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第一节第一节

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： 组织结构：组织结构： 损伤修复损伤修复 内皮功能内皮功能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第二节第二节 角膜炎症角膜炎症keratitisthe second hospital of medical college, xian jiaotong un

4、iversitythe second hospital of medical college, xian jiaotong university6一、角膜炎总论一、角膜炎总论o病因： 1. 外源性：外源性： trauma infection (1)细菌：约占细菌：约占7277%，菌种包括，菌种包括 金黄色葡萄球菌、表皮菌、肺炎金黄色葡萄球菌、表皮菌、肺炎 链球菌、肠道菌、绿脓杆菌链球菌、肠道菌、绿脓杆菌 (2)真菌：约占真菌：约占24%，镰刀、曲霉，镰刀、曲霉 (3)棘阿米巴（棘阿米巴（ok镜）镜）the second hospital of medical college, xian jia

5、otong universitythe second hospital of medical college, xian jiaotong university7 2. 内源性：内源性： 全身感染，全身感染，dystrophy营养不良，营养不良， 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病理改变病理改变

6、：致病因素致病因素角膜角膜角膜缘血管反应角膜基质水肿、浸润炎症消退，无组织坏死炎症消退，无组织坏死反应性反应性虹膜炎虹膜炎角膜溃疡角膜溃疡修复愈合修复愈合瘢痕瘢痕云翳云翳瘢翳瘢翳白瘢白瘢炎症消退有组织坏死炎症消退有组织坏死虹膜前粘边虹膜前粘边穿孔穿孔细菌侵入细菌侵入眼内炎眼内炎眼球萎缩眼球萎缩位于中央，瘘管形成位于中央，瘘管形成房水排出受阻位于周边位于周边角膜葡萄肿（大面积穿孔）继发青光眼继发青光眼炎症发展表层组织坏死炎症发展表层组织坏死角膜恢复透明角膜恢复透明角膜前粘边白瘢（小面积穿孔）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治疗：治疗：n 去除病因，积极控制感染，促进溃疡愈合，去除病因，积极控制感染，促进溃疡愈合，减少瘢痕形成。减少瘢痕形成。n 运用敏感抗生素运用敏感抗生素n 联合用药联合用药the second hospital of medical college, xian jiaotong univers

9、itythe second hospital of medical college, xian jiaotong university12o外伤，去异物所致外伤，去异物所致o常见病菌：常见病菌：n 肺炎双球菌，金黄色葡萄球菌，链球菌科，肺炎双球菌，金黄色葡萄球菌，链球菌科，假单胞菌科，绿脓杆菌，假单胞菌科，绿脓杆菌，n 肠杆菌科：枸椽酸杆菌属、肠杆菌属、变肠杆菌科：枸椽酸杆菌属、肠杆菌属、变形杆菌属，沙雷氏菌属等形杆菌属，沙雷氏菌属等二、细菌性角膜炎二、细菌性角膜炎the second hospital of medical college, xian jiaotong universityt

10、he second hospital of medical college, xian jiaotong university13细菌性角膜炎细菌性角膜炎o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 细球菌细球菌n 棒状杆菌棒状杆菌n 丙酸菌属丙酸菌属n 链球菌属（儿童多见）等链球菌属（儿童多见）等the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university14o细

11、菌性角膜炎的危险因素：细菌性角膜炎的危险因素： 眼部眼部 全身全身 干眼症干眼症泪道阻塞泪道阻塞睑炎睑炎大泡性角膜炎大泡性角膜炎倒睫倒睫接触镜接触镜角膜暴露、外伤角膜暴露、外伤污染的眼液污染的眼液免疫制剂免疫制剂糖尿病糖尿病风湿病风湿病酒精中毒酒精中毒营养障碍营养障碍严重烧伤严重烧伤昏迷昏迷细菌性角膜炎细菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university15o clinic man

12、ifestation ：n 外伤后外伤后24-48小时小时n 刺激症状刺激症状n 球结膜急性混合充血球结膜急性混合充血 hyperaemian 角膜上点状黄白色浸润病灶，迅速扩大，角膜上点状黄白色浸润病灶，迅速扩大，n 形成形成ulcer, 呈匍行性，穿凿性发展呈匍行性，穿凿性发展n 毒素可引起虹膜睫状体炎，前房积脓毒素可引起虹膜睫状体炎，前房积脓 n 潰疡发展潰疡发展角膜穿孔角膜穿孔化脓性眼内炎化脓性眼内炎 细菌性角膜炎细菌性角膜炎细菌性角膜炎细菌性角膜炎细菌性角膜炎细菌性角膜炎the second hospital of medical college, xian jiaotong uni

