几种特殊类型单疱病毒性角膜炎的诊疗课件

1、几种特殊类型单疱病毒性角膜炎的诊疗几种特殊类型单疱病毒性角膜炎的诊疗2006年7月5日白内障术后HSK病例1白内障术后2月治疗:ACV 1.0DXM 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5日白内障术后HSK病例1白内障术后2月2006年7月24日7.8 停ACV针,改口服ACV 2# 5/日7.10 丽科明和 自体血清7.11 改0.02%FMT为典必殊qid7.21 出院可乐必妥 BID1%CSA BID人工泪液 QID典必殊 tidACV 2# 5/日2006年7月24日7.8 停ACV针,改口服ACV 2# 2006年8月2日 出院随访2006年

2、8月16日2006年10月17日2006年8月2日 出院随访2006年右眼白内障术后2月白内障术后HSK病例2左眼白内障术后1个半月右眼白内障术后2月白内障术后HSK病例2左眼白内障术后1个半综合治疗2月后综合治疗2月后PKP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。PKP术后复发单疱病毒性角膜炎容易和排斥反应混淆几种特殊类型单疱病毒性角膜炎的诊疗课件眼部手术并发HSK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

3、服激素病情严重，可静脉注射ACV1.0+DXM5mg眼部手术并发HSK治疗方案尽量减少局部用药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无菌性溃疡几种特殊类型单疱病毒性角膜炎的诊疗课件神经营养性角膜溃疡 治疗配戴高含水量可过夜的隐形眼镜（Advance Acuve 2 weeks Johnson& Johnson）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

4、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 治疗配戴高含水量可过夜的隐形眼镜（Adv神经营养性角膜溃疡 治疗酌情使用低浓度的激素（如0.02%氟美瞳） 12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，必要时角膜移植神经营养性角膜溃疡 治疗酌情使用低浓度的激素（如0.02%氟全角膜型HSK累及上皮层、基质和内皮层全角膜型HSK累及上皮层、基质和内皮层几种特殊类型单疱病毒性角膜炎的诊疗课件Stromal diseaseControl of trigger mechanisms of recurrent病情严

5、重，可静脉注射ACV1.general acyclovirrisk of recurrence is 12% to 19%02%FMT为典必殊qidDebridement2006年10月17日Prophylaxis for postPK patients with history of HSV keratitisscattered KP over the entire cornea with overlying diffuse stromal edemaIn severe cases, a dense, retrocorneal plaque of inflammatory cells acc

6、ompanied by hypopyon may be seen自体血清如果有上皮病变或者植片溶解，局部不能用激素。minute, raised, clear vesicles累及上皮层、基质和内皮层Immune stromal (interstitial) keratitisidoxuridine (IDU)Dendritic keratitisbranching, linear lesion with terminal bulbs and swollen epithelial borders that contain live virus溃疡底部呈灰白色混浊，边缘光滑增厚，甚至基质溶解变薄

7、，导致角膜穿孔Stromal disease2006年8月28日2006年9月5日2006年9月16日2006年8月28日2006年9月5日2006年9月16日HSK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HSK混合型治疗方案尽量减少局部用药The Diagnosis and Treatment of herpes simplex keratitis The Diagnosis and Treatment ofClassification of HSV keratitisI.

8、Infectious epithelial keratitisA. Cornea vesiclesB. Dendritic ulcerC. Geographic ulcerD. Marginal ulcerII. Stromal keratitisA. Necrotizing stromal keratitisB. Immune stromal (interstitial) keratitisIII. EndotheliitisA. DisciformB. DiffuseC. LinearClassification of HSV keratitiI. Infectious epithelia

9、l keratitis A. punctate epithelial keratopathy (PEK)minute, raised, clear vesicles in the early stages of a recurrenceWithin 24 hours, the vesicles coalesce to form the typical dendritic and geographic ulcers I. Infectious epithelial keratB. dendritic ulcerbranching, linear lesion with terminal bulb

10、s and swollen epithelial borders that contain live virusstains positive for fluorescein B. dendritic ulcerbranching, ldendritic ulcerdendritic ulcerC. geographic ulcerepithelial lesion that extends through the basement membraneassociated with the previous use of topical corticosteroidsC. geographic

11、ulcerepithelial geographic ulcergeographic ulcerD. HSV marginal ulcerresults from active viral disease like dendritic ulcerproximity to limbus, accompanying blood vessels, unique clinical featuresanterior stromal infiltrate underlying the ulcer and adjacent limbal injection dendritic ulcer overlying

12、 the stromal infiltratemore symptomatic more intense and longer lasting diseaseSome patients require topical corticosteroids D. HSV marginal ulcerresults f HSV marginal ulcer HSV marginal ulcer II. Stromal diseaseII. Stromal diseaseModerate disciform endotheliitis丽科明、无防腐剂人工泪液、自体血清02%FMT为典必殊qid2006年1

