八章角膜病Keratopathy

1、the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university第八章第八章 角膜病角膜病keratopathykeratopathy the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university2第一節(jié)第一節(jié)

2、概概 述述the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university3o基本概念基本概念： 組織結(jié)構(gòu)：組織結(jié)構(gòu)： 損傷修復(fù)損傷修復(fù) 內(nèi)皮功能內(nèi)皮功能endothelium 屈光力屈光力+43d 占眼球屈光力占眼球屈光力3/4 the second hospital of medical college, xian jiaotong universitythe second hospital of m

3、edical college, xian jiaotong university4 cornea-protective membrane “window”-retina “pump”the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university5第二節(jié)第二節(jié) 角膜炎癥角膜炎癥keratitisthe second hospital of medical college, xian jiaotong un

4、iversitythe second hospital of medical college, xian jiaotong university6一、角膜炎總論一、角膜炎總論o病因： 1. 外源性：外源性： trauma infection (1)細(xì)菌：約占細(xì)菌：約占7277%，菌種包括，菌種包括 金黃色葡萄球菌、表皮菌、肺炎金黃色葡萄球菌、表皮菌、肺炎 鏈球菌、腸道菌、綠膿桿菌鏈球菌、腸道菌、綠膿桿菌 (2)真菌：約占真菌：約占24%，鐮刀、曲霉，鐮刀、曲霉 (3)棘阿米巴（棘阿米巴（ok鏡）鏡）the second hospital of medical college, xian jia

5、otong universitythe second hospital of medical college, xian jiaotong university7 2. 內(nèi)源性：內(nèi)源性： 全身感染，全身感染，dystrophy營養(yǎng)不良，營養(yǎng)不良， immune disease 3. 局部蔓延局部蔓延local spreadthe second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university8o病理改變病理改變

6、：致病因素致病因素角膜角膜角膜緣血管反應(yīng)角膜基質(zhì)水腫、浸潤炎癥消退，無組織壞死炎癥消退，無組織壞死反應(yīng)性反應(yīng)性虹膜炎虹膜炎角膜潰瘍角膜潰瘍修復(fù)愈合修復(fù)愈合瘢痕瘢痕云翳云翳瘢翳瘢翳白瘢白瘢炎癥消退有組織壞死炎癥消退有組織壞死虹膜前粘邊虹膜前粘邊穿孔穿孔細(xì)菌侵入細(xì)菌侵入眼內(nèi)炎眼內(nèi)炎眼球萎縮眼球萎縮位于中央，瘺管形成位于中央，瘺管形成房水排出受阻位于周邊位于周邊角膜葡萄腫（大面積穿孔）繼發(fā)青光眼繼發(fā)青光眼炎癥發(fā)展表層組織壞死炎癥發(fā)展表層組織壞死角膜恢復(fù)透明角膜恢復(fù)透明角膜前粘邊白瘢（小面積穿孔）the second hospital of medical college, xian jiaotong

7、 universitythe second hospital of medical college, xian jiaotong university10corneal resistance to infection the epithelium is an barrier to entrance of microorganisms into the corneal . once the epithelium is traumatized, the avascular stroma and bowmans layer become susceptibal to infection with a

8、 variety of organisms.the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university11o治療：治療：n 去除病因，積極控制感染，促進(jìn)潰瘍愈合，去除病因，積極控制感染，促進(jìn)潰瘍愈合，減少瘢痕形成。減少瘢痕形成。n 運(yùn)用敏感抗生素運(yùn)用敏感抗生素n 聯(lián)合用藥聯(lián)合用藥the second hospital of medical college, xian jiaotong univers

9、itythe second hospital of medical college, xian jiaotong university12o外傷，去異物所致外傷，去異物所致o常見病菌：常見病菌：n 肺炎雙球菌，金黃色葡萄球菌，鏈球菌科，肺炎雙球菌，金黃色葡萄球菌，鏈球菌科，假單胞菌科，綠膿桿菌，假單胞菌科，綠膿桿菌，n 腸桿菌科：枸椽酸桿菌屬、腸桿菌屬、變腸桿菌科：枸椽酸桿菌屬、腸桿菌屬、變形桿菌屬，沙雷氏菌屬等形桿菌屬，沙雷氏菌屬等二、細(xì)菌性角膜炎二、細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universityt

