病例12　60歲女性，右眼眼痛、異物感3個月余

CASE 12　A 60-year-old female complaining of right eye pain with foreign body sensation for more than 3 months

見圖1-17、圖1-18。See Figs. 1-17 and 1-18.

鑒別診斷

Differential Diagnosis

◎ 暴露性角膜炎：瞼裂閉合不全的病史和眼部典型的臨床表現(xiàn)可幫助診斷。眼部存在暴露因素，如眼部外傷史、手術(shù)史（如眼瞼成形術(shù)）、全身性疾病（如甲狀腺功能亢進或面神經(jīng)麻痹）。本患者因右側(cè)面神經(jīng)麻痹，右眼瞼不能完全閉合，中央及下方角膜暴露不能被淚液濕潤。暴露性角膜炎多是角膜下方1/3的上皮點狀或頑固性缺損。初期可見角膜、結(jié)膜上皮干燥、粗糙。角膜上皮點狀糜爛逐漸融合為大片上皮缺損，繼而可出現(xiàn)角膜基質(zhì)融解，偶爾嚴重的角膜潰瘍可導(dǎo)致角膜穿孔。

◎ Exposure keratopathy: The history of hypophasis and the typical clinical manifestations can aid diagnosis. Causes of eye exposure include eye trauma history, surgery history, such as blepharoplasty and systemic disease, such as hyperthyroidism, or facial nerve palsy. In this patient,the right eyelid cannot be fully closed due to the right facial nerve palsy, and the central and lower cornea cannot be wetted by tear f ilm. Exposure keratopathy is mostly punctate or stubborn defects of the epithelium in the lower one third of the cornea. The cornea and conjunctival epithelium are dry and rough at the beginning. The corneal epithelial punctate erosions gradually merges into large epithelial defect. Subsequently, the corneal stromal melting may occur, occasionally leading to perforation.

◎ 感染性角膜炎：應(yīng)該與細菌性角膜炎、真菌性角膜炎、皰疹病毒性角膜炎和棘阿米巴性角膜炎鑒別。

◎ Infectious keratitis

細菌性角膜炎：患者可有角膜接觸鏡配戴史、眼部外傷史，眼部手術(shù)史等，角膜潰瘍凹陷，基底壞死物質(zhì)多。

Bacterial keratitis: Patients may have a history of contact lens wearing, ocular trauma history, eye surgery history. The corneal ulceration has more necrotic tissue at the base of the ulcer.

真菌性角膜炎：患者多有植物外傷史，角膜病灶表面干燥，可見苔被、偽足、衛(wèi)星灶、前房積膿、免疫環(huán)、內(nèi)皮斑等典型表現(xiàn)。

Fungal keratitis: Many patients have a history of plant trauma, the corneal ulceration surface is dry. Typical features such as moss cover, pseudopodia, satellite focus, anterior chamber accumulation, immune ring and endothelial plaque can be seen.

皰疹病毒性角膜炎：多數(shù)患者具有反復(fù)發(fā)作病史，抵抗力低下，角膜病灶可有樹枝狀、地圖狀、盤狀等。

Herpes simplex keratitis: Most patients have a history of recurrent attacks with low resistance, and corneal lesions can be dendritic, map-like, discoid.

棘阿米巴性角膜炎：患者可有角膜接觸鏡配戴史、疫水接觸史、病變遷延不愈傾向等，眼部劇烈疼痛，角膜病灶不具有典型特征，角膜潰瘍類似盤狀角膜炎，出現(xiàn)放射狀角膜神經(jīng)炎有助于診斷，主要依靠角膜共聚焦顯微鏡觀察到阿米巴包囊來確診。

Acanthamoeba keratitis: Patients may have contact lens wearing history, contact history of epidemic water, and disease extension tendency. The corneal ulcer is similar to discoid keratitis. The occurrence of radial corneal neuritis is helpful for the diagnosis. The diagnosis is mainly based on corneal confocal microscope.

◎ 神經(jīng)營養(yǎng)性角膜炎：通常是由眼部病毒感染、手術(shù)、顱腦腫瘤等原因使角膜失去神經(jīng)支配，導(dǎo)致角膜敏感度下降，同時角膜神經(jīng)營養(yǎng)支持作用減弱或消失，導(dǎo)致角膜潰瘍。典型表現(xiàn)為：眼紅伴視力下降，角膜知覺減退或消失。

◎ Neurotrophic keratopathy: This is a disease that the cornea losses of innervation due to ocular virus infection,surgery, intracranial tumors or any other relative causes,leading to the cornea decreases its sensitivity and defensive,as well as the corneal neurotrophic effect is weakened or disappeared. Typical symptoms are painless redness and decreased vision. Diminished or disappeared corneal sensation is typical sign.

