巩巩 膜膜 病病 概概 述述•组成：由胶原纤维和弹力纤维交织组成组成：由胶原纤维和弹力纤维交织组成•功能：维持眼球形状功能：维持眼球形状•病理改变：肉芽肿性增殖反应、变性、坏死病理改变：肉芽肿性增殖反应、变性、坏死 巩膜炎容易发生在表层血管较多巩膜炎容易发生在表层血管较多 （尤其是前睫状血管穿过巩膜）的部位尤其是前睫状血管穿过巩膜）的部位•修复能力差：因为血管和神经少，代谢不活跃，药物疗修复能力差：因为血管和神经少，代谢不活跃，药物疗效较差•特点：病程长、反复发作、疼痛、畏光、流泪特点：病程长、反复发作、疼痛、畏光、流泪•常见巩膜病：表层巩膜炎常见巩膜病：表层巩膜炎(episcleritis)(episcleritis)、巩膜炎、巩膜炎(scleritis)(scleritis)、巩膜葡萄肿、巩膜葡萄肿(staphyloma)(staphyloma) •Episcleritis •Sectoral redness, engorged episcleral vessels, mild pain •Normal vision •Typically idiopathic, sometimes collagen-vascular disease related •Rx – topical steroids, REFER if recurrent •Episcleral redness with localized tenderness, usually sectoral, may be nodular, blanches with topical epinephrine 2.5%, benign and self-limited •Etiology: idiopathic, collagen vascular disease - RA, SLE, gout 表层巩膜炎表层巩膜炎(episcleritis)•是复发性、暂时性、自限性巩膜表层组织的非特异性是复发性、暂时性、自限性巩膜表层组织的非特异性炎症。
炎症 •特征：无刺激症状的眼红特征：无刺激症状的眼红•常发生于角膜缘至肌肉附着点、睑裂部常见常发生于角膜缘至肌肉附着点、睑裂部常见•发病率：女发病率：女: :男男=3:1=3:1•好发于年轻人好发于年轻人•类型：结节性表层巩膜炎类型：结节性表层巩膜炎(nodular episcleritis)(nodular episcleritis)、、周期性表层巩膜炎周期性表层巩膜炎(periodic episcleritis)(periodic episcleritis)•治疗：本病具有自限性，治疗：本病具有自限性，1 1～～2 2周内自愈，一般无需特周内自愈，一般无需特殊治疗 结节性表层巩膜炎结节性表层巩膜炎 (nodular episcleritis)•特征：局限性结节样隆起•结节直径约2～3mm，单发或数个，暗红色•结节及周围结膜充血和水肿•疼痛和压痛，轻度刺激症状•发病持续约两周，易复发•起病隐匿，症状严重，病程长 周期性表层巩膜炎周期性表层巩膜炎(periodic episcleritis)•又称单纯性表层巩膜炎（simple episcleritis),周期性发作，间隔可为1～3个月，每次发病通常持续1～数天。
•巩膜表层和球结膜呈弥漫性充血和水肿•病程持续3～6年或更长•妇女月经期发作多见,一般不影响视力 巩巩 膜膜 炎炎（scleritis) •为巩膜基质层的炎症，病情和预后较表层巩膜炎严重为巩膜基质层的炎症，病情和预后较表层巩膜炎严重•2020～～6060岁、女性、双眼多见岁、女性、双眼多见 •病因：病因：1.1.全身感染性疾病：结核、麻风、带状疱疹或全身感染性疾病：结核、麻风、带状疱疹或 感染病灶引起的过敏反应有关感染病灶引起的过敏反应有关 2. 2.自身免疫性疾病：风湿性关节炎、自身免疫性疾病：风湿性关节炎、WegenerWegener肉肉 芽肿芽肿 、系统性红斑狼疮、多发性结节性动脉、系统性红斑狼疮、多发性结节性动脉 炎等 3. 3.代谢性疾病：痛风代谢性疾病：痛风 4. 4.其他：外伤或结膜、角膜、葡萄膜、眶内炎症其他：外伤或结膜、角膜、葡萄膜、眶内炎症 感染扩散感染扩散 ↗ ↗结节性结节性•分类：分类：1.1.前部巩膜炎前部巩膜炎(anterior scleritis→(anterior scleritis→弥漫性弥漫性 ↘ ↘坏死性坏死性 2. 2.