10、he second hospital of medical college, xian jiaotong university13細(xì)菌性角膜炎細(xì)菌性角膜炎o(hù)外眼的正常菌群：外眼的正常菌群：n 表皮葡萄球菌表皮葡萄球菌n 金葡菌金葡菌n 細(xì)球菌細(xì)球菌n 棒狀桿菌棒狀桿菌n 丙酸菌屬丙酸菌屬n 鏈球菌屬（兒童多見）等鏈球菌屬（兒童多見）等the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university14o細(xì)

11、菌性角膜炎的危險因素：細(xì)菌性角膜炎的危險因素： 眼部眼部 全身全身 干眼癥干眼癥淚道阻塞淚道阻塞瞼炎瞼炎大泡性角膜炎大泡性角膜炎倒睫倒睫接觸鏡接觸鏡角膜暴露、外傷角膜暴露、外傷污染的眼液污染的眼液免疫制劑免疫制劑糖尿病糖尿病風(fēng)濕病風(fēng)濕病酒精中毒酒精中毒營養(yǎng)障礙營養(yǎng)障礙嚴(yán)重?zé)齻麌?yán)重?zé)齻杳曰杳约?xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university15o clinic man

12、ifestation ：n 外傷后外傷后24-48小時小時n 刺激癥狀刺激癥狀n 球結(jié)膜急性混合充血球結(jié)膜急性混合充血 hyperaemian 角膜上點(diǎn)狀黃白色浸潤病灶，迅速擴(kuò)大，角膜上點(diǎn)狀黃白色浸潤病灶，迅速擴(kuò)大，n 形成形成ulcer, 呈匍行性，穿鑿性發(fā)展呈匍行性，穿鑿性發(fā)展n 毒素可引起虹膜睫狀體炎，前房積膿毒素可引起虹膜睫狀體炎，前房積膿 n 潰瘍發(fā)展?jié)儼l(fā)展角膜穿孔角膜穿孔化膿性眼內(nèi)炎化膿性眼內(nèi)炎 細(xì)菌性角膜炎細(xì)菌性角膜炎細(xì)菌性角膜炎細(xì)菌性角膜炎細(xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong uni

13、versitythe second hospital of medical college, xian jiaotong university18o綠膿桿菌性角膜潰瘍綠膿桿菌性角膜潰瘍 pseudomonas corneal ulcer 多見于去異物或戴接觸鏡多見于去異物或戴接觸鏡 傷后數(shù)小時或傷后數(shù)小時或12天，天， 癥狀嚴(yán)重，發(fā)展迅速，劇烈的刺激癥狀，癥狀嚴(yán)重，發(fā)展迅速，劇烈的刺激癥狀， secretion: 黃白色分泌物，量多黃白色分泌物，量多 蛋白分解酶，迅速擴(kuò)展的浸潤及粘液性壞死蛋白分解酶，迅速擴(kuò)展的浸潤及粘液性壞死 角膜易穿孔角膜易穿孔perforation細(xì)菌性角膜炎細(xì)菌性角膜炎

14、細(xì)菌性角膜炎細(xì)菌性角膜炎細(xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university21o treatment n 點(diǎn)眼點(diǎn)眼 n 球結(jié)膜下注射球結(jié)膜下注射 n 全身用藥：全身用藥：選擇廣譜、有效的抗生素積極治療選擇廣譜、有效的抗生素積極治療o 頭孢唑啉鈉頭孢唑啉鈉+妥布霉素妥布霉素o 頭孢唑啉鈉頭孢唑啉鈉+喹諾酮類喹諾酮類n 涂片培養(yǎng)，根據(jù)細(xì)菌學(xué)檢查及藥物敏感試涂片培養(yǎng)，根據(jù)細(xì)