13、0月17日Infectious epithelial keratitisTopical antiviralsNecrotizing stromal keratitis丽科明、无防腐剂人工泪液、自体血清白内障术后HSK病例1No corticosteroidsEndotheliitisthinning and perforationIn severe cases, a dense, retrocorneal plaque of inflammatory cells accompanied by hypopyon may be seenMild disciform endotheliitis wi

14、thout prior corticosteroid useStromal diseaseDNA hybridization techniquesTopical corticosteroidsHerpes simplex disciform keratitisanterior stromal infiltrate underlying the ulcer and adjacent limbal injectionControl of trigger mechanisms of recurrentboth corticosteroids and antiviral agentsA. Necrot

15、izing stromal keratitisdirect viral invasion of the corneal stromaclinical findings are necrosis, ulceration, and dense infiltration of the stroma with an overlying epithelial defectthinning and perforation Moderate disciform endotheliitperforation, infectionperforation, infectionnecrosis, ulceratio

16、n, thinning, perforationnecrosis, ulceration, thinningB. Immune stromal (interstitial) keratitisretained viral antigen within the stromaStromal infiltration immune ringstromal neovascularization，sectoralB. Immune stromal (interstitiastromal keratitisstromal keratitisstromal keratitisstromal keratiti

17、sstromal keratitisstromal keratitisIII. Endotheliitisstromal edema without stromal infiltratekeratic precipitates (KP), overlying stromal and epithelial edema, and iritisthe presence of HSV I antigen in corneal endothelial cellsthree forms: disciform, diffuse, and linear III. Endotheliitisstromal ed

18、emA. Disciform endothelitisKPiritisedema from endothelial decompensationsensitive to topical corticosteroidsA. Disciform endothelitisKP Herpes simplex disciform keratitis Herpes simplex disciformB. Diffuse endotheliitisscattered KP over the entire cornea with overlying diffuse stromal edemairitisIn

19、severe cases, a dense, retrocorneal plaque of inflammatory cells accompanied by hypopyon may be seen B. Diffuse endotheliitisscattebranching, linear lesion with terminal bulbs and swollen epithelial borders that contain live virusbranching, linear lesion with terminal bulbs and swollen epithelial bo

20、rders that contain live virusModerate diffuse endotheliitisscattered KP over the entire cornea with overlying diffuse stromal edemavidarabine or AraAHSV blepharitisTopical corticosteroidsminute, raised, clear vesiclesProphylaxis for postPK patients with history of HSV keratitis2006年10月17日Diffuse end

21、otheliitisWithin 24 hours, the vesicles coalesce to form the typical dendritic and geographic ulcersControl of trigger mechanisms of recurrentAll cases of linear endotheliitis如果有上皮病变或者植片溶解，局部不能用激素。EndotheliitisA.Primary HSV infection典必殊 tid Diffuse endotheliitis branching, linear lesion with C. Line

22、ar endotheliitisline of KPKP can be sectoral or, in some cases, circumferential edema between the KP and the limbus KP located at the leading edge of the edemaboth corticosteroids and antiviral agentsC. Linear endotheliitisline of Linear endotheliitis Linear endotheliitis Diagnosisthorough ophthalmi

23、c examinationviral culture: slow Cytologic examination of specimens stained with Giemsa or Wright stains, Multinucleated giant cells, nonspecific, intranuclear inclusions Immunologic tests:The Herpchek, Virogenlatex agglutination, enzyme immunofiltration, and the 1hour enzyme linked immunoassay can

24、detect HSV antigen in cell culture and direct specimens within 5 hours electron microscopy DNA hybridization techniques Serum antibody titers: diagnosis of primary infectionDiagnosisthorough ophthalmic eTreatmentDebridementDrug therapySurgicalControl of trigger mechanisms of recurrentTreatmentDebrid

25、ementDebridementDendritic keratitisWound cottontipped applicatorNo topical iodine or etherCycloplegicWith antiviralDebridementDendritic keratitisDrug therapyAntiviral agentsidoxuridine (IDU)vidarabine or AraAtrifluridine (F3T)Cyclocytidine(CC)acyclovirbromovinyldeoxyuridine (BVDU): Europegeneral acy

26、clovirDrug therapyAntiviral agentsiTopical antiviralsHSV blepharitisHSV conjunctivitisInfectious epithelial keratitisProphylaxis for corticosteroid treatment of immune stromal keratitis (drop for drop with topical corticosteroid)Topical antiviralsHSV blephariOral antiviralsPrimary HSV infectionSelec

27、ted cases of severe diffuse endotheliitisSelected cases of severe iridocyclitis/trabeculitisLinear endotheliitisImmunocompromised patientsPediatric patients refractory to topical medicationsProphylaxis against recurrent infectious epithelial keratitisProphylaxis for postPK patients with history of H

28、SV keratitisOral antiviralsPrimary HSV infCorticosteroidsAdvantages: inhibition of cellular infiltration and opacification and scarring, inhibition of the release of toxic enzymes, and inhibition of neovascularizationDisadvantages: exacerbation and spread of active viral infection, enhancement of collagenolytic enzyme, corneal thinnningCo