病例12　60岁女性，右眼眼痛、异物感3个月余

CASE 12　A 60-year-old female complaining of right eye pain with foreign body sensation for more than 3 months

见图1-17、图1-18。See Figs. 1-17 and 1-18.

鉴别诊断

Differential Diagnosis

◎ 暴露性角膜炎：睑裂闭合不全的病史和眼部典型的临床表现可帮助诊断。眼部存在暴露因素，如眼部外伤史、手术史（如眼睑成形术）、全身性疾病（如甲状腺功能亢进或面神经麻痹）。本患者因右侧面神经麻痹，右眼睑不能完全闭合，中央及下方角膜暴露不能被泪液湿润。暴露性角膜炎多是角膜下方1/3的上皮点状或顽固性缺损。初期可见角膜、结膜上皮干燥、粗糙。角膜上皮点状糜烂逐渐融合为大片上皮缺损，继而可出现角膜基质融解，偶尔严重的角膜溃疡可导致角膜穿孔。

◎ Exposure keratopathy: The history of hypophasis and the typical clinical manifestations can aid diagnosis. Causes of eye exposure include eye trauma history, surgery history, such as blepharoplasty and systemic disease, such as hyperthyroidism, or facial nerve palsy. In this patient,the right eyelid cannot be fully closed due to the right facial nerve palsy, and the central and lower cornea cannot be wetted by tear f ilm. Exposure keratopathy is mostly punctate or stubborn defects of the epithelium in the lower one third of the cornea. The cornea and conjunctival epithelium are dry and rough at the beginning. The corneal epithelial punctate erosions gradually merges into large epithelial defect. Subsequently, the corneal stromal melting may occur, occasionally leading to perforation.

◎ 感染性角膜炎：应该与细菌性角膜炎、真菌性角膜炎、疱疹病毒性角膜炎和棘阿米巴性角膜炎鉴别。

◎ Infectious keratitis

细菌性角膜炎：患者可有角膜接触镜配戴史、眼部外伤史，眼部手术史等，角膜溃疡凹陷，基底坏死物质多。

Bacterial keratitis: Patients may have a history of contact lens wearing, ocular trauma history, eye surgery history. The corneal ulceration has more necrotic tissue at the base of the ulcer.

真菌性角膜炎：患者多有植物外伤史，角膜病灶表面干燥，可见苔被、伪足、卫星灶、前房积脓、免疫环、内皮斑等典型表现。

Fungal keratitis: Many patients have a history of plant trauma, the corneal ulceration surface is dry. Typical features such as moss cover, pseudopodia, satellite focus, anterior chamber accumulation, immune ring and endothelial plaque can be seen.

疱疹病毒性角膜炎：多数患者具有反复发作病史，抵抗力低下，角膜病灶可有树枝状、地图状、盘状等。

Herpes simplex keratitis: Most patients have a history of recurrent attacks with low resistance, and corneal lesions can be dendritic, map-like, discoid.

棘阿米巴性角膜炎：患者可有角膜接触镜配戴史、疫水接触史、病变迁延不愈倾向等，眼部剧烈疼痛，角膜病灶不具有典型特征，角膜溃疡类似盘状角膜炎，出现放射状角膜神经炎有助于诊断，主要依靠角膜共聚焦显微镜观察到阿米巴包囊来确诊。

Acanthamoeba keratitis: Patients may have contact lens wearing history, contact history of epidemic water, and disease extension tendency. The corneal ulcer is similar to discoid keratitis. The occurrence of radial corneal neuritis is helpful for the diagnosis. The diagnosis is mainly based on corneal confocal microscope.

◎ 神经营养性角膜炎：通常是由眼部病毒感染、手术、颅脑肿瘤等原因使角膜失去神经支配，导致角膜敏感度下降，同时角膜神经营养支持作用减弱或消失，导致角膜溃疡。典型表现为：眼红伴视力下降，角膜知觉减退或消失。

◎ Neurotrophic keratopathy: This is a disease that the cornea losses of innervation due to ocular virus infection,surgery, intracranial tumors or any other relative causes,leading to the cornea decreases its sensitivity and defensive,as well as the corneal neurotrophic effect is weakened or disappeared. Typical symptoms are painless redness and decreased vision. Diminished or disappeared corneal sensation is typical sign.

