病例19　50歲中年女性，主訴左眼視力下降、異物感伴角膜變白5年

CASE 19　A 50-year-old female complaining of decreased vision, foreign body sensation and corneal whitening in her left eye for 5 years

見圖1-32。See Fig. 1-32.

鑒別診斷

Differential Diagnosis

◎ 角膜帶狀變性：常發(fā)生于眼部慢性疾病或?qū)е赂哜}血癥的全身性疾病引起的角膜鈣化沉著，在Bowman層、上皮基底膜及淺基質(zhì)層均可見羥基磷灰石的沉積。角膜鈣化多見于瞼裂區(qū)，且在鈣化帶和角膜緣之間可見清晰的間隙。除引起不同程度視力下降外，還可引起角膜上皮糜爛，從而導(dǎo)致畏光、流淚、眼磨、眼痛等刺激癥狀。常見的眼部病因包括：慢性葡萄膜炎、晚期青光眼、角膜基質(zhì)炎、復(fù)合性眼外傷、眼球萎縮、眼部結(jié)核和內(nèi)眼手術(shù)史。高鈣血癥的全身病因包括：甲狀旁腺功能亢進(jìn)、痛風(fēng)、惡性腫瘤、結(jié)節(jié)病、維生素D中毒等。特發(fā)性（如頗為常見的與年齡相關(guān)）或長期暴露于有毒蒸氣或物質(zhì)（如汞）也可能導(dǎo)致角膜帶狀變性。

◎ Band keratopathy: It is a corneal calcif ication caused by chronic diseases of the eye diseases or hypercalcemia. The deposition of calcium hydroxyapatite can be seen on the Bowman’s layer, the epithelium and the anterior stroma.Corneal calcif ication is more common in the interpalpebral area, and a clear gap can be seen between the calcif ication zone and the limbus. In addition to causing varying degrees of vision loss, it can cause corneal epithelial erosion accompanying with ocular irritation such as photophobia,tearing, and eye pain. Etiologies include chronic ocular inf lammation, chronic uveitis, advanced glaucoma, interstitial keratitis, ocular trauma, eyeball atrophy, phthisis bulbi,and history of internal eye surgery. Systemic causes of hypercalcemia include hyperparathyroidism, gout, malignant tumors, sarcoidosis, and vitamin D poisoning. Idiopathic (age related, fairly common) or chronic exposure to toxic vapors or substances (e.g., mercury) also can cause band keratopathy.

◎ 基質(zhì)型角膜營養(yǎng)不良：為雙側(cè)發(fā)病的、遺傳性角膜疾病，通常不伴炎癥及角膜新生血管形成。如顆粒狀角膜營養(yǎng)不良，角膜混濁呈“面包屑狀”或顆粒狀分布于角膜中央及旁中央?yún)^(qū)，混濁灶之間由透明角膜隔開，且角膜周邊不受累。斑塊狀角膜營養(yǎng)不良的灰白色基質(zhì)混濁邊界不清晰，隔有云霧狀混濁區(qū)，可累及全角膜及角膜全層。

◎ Corneal stromal dystrophies: It is a bilateral and inherited cor neal disorders without inf lammation or neovascula r i zation in general. Such as granular dystrophy, which appears deposits in the central and paracentral cornea, separated by discrete clear intervening spaces (“bread-crumb-like” opacities), but the corneal periphery is spared. Macular dystrophy appears graywhite stromal opacities with ill-def ined edges extending from limbus to limbus with cloudy intervening spaces, can involve the full thickness of the stroma, more superf icial centrally and deeper peripherally.

◎ 角膜白斑：多見于感染性角膜病、角膜創(chuàng)傷后的并發(fā)癥及部分先天性角膜發(fā)育異常。角膜混濁無特殊形態(tài)及部位，混濁區(qū)不能透見虹膜，根據(jù)是否有原發(fā)病因較易鑒別。

◎ Corneal leukoma: It often occurs after infectious keratopathy, corneal trauma and some congenital corneal abnormalities. There is no special shape and location of corneal opacity. The iris can’t be seen at this area. It is easy to be identif ied based on the primary diseases.

