病例3　64歲老年女性，發現左眼眼紅伴異物感5年余

CASE 3　A 64-year-old female complaining of left eye redness and foreign body sensation for more than 5 years

見圖1-4。See Fig. 1-4.

鑒別診斷

Differential Diagnosis

◎ 翼狀胬肉：位于角膜上隆起的三角形纖維血管球結膜組織，基底位于角膜緣旁的結膜，尖端指向角膜中央。翼狀胬肉通常是在角膜緣處與角膜緣粘連，而假性胬肉可累及球結膜、穹窿結膜或者瞼結膜，跨越角膜而無粘連。

◎ Pterygium: It is a triangular f ibrovascular bulbar conjunctival tissue ingrowth over the limbus encroach onto the cornea. The base part of pterygium located in the bulbar conjunctiva near the corneal limbus and the tip pointing toward the center of the cornea. The pterygium adheres to the limbus, while the pseudopterygium is the adhesion of the tarsal conjunctiva, usually across the limbus without adhesion.

◎ 假性胬肉：常見原因包括眼部化學傷、手術、機械性眼外傷、瘢痕性結膜炎、周邊角膜潰瘍、嚴重感染性炎癥或結膜瘢痕化等。假性胬肉通?？邕^角膜緣處不形成粘連。該病可發生在角膜緣的任何位置，而翼狀胬肉多發生在角膜的3：00位和9：00位。

◎ Pseudopterygium: It is the secondary changes due to the common causes including chemical injuries,surgery, eye trauma, scarring conjunctivitis, peripheral corneal ulcers, severe infectious inf lammation or cicatrizing conjunctivitis. The band of conjunctiva adheres to the cornea at its apex. The disease can occur at any position of corneal limbal, while pterygium occurs mostly at 3 o’clock and 9 o’clock of cornea.

◎ 瞼裂斑：位于瞼裂區靠近角膜緣的變性球結膜，為一呈水平帶狀、三角形或橢圓形隆起的灰黃色病灶，一般不侵犯角膜。

◎ Pinguecula: It is located on the bulbar conjunctiva near the limbus, not encroach onto the cornea. It is degenerative changes of bulbar conjunctival tissue. It can be ribbonshaped, triangular, or oval, which is a raised gray-yellow lesion, generally do not invade the cornea.

病史詢問

Asking History

◎ 詢問病程進展。

◎ Asking the onset and progression of the lesion.

◎ 詢問眼部外傷史、化學燒傷史、眼部手術史。

◎ Asking the history of eye trauma, chemical burn, surgery.

◎ 詢問是否長時間戶外工作。

◎ Asking if he has been working outdoors for a long time.

◎ 詢問疾病原發或術后復發。

◎ Asking if there was treatment with surgery previously.

檢查

Examination

◎ 視力：較小的翼狀胬肉多無癥狀，胬肉較大較厚時會引起角膜散光，侵及瞳孔區導致視力下降。

◎ Visual acuity: The smaller pterygium is asymptomatic, and the larger and thicker can cause corneal astigmatism, which invades the pupil area will cause vision loss.

◎ 裂隙燈檢查：位于角膜淺層，逐漸向角膜中央生長的三角形纖維血管球結膜組織，基底位于角膜緣旁的結膜，尖端指向角膜中央。通常在角膜緣處與角膜緣粘連。常見于鼻側，也可見鼻、顳兩側同時生長。靜止期的胬肉頭部平坦、體部不充血，血管少。進展期頭部肥厚，體部明顯充血。

◎ Slit-lamp examination: It is a triangular f ibrovascular bulbar conjunctival tissue which located in the superf icial layer of the cornea and ingrowth over the limbus encroach onto the cornea. The base part of pterygium located in the bulbar conjunctiva near the corneal limbus and the tip pointing toward the center of the cornea. It usually adheres to the limbus. It is common on the nasal side, and it can also be seen on both sides of the nasal and temporal. The pterygium in the resting period has a f lat head, no congestion in the body,and few blood vessels. In the advanced stage, the head is hypertrophic, and the body is obviously congested.

◎ 角膜地形圖：胬肉覆蓋部位可出現不規則角膜散光。

◎ Corneal topography: Irregular corneal astigmatism may appear in the pterygium covered area.

診斷

Diagnosis

翼狀胬肉。

Pterygium.

治療

Management

◎ 藥物治療：人工淚液可減輕患者眼部刺激感、異物感或干澀。局部點非甾體眼藥水或短期激素類眼藥水可減輕炎癥反應、減輕結膜充血。對于相對早期或術后復發的翼狀胬肉，局部可點免疫抑制劑類眼藥水如環孢素可以幫助減緩增長速度。

◎ Medical treatment: Topical lubrication can help to release the irritation、foreign body sensation or dryness.Topical NSAID or short time steroids can reduce conjunctival inf lammation and congestion. Topical immunosuppressants such as ciclosporin can slow down but can not stop the progression of disease, which is suitable for early or recurrent cases.

◎ 手術治療：對視力明顯下降或有眼部癥狀影響正常生活的患者可行手術治療。單純翼狀胬肉切除術復發率大概為80%。臨床常采用翼狀胬肉切除聯合組織移植，如自體結膜移植術、角膜緣干細胞移植術、羊膜移植術等；組織植片移植手術中可聯合絲裂霉素C減少復發率。

◎ Surgical treatment for patients with vision or symptom bothering patient normal life. Simple pterygium resection is associated with about 80% recurrent rate. Pterygia excision is often combined with tissue transplantation including autoconjunctival grate transplantation, corneal limbal stem cell transplantation, or amniotic membrane transplantation.Mitomycin C sometimes is used for adjunctive drug for graft technique.

患者教育和預后

Patient Education & Prognosis

◎ 戶外配戴遮陽鏡減少紫外線暴露。

◎ Advise patient to wear sunglasses to avoid ultraviolet exposure.

◎ 建議患者早期手術治療，避免胬肉面積過大導致術后角膜散光或角膜中央區瘢痕。

◎ Follow-up and early treatment is advised to avoid postoperative astigmatism or central corneal scar caused by large area of lesion.