15、菌學(xué)檢查及藥物敏感試驗(yàn)結(jié)果，及時調(diào)整使用有效的抗生素驗(yàn)結(jié)果，及時調(diào)整使用有效的抗生素細(xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university22o 臨床應(yīng)用經(jīng)驗(yàn)：臨床應(yīng)用經(jīng)驗(yàn)：n 從培養(yǎng)結(jié)果看，最常見是金葡菌，其次從培養(yǎng)結(jié)果看，最常見是金葡菌，其次是綠膿桿菌，第三位是表葡菌。是綠膿桿菌，第三位是表葡菌。n 藥敏試驗(yàn)氧氟沙星、環(huán)丙沙星最高藥敏試驗(yàn)氧氟沙星、環(huán)丙沙星最高（89.

16、58%），妥布霉素其次），妥布霉素其次（ 77.08%），療效上兩組沒有明顯），療效上兩組沒有明顯差異。差異。 細(xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university23o注意服用抗生素的局部毒性注意服用抗生素的局部毒性n 氨基甙類：對角結(jié)膜上皮損傷作用最大，氨基甙類：對角結(jié)膜上皮損傷作用最大，慶大慶大新霉素新霉素妥布霉素妥布霉素n 氟喹諾酮類：對角膜基質(zhì)細(xì)胞增殖有一定氟

17、喹諾酮類：對角膜基質(zhì)細(xì)胞增殖有一定抑制（氧氟沙星、環(huán)丙沙星），長期應(yīng)用抑制（氧氟沙星、環(huán)丙沙星），長期應(yīng)用會形成藥物性白斑。而會形成藥物性白斑。而泰利必妥毒性最小。泰利必妥毒性最小。為治療角膜感染性疾病一線藥為治療角膜感染性疾病一線藥細(xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university24n 氯霉素：長期應(yīng)用致角膜上皮點(diǎn)狀糜爛、氯霉素：長期應(yīng)用致角膜上皮點(diǎn)狀糜爛、脫落、

18、骨脫落、骨 髓抑制。髓抑制。n 磺胺類：可致超敏反應(yīng)，角膜免疫環(huán)，瞼磺胺類：可致超敏反應(yīng)，角膜免疫環(huán)，瞼結(jié)膜藥物性結(jié)石。結(jié)膜藥物性結(jié)石。n 四環(huán)素：安全性好四環(huán)素：安全性好n 大環(huán)內(nèi)酯：紅霉素、利福平，副作用小。大環(huán)內(nèi)酯：紅霉素、利福平，副作用小。細(xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university25o兒童用藥：兒童用藥： 泰利必妥無防腐劑和刺激性，穿透性和有泰利必妥

19、無防腐劑和刺激性，穿透性和有效性好，氧氟沙星對兒童也較安全（效性好，氧氟沙星對兒童也較安全（14歲以下歲以下兒童只有兒童只有4% 能在血清中檢出）能在血清中檢出）細(xì)菌性角膜炎細(xì)菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university26三真菌性角膜炎三真菌性角膜炎 fungal keratitiso 病因：n 角膜外傷、角膜外傷、n 菌群失調(diào)菌群失調(diào)n 真菌感染真菌感染o 鐮刀菌屬、念珠

20、菌屬、鐮刀菌屬、念珠菌屬、o 曲霉菌屬、青霉菌屬和酵母菌屬曲霉菌屬、青霉菌屬和酵母菌屬 the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university27o臨床表現(xiàn)：臨床表現(xiàn)：n 起病緩慢起病緩慢 n 刺激癥狀刺激癥狀n 潰瘍形成：灰白色潰瘍形成：灰白色gray infiltrate、較干、較干燥、牙膏狀、周邊淺溝燥、牙膏狀、周邊淺溝n “偽足偽足”，“衛(wèi)星灶衛(wèi)星灶”satellite lesionsn