13、versitythe second hospital of medical college, xian jiaotong university18o绿脓杆菌性角膜潰疡绿脓杆菌性角膜潰疡 pseudomonas corneal ulcer 多见于去异物或戴接触镜多见于去异物或戴接触镜 伤后数小时或伤后数小时或12天，天， 症状严重，发展迅速，剧烈的刺激症状，症状严重，发展迅速，剧烈的刺激症状， secretion: 黄白色分泌物，量多黄白色分泌物，量多 蛋白分解酶，迅速扩展的浸润及粘液性坏死蛋白分解酶，迅速扩展的浸润及粘液性坏死 角膜易穿孔角膜易穿孔perforation细菌性角膜炎细菌性角膜炎

14、细菌性角膜炎细菌性角膜炎细菌性角膜炎细菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university21o treatment n 点眼点眼 n 球结膜下注射球结膜下注射 n 全身用药：全身用药：选择广谱、有效的抗生素积极治疗选择广谱、有效的抗生素积极治疗o 头孢唑啉钠头孢唑啉钠+妥布霉素妥布霉素o 头孢唑啉钠头孢唑啉钠+喹诺酮类喹诺酮类n 涂片培养，根据细菌学检查及药物敏感试涂片培养，根据细

15、菌学检查及药物敏感试验结果，及时调整使用有效的抗生素验结果，及时调整使用有效的抗生素细菌性角膜炎细菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university22o 临床应用经验：临床应用经验：n 从培养结果看，最常见是金葡菌，其次从培养结果看，最常见是金葡菌，其次是绿脓杆菌，第三位是表葡菌。是绿脓杆菌，第三位是表葡菌。n 药敏试验氧氟沙星、环丙沙星最高药敏试验氧氟沙星、环丙沙星最高（89.

16、58%），妥布霉素其次），妥布霉素其次（ 77.08%），疗效上两组没有明显），疗效上两组没有明显差异。差异。 细菌性角膜炎细菌性角膜炎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 氨基甙类：对角结膜上皮损伤作用最大，氨基甙类：对角结膜上皮损伤作用最大，庆大庆大新霉素新霉素妥布霉素妥布霉素n 氟喹诺酮类：对角膜基质细胞增殖有一定氟

17、喹诺酮类：对角膜基质细胞增殖有一定抑制（氧氟沙星、环丙沙星），长期应用抑制（氧氟沙星、环丙沙星），长期应用会形成药物性白斑。而会形成药物性白斑。而泰利必妥毒性最小。泰利必妥毒性最小。为治疗角膜感染性疾病一线药为治疗角膜感染性疾病一线药细菌性角膜炎细菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university24n 氯霉素：长期应用致角膜上皮点状糜烂、氯霉素：长期应用致角膜上皮点状糜烂、脱落、

18、骨脱落、骨 髓抑制。髓抑制。n 磺胺类：可致超敏反应，角膜免疫环，睑磺胺类：可致超敏反应，角膜免疫环，睑结膜药物性结石。结膜药物性结石。n 四环素：安全性好四环素：安全性好n 大环内酯：红霉素、利福平，副作用小。大环内酯：红霉素、利福平，副作用小。细菌性角膜炎细菌性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university25o儿童用药：儿童用药： 泰利必妥无防腐剂和刺激性，穿透性和有泰利必妥

19、无防腐剂和刺激性，穿透性和有效性好，氧氟沙星对儿童也较安全（效性好，氧氟沙星对儿童也较安全（14岁以下岁以下儿童只有儿童只有4% 能在血清中检出）能在血清中检出）细菌性角膜炎细菌性角膜炎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 角膜外伤、角膜外伤、n 菌群失调菌群失调n 真菌感染真菌感染o 镰刀菌属、念珠

20、菌属、镰刀菌属、念珠菌属、o 曲霉菌属、青霉菌属和酵母菌属曲霉菌属、青霉菌属和酵母菌属 the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university27o临床表现：临床表现：n 起病缓慢起病缓慢 n 刺激症状刺激症状n 溃疡形成：灰白色溃疡形成：灰白色gray infiltrate、较干、较干燥、牙膏状、周边浅沟燥、牙膏状、周边浅沟n “伪足伪足”，“卫星灶卫星灶”satellite lesionsn

