病例13　57歲男性，主訴右眼無痛性眼紅、視力下降3個月

CASE 13　A 57-year-old male complaining of right eye with painless red and decreased vision for three months

見圖1-19、圖1-20。See Figs. 1-19 and 1-20.

鑒別診斷

Differential Diagnosis

◎ 神經(jīng)營養(yǎng)性角膜病變：這是一類由于眼部病毒感染、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，其防御性隨之下降，同時角膜神經(jīng)營養(yǎng)支持作用減弱或消失，最終導(dǎo)致角膜病損的疾病。可發(fā)生于任何年齡，典型癥狀為無痛性視力下降及眼紅。早期體征為瞼裂區(qū)角膜上皮點(diǎn)狀缺損或愈合緩慢的上皮缺損，常累及角膜下部，可被熒光素染色。嚴(yán)重者角膜中下部出現(xiàn)橢圓形或類圓形浸潤或潰瘍，甚至角膜穿孔。患者角膜知覺檢查表現(xiàn)為知覺減退或消失。

◎ Neurotrophic keratopathy: It is a kind of corneal injury disease in which the cornea loses innervation due to ocular virus infection, surgery, intracranial tumors or any other relative causes. Loss of corneal innervation can diminish corneal sensation and defense capability, weaken or disappear the corneal neurotrophic effect. It may occur at any age. Typical symptoms are painless decreased vision and redness. Interpalpebral punctate epithelial erosions or slow to heal epithelial defects are early signs. Defects commonly involve the inferior half of the cornea and can be stained with f luorescein. An elliptic or orbicular inf iltration or ulceration in the inferior half of the cornea or even corneal perforation is severe sign. The patient’s corneal sensation decreases or disappears.

◎ 暴露性角膜炎：這是由面神經(jīng)麻痹、瞼外翻、突眼及眼外傷等原因所致的眼瞼閉合不全，使角膜失去眼瞼濕潤與保護(hù)而暴露于空氣中，引起角膜干燥、上皮缺損，甚至有角膜潰瘍形成的一種疾病。病灶通常見于角膜下部。

◎ Exposure keratopathy: It can occur in incomplete eyelid closure caused by facial nerve palsy, ectropion, proptosis,ocular trauma and any other relative causes, which can induce exposure of the cornea to the air without proper humidif ication and protection by the eyelids. It can cause corneal desiccation, epithelial defect and even ulceration.Lesions usually occur in the inferior interpalpebral region.

◎ 干眼綜合征：這是一種由多種情況導(dǎo)致眼表環(huán)境受到輕到重度損害，使角膜處于輕度炎癥環(huán)境的疾病。患者可出現(xiàn)異物感、燒灼感、疲勞感、流淚等癥狀，部分患者會抱怨視力變差或視力波動。患者淚湖變淺或不規(guī)則，角膜可被熒光素染色。

◎ Dry-eye syndrome: It encompasses a variety of conditions that causes mild-to-severe disruption of the ocular surface, and leads to a mild inf lammatory environment of the cornea. Patients can appear foreign body sensation, burning, tired feeling, tearing and other symptoms. May complain of poor and/or f luctuating vision. Scanty or irregular tear meniscus can be seen.Cornea can be stained with f luorescein.

◎ 細(xì)菌性角膜炎：由細(xì)菌（如金黃色葡萄球菌、表皮葡萄球菌、肺炎鏈球菌等）感染引起，病變早期可出現(xiàn)邊界清晰的角膜潰瘍及潰瘍邊緣邊界模糊的浸潤灶，組織水腫，黏膿性分泌物，進(jìn)一步浸潤灶迅速擴(kuò)大，形成潰瘍，可伴前房積膿。

◎ Bacterial keratitis: It is caused by bacterial infection such as staphylococcus aureus, staphylococcus epidermidis,streptococcus pneumoniae, etc. A well-def ined ulcer is surrounded by a poorly def ined inf iltration, cornea edema and mucopurulent discharge can be seen in the early stage.Then the inf iltration rapidly develops to ulcer, which may accompany with hypopyon.

◎ 角膜軟化癥：由維生素A缺乏引起，多見于營養(yǎng)不良的兒童。患兒常有睡眠差、易暴躁，嚴(yán)重者出現(xiàn)精神萎靡、皮膚干燥、角化等表現(xiàn)。角膜變軟，易壞死，常出現(xiàn)穿孔。

◎ Keratomalacia: It is caused by vitamin A def iciency and appeared in malnourished children commonly, whom often have poor sleep and irritability. Severe cases can even have dispiritedness, skin drying and keratinization. Corneal softening, necrosis and perforation can be found in this disease.

病史詢問

Asking History

◎ 眼部癥狀出現(xiàn)及持續(xù)時間，是否伴隨眼痛、畏光等癥狀。

◎ It is imperative to ask about the onset and duration of ocular symptoms, such as eye pain, photophobia and other symptoms.