病史詢問

Asking History

◎ 詢問發(fā)病時間、進展以及診療經(jīng)過。

◎ Asking the onset, progression and treatment history.

◎ 詢問眼部暴露因素和暴露病史，包括用藥史、眼外傷、眼瞼整形等眼部手術(shù)史、全身性疾病史如甲狀腺功能亢進病史或面神經(jīng)麻痹史。

◎ Asking the causes of eye exposure factors and exposure history include medical history, eye trauma history,surgery history, such as blepharoplasty and systemic disease, such as hyperthyroidism, or facial nerve spasm and palsy.

檢查

Examination

◎ 視力、眼壓：視力下降，出現(xiàn)角膜穿孔后眼壓下降。

◎ Visual acuity, IOP：Visual acuity is decreased. IOP is decreased after corneal perforation.

◎ 裂隙燈檢查：初期瞼裂部結(jié)膜水腫、粗糙，進而可出現(xiàn)干燥斑。嚴重者可出現(xiàn)角膜損傷，多位于角膜下方1/3。熒光素鈉染色觀察角膜干燥程度、角膜上皮缺損面積、是否出現(xiàn)角膜穿孔。

◎ Slit-lamp examination: Conjunctiva edema and roughness are at the initial stage of blepharophesis, and then dry spots may appear. In severe cases, corneal injury may occur. Exposure keratopathy often affects the lower one third of the cornea. Fluorescein staining is used to observe the corneal dryness, corneal epithelial defect area,and whether corneal perforation occurs.

◎ 角膜知覺檢查：角膜知覺正常（可以與神經(jīng)營養(yǎng)性角膜炎相鑒別，神經(jīng)營養(yǎng)性角膜炎的角膜知覺檢查多減弱或消失）。

◎ Corneal sensation: Normal (It can be distinguished from neurotrophic keratopathy. The corneal sensation of neurotrophic keratopathy is weaken or disappear).

◎ 共聚焦顯微鏡檢查：了解病灶區(qū)是否存在真菌、阿米巴等病原微生物。

◎ Corneal confocal microscopy examination: Check the presence of fungi, acanthamoeba and other pathogenic microorganisms in the lesion.

◎ Bell征：患者閉眼時眼球向外上方轉(zhuǎn)動，露出白色鞏膜，為Bell征陽性。多見于面神經(jīng)麻痹患者。

◎ Bell palsy: When the patient closed eyes, the eyeballs turned outward and upward, exposing the sclera, which was Bell palsy. It is more common in patients with facial nerve palsy.

◎ 眼球突出度檢查：眼眶病變導(dǎo)致的突眼可使眼球突出度增加。

◎ Eyeball protrusion examination (orbital lesions can lead to increased protrusion).

實驗室檢查

Lab

◎ 角膜刮片、培養(yǎng)：病原微生物陰性。

◎ Corneal scraping and culture: Pathogenic microor ganism negative.

診斷

Diagnosis

暴露性角膜炎。

Exposure keratopathy.

治療

Management

◎ 維持眼表濕潤，預(yù)防感染：白天點人工淚液，晚上點抗生素眼膏。

◎ Artif icial tears applied during day time and antib i otic ointment at night to keep eye moist and prevent infection.

◎ 繃帶鏡聯(lián)合人工淚液。

◎ Bandage contact lenses combined with artif icial tears.

◎ 角膜融解時可行結(jié)膜瓣遮蓋術(shù)、羊膜移植術(shù)來保護角膜。

◎ Amniotic membrane graft or conjunctival f lap when corneal melting gets progress.

◎ 去除暴露因素：暫時性眼瞼閉合不全患者可采用暫時性眼瞼縫合，永久性眼瞼閉合不全可采用永久性眼瞼縫合。

◎ Temporary tarsorrhaphy for reversible exposure, and permanent tarsorrhaphy for permanent exposure.

患者教育和預(yù)后

Patient Education & Prognosis

◎ 去除眼部暴露因素是關(guān)鍵的治療手段，患者需要密切隨訪觀察眼部病情變化。

◎ Removing the eye exposure factor is the key trea t ment.Patients need to be closely followed.

◎ 預(yù)后：取決于角膜潰瘍暴露原因和持續(xù)時間，以及角膜潰瘍嚴重程度。角膜知覺減退患者預(yù)后較差。

◎ The prognosis depends on the exposure factors, severity and duration of exposure. The prognosis of patie nts with impaired corneal sensation is poor.