21、 前房積膿前房積膿 hypopyon真菌性角膜炎真菌性角膜炎真菌性角膜炎真菌性角膜炎真菌性角膜炎真菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university30o diagnosis： 外傷史外傷史trauma， 角膜病灶角膜病灶corneal superficial ulceration， 角膜刮片，培養(yǎng)角膜刮片，培養(yǎng) 真菌性角膜炎真菌性角膜炎the second hospital of

22、 medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university31o治療：治療：n 抗真菌類藥物抗真菌類藥物n 點(diǎn)眼點(diǎn)眼 球結(jié)膜下注射球結(jié)膜下注射 全身用藥全身用藥 o 多烯類：多烯類：0.25%兩性霉素滴眼液兩性霉素滴眼液 5%匹馬霉素滴眼液匹馬霉素滴眼液o 咪唑類咪唑類: 0.5% 咪康唑滴眼液咪康唑滴眼液o 嘧啶類嘧啶類: 1%氟胞嘧啶滴眼液氟胞嘧啶滴眼液真菌性角膜炎真菌性角膜炎the second hospital of medical

23、college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university32n 并發(fā)色素膜炎者，并發(fā)色素膜炎者，1%阿托品眼液散瞳阿托品眼液散瞳n 角膜即將穿孔者，角膜移植術(shù)角膜即將穿孔者，角膜移植術(shù) 結(jié)膜瓣掩蓋術(shù)結(jié)膜瓣掩蓋術(shù)真菌性角膜炎真菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaot

24、ong university33四、單純皰疹病毒性角膜炎四、單純皰疹病毒性角膜炎erpes simplex keratitiserpes simplex keratitiso 病原學(xué)病原學(xué) hsv-i：眼部皰疹：眼部皰疹 hsv-：生殖器皰疹：生殖器皰疹 the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university34oclinic findings： two forms:n 原發(fā)感染原發(fā)感染 pri

25、maryn 復(fù)發(fā)感染復(fù)發(fā)感染 recurrento 樹枝狀和地圖狀角膜炎樹枝狀和地圖狀角膜炎o(hù) 角膜基質(zhì)炎角膜基質(zhì)炎: 盤狀角膜炎盤狀角膜炎單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university35o樹枝狀角膜炎樹枝狀角膜炎 dendritic ulcer 觸發(fā)觸發(fā)triggered by fever, overexposure to ultraviole

26、t light, trauma, 精神的精神的psychic stress, the onset of menstruation月經(jīng)來潮月經(jīng)來潮, or some other local or systemic source of immunosuppression(局部或全身使用局部或全身使用免疫抑制劑免疫抑制劑).單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong un

27、iversity36n 異物感、異物感、 畏光、畏光、tearing、 視物模糊視物模糊n 角膜上皮點(diǎn)狀浸潤角膜上皮點(diǎn)狀浸潤點(diǎn)狀角膜炎點(diǎn)狀角膜炎 線狀浸潤線狀浸潤線狀角膜炎線狀角膜炎 樹枝狀角膜炎樹枝狀角膜炎n 睫狀充血睫狀充血 hyperaemian 角膜知覺減退：局部或彌漫性角膜知覺減退：局部或彌漫性單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong universit

28、y37o地圖狀角膜炎地圖狀角膜炎 hsv沿樹枝狀病灶呈沿樹枝狀病灶呈離心性向周邊部及基離心性向周邊部及基質(zhì)淺層擴(kuò)展而形成。質(zhì)淺層擴(kuò)展而形成。 單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university39o角膜基質(zhì)炎角膜基質(zhì)炎 corneal stromal keratitisn 盤狀角膜炎盤狀角膜炎(disciform

