病例13　57岁男性，主诉右眼无痛性眼红、视力下降3个月

CASE 13　A 57-year-old male complaining of right eye with painless red and decreased vision for three months

见图1-19、图1-20。See Figs. 1-19 and 1-20.

鉴别诊断

Differential Diagnosis

◎ 神经营养性角膜病变：这是一类由于眼部病毒感染、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，其防御性随之下降，同时角膜神经营养支持作用减弱或消失，最终导致角膜病损的疾病。可发生于任何年龄，典型症状为无痛性视力下降及眼红。早期体征为睑裂区角膜上皮点状缺损或愈合缓慢的上皮缺损，常累及角膜下部，可被荧光素染色。严重者角膜中下部出现椭圆形或类圆形浸润或溃疡，甚至角膜穿孔。患者角膜知觉检查表现为知觉减退或消失。

◎ Neurotrophic keratopathy: It is a kind of corneal injury disease in which the cornea loses innervation due to ocular virus infection, surgery, intracranial tumors or any other relative causes. Loss of corneal innervation can diminish corneal sensation and defense capability, weaken or disappear the corneal neurotrophic effect. It may occur at any age. Typical symptoms are painless decreased vision and redness. Interpalpebral punctate epithelial erosions or slow to heal epithelial defects are early signs. Defects commonly involve the inferior half of the cornea and can be stained with f luorescein. An elliptic or orbicular inf iltration or ulceration in the inferior half of the cornea or even corneal perforation is severe sign. The patient’s corneal sensation decreases or disappears.

◎ 暴露性角膜炎：这是由面神经麻痹、睑外翻、突眼及眼外伤等原因所致的眼睑闭合不全，使角膜失去眼睑湿润与保护而暴露于空气中，引起角膜干燥、上皮缺损，甚至有角膜溃疡形成的一种疾病。病灶通常见于角膜下部。

◎ Exposure keratopathy: It can occur in incomplete eyelid closure caused by facial nerve palsy, ectropion, proptosis,ocular trauma and any other relative causes, which can induce exposure of the cornea to the air without proper humidif ication and protection by the eyelids. It can cause corneal desiccation, epithelial defect and even ulceration.Lesions usually occur in the inferior interpalpebral region.

◎ 干眼综合征：这是一种由多种情况导致眼表环境受到轻到重度损害，使角膜处于轻度炎症环境的疾病。患者可出现异物感、烧灼感、疲劳感、流泪等症状，部分患者会抱怨视力变差或视力波动。患者泪湖变浅或不规则，角膜可被荧光素染色。

◎ Dry-eye syndrome: It encompasses a variety of conditions that causes mild-to-severe disruption of the ocular surface, and leads to a mild inf lammatory environment of the cornea. Patients can appear foreign body sensation, burning, tired feeling, tearing and other symptoms. May complain of poor and/or f luctuating vision. Scanty or irregular tear meniscus can be seen.Cornea can be stained with f luorescein.

◎ 细菌性角膜炎：由细菌（如金黄色葡萄球菌、表皮葡萄球菌、肺炎链球菌等）感染引起，病变早期可出现边界清晰的角膜溃疡及溃疡边缘边界模糊的浸润灶，组织水肿，黏脓性分泌物，进一步浸润灶迅速扩大，形成溃疡，可伴前房积脓。

◎ Bacterial keratitis: It is caused by bacterial infection such as staphylococcus aureus, staphylococcus epidermidis,streptococcus pneumoniae, etc. A well-def ined ulcer is surrounded by a poorly def ined inf iltration, cornea edema and mucopurulent discharge can be seen in the early stage.Then the inf iltration rapidly develops to ulcer, which may accompany with hypopyon.

◎ 角膜软化症：由维生素A缺乏引起，多见于营养不良的儿童。患儿常有睡眠差、易暴躁，严重者出现精神萎靡、皮肤干燥、角化等表现。角膜变软，易坏死，常出现穿孔。

◎ Keratomalacia: It is caused by vitamin A def iciency and appeared in malnourished children commonly, whom often have poor sleep and irritability. Severe cases can even have dispiritedness, skin drying and keratinization. Corneal softening, necrosis and perforation can be found in this disease.

病史询问

Asking History

◎ 眼部症状出现及持续时间，是否伴随眼痛、畏光等症状。

◎ It is imperative to ask about the onset and duration of ocular symptoms, such as eye pain, photophobia and other symptoms.

