xì)胞抑制劑，烷基化藥物以及生物制劑。

◎ Steroid sparing agents include antimetabolites T cell inhibitors, alkylating agents and biologic agents.

◎ 手術(shù)治療：適用于角膜穿孔，或者有穿孔風(fēng)險(xiǎn)的角膜潰瘍。手術(shù)方式包括板層或穿透性角膜移植術(shù)、角膜 - 鞏膜移植術(shù)。

◎ Surgery: Indications for surgical intervention include corneal perforation or excessive corneal thinning with impending perforation. Surgical options include lamellar keratoplasty, penetrating keratoplasty, as well as possible cornea-scleral keratoplasty.

患者教育和預(yù)后

Patient Education & Prognosis

◎ 邊緣性角膜潰瘍通常是全身疾病未得到控制的表現(xiàn)，需要全身免疫抑制治療。

◎ Peripheral ulcerative keratitis is often a sign of an unco n t r o lled systemic disease requiring systemic immunosuppr e s s ion.

◎ 對(duì)于全身疾病未控制和反復(fù)發(fā)作的患者，預(yù)后差。有角膜穿孔風(fēng)險(xiǎn)的患者通常需要手術(shù)干預(yù)。

◎ The visual prognoses in patients with uncontrolled systemic disease and repeated attacked is poor. Surgical management for PUK is required in cases of impending corneal perforation.