病例20　46岁男性，主诉异物感伴视物模糊3个月

CASE 20　A 46-year-old male complaining of foreign body sensation and blurred vision for 3 months

见图1-33。See Fig. 1-33.

鉴别诊断

Differential Diagnosis

◎ 上部角膜缘角结膜炎(superior limbic kerat o c o n j un c t ivitis, SLK)：是以上睑结膜、上方球结膜、上方角膜缘和邻近角膜反复发作的慢性角结膜炎为特征的一种疾病，病因不明，多为双侧发病。上睑结膜充血并伴细小乳头增生。有1/3~1/2的SLK患者合并丝状角膜炎，丝状物一般位于上方角膜和上方角膜缘处。甲状腺疾病患者易患SLK。

◎ Superior limbic keratoconjunctivitis (SLK): It is a kind of chronic keratoconjunctivitis characterized by recurrent attack of upper palpebral conjunctiva, superior bulbar conjunctiva, superior limbus and adjacent cornea. The cause is unknown and most of the disease is bilateral.The upper palpebral conju n ctiva is congested with small papilla. There are 1/3 to 1/2 of SLK patients with f ilamentous keratitis, f ila m e n ts are generally located in the upper cornea and the upper limbus. Patients with thyroid disease prone to have SLK.

◎ 过敏性结膜炎：主要与春季角结膜炎相鉴别，分为结膜型，以结膜铺路石样乳头为主；角膜缘型，以角巩膜缘区的胶质样结节或隆起为主，大多位于上1/2的角巩膜缘区，赘疣状的小白色斑，称为Horner-Trantas结节；混合型，结膜和角膜缘均累及，严重者合并角膜盾形溃疡。

◎ Allergic conjunctivitis：especially should be diffe rentiated with vernal keratoconjunctivitis. It can be divided into conjunctival type, mainly conju n c t ival paving stone like papilla; limbal type, mainly col lo idal nodule or protuberance in the limbal area of corneosclera, mostly in the upper 1/2 of the limbal area of corneosclera, verrucous small white spots, known as Horner-Trantas dots; Mixed type, conjunctiva and limbus involvement, serious cases with corneal shield ulcer.

◎ 结节性巩膜炎：女性较男性常见，自限性疾病。常因晨起发现眼红就诊。表现为鲜红色结节状睫状充血。几次发作后，血管可能永久性扩张。

◎ Nodular Episcleritis: Females may be affected more commonly than males. It is self-limiting. A red eye is typically f irst noted on waking. It presents as tender red nodular ciliary bleeding. After several episodes inf lamed vessels may become permanently dilated.

◎ 眼睑松弛综合征(FES)：一种罕见的且常被忽视的疾病，可单眼或双眼发病，引发一系列持续性眼表症状。好发于肥胖的中老年男性。可导致慢性眼部疾病，如干眼、上睑结膜乳头状结膜炎、点状角膜病变、丝状角膜炎和上方角膜缘血管化。阻塞性睡眠呼吸暂停(OSA)与此病密切相关。上睑睑板通常非常松弛，伴随松弛的上睑皮肤。

◎ Floppy eyelid syndrome (FES): It is an uncommon unilateral or bilateral condition that is often over l o oked as a cause of persistent ocular surface sym p t o m s. It typically affects obese middle-aged and older men. It can result in chronic ocular disorders, such as dry eye, papillary conjunctivitis of the superior tarsal conjunctiva, punctate keratopathy, f ilamentary keratitis and superior superf icial vascularization. Obstructive sleep apnoea (OSA) is strongly asso c i a ted. The upper eyelid is typically extremely lax,often with substantial excess loose upper lid skin.

◎ 泡性角结膜炎：一般单眼发病，轻微异物感，累及角膜则症状加重。反复发作后疱疹可向中央进犯，新生血管长入，称为束状角膜炎，痊愈后遗留带状薄翳，根据典型的角膜缘或球结膜处实性结节样小泡，周围充血等症状可正确诊断。

◎ Vesicular keratoconjunctivitis: Often one eye inv o lved,slight foreign body sensation, corneal invol v e m ent will aggravate the symptoms. After repeated attacks, herpes may invade into the center and new blood vessels grow in, which is called fascicular kera titis. After recovery,shingles and pannus are left. It can be correctly diagnosed according to typical sym p t o ms such as solid nodular vesicles at cornea edge or bulbar conjunctiva, peripheral congestion.