◎ 既往是否有腦部腫瘤病史及手術(shù)史，有無腦卒中或聽力障礙，有無眼部皰疹感染史、糖尿病史、眼部手術(shù)史、長期用眼藥史（如麻醉藥、非甾體抗炎藥），既往是否有挑食習(xí)慣、長期配戴角膜接觸鏡、長時間使用視頻終端或者睜眼睡覺史。該病例有右側(cè)聽神經(jīng)瘤切除手術(shù)史。

◎ Any medical histories of brain tumors or surgery, stroke,hearing problem, herpes simplex virus infection, diabetes mellitus, eye surgery or chronic topical medications (e.g.,anesthetic, nonsteroidal anti-inf lammatory agents). Any history of picking eating, chronic contact lens wear, extended periods of using video display or sleeping with eyes open.This case has a history of right acoustic neuroma resection.

檢查

Examination

◎ 視力：漸進(jìn)性視力下降。

◎ Visual acuity: Decreased vision onset is gradual.

◎ 眼瞼：檢查眼瞼外觀是否有畸形或位置不正，檢查眼瞼閉合程度及閉合不全的原因。

◎ Eyelid: Eyelid deformity or malposition may be noted.Examine the degree of eyelid closure and f ind the reason.

◎ 角膜知覺檢查：角膜知覺減弱或消失（注意與對側(cè)眼對比）。

◎ Corneal sensation: Weaken or disappear (need to check the fellow eye for comparation).

◎ 裂隙燈檢查：角膜熒光染色前后了解角膜浸潤、潰瘍部位、范圍。前房閃輝、房水細(xì)胞情況。

◎ Slit-lamp examination: To detect the size, location of ulcer and inf iltration with and without corneal f luorescein staining. Check cells and f lare in anterior chamber.

◎ 皮膚檢查：注意有無眼周局部皰疹性損害或帶狀皰疹病毒感染后瘢痕。

◎ Skin: Check the skin around the eyes to f ind if there is local herpetic lesions or scars from a previous herpes zoster infection.

◎ 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，了解角膜神經(jīng)密度（病灶及病灶周圍角膜神經(jīng)密度降低或消失）。

◎ Confocal microscopy: Check the presence of fungi,acanthamoeba and other pathogenic microorganisms in the lesion; check the corneal nerve density. (The density of corneal nerve may be decreased or disappeared in and around the lesion).

◎ 顱腦CT：如有顱腦疾病及手術(shù)史者，可有相應(yīng)特征性表現(xiàn)。

◎ Brain CT: If the patient has the history of brain tumor or surgery, the CT result will have corresponding characteristic features.

實(shí)驗(yàn)室檢查

Lab

◎ 角膜刮片鏡檢，細(xì)菌、真菌培養(yǎng)：病原微生物陰性。

◎ Corneal scraping and microscopic examination, pathogenic microorganism culture: Pathogenic microorganism negative.

◎ 血糖監(jiān)測：排除是否合并糖尿病。

◎ Blood glucose measurement: To exclude diabetes history.

診斷

Diagnosis

神經(jīng)營養(yǎng)性角膜病變。

Neurotrophic keratopathy.

治療

Management

◎ 根據(jù)患者角膜上皮缺損程度進(jìn)行治療。

◎ Patients should be treated according to the degree of corneal lesion.

◎ 輕中度上皮點(diǎn)狀著染：使用無防腐劑的人工淚液，睡前加用無防腐劑的人工淚液凝膠。

◎ Mildly to moderately punctate epithelial staining: Treated with preservative-free artif icial tears during the day, and preservative-free artif icial tear gel at night.

◎ 輕度角膜上皮缺損：連續(xù)使用抗生素眼膏（如紅霉素）至痊愈，同時使用人工淚液。可考慮使用軟性角膜接觸鏡保護(hù)眼表。

◎ Mild corneal epithelial defect: Treated with antibiotic ointments (e.g., erythromycin) and artif icial tear continuously until the cornea healed. The soft contact lenses can be considered to protect ocular surface.

◎ 角膜潰瘍：使用抗生素眼膏，口服膠原酶抑制劑，如多西環(huán)素，減緩角膜基質(zhì)融解。可聯(lián)合自體血清點(diǎn)眼。嚴(yán)重者須進(jìn)行瞼緣縫合術(shù)、結(jié)膜瓣覆蓋術(shù)、羊膜移植術(shù)或人工角膜移植術(shù)。

◎ Corneal ulcer: Treated with antibiotic ointment and oral collagenase inhibitors (e.g., doxycycline) to slow down the progression of stromal melting. Autologous serum eye drops can be combined. In severe cases, tarsorrhaphy, conjunctival f lap covering, amniotic membrane graft or keratoprosthesis should be performed.

患者教育和預(yù)后

Patient Education & Prognosis

◎ 在積極治療原發(fā)病的同時，注意保護(hù)眼表，預(yù)防并發(fā)癥，定期進(jìn)行眼科檢查。

◎ Apart from better control of the primary disease,patient should pay more attention to ocular surface protection, prevention of secondary complications and regular follow-up.

◎ 該病預(yù)后欠佳，多遺留角膜瘢痕影響視力。部分患者因角膜神經(jīng)功能永久性喪失導(dǎo)致疾病遷延不愈。

◎ Prognosis of this disease is relatively poor. Corneal scar often forms and affects vision. In some patients, the disease is difficult to recover due to permanent loss of corneal nerve function.