病例23　36歲男性，眼紅、畏光，伴視力下降2天（角膜移植術后2年）

CASE 23　A 36-year-old male with penetrating keratoplasty for 2 years complaining of eye redness, photophobia and vision decreased for 2 days

見圖1-38。See Fig. 1-38.

鑒別診斷

Differential Diagnosis

◎ 角膜植片排斥：可以發生在角膜移植術后任何時間，患眼突然充血，疼痛畏光伴視力下降，角膜植片水腫，植片出現上皮排斥線，或基質浸潤，或內皮排斥線及角膜后沉著物。

◎ Corneal endothelial graft rejection: It can occur at any time post keratoplasty. The affected eyes presented with suddenly congestion, pain and phot o p h obia combined with vision loss. The grafts are edema with epithelial rejection line, or stromal inf ilt r ation, or endothelial rejection line and keratic precipitates.

◎ 角膜植片慢性失功：一般發生在角膜移植術后1年以上，出現無癥狀的視力下降，角膜植片全層水腫，無排斥跡象。

◎ Graft dysfunction: After one year of operation, there is no special reason for graft function prog r e s sive decline,which eventually leads to the opacity of the grafts, also known as “graft failure” (no infla m m a t ion).

◎ 病毒性角膜炎：患者多有前驅感冒癥狀，角膜可以顯示小的凸起的透明的囊泡，樹枝狀潰瘍。神經營養性角膜病變的早期癥狀包括角膜表面不規則和點狀上皮糜爛。壞死性角膜基質炎的特征是角膜基質浸潤、潰瘍和壞死。免疫性角膜基質炎(ISK)臨床上可表現為局限性、多灶性或彌漫性細胞浸潤、免疫環、新生血管或角膜血管影。結膜充血伴水樣分泌物增多，眼壓升高，需要聯合全身抗病毒治療。

◎ Viral keratitis: Most patients have precursor sym p t oms such as cold. The cornea could show small, raised, clear vesicles, dendritic ulcers. The earliest signs of neurotrophic keratopathy include an irregular corneal surface and punctate epithelial erosions. Ne c r otizing stromal keratitis is characterized by dense stromal inf iltrate, ulceration,and necrosis. Immune stromal keratitis (ISK) may present clinically with focal, multifocal, or diffuse cellular inf iltrates; imm u ne rings; neovascularization; or ghost vessels at any level of the cornea. Conjunctival congestion with the increase of aqueous secretion can be found. The IOP may be elevated. The treatment needs to be combined with systemic antiviral drug.

病史詢問

Asking History

◎ 角膜移植的手術時間及原發病。

◎ Asking original disease and the operation of corneal transplantation.

◎ 術后抗排斥用藥是否規律及癥狀出現時間。

◎ Asking the usage of anti-rejection drugs post operation and onset of the symptoms.

◎ 近期是否有發燒、不適和上呼吸道癥狀。

◎ Asking fever, malaise and upper respiratory tract symptoms.

檢查

Examination

◎ 視力、眼壓。

◎ Vision, IOP.

◎ 裂隙燈檢查：結膜充血，角膜植片增厚，角膜基質浸潤、血管化以及縫線的完整性。可發現上皮排斥反應線或內皮排斥反應線以及角膜后沉著物。

◎ Slit lamp examination: Conjuctiva congestion, corneal graft thickening, transparency, inf iltration, neovasculization,intact suture and exposure. Epithelial rejection line,endothelial rejection line or keratic precipitates may be found.

實驗室檢查

Lab

◎ 結膜囊取分泌物鏡檢及培養。

◎ Microbiologic examination and culture of conjun c tival sac secretion.

診斷

Diagnosis

角膜移植術后排斥（內皮型）。

Corneal endothelial graft rejection.

治療（圖1-39）

Management (Fig. 1-39)

◎ 激素沖擊治療，糖皮質激素滴眼液頻點，每1小時1次持續1天，之后每2小時1次，持續3天，口服潑尼松每天40~80mg或全身靜脈滴注甲潑尼龍500mg，必要時聯合結膜下注射地塞米松3mg。同時可聯合使用環孢素或他克莫司。局部預防性應用抗生素。如伴隨眼壓升高，須聯合抗青光眼滴眼液。

◎ The frequency of glucocorticoid eye drops is 1 hour for 1 day, and then every 2 hours for 3 days. Oral take prednisone 40 to 80 mg per day or systemic intravenous methylprednisolone 500 mg. If necessary, combined with subconjunctival dexamethasone 3 mg. At the same time,cyclosporine or tacrolimus can be used in combination. If IOP increase, add anti-glaucoma drops.

患者教育和預后

Patient Education & Prognosis

◎ 角膜移植較其他器官移植排斥發生概率低，但高危患者術后依然可以出現排斥反應，角膜移植術后需要長期規律用藥。

◎ The rejection rate of keratoplasty is lower than that of other organ transplantation, but rejection can still occur in high-risk patients, and regular medication is needed for a long time after keratoplasty.

◎ 出現眼紅、畏光、視力下降、眼痛的情況，要及時就診。就診及時預后很好，若延遲1~2周預后較差。

◎ Educate patients to recognize symptoms of rejection and to seek treatment. The prognosis was good for patients who get an in-time treatment, but poor if delayed for 1 to 2 weeks.