病例26　64岁女性，白内障术后3天，术眼眼红、眼痛伴视力下降半天

CASE 26　A 64-year-old female, three days after cataract surgery, with sudden redness and pain accompany with vision blur

见图1-43。See Fig. 1-43.

鉴别诊断

Differential Diagnosis

◎ 急性感染性眼内炎：是眼内（玻璃体和前房）的化脓性炎症，通常与感染有关。其表现为术后突然视力下降和眼痛加重；大多数病例发生于术后1~2周内，更常见于术后3~5天。体征包括：前房积脓、纤维蛋白形成、严重的前房反应、玻璃体细胞和红光反射减弱，可能合并眼睑水肿、角膜水肿和明显的结膜充血。

◎ Acute infectious endophthalmitis: Purulent inf lammation of the intraocular f luids (vitreous and aqueous), which is usually associated with infection. It presents with sudden onset of reduced vision and increasing eye pain following surgery;most cases present within 1 to 2 weeks and usually 3 to 5 days postoperatively. The signs include hypopyon, f ibrin formation, severe anterior chamber reaction, vitreous cells and reduced red ref lex. Eyelid edema, corneal edema, and intense conjunctival injection may be present.

◎ 其他内眼术后非感染性眼内炎症和各类葡萄膜炎：术中过多的操作会引起术后严重的非感染性眼内炎，尤其是涉及玻璃体的操作，可伴前房积脓和轻度的玻璃体炎性反应。通常不会合并显著及进行性疼痛或视力下降。局部激素治疗有效。

◎ Aseptic endophthalmitis or uveitis: Severe pos toperative sterile uveitis caused by excess tissue m a nipulation, especially intraoperative vitreous mani p ul ation.Hypopyon and mild vitreous cellular reaction may develop. Profound or progressive pain or visual loss is usually not present, and it usually resolves with topical steroid therapy.

◎ 眼前节毒性综合征：眼前节毒性综合征是在术后12~24小时内迅速发生的急性、无菌性炎症。以前房细胞和闪辉、纤维素或前房积脓，以及术后非预期的严重角膜水肿为特征，可能伴随眼压升高。通常源于术中进入眼内的某些物质，包括灌注液、眼内注射物或者器械清洁过程中的残留物、人工晶状体或其携带的物质等。

◎ Toxic anterior segment syndrome: Acute, sterile inf lammation that develops rapidly within 12 to 24 hours following an uneventful surgery. It is characterized by anterior chamber cells and f lares, possibly with f ibrin formation or hypopyon, and severe corneal edema beyond what is expected following surgery. The intraocular pressure (IOP) may also increase. This condition is usually caused by materials placed in the eye intraoperatively,including irrigating solutions or injections, remnants of improperly cleaned instruments, or intraocular lens (IOL).

病史询问

Asking History

◎ 是否有手术并发症。

◎ Enquire about any complications associated with the surgery.

◎ 术后是否有术眼不洁接触史。

◎ History of any postoperative eye contact with an unclean object.

◎ 是否合理应用抗生素、激素类眼药水以及中途突然停药。

◎ History of steroid drops or antibiotic adminis t r a t i o n or their abrupt cessation.

◎ 是否有糖尿病、免疫功能低下、睑缘炎、泪囊炎、眼周组织疾病或者葡萄膜炎。

◎ History of diabetes mellitus, immunocompromised disease, blepharitis, dacryocystitis, periocular tissue diseases, or uveitis.

检查

Examination

◎ 检查视力，手动和光感是很重要的提示，评估眼压高低。

◎ Visual acuity (distinguishing between hand motion vs light perception is important). Increase or decrease in IOP should be assessed.

◎ 裂隙灯检查：明确是否有伤口的渗漏、眼内缝线的暴露、伤口处玻璃体的嵌顿、睑缘炎等容易引起眼内炎的因素；评估前房积脓，人工晶状体表面渗出膜包裹，前部玻璃体腔大量炎症细胞。

◎ Slit lamp examination: To evaluate wounds/bleb leaks,exposed sutures, vitreous to wound, blepharitis, or other predisposing factors for endophthalmitis; to measure hypopyon; and to assess exudative membrane around the IOL, and inf lammatory cells in the anterior vitreous cavity.

◎ 超声影像：B超是眼底无法窥入时的重要检查手段，可以辅助判断炎症的严重程度，并可以作为评判治疗有效性的基线标准。

◎ Ultrasonography: Consider B-scan ultrason o g r a phy if the view to the posterior segment is limited, which may conf irm marked vitritis and establish a baseline against which therapeutic success can be measured.

实验室检查

Lab

◎ 血白细胞计数和C反应蛋白测定。

◎ Evaluate white blood cell count and C-reactive protein levels.

◎ 前房水及玻璃体涂片检查、细菌培养等。

◎ Obtaining aqueous and vitreous to bacterial culture and smear.

诊断

Diagnosis

急性感染性眼内炎（白内障术后）。

Acute infectious endophthalmitis (post-phacoe m u l s i f ication).

治疗

Management

◎ 根据房水或玻璃体标本涂片结果选择相应的抗菌药物。根据细菌培养+药敏结果合理调整用药。

◎ Appropriate antibiotics may be administered based on the smear results of aqueous or vitreous. The drugs should be adjusted according to the bacterial culture and drug sensitivity results.

◎ 革兰氏阳性菌使用万古霉素，革兰氏阴性菌使用头孢他啶。

◎ Vancomycin and ceftazidime are recommended for Gram-positive and Gram-negative bacteria, respe c tively.

◎ 给药途径包括：点眼、球旁注射、前房及玻璃体腔注药、口服以及静脉滴注。

◎ Administration routes include ophthalmic drops, parabulbal injections, anterior chamber and vitreous cavity injections, and oral and intravenous infusions.

◎ 视力光感的患者应行睫状体扁平部玻璃体切除术。视力在手动以上的患者可先考虑眼内注射。

◎ Pars plana vitrectomy is recommended in patients with a visual acuity of light perception. For those with a visual acuity of hand motion or better, intravitreal injections are recommended.

患者教育和预后

Patient Education & Prognosis

◎ 注意眼周卫生，避免碰触，按医嘱要求点眼，糖尿病患者须注意监测血糖。

◎ Instruct patients about the correct use of eye drops,maintaining periocular hygiene, and protecting their eyes against any injury. Patients with diabetes mell i t us should be instructed to monitor their blood glucose levels.

◎ 初次治疗后需要每12小时观察1次病情。如果治疗有效，应在48小时内有所反应，如眼疼减轻、炎症减轻、前房积脓减少。如果无效，或者培养显示与初次用药不一致，可以考虑二次玻璃体腔注药。若炎症恶化，应及时行玻璃体切除术。若局部强效抗生素滴眼治疗有效，48小时后可逐渐减量，并替换成常规抗生素滴眼液。

◎ Monitor the clinical course Q12h. If the therapy is effective, patients should show clinical impr o v ement after 48h (e.g., pain relief, and redu ction in inf lammation and hypopyon). A secondary intr a v irtreal injection may be considered if there is no impr o vement in the condition or if Gram staining demons t rates an unusual organism.Vitrectomy may be cons idered if the patient’s condition deteriorates. The antib iotic regimen is ref ined according to treatment response, and bacterial culture and antibiotic sensit i vity results. If the patient responds well, topical forti f ied antibiotics may be slowly tapered after 48h and then switched to regular-strength antibiotics.

◎ 预后与致病菌的毒性及患者的全身状况有关。

◎ The prognosis of acute infectious endophthalmitis is rela ted to the pathogen species and the general con di tion of the patient.