病例20　46歲男性，主訴異物感伴視物模糊3個月

CASE 20　A 46-year-old male complaining of foreign body sensation and blurred vision for 3 months

見圖1-33。See Fig. 1-33.

鑒別診斷

Differential Diagnosis

◎ 上部角膜緣角結膜炎(superior limbic kerat o c o n j un c t ivitis, SLK)：是以上瞼結膜、上方球結膜、上方角膜緣和鄰近角膜反復發作的慢性角結膜炎為特征的一種疾病，病因不明，多為雙側發病。上瞼結膜充血并伴細小乳頭增生。有1/3~1/2的SLK患者合并絲狀角膜炎，絲狀物一般位于上方角膜和上方角膜緣處。甲狀腺疾病患者易患SLK。

◎ Superior limbic keratoconjunctivitis (SLK): It is a kind of chronic keratoconjunctivitis characterized by recurrent attack of upper palpebral conjunctiva, superior bulbar conjunctiva, superior limbus and adjacent cornea. The cause is unknown and most of the disease is bilateral.The upper palpebral conju n ctiva is congested with small papilla. There are 1/3 to 1/2 of SLK patients with f ilamentous keratitis, f ila m e n ts are generally located in the upper cornea and the upper limbus. Patients with thyroid disease prone to have SLK.

◎ 過敏性結膜炎：主要與春季角結膜炎相鑒別，分為結膜型，以結膜鋪路石樣乳頭為主；角膜緣型，以角鞏膜緣區的膠質樣結節或隆起為主，大多位于上1/2的角鞏膜緣區，贅疣狀的小白色斑，稱為Horner-Trantas結節；混合型，結膜和角膜緣均累及，嚴重者合并角膜盾形潰瘍。

◎ Allergic conjunctivitis：especially should be diffe rentiated with vernal keratoconjunctivitis. It can be divided into conjunctival type, mainly conju n c t ival paving stone like papilla; limbal type, mainly col lo idal nodule or protuberance in the limbal area of corneosclera, mostly in the upper 1/2 of the limbal area of corneosclera, verrucous small white spots, known as Horner-Trantas dots; Mixed type, conjunctiva and limbus involvement, serious cases with corneal shield ulcer.

◎ 結節性鞏膜炎：女性較男性常見，自限性疾病。常因晨起發現眼紅就診。表現為鮮紅色結節狀睫狀充血。幾次發作后，血管可能永久性擴張。

◎ Nodular Episcleritis: Females may be affected more commonly than males. It is self-limiting. A red eye is typically f irst noted on waking. It presents as tender red nodular ciliary bleeding. After several episodes inf lamed vessels may become permanently dilated.

◎ 眼瞼松弛綜合征(FES)：一種罕見的且常被忽視的疾病，可單眼或雙眼發病，引發一系列持續性眼表癥狀。好發于肥胖的中老年男性。可導致慢性眼部疾病，如干眼、上瞼結膜乳頭狀結膜炎、點狀角膜病變、絲狀角膜炎和上方角膜緣血管化。阻塞性睡眠呼吸暫停(OSA)與此病密切相關。上瞼瞼板通常非常松弛，伴隨松弛的上瞼皮膚。

◎ Floppy eyelid syndrome (FES): It is an uncommon unilateral or bilateral condition that is often over l o oked as a cause of persistent ocular surface sym p t o m s. It typically affects obese middle-aged and older men. It can result in chronic ocular disorders, such as dry eye, papillary conjunctivitis of the superior tarsal conjunctiva, punctate keratopathy, f ilamentary keratitis and superior superf icial vascularization. Obstructive sleep apnoea (OSA) is strongly asso c i a ted. The upper eyelid is typically extremely lax,often with substantial excess loose upper lid skin.

◎ 泡性角結膜炎：一般單眼發病，輕微異物感，累及角膜則癥狀加重。反復發作后皰疹可向中央進犯，新生血管長入，稱為束狀角膜炎，痊愈后遺留帶狀薄翳，根據典型的角膜緣或球結膜處實性結節樣小泡，周圍充血等癥狀可正確診斷。

◎ Vesicular keratoconjunctivitis: Often one eye inv o lved,slight foreign body sensation, corneal invol v e m ent will aggravate the symptoms. After repeated attacks, herpes may invade into the center and new blood vessels grow in, which is called fascicular kera titis. After recovery,shingles and pannus are left. It can be correctly diagnosed according to typical sym p t o ms such as solid nodular vesicles at cornea edge or bulbar conjunctiva, peripheral congestion.