病史詢問

Asking History

◎ 需要詢問眼部癥狀出現(xiàn)、進(jìn)展及持續(xù)時(shí)間，是否伴隨畏光、眼痛等刺激癥狀。

◎ It is necessary to ask about the onset and progre s s ion of ocular symptoms, such as photophobia, eye pain and other symptoms.

◎ 既往是否有慢性葡萄膜炎、晚期青光眼、角膜基質(zhì)炎等病史，是否有內(nèi)眼手術(shù)史及角膜外傷史，是否有引起高鈣血癥的全身性疾病，如甲狀旁腺功能亢進(jìn)、痛風(fēng)、惡性腫瘤、結(jié)節(jié)病、維生素D中毒，有無長期接觸有毒蒸氣或物質(zhì)（例如汞）等。有無家族性或遺傳性眼病史。

◎ Any history of eye diseases such as chronic uveitis,advanced glaucoma, interstitial keratitis and history of internal eye surgery or ocular trauma. Patients should also be asked if they have any history of systemic diseases causing hypercalcemia, such as hyperparathyroidism, gout,malignant tumors, sarcoidosis, and vitamin D poisoning. Any history of chronic exposure to toxic vapors or substances (e.g.,mercury); any history of familial or hereditary eye diseases.

◎ 本例患者曾因左眼“孔源性視網(wǎng)膜脫離”行玻璃體切除術(shù)和硅油填充術(shù)。角膜帶狀變性是復(fù)雜玻璃體視網(wǎng)膜手術(shù)后的嚴(yán)重并發(fā)癥之一。

◎ In this case, the patient had undergone vitrectomy and silicone oil f illing surgery for rhegmatogenous retinal detachment in her left eye. Band keratopathy is one of the severe complications after complicated vitreoretinal surgery.

檢查

Examination

◎ 視力：視力受病灶部位影響。若病變區(qū)域不在視軸，通常無癥狀；若病灶居中，視力受損。

◎ Visual acuity: Often asymptomatic without invol v ed visual axial. If central, vision may be affected.

◎ 裂隙燈：可見角膜上皮下、Bowman層和前基質(zhì)中的鈣沉積，通常通過一條透明的角膜細(xì)線與角膜緣分開。斑塊通常從鼻部和顳部角膜向中央延伸，通常包含小孔和裂縫，具有“瑞士奶酪”的外觀。病變晚期可能變成斑塊狀、結(jié)節(jié)狀和隆起狀。

◎ Slit lamp examination: Anterior segment exam i n ation reveals calcium deposits in the subepithelial space, Bowman’s layer, and anterior stroma, and usually separated from the limbus by a thin line of clear cornea. The plaque typically begins at the nasal and temporal cornea and extends centrally.It often contains small holes and clefts, giving it a “Swiss cheese” appearance. Advanced lesions may become plaquelike, nodular, and elevated.

◎ 檢查是否有其他眼部慢性疾病：以排除慢性眼部炎癥、慢性葡萄膜炎、晚期青光眼、角膜基質(zhì)炎、眼外傷、眼球萎縮等眼病。

◎ Check other chronic eye diseases: Exclude chronic ocular inf lammation, chronic uveitis, advanced glauc o ma, interstitial keratitis, eye trauma, eyeball atrophy and other eye diseases.