◎ 流行性角结膜炎(EKC)：主要由腺病毒8、19、37血清型引起，是眼部最严重的腺病毒感染。可表现为结膜充血，睑结膜滤泡增生，约80%发展为角膜炎，出现畏光症状。

◎ Epidemic keratoconjunctivitis (EKC): It is caused mainly by adenovirus serovars 8, 19 and 37, and is the most severe ocular adenoviral infection. It can present with conjunctival hyperemia, papillary conjunctivitis. Keratitis,which may be marked, develops in about 80%. Photophobia may be correspondingly pro m i n ent.

病史询问

Asking History

◎ 眼部出现症状的时间，是否与季节相关；是否有波动及反复。

◎ Asking the onset, is this correlated with seasons,f luctuation, duration and return of symptoms.

◎ 是否伴全身性疾病，特别是甲状腺相关疾病。

◎ Asking systemic diseases, especially thyroid related diseases.

检查

Examination

◎ 视力、眼压。

◎ Vision, IOP.

◎ 裂隙灯检查：观察上睑结膜是否存在弥漫细小绒毛状乳头样改变。是否存在上方球结膜堆叠、充血、角化，以及角膜丝状物形成。荧光素和丽丝胺绿或玫瑰红染色。

◎ Slit lamp examination: Careful slit lamp exam i n ation of the upper tarsal conjunctiva looking for papillary reaction.

◎ Evaluation of the upper bulbar conjunctiva, look i n g for foldings, hyperemia, redundancy, and f ilament for m ation.Fluorescein and lissamine green, or rose bengal staining.

◎ Schirmer试验。

◎ Schirmer test.

◎ 排除甲状腺相关性眼病。

◎ Rule out dysthyroid orbitopathy.

实验室检查

Lab

◎ 甲状腺功能试验，自身免疫血清学试验，如抗Ro(SSA)和抗La(SS-B)抗体，以及环瓜氨酸肽抗体，具体取决于症状和临床表现。如果怀疑有相关全身性疾病，建议由风湿病学医生或内分泌学医生进行评估。

◎ Thyroid function tests, autoimmune serologic tests like, anti-Ro (SS-A) and anti-La (SS-B) antibodies, and cyclic citrullinated-peptide antibodies, depending on the symptoms and clinical f indings. Medical evaluation by a rheumatologist or endocrinologist is recommended in case of suspected associated systemic disease.

诊断

Diagnosis

上部角膜缘角结膜炎。

SLK：superior limbic keratoconjunctivitis.

治疗（图1-34、图1-35）

Management (Fig. 1-34, Fig. 1-35)

◎ SLK的治疗没有“金标准”。许多不同的治疗方法已经被报道，包括局部应用硝酸银、治疗性软性角膜接触镜、泪点塞、维生素A凝胶、0.5%环孢素滴眼液、富马酸酮替芬、自体血清、色甘酸钠、洛度沙胺氨丁三醇、肌内注射肉毒杆菌毒素，以及睑板腺注射曲安奈德，所有这些都显示出不同的治疗反应。

◎ There is not a gold standard in the treatment of SLK. Many different therapeutic modalities have been reported, including topical silver nitrate, therapeutic soft contact lens, lacrimal puncta occlusion, topical vitamin-A, topical cyclosporine 0.5%, ketotifen fumarate, autologous serum, cromolyn sodium, lodoxamide tromethamine, botulinum injection in the muscle of Riolan, and supratarsal triamcinolone injection,all of which have shown variable therapeutic responses.

◎ 如果患者合并甲状腺功能亢进或干燥综合征，需要联合全身治疗。

◎ In case of hyperthyroidism or Sjögren’s syndrome,general treatment is needed.

◎ 局部用药控制不佳者，可以联合手术治疗，包括结膜烧烙术、结膜切除术。

◎ If the local medication is not well controlled, it can be combined with surgery, including conjunctival cauterization and conjunctivectomy.

患者教育和预后

Patient Education & Prognosis

◎ 多见于中年女性，多为双眼发病(70%)，男女之比为1∶3，1/4患者合并干眼，26%~50%的患者伴有甲状腺功能异常。

◎ Most of them are middle-aged women, most of them have double eye diseases (70%), the ratio of male to female is 1∶3, 1/4 patients with dry eye, 26% to 50% patients have thyroid dysfunction.

该病容易反复，可持续数年，但具有自限性，一般预后良好，不会明显影响视功能。

The disease is prone to recur and can last for several years,but it has self-limitation and generally has a good prognosis,which will not signif icantly affect the visual function.

SLK可能有遗传倾向。

There may be a genetic predisposition to SLK.