后部巩膜炎后部巩膜炎(posterior scleritis) (posterior scleritis) • •Clinical features: Clinical features: – –Granulomatous inflammation of the sclera. Granulomatous inflammation of the sclera. – –May present in association with systemic diseases i.e. May present in association with systemic diseases i.e. rheumatoid arthritis, SLE, polyarteritis nodosa, or Wegener's rheumatoid arthritis, SLE, polyarteritis nodosa, or Wegener's granulomatosis. granulomatosis. – –Symptoms: ocular pain with or without decreased vision. Symptoms: ocular pain with or without decreased vision. • •May be self-limiting or progress to necotizing process that may May be self-limiting or progress to necotizing process that may be potentially blinding. be potentially blinding. • •May be classified into non-necrotizing or necrotizing anterior May be classified into non-necrotizing or necrotizing anterior scleritis and non-necrotizing or necrotizing posterior scleritis. scleritis and non-necrotizing or necrotizing posterior scleritis. • •Non-necrotizing inflammation may be differentiated into nodular Non-necrotizing inflammation may be differentiated into nodular and diffuse scleritis. and diffuse scleritis. • •Complications: scleral thinning (especially in the chronic Complications: scleral thinning (especially in the chronic recurrent scleritis), scleromalacia, scleral perforation, sclerosing recurrent scleritis), scleromalacia, scleral perforation, sclerosing keratitis, peripheral corneal melting, uveitis, cataract, macula keratitis, peripheral corneal melting, uveitis, cataract, macula edema, retinal detachment and choroidal granuloma. edema, retinal detachment and choroidal granuloma. • •Work up: Work up: – –Systemic rheumatology evaluation. Systemic rheumatology evaluation. – –Always rule out infection in cases of necrotizing scleritis. Always rule out infection in cases of necrotizing scleritis. • •Treatment: systemic NSAIDs, systemic or topical corticosteroids, Treatment: systemic NSAIDs, systemic or topical corticosteroids, cyclophosphamide, cyclosporin or other immunosuppressive cyclophosphamide, cyclosporin or other immunosuppressive therapies.therapies. 前部巩膜炎前部巩膜炎 (anterior scleritis)•病变位于赤道部之前。
