病例4　49岁男性，热铜水溅入左眼，眼疼流泪伴视力下降4天

CASE 4　A 49-year-old male complaining of painful, tearing and decreased vision due to hot liquid copper burns in left eye for 4 days

见图1-5、图1-6。See Figs. 1-5 and 1-6.

鉴别诊断

Differential Diagnosis

◎ 角膜热烧伤：角膜热烧伤有热物质接触眼部病史，包括各种高温固体、液体、气体，急性发病。烧伤严重程度与接触物的温度、时间和接触面积有关。可伴眼睑、结膜、巩膜烧伤和颜面部皮肤及全身皮肤烧伤。轻度角膜烧伤可仅表现为角膜轻度混浊，上皮剥脱，严重角膜烧伤可引起角膜组织坏死、融解及穿孔、睑球粘连、眼睑畸形、眼睑闭合不全、眼球萎缩等。

◎ Corneal thermal burns: Corneal thermal burn has a history of contact with hot substances, including various high temperature solids, liquids, gases. The degree of burn is related to the temperature, time and area of contact. It can be accompanied with burns of eyelid, conjunctiva,sclera, facial skin and whole body skin. The mild corneal burn can only be manifested as mild corneal haze and epithelial exfoliation. Severe corneal burn can cause corneal tissue necrosis, dissolution and perforation, and produce complication of symblepharon, eyelid deformity,incomplete closure of eyelid, atrophy of eyeball, etc.

◎ 角膜化学伤：角膜化学伤有角膜接触酸碱物质史，病情严重程度与接触化学物质的性质、浓度、接触时间、接触面积、处理是否及时合理等因素有关。角膜酸烧伤中酸性物质使角膜蛋白凝固坏死，故病变部位边缘较清晰，同时凝结的蛋白质起着屏障作用，防止酸性物质进一步渗透。但氢氟酸是例外，氢氟酸中的氢离子会迅速穿透角膜，导致严重的眼前节损伤。对于角膜碱烧伤，碱性化学物质会导致细胞膜中的脂肪酸皂化，从而穿透眼表上皮细胞及更深的细胞结构。病灶边缘不清，灼伤组织无色或者灰白色，角膜上皮剥脱，眼内组织炎症反应逐渐加重。最终，依损害程度不同可表现为角膜不同程度混浊、角膜血管纤维化、结膜瘢痕、睑球粘连、继发青光眼、继发白内障、角膜穿孔和眼球萎缩等。

◎ Corneal chemical burns: It has a history of contact with acid or alkali substances. The severity of the disease is related to the chemical properties of substance, concentration, contact time, contact area, and whether the treatment is timely and reasonable. For corneal acid burns, the acid substance makes the cornea protein coagulate and precipitation, so the edge of lesion is clear. The coagulated proteins act as a barrier to prevent further penetration. The one exception to this is hydrof luoric acid, where the hydrogen ion rapidly penetrates the thickness of the cornea and causes signif icant anterior segment destruction. For corneal alkali burns, alkaline compounds cause saponif ication of the fatty acids in cell membranes, which penetrates the ocular surface epithelium as well as deeper cellular structures.The edge of the lesion unclear, the burned tissue colorless or gray white, the corneal epithelium exfoliation, and the inf lammatory reaction of the tissue in the eye gradually aggravating. Finally, depending on the degree of damage,it can be manifested as corneal opacity, corneal vascular f ibrosis, conjunctival scar, symblepharon, secondary glaucoma, secondary cataract, corneal perforation and eyeball atrophy.

病史询问

Asking History

◎ 何时何地发生的眼部何种热物质的接触，接触时间以及局部和全身接触面积。

◎ Asking what kind of contact with hot substances, contact time and local and systemic contact area.

◎ 是否进行了即刻的紧急处理，是否用洁净水大量冲洗或者是否自行异物取出。

◎ Asking whether immediate emergency treatment has been carried out, whether a large amount of clean water has been used to wash out foreign material immediately.

◎ 既往眼部病史和全身病史。

◎ And ask about the history of eye or systemic condition.