21、 前房积脓前房积脓 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： 外伤史外伤史trauma， 角膜病灶角膜病灶corneal superficial ulceration， 角膜刮片，培养角膜刮片，培养 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治疗：治疗：n 抗真菌类药物抗真菌类药物n 点眼点眼 球结膜下注射球结膜下注射 全身用药全身用药 o 多烯类：多烯类：0.25%两性霉素滴眼液两性霉素滴眼液 5%匹马霉素滴眼液匹马霉素滴眼液o 咪唑类咪唑类: 0.5% 咪康唑滴眼液咪康唑滴眼液o 嘧啶类嘧啶类: 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 并发色素膜炎者，并发色素膜炎者，1%阿托品眼液散瞳阿托品眼液散瞳n 角膜即将穿孔者，角膜移植术角膜即将穿孔者，角膜移植术 结膜瓣掩盖术结膜瓣掩盖术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、单纯疱疹病毒性角膜炎四、单纯疱疹病毒性角膜炎erpes simplex keratitiserpes simplex keratitiso 病原学病原学 hsv-i：眼部疱疹：眼部疱疹 hsv-：生殖器疱疹：生殖器疱疹 the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university34oclinic findings： two forms:n 原发感染原发感染 pri

25、maryn 复发感染复发感染 recurrento 树枝状和地图状角膜炎树枝状和地图状角膜炎o 角膜基质炎角膜基质炎: 盘状角膜炎盘状角膜炎单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university35o树枝状角膜炎树枝状角膜炎 dendritic ulcer 触发触发triggered by fever, overexposure to ultraviole

26、t light, trauma, 精神的精神的psychic stress, the onset of menstruation月经来潮月经来潮, 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剂免疫抑制剂).单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong un

27、iversity36n 异物感、异物感、 畏光、畏光、tearing、 视物模糊视物模糊n 角膜上皮点状浸润角膜上皮点状浸润点状角膜炎点状角膜炎 线状浸润线状浸润线状角膜炎线状角膜炎 树枝状角膜炎树枝状角膜炎n 睫状充血睫状充血 hyperaemian 角膜知觉减退：局部或弥漫性角膜知觉减退：局部或弥漫性单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong universit

28、y37o地图状角膜炎地图状角膜炎 hsv沿树枝状病灶呈沿树枝状病灶呈离心性向周边部及基离心性向周边部及基质浅层扩展而形成。质浅层扩展而形成。 单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university39o角膜基质炎角膜基质炎 corneal stromal keratitisn 盘状角膜炎盘状角膜炎(disciform

29、 keratitis)系典型表现系典型表现n 角膜中央区基质呈盘状水肿角膜中央区基质呈盘状水肿n 无炎症细胞浸润无炎症细胞浸润n 角膜上皮完好角膜上皮完好单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎the second hospital of medical college, xian jiaotong universitythe second hospital of medical college, xian jiaotong university41o 治疗：治疗：n 无环鸟苷、干扰素无环鸟苷、干扰素n 反复发作致角膜浑浊，板层或穿透性角膜反复发作致角膜

30、浑浊，板层或穿透性角膜移植术移植术单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎单纯疱疹病毒性角膜炎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、空气、存在于土壤、淡水、海水、游泳池、空气、谷物和家畜。谷物和家畜。n 常因角膜接触棘阿米巴污染的水源，特别是常因角膜接触棘阿米巴污染的水源，特别是通过污染了

31、的接触镜或清洗镜片的药液感染通过污染了的接触镜或清洗镜片的药液感染发病。发病。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 单侧多见单侧多见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，上皮混浊、点状缺损初期，上皮混浊、点状缺损o 角膜基质浸润，炎症延角膜神经分布的放射状角膜基质浸润，炎症延角膜神经分布的放射状浸润浸润 放射状角膜神经炎放射状角膜神经炎o

33、基质形成炎症浸润环，环周有白色卫星灶，基质形成炎症浸润环，环周有白色卫星灶，o 中央基质盘状浸润中央基质盘状浸润o 前房积脓前房积脓 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 病灶取材涂片或培养，棘阿米巴原虫病灶取材涂片或培养，棘阿米巴原虫n 共焦显

34、微镜，棘阿米巴滋养体和包囊共焦显微镜，棘阿米巴滋养体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 二咪或联咪类：二咪或联咪类：0.15%羟乙磺酸双溴丙咪羟乙磺酸双溴丙咪n 咪唑类：咪唑类： 10%/ ml 咪康唑咪康唑 用药量先频后减，用药量先频后减， 疗程疗程4 个月以上个月以上 n 角膜移植术角膜移植术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 眼睑缺损眼睑缺损n 眼球突出、眼球突出、n 瘢痕性睑内翻瘢痕性睑内翻n 上睑下垂术后上睑下垂术后六、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oclinic findings: 上皮糜烂上皮糜烂ulcer感染感染 perforationo治疗：治疗：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 自发性、慢性、边缘性、进行性、疼痛性角膜溃疡自发性、慢性、边缘性、进行性、疼痛性角膜溃疡 o病因病因：n 不