◎ 既往是否有脑部肿瘤病史及手术史，有无脑卒中或听力障碍，有无眼部疱疹感染史、糖尿病史、眼部手术史、长期用眼药史（如麻醉药、非甾体抗炎药），既往是否有挑食习惯、长期配戴角膜接触镜、长时间使用视频终端或者睁眼睡觉史。该病例有右侧听神经瘤切除手术史。

◎ Any medical histories of brain tumors or surgery, stroke,hearing problem, herpes simplex virus infection, diabetes mellitus, eye surgery or chronic topical medications (e.g.,anesthetic, nonsteroidal anti-inf lammatory agents). Any history of picking eating, chronic contact lens wear, extended periods of using video display or sleeping with eyes open.This case has a history of right acoustic neuroma resection.

检查

Examination

◎ 视力：渐进性视力下降。

◎ Visual acuity: Decreased vision onset is gradual.

◎ 眼睑：检查眼睑外观是否有畸形或位置不正，检查眼睑闭合程度及闭合不全的原因。

◎ Eyelid: Eyelid deformity or malposition may be noted.Examine the degree of eyelid closure and f ind the reason.

◎ 角膜知觉检查：角膜知觉减弱或消失（注意与对侧眼对比）。

◎ Corneal sensation: Weaken or disappear (need to check the fellow eye for comparation).

◎ 裂隙灯检查：角膜荧光染色前后了解角膜浸润、溃疡部位、范围。前房闪辉、房水细胞情况。

◎ Slit-lamp examination: To detect the size, location of ulcer and inf iltration with and without corneal f luorescein staining. Check cells and f lare in anterior chamber.

◎ 皮肤检查：注意有无眼周局部疱疹性损害或带状疱疹病毒感染后瘢痕。

◎ Skin: Check the skin around the eyes to f ind if there is local herpetic lesions or scars from a previous herpes zoster infection.

◎ 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，了解角膜神经密度（病灶及病灶周围角膜神经密度降低或消失）。

◎ Confocal microscopy: Check the presence of fungi,acanthamoeba and other pathogenic microorganisms in the lesion; check the corneal nerve density. (The density of corneal nerve may be decreased or disappeared in and around the lesion).

◎ 颅脑CT：如有颅脑疾病及手术史者，可有相应特征性表现。

◎ Brain CT: If the patient has the history of brain tumor or surgery, the CT result will have corresponding characteristic features.

实验室检查

Lab

◎ 角膜刮片镜检，细菌、真菌培养：病原微生物阴性。

◎ Corneal scraping and microscopic examination, pathogenic microorganism culture: Pathogenic microorganism negative.

◎ 血糖监测：排除是否合并糖尿病。

◎ Blood glucose measurement: To exclude diabetes history.

诊断

Diagnosis

神经营养性角膜病变。

Neurotrophic keratopathy.

治疗

Management

◎ 根据患者角膜上皮缺损程度进行治疗。

◎ Patients should be treated according to the degree of corneal lesion.

◎ 轻中度上皮点状着染：使用无防腐剂的人工泪液，睡前加用无防腐剂的人工泪液凝胶。

◎ Mildly to moderately punctate epithelial staining: Treated with preservative-free artif icial tears during the day, and preservative-free artif icial tear gel at night.

◎ 轻度角膜上皮缺损：连续使用抗生素眼膏（如红霉素）至痊愈，同时使用人工泪液。可考虑使用软性角膜接触镜保护眼表。

◎ Mild corneal epithelial defect: Treated with antibiotic ointments (e.g., erythromycin) and artif icial tear continuously until the cornea healed. The soft contact lenses can be considered to protect ocular surface.

◎ 角膜溃疡：使用抗生素眼膏，口服胶原酶抑制剂，如多西环素，减缓角膜基质融解。可联合自体血清点眼。严重者须进行睑缘缝合术、结膜瓣覆盖术、羊膜移植术或人工角膜移植术。

◎ Corneal ulcer: Treated with antibiotic ointment and oral collagenase inhibitors (e.g., doxycycline) to slow down the progression of stromal melting. Autologous serum eye drops can be combined. In severe cases, tarsorrhaphy, conjunctival f lap covering, amniotic membrane graft or keratoprosthesis should be performed.

患者教育和预后

Patient Education & Prognosis

◎ 在积极治疗原发病的同时，注意保护眼表，预防并发症，定期进行眼科检查。

◎ Apart from better control of the primary disease,patient should pay more attention to ocular surface protection, prevention of secondary complications and regular follow-up.

◎ 该病预后欠佳，多遗留角膜瘢痕影响视力。部分患者因角膜神经功能永久性丧失导致疾病迁延不愈。

◎ Prognosis of this disease is relatively poor. Corneal scar often forms and affects vision. In some patients, the disease is difficult to recover due to permanent loss of corneal nerve function.