检查

Examination

◎ 根据烧伤的深度及范围不同，视力改变可从不受影响到下降至光感，甚或失明。

◎ From not affected to light perception, or even blindness,depending on the depth and extent of the burn.

◎ 裂隙灯检查：烧伤急性期，轻度热烧伤角膜可见轻度雾状混浊，荧光素染色阳性，结膜充血水肿。严重热烧伤多见于热金属烧伤，可见角膜瓷白色混浊、糜烂甚至融解穿孔，角巩膜缘、结膜、巩膜缺血苍白、组织坏死、睑球粘连。或可见金属异物残留，通常位于下方角膜或结膜囊下穹窿部。

◎ Slit-lamp examination: In acute stage, examine location,size, depth and opacity of cornea lesion, f luorescein staining to detect epithelium defect, conjunctival congestion and edema for mild burns. Severe thermal burns are often seen in hot metal burns, and its corresponding symptoms including white opacity, corneal erosion, even dissolution or perforation, ischemia and pale color in the limbus,conjunctiva and sclera, tissue necrosis and symblepharon.The residual of metal foreign body can be seen, which is often located at the inferior cornea or the conjunctival sac.

◎ 全身检查查明眼睑、面部及全身烧伤范围及程度；如气体或火焰烧伤，须检查呼吸道；对于疑似休克的患者，应监测血压、体温、脉搏和呼吸。

◎ Systemic examination: Extent and depth of burns on eyelid, face and whole body; It needs to inspect respiratory tract for patient with gas or f lame burns; For patients with suspected shock, blood pressure, body temperature, pulse and respiration should be monitored.

实验室检查

Lab

◎ 对于合并全身烧伤的严重患者，需要进行血常规检查、尿常规检查、血气分析、血电解质检查，以全面评估全身情况，如合并感染，则须进行细菌培养。

◎ For severe patients with combined systemic burns,blood routine examination, urine routine, blood gas analysis, blood electrolyte examination are required to comprehensively assess the general condition. If some patients with complicated infections, bacterial culture is required.

诊断

Diagnosis

角膜热烧伤。

Corneal thermal burns.

治疗

Treatment

◎ 烧伤后立即大量冷水冲洗，迅速降低温度，清理创面，在表面麻醉下去除坏死组织及异物。

◎ Immediately washing with plenty of cold water gently,reduce the temperature rapidly, clean the wound, and remove necrotic tissue and foreign matters with topical anesthesia.

◎ 使用抗生素眼药水或眼药膏以预防感染。

◎ Antibiotic eye drops or ointment, mydriatic drop.

◎ 使用散瞳药物减轻眼部刺激症状。

◎ Steroid eye drops (under certain conditions).

◎ 酌情使用激素类眼药水减轻炎症反应。

◎ Bandage contact lens for large epithelium defect.

◎ 可使用角膜绷带镜、人工泪液或自体血清等减轻症状并促进愈合。

◎ Artif icial tears or auto serum.

◎ 手术包括羊膜移植术、结膜囊成形术、角膜板层移植术、穿透性角膜移植术、角膜缘干细胞移植术。

◎ Amniotic membrane transplantation, conjunct ivoplasty,lamellar corneal transplantation, penetrating keratoplasty,corneal stem cell transplantation.

患者教育和预后

Patient Education & Prognosis

◎ 轻度病例，角膜可完全恢复，或只残留部分混浊。严重者可表现为角膜混浊、角膜白斑和新生血管、眼睑内翻或外翻、眼睑畸形甚或眼球萎缩。

◎ In mild cases, the cornea can be completely rec over ed or only partial cloudiness can be seen. In severe cases, it can be manifested as corneal clou d iness, corneal leukoplakia, corneal scarring and neo vas c u la rization, entropion or ectropion,deformity of eyelid or eyeball atrophy, etc.

◎ 根据病情的发展和预后，可能需要多次手术，以促进眼损伤恢复、改善视力、修复睑球粘连及眼睑畸形，即使进行积极的努力，极少数患者视力最终也可能完全丧失。

◎ According to the development and prognosis of the disease, multiple operations may be needed to promote eye injury recovery, improve vision, repair eyelid adhesion and eyelid deformity. Even with active efforts, very few patients may also eventually experience complete loss of vision.