病例16　34歲女性，主訴左眼畏光、疼痛、異物感、流淚伴視力下降3天

CASE 16　A 34-year-old female complaining of photophobia, pain, foreign body sensation, tearing and diseased vision in left eye for 3 days

見圖1-25、圖1-26。See Figs. 1-25 and 1-26.

鑒別診斷

Differential Diagnosis

◎ 樹枝狀角膜炎：是單純皰疹病毒性角膜炎中的最常見類型。它通常是由角膜上皮細胞中存在的活病毒引起的單眼病癥（在免疫功能低下的患者和特應性患者中可為雙側發病）。早期角膜上皮層出現點狀或簇狀的灰白色、微隆起的針尖樣浸潤。1~2天后，浸潤擴大融合，形成典型的樹枝狀潰瘍。樹枝狀末端呈球狀膨大。熒光素鈉染色可見中央深綠色潰瘍，病灶邊緣淡綠色包繞。常見癥狀有眼紅、眼痛、畏光、流淚及視力下降。該病易反復發作并導致角膜敏感度降低。

◎ Dendritic keratitis: Is the most common type of herpes simplex keratitis. It is a usually unilateral condition caused by the presence of live virus within corneal epithelial cells.(It also can be bilateral, especially in immunocompromised patients and those with atopy. ) Early corneal epithelial layer shows punctate gray and raised needle-shape inf iltration. After 1 to 2 days, the inf iltration expand and merge to form a typical dendritic ulcer. Each dendritic branch has spherically terminal bulb. After stained with f luorescein, the central part of the ulcer shows dark green because epithelium defect and the peripheral part shows light green. Common symptoms include unilateral redness,eye pain, photophobia, tearing and decreased vision. The disease tend to recur and can lead to corneal sensitivity decrease.

◎ 假樹枝狀角膜病變：可見于帶狀皰疹病毒性角膜炎、棘阿米巴性角膜炎、復發性角膜上皮糜爛及藥物毒性角膜上皮病變等疾病中，鑒別如下。

◎ Pseudodendritic keratopathy: Can be seen in her pes zoster virus keratitis, acanthamoeba keratitis, rec urrent corneal epithelial erosion and drug-induced toxic keratopathy. The different is below.

帶狀皰疹病毒性角膜炎(HZK)：角膜特征性表現為假樹枝狀角膜炎、基質炎或神經麻痹性角膜炎。角膜上皮病變區熒光素鈉染色不如HSK明顯，且無樹枝末端球狀膨大的特征性表現。同時HZK通常伴同側鼻翼、額部和 / 或頭頂部皮膚的皰疹或皰疹后瘢痕，且常伴皰疹后神經痛或神經感覺異常。以上兩大特點有助于與HSK鑒別。

Herpes zoster keratitis (HZK): The cornea is cha ra cterized by pseudodendritic keratitis, stromal inflammation,or neuroparalytic keratitis. Corneal ep ithelial lesions are stained with less f luorescein than HSK, without characteristic terminal bulb at each ending of the branch.HZK patients usually have rashes or scars on forehead,scalp and tip of nose accompanying with postherpetic neuralgia or neur o s e nsory abnormalities. The two characteristics above are helpful for identif ication.

棘阿米巴性角膜炎：在疾病的早期可有假樹枝狀角膜病灶，其上皮病變是隆起性而非潰瘍性，且無樹枝末端球狀膨大的特征性表現。患者常有角膜接觸鏡配戴史、眼異物史或外傷史，眼痛劇烈，且癥狀與體征程度不相符，屬于慢性病程。角膜刮片鏡檢或共聚焦顯微鏡檢查可見典型棘阿米巴包囊。

Acanthamoeba keratitis: In the early stage, pseud odendritic corneal lesions are raised and not ulcerative, without characteristic terminal bulb at each ending of the branch.Patients often have a history of wea r ing corneal contact lens,corneal foreign body or tra u ma. Eye pain is often very sharp,while the signs are not so severe, which lead to inconsistent sym p toms and signs. Corneal scraping staining and con focal microscope are very useful to f ind typical acant h a m o eba cysts.

復發性角膜上皮糜爛：病因復雜多樣，常見病因有前部角膜營養不良、角膜擦傷、角膜變性、角膜屈光手術及糖尿病等。表現為反復發生的急性眼痛、畏光、異物感和流淚。角膜上皮糜爛區在愈合過程中可呈現假樹枝狀或地圖狀外觀，但無樹枝末端球狀膨大的特征性表現。

Recurrent corneal epithelial erosion: The causes are complex. Common causes include anterior corneal dyst rophy, corneal abrasion, corneal degeneration, corneal refractive surgery and diabetes mellitus. It is characterized by recurrent acute eye pain, ph o t o phobia, foreign body sensation and tearing. The erosion area may present a pseudodendritic or geog r a p hic-shaped appearance during healing, but without characteristic spherical terminal bulb at each ending of the branch.

藥物毒性角膜上皮病變：眼局部不合理用藥所引起的角膜組織病理性改變，多由藥物本身或防腐劑引起的角膜細胞毒性或變態反應。早期表現為局限性或彌漫性的上皮浸潤糜爛，后期可發展至假樹枝狀角膜上皮潰瘍，若繼續不合理用藥，可發展至基質潰瘍乃至穿孔。該類疾病特點為：在原發病基礎上，通常有明確的長期點藥史或短期多種眼藥高頻次點藥史；角膜熒光素鈉染色除了潰瘍區著染外，周圍角膜上皮也被著染。

Drug-induced toxic keratopathy: It is a severe path ological changes of cornea caused by unreasonable local drug application on the eyes. The eyedrops and preservatives inside may cause corneal cytotoxicity or allergic reaction.In the early stage, local or diffuse epithelial inf iltration appear. While in the later stage, erosion can develop into pseudodendritic ulcer. If the unreasonable treatment is continued, the pseudodendritic ulcer can develop into stromal ulcer and even perforation. Patients commonly have a history of long-term or high-frequency application of multiple eyedrops for their primary diseases. Not only the ulcer, but also the surrounding corneal epithelium is abnormal and can be stained with f luorescein.