◎ 流行性角結膜炎(EKC)：主要由腺病毒8、19、37血清型引起，是眼部最嚴重的腺病毒感染。可表現為結膜充血，瞼結膜濾泡增生，約80%發展為角膜炎，出現畏光癥狀。

◎ Epidemic keratoconjunctivitis (EKC): It is caused mainly by adenovirus serovars 8, 19 and 37, and is the most severe ocular adenoviral infection. It can present with conjunctival hyperemia, papillary conjunctivitis. Keratitis,which may be marked, develops in about 80%. Photophobia may be correspondingly pro m i n ent.

病史詢問

Asking History

◎ 眼部出現癥狀的時間，是否與季節相關；是否有波動及反復。

◎ Asking the onset, is this correlated with seasons,f luctuation, duration and return of symptoms.

◎ 是否伴全身性疾病，特別是甲狀腺相關疾病。

◎ Asking systemic diseases, especially thyroid related diseases.

檢查

Examination

◎ 視力、眼壓。

◎ Vision, IOP.

◎ 裂隙燈檢查：觀察上瞼結膜是否存在彌漫細小絨毛狀乳頭樣改變。是否存在上方球結膜堆疊、充血、角化，以及角膜絲狀物形成。熒光素和麗絲胺綠或玫瑰紅染色。

◎ Slit lamp examination: Careful slit lamp exam i n ation of the upper tarsal conjunctiva looking for papillary reaction.

◎ Evaluation of the upper bulbar conjunctiva, look i n g for foldings, hyperemia, redundancy, and f ilament for m ation.Fluorescein and lissamine green, or rose bengal staining.

◎ Schirmer試驗。

◎ Schirmer test.

◎ 排除甲狀腺相關性眼病。

◎ Rule out dysthyroid orbitopathy.

實驗室檢查

Lab

◎ 甲狀腺功能試驗，自身免疫血清學試驗，如抗Ro(SSA)和抗La(SS-B)抗體，以及環瓜氨酸肽抗體，具體取決于癥狀和臨床表現。如果懷疑有相關全身性疾病，建議由風濕病學醫生或內分泌學醫生進行評估。

◎ Thyroid function tests, autoimmune serologic tests like, anti-Ro (SS-A) and anti-La (SS-B) antibodies, and cyclic citrullinated-peptide antibodies, depending on the symptoms and clinical f indings. Medical evaluation by a rheumatologist or endocrinologist is recommended in case of suspected associated systemic disease.

診斷

Diagnosis

上部角膜緣角結膜炎。

SLK：superior limbic keratoconjunctivitis.

治療（圖1-34、圖1-35）

Management (Fig. 1-34, Fig. 1-35)

◎ SLK的治療沒有“金標準”。許多不同的治療方法已經被報道，包括局部應用硝酸銀、治療性軟性角膜接觸鏡、淚點塞、維生素A凝膠、0.5%環孢素滴眼液、富馬酸酮替芬、自體血清、色甘酸鈉、洛度沙胺氨丁三醇、肌內注射肉毒桿菌毒素，以及瞼板腺注射曲安奈德，所有這些都顯示出不同的治療反應。

◎ There is not a gold standard in the treatment of SLK. Many different therapeutic modalities have been reported, including topical silver nitrate, therapeutic soft contact lens, lacrimal puncta occlusion, topical vitamin-A, topical cyclosporine 0.5%, ketotifen fumarate, autologous serum, cromolyn sodium, lodoxamide tromethamine, botulinum injection in the muscle of Riolan, and supratarsal triamcinolone injection,all of which have shown variable therapeutic responses.

◎ 如果患者合并甲狀腺功能亢進或干燥綜合征，需要聯合全身治療。

◎ In case of hyperthyroidism or Sj?gren’s syndrome,general treatment is needed.

◎ 局部用藥控制不佳者，可以聯合手術治療，包括結膜燒烙術、結膜切除術。

◎ If the local medication is not well controlled, it can be combined with surgery, including conjunctival cauterization and conjunctivectomy.

患者教育和預后

Patient Education & Prognosis

◎ 多見于中年女性，多為雙眼發病(70%)，男女之比為1∶3，1/4患者合并干眼，26%~50%的患者伴有甲狀腺功能異常。

◎ Most of them are middle-aged women, most of them have double eye diseases (70%), the ratio of male to female is 1∶3, 1/4 patients with dry eye, 26% to 50% patients have thyroid dysfunction.

該病容易反復，可持續數年，但具有自限性，一般預后良好，不會明顯影響視功能。

The disease is prone to recur and can last for several years,but it has self-limitation and generally has a good prognosis,which will not signif icantly affect the visual function.

SLK可能有遺傳傾向。

There may be a genetic predisposition to SLK.