29、 keratitis)系典型表現(xiàn)系典型表現(xiàn)n 角膜中央?yún)^(qū)基質(zhì)呈盤狀水腫角膜中央?yún)^(qū)基質(zhì)呈盤狀水腫n 無炎癥細(xì)胞浸潤無炎癥細(xì)胞浸潤n 角膜上皮完好角膜上皮完好單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university41o 治療：治療：n 無環(huán)鳥苷、干擾素?zé)o環(huán)鳥苷、干擾素n 反復(fù)發(fā)作致角膜渾濁，板層或穿透性角膜反復(fù)發(fā)作致角膜

30、渾濁，板層或穿透性角膜移植術(shù)移植術(shù)單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎單純皰疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university43opathogeny: 棘阿米巴n 存在于土壤、淡水、海水、游泳池、空氣、存在于土壤、淡水、海水、游泳池、空氣、谷物和家畜。谷物和家畜。n 常因角膜接觸棘阿米巴污染的水源，特別是常因角膜接觸棘阿米巴污染的水源，特別是通過污染了

31、的接觸鏡或清洗鏡片的藥液感染通過污染了的接觸鏡或清洗鏡片的藥液感染發(fā)病。發(fā)病。五、五、 棘阿米巴角膜炎棘阿米巴角膜炎(acanthamoeba keratitis)the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university44oclinic findings:n symptoms:o corneal traumao laterality 單側(cè)多見單側(cè)多見o pain o foreign body s

32、ensation o photophobia o tearing o vision acuity decline 棘阿米巴角膜炎棘阿米巴角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university45n signs:o 初期，上皮混濁、點(diǎn)狀缺損初期，上皮混濁、點(diǎn)狀缺損o 角膜基質(zhì)浸潤，炎癥延角膜神經(jīng)分布的放射狀角膜基質(zhì)浸潤，炎癥延角膜神經(jīng)分布的放射狀浸潤浸潤 放射狀角膜神經(jīng)炎放射狀角膜神經(jīng)炎o(hù)

33、基質(zhì)形成炎癥浸潤環(huán)，環(huán)周有白色衛(wèi)星灶，基質(zhì)形成炎癥浸潤環(huán)，環(huán)周有白色衛(wèi)星灶，o 中央基質(zhì)盤狀浸潤中央基質(zhì)盤狀浸潤o 前房積膿前房積膿 hypopyon棘阿米巴角膜炎棘阿米巴角膜炎棘阿米巴角膜炎棘阿米巴角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university47odiagnosis:n clinic findingsn 病灶取材涂片或培養(yǎng)，棘阿米巴原蟲病灶取材涂片或培養(yǎng)，棘阿米巴原蟲n 共焦顯

34、微鏡，棘阿米巴滋養(yǎng)體和包囊共焦顯微鏡，棘阿米巴滋養(yǎng)體和包囊棘阿米巴角膜炎棘阿米巴角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university48otreatment:n 二咪或聯(lián)咪類：二咪或聯(lián)咪類：0.15%羥乙磺酸雙溴丙咪羥乙磺酸雙溴丙咪n 咪唑類：咪唑類： 10%/ ml 咪康唑咪康唑 用藥量先頻后減，用藥量先頻后減， 療程療程4 個月以上個月以上 n 角膜移植術(shù)角膜移植術(shù)棘阿米巴角膜炎棘阿

35、米巴角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university49o 病因：病因：n 眼瞼缺損眼瞼缺損n 眼球突出、眼球突出、n 瘢痕性瞼內(nèi)翻瘢痕性瞼內(nèi)翻n 上瞼下垂術(shù)后上瞼下垂術(shù)后六、暴露性角膜炎六、暴露性角膜炎（exposure keratitis）the second hospital of medical college, xian jiaotong universitythe sec

36、ond hospital of medical college, xian jiaotong university50暴露性角膜炎暴露性角膜炎o(hù)clinic findings: 上皮糜爛上皮糜爛ulcer感染感染 perforationo治療：治療：去除暴露因素去除暴露因素 the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university51 自發(fā)性、慢性、邊緣性、進(jìn)行性、疼痛性角膜潰瘍自發(fā)性、慢性、邊緣性、進(jìn)行性、疼痛性角膜潰瘍 o病因病因：n 不