病史询问

Asking History

◎ 询问发病时间、进展以及诊疗经过。

◎ Asking the onset, progression and treatment history.

◎ 询问眼部暴露因素和暴露病史，包括用药史、眼外伤、眼睑整形等眼部手术史、全身性疾病史如甲状腺功能亢进病史或面神经麻痹史。

◎ Asking the causes of eye exposure factors and exposure history include medical history, eye trauma history,surgery history, such as blepharoplasty and systemic disease, such as hyperthyroidism, or facial nerve spasm and palsy.

检查

Examination

◎ 视力、眼压：视力下降，出现角膜穿孔后眼压下降。

◎ Visual acuity, IOP：Visual acuity is decreased. IOP is decreased after corneal perforation.

◎ 裂隙灯检查：初期睑裂部结膜水肿、粗糙，进而可出现干燥斑。严重者可出现角膜损伤，多位于角膜下方1/3。荧光素钠染色观察角膜干燥程度、角膜上皮缺损面积、是否出现角膜穿孔。

◎ Slit-lamp examination: Conjunctiva edema and roughness are at the initial stage of blepharophesis, and then dry spots may appear. In severe cases, corneal injury may occur. Exposure keratopathy often affects the lower one third of the cornea. Fluorescein staining is used to observe the corneal dryness, corneal epithelial defect area,and whether corneal perforation occurs.

◎ 角膜知觉检查：角膜知觉正常（可以与神经营养性角膜炎相鉴别，神经营养性角膜炎的角膜知觉检查多减弱或消失）。

◎ Corneal sensation: Normal (It can be distinguished from neurotrophic keratopathy. The corneal sensation of neurotrophic keratopathy is weaken or disappear).

◎ 共聚焦显微镜检查：了解病灶区是否存在真菌、阿米巴等病原微生物。

◎ Corneal confocal microscopy examination: Check the presence of fungi, acanthamoeba and other pathogenic microorganisms in the lesion.

◎ Bell征：患者闭眼时眼球向外上方转动，露出白色巩膜，为Bell征阳性。多见于面神经麻痹患者。

◎ Bell palsy: When the patient closed eyes, the eyeballs turned outward and upward, exposing the sclera, which was Bell palsy. It is more common in patients with facial nerve palsy.

◎ 眼球突出度检查：眼眶病变导致的突眼可使眼球突出度增加。

◎ Eyeball protrusion examination (orbital lesions can lead to increased protrusion).

实验室检查

Lab

◎ 角膜刮片、培养：病原微生物阴性。

◎ Corneal scraping and culture: Pathogenic microor ganism negative.

诊断

Diagnosis

暴露性角膜炎。

Exposure keratopathy.

治疗

Management

◎ 维持眼表湿润，预防感染：白天点人工泪液，晚上点抗生素眼膏。

◎ Artif icial tears applied during day time and antib i otic ointment at night to keep eye moist and prevent infection.

◎ 绷带镜联合人工泪液。

◎ Bandage contact lenses combined with artif icial tears.

◎ 角膜融解时可行结膜瓣遮盖术、羊膜移植术来保护角膜。

◎ Amniotic membrane graft or conjunctival f lap when corneal melting gets progress.

◎ 去除暴露因素：暂时性眼睑闭合不全患者可采用暂时性眼睑缝合，永久性眼睑闭合不全可采用永久性眼睑缝合。

◎ Temporary tarsorrhaphy for reversible exposure, and permanent tarsorrhaphy for permanent exposure.

患者教育和预后

Patient Education & Prognosis

◎ 去除眼部暴露因素是关键的治疗手段，患者需要密切随访观察眼部病情变化。

◎ Removing the eye exposure factor is the key trea t ment.Patients need to be closely followed.

◎ 预后：取决于角膜溃疡暴露原因和持续时间，以及角膜溃疡严重程度。角膜知觉减退患者预后较差。

◎ The prognosis depends on the exposure factors, severity and duration of exposure. The prognosis of patie nts with impaired corneal sensation is poor.