◎ 角膜共聚焦顯微鏡：于角膜前彈力層和淺基質(zhì)層可見大量點(diǎn)狀高反光沉積物。病變較重者，病變區(qū)角膜上皮下可見大量片狀高反光結(jié)構(gòu)，基質(zhì)細(xì)胞結(jié)構(gòu)不清，部分患者角膜內(nèi)皮層可見不規(guī)則高反光物質(zhì)沉積。

◎ Confocal microscope: A large number of spot-like hyperref lective deposits can be seen in the Bowman’s layer and anterior stromal of the cornea. In severe lesions, a large number of sheet-like hyperref lective deposits can be seen under the corneal epithelium, and the shape of stromal cells are unclear. In some patients, irregular hyperref lective deposits can be found in the endothelium.

實(shí)驗(yàn)室檢查

Lab

◎ 如患者無慢性眼病，為排除引起高鈣血癥的全身性疾病，須檢測血清鈣、白蛋白、鎂和磷酸鹽水平、血尿素氮和肌酐水平。如果懷疑有痛風(fēng)，檢測尿酸水平。

◎ To rule out systemic diseases causing hyperc a l cemia,serum calcium, albumin, magnesium and phosphate levels,blood urea nitrogen and creatinine sho uld be measured if there isn’t any evidence of eye disor ders. Uric acid levels should be measured if gout is suspected.

診斷

Diagnosis

角膜帶狀變性。

Band keratopathy.

治療

Management

◎ 輕癥患者無須治療。有輕微不適癥狀者可選擇不含防腐劑的人工淚液點(diǎn)眼。部分角膜帶狀變性可以自行脫落，使角膜再次恢復(fù)透明。發(fā)生上皮糜爛引起刺激癥狀患者，可配戴角膜繃帶鏡。

◎ Mild lesion: No treatment for patients without any ocular symptoms. If patient feel uncomfortable, preservative free artif icial tear can be used (PRN). Calcium deposits can detach itself in some cases, and the cornea return to be transparent. Bandage contact lens can be used for patients with ocular irritation caused by epithelial erosion for comfort.

◎ 以下治療可改善患者視力。

◎ The following treatments could improve visual acuity:

去除病灶區(qū)角膜上皮并應(yīng)用0.37%依地酸二鈉（乙二胺四乙酸二鈉，EDTA）點(diǎn)眼可改善角膜混濁，提高視力。聯(lián)合表面麻醉后去除角膜病灶區(qū)上皮有助于增強(qiáng)藥物效果。

Removal of local epithelium and applying 0.37% disodium edetate (EDTA) can improve corneal opacif ication and vision.Removal of the epithelium of the focal area of the cornea after combined topical anesthesia can enhance the effect of the drug.

角膜混濁嚴(yán)重者可手術(shù)治療：角膜表層病灶切除、治療性準(zhǔn)分子激光角膜切削術(shù)(PTK)、角膜板層移植術(shù)等。

Severe corneal opacity patients should be consi d ered to have surgery including excision of corneal lesions, phototherapeutic keratotomy (PTK), lamellar keratoplasty, etc.

◎ 對眼球萎縮無光感，并且有明顯的眼部刺激癥狀者，為改善外觀緩解癥狀，可以謹(jǐn)慎選擇眼球摘除聯(lián)合義眼植入術(shù)。

◎ In order to improve the appearance and relieve the obvious ocular irritation symptom, ophthalmectomy com bined with ocular prosthesis implantation should be con sidered carefully for the patients who have no light perception.

患者教育和預(yù)后

Patient Education & Prognosis

◎ 在原發(fā)病控制不良的情況下，本病可復(fù)發(fā)。應(yīng)積極控制原發(fā)病。

◎ Band keratopathy can recur if the primary diseases are not controlled.

◎ 可出現(xiàn)角膜上皮愈合不良問題。

◎ Epithelial healing problems may occur.

◎ 由于斑塊剝脫后殘留的角膜瘢痕或因合并其他眼部病變，視力通常受損。

◎ Vision is often limited, as a result of residual corneal scarring or other ocular pathology.

◎ 須定期眼科復(fù)查，注意眼表保護(hù)。

◎ To pay more attention to corneal protection and do ocular examinations routinely.