病史詢問

Asking History

◎ 明確眼部癥狀出現及持續時間，眼痛是否劇烈。

◎ Determent the onset and duration of ocular symp t o ms,eye pain is severe or not.

◎ 眼周皮膚是否有異常感覺：痛覺、針刺感或感覺遲鈍等。

◎ Ask about any abnormal sensation in the skin around the eyes: Pain, pinprick feeling or dullness of skin sensation, etc.

◎ 既往是否反復出現類似癥狀，有無其他眼部病史、角膜外傷史、眼部手術史及角膜接觸鏡配戴史；有無長期點藥或近期頻繁使用多種眼藥史；有無全身免疫性疾病史及糖尿病史。

◎ Any history of similar symptoms previously. Any other primary eye diseases, or corneal trauma, ocular surgery,wearing contact lenses, etc. Any history of long-term eyedrops treatment or application of multiple eyedrops frequently. Any history of systemic immunity diseases or diabetes mellitus.

◎ 近期有無發熱史。

◎ Does the patient have a fever recently?

檢查

Examination

◎ 視力：發病后視力急速下降。

◎ Visual acuity: Always decreases rapidly after the attack of the disease.

◎ 裂隙燈檢查：可見單個或多個分支、邊緣凸起、末端是球莖形狀的潰瘍性上皮病變。潰瘍擴大可形成“地圖狀”，可被熒光素染色。在上皮病灶下方可見被稱為“鬼影狀樹枝”的前基質混濁。檢查是否有角膜基質浸潤、內皮炎、葡萄膜炎、急性視網膜壞死和血管炎。

◎ Slit lamp examination: Single or multiple branching,ulcerating epithelial lesions with raised edges and terminal bulb formation. Enlargement of ulcers can lead to the formation of a “geographic” ulcer, which can be stained with f luorescein. Anterior stromal haze called “ghost dendrites” may develop below the epithelial lesions. Check if there is stroma inf iltration, endothelitis, uveitis, acute retinal necrosis and vasculitis.

◎ 角膜熒光素染色：角膜著染呈樹枝狀，分支末端呈球形膨大，以資與其他假樹枝性角膜病變鑒別。

◎ Corneal f luorescent stain: The stain of terminal bulb at each ending of branch is easy to differential pseudodendritis.

◎ 角膜知覺檢查：復發病例可有角膜知覺減退。

◎ Corneal sensation: Weaken or disappear in patients with recurrent onset.

◎ 皮膚及顏面檢查：觀察眼周皮膚是否有皰疹，是否沿三叉神經第一支、第二支支配區域分布，以排除帶狀皰疹病毒性角膜炎。

◎ Skin and face inspection: Check periocular skin blister lesion distribution (CN V1 and V2 region) to distinguish from HZK infection.

實驗室檢查

Lab

◎ 角膜及房水病毒PCR檢測：存在假陰性率，尤其對已經接受抗病毒藥物及激素治療的患者。

◎ PCR detection of corneal and aqueous viruses: False negative rate exists, especially for patients who have received antiviral drugs and steroids therapy.

◎ 角膜刮片鏡檢及培養：對于存在上皮缺損者，可進行該檢查，有助于排除其他感染性角膜炎。

◎ Corneal scraping for microscopy and culture (if epithelial defect exists): To exclude other infectious keratitis.

診斷

Diagnosis

單純皰疹病毒性角膜炎（上皮型）- 樹枝狀潰瘍。

Herpes simplex epithelial keratitis-dendritic ulcer.

治療

Management

◎ 急性期治療原則：控制病毒在角膜內復制，減輕炎癥反應引起的角膜損傷。首選局部抗病毒藥物治療：阿昔洛韋(ACV)、更昔洛韋(GCV)滴眼液或眼膏。用藥期間監控藥物副作用。

◎ Principles of treatment in acute phase: Control virus replication in cornea, reduce corneal injury caused by inf lammatory reaction. Prefer topical antiviral therapy:acyclovir (ACV), ganciclovir (GCV) eye drops or eye ointments. Monitor side effect.

◎ 聯合抗細菌眼藥預防繼發細菌感染。

◎ Combined with antibacterial eyedrops to prevent secondary bacterial infection.

◎ 輔助人工淚液治療，促進上皮愈合。

◎ Application of artif icial tears to promote epithelial healing.

◎ 為減少病毒向角膜基質蔓延，可酌情刮除病灶區上皮聯合抗病毒藥物以利病毒清除。

◎ To prevent the process of the virus goes into the corneal stroma, debridement of the lesion can be considered, and applied with antiviral drugs to facilitate virus clearance.

患者教育和預后

Patient Education & Prognosis

◎ 預后通常較好，但該病易復發，須在嚴格隨診下規范接受治療。

◎ The prognosis is good, but easy to recur, stand a rdized treatment under strict follow-up is very important.

◎ 角膜上皮可愈合或形成角膜云翳，一般對視力影響較小；若病情進展，則會發展為地圖狀角膜潰瘍或向角膜基質層發展。

◎ Corneal epithelium can heal or form corneal nebula,which generally have less impact on vision; while if the disease progresses, it will develop to geographic or stromal keratitis.

◎ 改善不良生活及用眼習慣，增強機體抵抗力，有助于減少復發。

◎ Improve living and eye using habits, proper physical exercise can enhance the body immunity and reduce the recurrence rate.