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1、几种特殊类型单疱病毒性角膜眼的几种特殊类型单疱病毒性角膜眼的 诊治诊治温州医学院附属眼视光医院温州医学院附属眼视光医院 陈陈 蔚蔚 2007-8-022007-8-02白内障术后并发单疱病毒性角膜炎白内障术后并发单疱病毒性角膜炎 机理： 1、激素的长期应用，改变了局部眼免疫状态 2、药物毒性（大量局部眼药水） 3、干眼 4、角膜神经破坏 5、不适当治疗加重病情2006年7月5日白内障术后白内障术后HSKHSK病例病例1 1 白内障术后2月 治疗: ACV 1.0 DXM 5mg 无防腐剂人工泪液 可乐必妥 1%环孢霉素 眼水 0.02%FMT2006年7月24日 7.8 停ACV针,改口服AC
2、V 2# 5/日 7.10 丽科明和自体血清 7.11 改0.02%FMT为典必殊 qid 7.21 出院 可乐必妥 BID 1%CSA BID 人工泪液 QID 典必殊 tid ACV 2# 5/日2006年8月2日出院随访出院随访2006年8月16日2006年10月17日右眼白内障术后2月白内障术后白内障术后HSKHSK病例病例2 2左眼白内障术后1个半月综合治疗2月后PKPPKP术后复发单疱病毒性角膜炎术后复发单疱病毒性角膜炎 容易和排斥反应混淆 术后应该至少口服ACV3月以上 出现排斥反应时，加用口服ACV 如果有上皮病变或者植片溶解，局部不能 用激素。眼部手术并发眼部手术并发HSKH
3、SK治疗方案治疗方案 尽量减少局部用药丽科明、无防腐剂人工泪液、自体血清 局部低浓度激素：0.02%氟美瞳 必要时用1%CSA 全身口服ACV 口服激素 病情严重，可静脉注射ACV1.0+DXM5mg神经营养性角膜溃疡神经营养性角膜溃疡 无菌性溃疡 病毒引起的基底膜的破坏，使得上皮不能 生长 分为点状上皮糜烂和神经营养性溃疡 早期表现为角膜表面不规整，无光泽 椭圆形，边缘光滑的 溃疡底部呈灰白色混浊，边缘光滑增厚， 甚至基质溶解变薄，导致角膜穿孔神经营养性角膜溃疡神经营养性角膜溃疡 治疗治疗 配戴高含水量可过夜的隐形眼镜（Advance Acuve 2 weeks Johnson& Johns
4、on）戴镜 期间用抗生素眼水 2次/日 预防感染 如果没有隐形眼镜，间断隔天涂抗生素眼 膏后加压包扎 使用不含防腐剂的人工泪液（瑞新、倍然 等）6次/日神经营养性角膜溃疡神经营养性角膜溃疡 治疗治疗 酌情使用低浓度的激素（如0.02%氟美瞳） 1-2次/日 有虹睫炎时适当散瞳（东莨菪碱）2次/日 同时口服抗病毒药物 基质有溶解穿孔的倾向，可羊膜移植或组 织粘合剂粘贴，必要时角膜移植全角膜型全角膜型HSKHSK累及上皮层、基质和内皮层2006年8月28日2006年9月5日2006年9月16日HSKHSK混合型治疗方案混合型治疗方案 尽量减少局部用药丽科明、无防腐剂人工泪液、自体血清 局部低浓度激
5、素：0.02%氟美瞳 必要时用1%CSA 全身口服ACV 口服激素 治疗性隐形眼镜 羊膜移植The The Diagnosis and Treatment of Diagnosis and Treatment of herpes simplex keratitisherpes simplex keratitis Classification of HSV keratitisClassification of HSV keratitis I. Infectious epithelial keratitis A. Cornea vesicles B. Dendritic ulcer C. Geog
6、raphic ulcer D. Marginal ulcer II. Stromal keratitis A. Necrotizing stromal keratitis B. Immune stromal (interstitial) keratitis III. Endotheliitis A. Disciform B. Diffuse C. LinearI. I. Infectious epithelial keratitisInfectious epithelial keratitisA. A. punctate epithelial keratopathy punctate epit
7、helial keratopathy (PEK)(PEK) minute, raised, clear vesicles in the early stages of a recurrence Within 24 hours, the vesicles coalesce to form the typical dendritic and geographic ulcers B. B. dendritic ulcerdendritic ulcer branching, linear lesion with terminal bulbs and swollen epithelial borders
8、 that contain live virus stains positive for fluorescein dendritic ulcerdendritic ulcerC. C. geographic ulcergeographic ulcer epithelial lesion that extends through the basement membrane associated with the previous use of topical corticosteroidsgeographic ulcergeographic ulcerD. D. HSV marginal ulc
9、erHSV marginal ulcer results from active viral disease like dendritic ulcer proximity to limbus, accompanying blood vessels, unique clinical features anterior stromal infiltrate underlying the ulcer and adjacent limbal injection dendritic ulcer overlying the stromal infiltrate more symptomatic more
10、intense and longer lasting disease Some patients require topical corticosteroids HSV marginal ulcerII. II. Stromal diseaseStromal diseaseA. A. Necrotizing stromal keratitisNecrotizing stromal keratitis direct viral invasion of the corneal stroma clinical findings are necrosis, ulceration, and dense
11、infiltration of the stroma with an overlying epithelial defect thinning and perforation perforation, infectionperforation, infectionnecrosis, ulceration, thinning, pnecrosis, ulceration, thinning, perforationerforationB. B. Immune stromal (interstitial) Immune stromal (interstitial) keratitiskeratit
12、is retained viral antigen within the stroma Stromal infiltration immune ring stromal neovascularization，sectoralstromal keratitisstromal keratitisstromal keratitisstromal keratitisstromal keratitisstromal keratitisIII. III. EndotheliitisEndotheliitis stromal edema without stromal infiltrate keratic
13、precipitates (KP), overlying stromal and epithelial edema, and iritis the presence of HSV I antigen in corneal endothelial cells three forms: disciform, diffuse, and linear A. A. Disciform endothelitisDisciform endothelitis KP iritis edema from endothelial decompensation sensitive to topical cortico
14、steroidsHerpes simplex disciform keratitisB. B. Diffuse endotheliitisDiffuse endotheliitis scattered KP over the entire cornea with overlying diffuse stromal edema iritis In severe cases, a dense, retrocorneal plaque of inflammatory cells accompanied by hypopyon may be seen Diffuse endotheliitisC. C
15、. Linear endotheliitisLinear endotheliitis line of KP KP can be sectoral or, in some cases, circumferential edema between the KP and the limbus KP located at the leading edge of the edema both corticosteroids and antiviral agentsLinear endotheliitisDiagnosisDiagnosis thorough ophthalmic examination
16、viral culture: slow Cytologic examination of specimens stained with Giemsa or Wright stains, Multinucleated giant cells, nonspecific, intranuclear inclusions Immunologic tests:The Herpchek, Virogen-latex agglutination, enzyme immunofiltration, and the 1- hour enzyme linked immunoassay can detect HSV antigen in cel