病变位于赤道部之前•双眼先后发病，可持续数周、数月、数年双眼先后发病，可持续数周、数月、数年•眼部疼痛剧烈，有刺激症状眼部疼痛剧烈，有刺激症状•弥漫性或局限的紫红色充血、隆起，有压痛，弥漫性或局限的紫红色充血、隆起，有压痛，结节不能推动结节不能推动•球结膜高度水肿球结膜高度水肿•并发症：葡萄膜炎、角膜炎、白内障，继发性并发症：葡萄膜炎、角膜炎、白内障，继发性青光眼•类型：类型：结节性前部巩膜炎、弥漫性前部巩膜炎、结节性前部巩膜炎、弥漫性前部巩膜炎、坏死性前部巩膜炎坏死性前部巩膜炎 前部巩膜炎前部巩膜炎(anterior scleritis)•结节性前部巩膜炎结节性前部巩膜炎(nodular anterior scleritis)(nodular anterior scleritis)：巩膜呈：巩膜呈紫红色结节样隆起，不能推动，质硬，压痛紫红色结节样隆起，不能推动，质硬，压痛, ,大约大约4444％％～～5050％的病人合并有系统性疾病％的病人合并有系统性疾病•弥漫性前部巩膜炎弥漫性前部巩膜炎(diffuse anterior scleritis)(diffuse anterior scleritis)：最常见，：最常见，症状最轻，巩膜呈弥漫性充血，球结膜水肿，预后相症状最轻，巩膜呈弥漫性充血，球结膜水肿，预后相对较好。
对较好•坏死性前部巩膜炎坏死性前部巩膜炎(necrotizing anterior scleritis)(necrotizing anterior scleritis)：破：破坏性较大，损害视力，双眼发病，可伴有严重的自身坏性较大，损害视力，双眼发病，可伴有严重的自身免疫性疾病局部巩膜斑块的边缘炎性反应较中间重，免疫性疾病局部巩膜斑块的边缘炎性反应较中间重，眼痛明显另有一种坏死性巩膜炎主要表现为进行性眼痛明显另有一种坏死性巩膜炎主要表现为进行性巩膜变薄、软化、坏死和穿孔巩膜变薄、软化、坏死和穿孔, ,又称穿孔性巩膜软化症又称穿孔性巩膜软化症（（scleromalacia perforans)scleromalacia perforans) diffuse 后部巩膜炎后部巩膜炎(posterior scleritis)•发生于赤道后方巩膜的一种肉芽肿性炎性发生于赤道后方巩膜的一种肉芽肿性炎性•多单眼发病，眼前段一般无明显改变多单眼发病，眼前段一般无明显改变•程度不同的眼痛和压痛，眼险及球结膜水肿，眼程度不同的眼痛和压痛，眼险及球结膜水肿，眼球轻度突出，眼球运动受限及复视球轻度突出，眼球运动受限及复视。
•若合并葡萄膜炎、玻璃体炎症、视神经炎、渗出若合并葡萄膜炎、玻璃体炎症、视神经炎、渗出性视网膜脱离时视力明显减退性视网膜脱离时视力明显减退•B B超、超、CTCT扫描或扫描或MRIMRI能显示后部巩膜增厚能显示后部巩膜增厚 巩膜炎的并发症•葡萄膜炎•角膜炎•角膜基质炎•眼内压增高•眼底异常 巩膜炎的治疗巩膜炎的治疗•针对病因治疗针对病因治疗•抗炎治疗：局部滴用及全身应用皮质类固醇抗炎治疗：局部滴用及全身应用皮质类固醇•免疫抑制剂、免疫调节剂、细胞毒制剂免疫抑制剂、免疫调节剂、细胞毒制剂 •阿托品阿托品•对坏死、穿孔的巩膜部位可试行异体巩膜移植术，对坏死、穿孔的巩膜部位可试行异体巩膜移植术，术后局部或全身应用免疫抑制剂出现并发症时术后局部或全身应用免疫抑制剂出现并发症时按相应的疾病处理原则进行按相应的疾病处理原则进行 先天性巩膜异常•蓝色巩膜（blue sclera) 生后3年巩膜仍为蓝色时，视为病理状态。
•巩膜色素斑（pigmentary patches of sclera) 临床无特殊意义 巩膜葡萄肿巩膜葡萄肿（scleral staphyloma)• 由于巩膜变薄，在眼内压作用下变薄的巩膜以及由于巩膜变薄，在眼内压作用下变薄的巩膜以及深层的葡萄膜向外扩张膨出，显露出葡萄膜颜色深层的葡萄膜向外扩张膨出，显露出葡萄膜颜色而呈蓝黑色，称为巩膜葡萄膜肿而呈蓝黑色，称为巩膜葡萄膜肿•前巩膜葡萄膜肿：膨出位于睫状体区常见于炎前巩膜葡萄膜肿：膨出位于睫状体区常见于炎症、外伤合并继发性青光眼症、外伤合并继发性青光眼•赤道部巩膜葡萄膜肿：多为绝对期青光眼并发症赤道部巩膜葡萄膜肿：多为绝对期青光眼并发症•后巩膜葡萄膜肿：位于眼底后极部及视盘周围，后巩膜葡萄膜肿：位于眼底后极部及视盘周围，多见于高度近视眼多见于高度近视眼 。