病例17　58歲中年男性主訴左眼視力下降、眼痛1周

CASE 17　A 58-year-old male complaining of left eye blurred vision and pain for 1 week

見圖1-27。See Fig. 1-27.

鑒別診斷

Differential Diagnosis

◎ 真菌性角膜炎：通常有植物接觸史或外傷史，病灶隆起、菌絲苔被、不規則羽毛狀邊緣、質地干燥粗糙和衛星灶等特征性表現。

◎ Fungal keratitis: It is usually caused by trauma with plants, especially by crops. Clinical f indings such as elevated areas, hyphae (branching) ulcers, irregular feathery margins,a dry rough texture, and satellite lesions, are suggestive of filamentous fungal keratitis.

◎ 細菌性角膜炎：細菌性角膜炎發生速度快，進展迅速，一般發生在角膜外傷或角膜異物取出術后。

◎ Bacterial keratitis: Bacterial keratitis always progressed rapidly. Trauma, contact lens and surgery are risk factors.

◎ 棘阿米巴性角膜炎：通常有接觸鏡配戴史及污水接觸史。眼痛劇烈。

◎ Acanthamoeba keratitis: Usually with contact lens wearing history and sewage exposure history. The eye pain is severe.

◎ 病毒性角膜炎：可伴感冒、發熱等癥狀，常反復發作。

◎ Virus keratitis: Usually accompanied by cold and fever,repeated attacks.

病史詢問

Asking History

◎ 是否有過植物、農作物接觸史，是否有外傷史，是否有角膜接觸鏡配戴史。

◎ History of eye trauma, especially with plants trauma,history of wearing of contact lens.

◎ 是否有污水接觸史，腫瘤或手術史、類固醇或抗生素滴眼液使用史、HSV感染史，既往有哪些眼部疾病，有哪些伴眼部癥狀的全身疾病史，有無免疫性疾病。

◎ History of contact with contaminated water, tumor or surgery, long term usage of steroid or antibiotic eye drops,HSV infection history, other eye disorders, systemic diseases with ocular manifestations, immune system diseases.

眼部檢查

Examination

◎ 視力、眼壓。

◎ Visual acuity, IOP.

◎ 裂隙燈檢查：使用熒光素染色輔助觀察角膜病灶是否隆起，苔被是否致密，刮除苔被后基質床是否致密，潰瘍邊緣界限是否清楚，有無衛星灶、免疫環等。

◎ Slit lamp examination: To check the size, location,depth and margin of the lesion. Fluorescein staining is mandatory to check the elevated corneal lesion, rough texture, clear margin of the ulcer, satellite lesions, immune ring, etc.

◎ 共聚焦顯微鏡檢查：是快速診斷真菌性角膜炎的一種直觀方法。須在角膜刮片及培養前進行（圖1-28，共聚焦顯微鏡顯示大量菌絲）。

◎ Confocal microscope is a visualized diagnostic approach for fungal keratitis. (Added picture Fig. 1-28 shows a mass of mycelium.) It should be performed before corneal scraping and culture.

◎ B超檢查，以排除眼內炎及視網膜脫離。

◎ In addition, if there is no view of fundus, B-scan ultrasound should be performed to eliminate endo p h t h a lmitis and retinal detachment.

◎ 前節OCT來確定角膜最薄點的厚度，是否有穿孔的風險。

◎ Anterior segment-OCT could be used to identify and quantify the thinnest point in the presence of corneal thinning.

實驗室檢查

Lab

◎ 從角膜潰瘍灶與正常角膜交界處進行角膜刮片可以提高病原體的檢出率，將標本進行涂片鏡檢和真菌培養。樣品制備通常采用10%氫氧化鉀(KOH)和革蘭氏染色。真菌培養是真菌性角膜炎診斷的金標準。

◎ Cornea scraping specimen from the base and edges of the corneal lesion, specimen should be subjected for microscopic examination and culture. 10% pota s s ium hydroxide (KOH)and Gram staining was nor m ally utilized for sample preparation. Culture is the golden standard of diagnosis.

診斷

Diagnosis

真菌性角膜炎。

Fungal keratitis.

治療

Management

真菌性角膜炎診療復雜，周期較長（數周或數月）。

Medical management of fungal keratitis is problematic. There are no standard guidlines for selecting and adm in istering current antifungals.

◎ 藥物治療

◎ Topical drugs

常用的抗真菌藥物有那他霉素、伏立康唑、兩性霉素B，初始給藥頻次可為每1小時1次或每2小時1次，根據病情和患者對藥物的反應也可選擇結膜下注射、基質注藥或全身給藥。

Common anti-fungal agents include natamycin,voriconazole and amphotericin B, initially given from Q1H to Q2H. Subconjunctival injection, intrastromal injection or systemic administration are optional according to medication response.

嚴禁使用局部類固醇類藥物。

Topical steroids are strictly forbidden.

前房積膿陽性時使用阿托品或托吡卡胺解除睫狀肌痙攣，非甾體抗炎藥可減輕前節炎癥反應。

Using atropine or tropicamide when hypopyon was present.

Non-steroid eye drops could be used to reduce anterior segment inf lammation.

◎ 手術治療

◎ Surgery

由于抗真菌類藥物對角膜基質的穿透性差，須輔以角膜清創，清除角膜潰瘍灶，改善藥物穿透力，以提高治療效果，但不建議頻繁做。

To improve therapeutic effect and poor drug penetration through the corneal stroma, debridement of cornea epithelium and ulceration are needed. But it’s not recommended to do it frequently.

當患者對藥物不敏感時可行角膜基質注藥術。

Corneal stromal injection is performed when drug reaction is poor.

結膜瓣覆蓋手術通常在對藥物反應良好，但有角膜穿孔傾向或已經穿孔又不具備角膜移植條件時進行。

Conjunctival f lap surgery is used when there’s some tendency for cornea perforation however medication is valid,or the perforation already happened however penetration keratoplasty is not available.

中淺層角膜潰瘍，且對藥物反應不佳時可采用板層角膜移植。

Lamellar corneal transplantation is applied in the middleshallow layer corneal ulceration where drug treatment is ineffective.

當患者對藥物反應不佳，角膜潰瘍擴大或角膜穿孔形成時，應行穿透性角膜移植術。

Penetration keratoplasty is an effective approach when poor response to medication, ulceration is consistently enlarged or perforation is existed.

患者教育和預后

Patient Education & Prognosis

◎ 病程長、預后差：通常需要幾個月的時間，即使角膜潰瘍灶完全愈合，大多數角膜潰瘍患者將會遺留角膜瘢痕，并伴不同程度視力下降。

◎ Longer course, poor prognosis: The patient should be acknowledged that the treatment course is relatively long,it would take months before the keratohelcosis healing.Most cases like these would lead to cornea scar and decreased vision.

◎ 如真菌感染不能控制或發生角膜穿孔時，須立即行角膜移植術或結膜瓣覆蓋術。

◎ The patient should be monitored daily and kept an eye on the thinnest point. Explain to the patient in case of cornea perforation, conjunctival f lap or keratoplasty are needed immediately.

◎ 如手術不能控制感染，可能發展為真菌性眼內炎時須行眼球摘除，嚴重者可致顱腦感染。

◎ If the operation can not control the infection, it may develop into fungal endophthalmitis when ophthalmectomy is needed, severe cases can lead to craniocerebral infection.