病例22　65歲老年女性，主訴右眼眼紅、眼痛、流淚6天

CASE 22　A 65-year-old female with left eye redness, pain and tearing for 6 days

見圖1-37。See Fig. 1-37.

鑒別診斷

Differential Diagnosis

◎ 藥源性角結膜炎：藥源性角結膜炎臨床表現不具備特異性，角膜病變表現多樣復雜，須仔細加以鑒別。大多數患者有長期眼局部用藥史。病毒性角結膜炎、青光眼及不明原因的角膜炎是藥源性角結膜炎的最常見原發病，因為這些病往往需要長時間眼部用藥。

◎ Drug-induced keratoconjunctivitis: Clinical man i f e stations of drug-induced keratoconjunctivitis are not specif ic. Manifestations are diverse and complex,which need to be carefully identif ied. Most patients had a long-term topical medication history for chronic eye diseases such as viral ker a t o c o n j u n c t i v itis, glaucoma, and unexplained keratitis.

◎ 神經營養性角膜炎：神經營養性角膜炎是一種以上皮延遲愈合為特征的角膜上皮營養性疾病，該病的特征是角膜知覺缺失，并可能最終引起角膜基質融解和穿孔。

◎ Neurotrophic keratitis: Neurotrophic keratitis is a corneal dystophy, caused by delayed healing of cornea epithelium. It is characterized by loss of corneal perception and may eventually result in corneal stromal dissolution and perforation.

◎ 感染性角膜炎：不同病原體所致的感染性角膜炎都有其臨床特點，可以根據這些特點鑒別，尋找病原體也是鑒別診斷的重要環節。

◎ Infectious keratitis: Infectious keratitis caused by different pathogens can be identif ied according to their clinical characteristics, looking for pathogens is most important for differential diagnosis.

病史詢問

Asking History

◎ 眼病史：尤其是干眼、病毒性角膜炎、青光眼等病史。

◎ History of eye disease: Especially the history of dry eye,viral keratitis, and glaucoma.

◎ 眼部滴眼液使用的類型和頻率。

◎ Type and frequency of eye drops used with ocular toxicity.

◎ 眼部手術或外傷史。

◎ History of surgeries or trauma.

◎ 全身性疾病、病毒感染史，化學物品或角膜接觸鏡護理液暴露史，免疫系統疾病史，顱腦手術史。

◎ Systemic disease with ocular manifestations, history of viral infections, exposure to chemical or contact lenses solutions, immune system disorder, cranial surgery history.

眼部檢查

Examination

◎ 視力、眼壓。

◎ Visual acuity and IOP.

◎ 裂隙燈檢查：熒光素染色檢查角膜上皮缺損情況。

◎ Slit lamp examination: Fluorescein staining was utilized for detecting epithelium defect.

◎ 共聚焦顯微鏡檢查：除外真菌、阿米巴等感染性角膜炎，觀察炎癥細胞種類、分布及活化情況輔助診斷。

◎ Confocal microscope: To exclude fungal, amoeba and other infectious keratitis. Types, distribution and activation of inf lammatory cells were observed to assist diagnosis.

診斷

Diagnosis

藥源性角結膜炎。

Drug-induced keratoconjunctivitis.

治療

Management

◎ 停止眼局部用藥：對于高度懷疑藥源性角結膜炎的患者，立即停止所有可能具有眼部毒性的滴眼液。

◎ For patients with highly suspected drug-induced kerat o c onjunctivitis, stop using all potentially toxic eye drops immediately.

◎ 角膜修復治療：程度較輕者可使用不含防腐劑的人工淚液或小牛血去蛋白提取物等促進角膜上皮修復，嚴重者須使用自體血清促進角膜上皮愈合。

◎ Cornea plerosis: Topical preservative free artif icial tears and autologous serum could accelerate corneal epithelial wound healing.

◎ 原發病治療：對于有原發病不能停藥的患者，應盡量使用不含防腐劑或低毒性防腐劑的劑型，同時調整用藥，在治療原發病的同時，盡量降低使用頻次和藥品種類以及減少使用時間。

◎ Primary disease treatment: If patients with primary disease cannot stop medicines, preservative free or low toxic preservatives dosage forms should be used as far as possible. Frequency, type and duration of eye drops for primary desease should be minimized.

◎ 抗炎治療：炎癥反應較重者可酌情使用類固醇抗炎治療。

◎ Anti-inf lammatory: Topical steroids can be added for severe inf lammatory response cases.

◎ 預防性抗生素：對于上皮持續缺損的患者，可給予預防性抗生素，避免繼發感染。

◎ Prophylactic antibiotics: For patients with persistent epithelial defects, prophylactic antibiotics should be given to avoid secondary infections.

◎ 角膜上皮持續不愈合者可考慮角膜接觸鏡治療或羊膜移植手術治療。

◎ In severe cases, contact lens and surgery (amniotic membrane transplant) should be considered.

患者教育和預后

Patients Education & Prognosis

◎ 藥源性角結膜炎必須以預防為主。須告知患者不可隨意自行使用眼局部藥物治療，對于原發性疾病必須用藥的情況，須在醫生的指導下盡量使用不含防腐劑的藥物，避免防腐劑對眼表的進一步損傷。眼表恢復可能需要幾周甚至幾個月的時間，多數預后良好。一些嚴重的病例，角膜殘留瘢痕致視力永久下降。

◎ Prevention is better than treating drug-induced keratoconjunctivitis. It is necessary to inform the patient not to use ophthalmic drugs at will. When the primary diseases must be treated with drugs, the drugs without preservatives should be used as far as possible under the guidance of the doctor to avoid further damage to the ocular surface caused by preservatives. It may take weeks or even months for the ocular surface to recover, and most of them have a good prognosis. In severe cases, the residual scar of cornea can cause the permanent vision lost.