杨某，女，63岁
Mrs.Yang, 63-years old, female patient
一、病例特点
General Information
主诉
左眼红、异物感、视力下降2月余，右眼畏光、流泪、视力下降1月余
Chief Complaint
The patient presented with redness, foreign body sensation with decreased vision for two months in the left eye and one month in the right eye.
病史
现病史：2个月前双眼行白内障手术治疗，术后给予抗炎抗感染抗病毒治疗，术后1周因左眼红，眼痛，畏光，流泪伴视力下降就诊于外院，诊断为右眼角膜炎，予抗炎抗感染抗病毒治疗后加重，1月前右眼畏光、流泪、视力下降，予角膜接触镜，激素及抗病毒药物等点眼，双眼症状无缓解，进一步加重，就诊于我院门诊，诊断为双眼角膜炎，为进一步诊治收入院。
既往史：糖尿病2年，药物控制可
个人史：生于原籍，无明确疫区、疫水接触史，无不良嗜好。
月经史：已绝经
婚育史：28岁结婚，生育1女，爱人及子女均体健
家族史:否认家族性遗传病史
过敏史：异丙嗪过敏
History of present illness(HPI)
Present medical History: Both of the eyes underwent phacoemulsification combined with IOL implantation two months ago. After one week, the patient suffered from redness, eye pain, photophobia, tearing and decreased vision of left eye. The diagnosis was keratitis of left eye in the local hospital and the patient was given antibiotic and antiviral eye drops. But the condition was worse. One month later, the right eye was involved. Antibiotic and antiviral eye drops with steroids and soft contact lens was given. But the condition of both eyes was worse. The patient was admitted to our hospital.
Past medical history: Diabetes history for 2 years and well controlled by medicine.
Personal history, family history and menstruation history were unremarkable.
Allergies: Allergic to Promethazine.
眼部检查
右眼：远视力0.3, 5米光感存在，1米光定位正常，红绿色觉正常，眼压7.7mmHg。外眼正常，眼睑无红肿及水肿，无内外翻及倒睫。泪道冲洗通畅，未见分泌物。睑板腺开口油脂滴阻塞，睑缘充血，睫状充血（+），巩膜无黄染及充血。角膜缘可见新生血管，角膜中央区上皮完整，粗糙，可见4mm愈合线，基质未见明显水肿，虹膜纹理清，瞳孔圆，直径3mm，光反射存，人工晶状体位正，眼底模糊未见明显异常。左眼：远视力0.05, 5米光感存在，1米光定位正常，红绿色觉正常，眼压7.7mmHg。外眼正常，眼睑无红肿及水肿，无内外翻及倒睫。泪道冲洗通畅，未见分泌物。睑板腺开口油脂滴阻塞，睑缘充血，睫状充血（++），巩膜无黄染及充血。角膜缘可见新生血管，角膜瞳孔区上皮缺损，全角膜上皮粗糙，基质水肿，后弹力层皱褶（++），虹膜纹理欠清，瞳孔圆，直径3mm，光反射存，人工晶状体位正，眼底模糊窥不入。
Ocular examination
OD：VA 0.3, IOP 7.7nnHg. There was no redness or swelling of eye lid, without entropion, ectropion or trichiasis. The conjunctival sac was clean. Meibomian glandular orifices were obstructed with oily secretion and lid margin was congested. Neovascularization at the corneal limbus and ciliary congestion could be found. The central corneal epithelium was intact, but rough, with 4mm healing line. And corneal stromal edema was not evident. Pupil was round with 3mm diameters and light reflex was normal. The intraocular lens was in the capsular bag. The fudus was normal.
OS：VA 0.05, IOP 7.7nnHg. There was no redness or swelling of eye lid, without entropion, ectropion or trichiasis. The conjunctival sac was clean. Meibomian glandular orifices were obstructed with oily secretion and lid margin was congested. Neovascularization at the corneal limbus and ciliary congestion could be found. The central corneal epithelium was defected and the whole corneal epithelium was rough, with stromal edema and Descement membrane folds(++). Pupil was round with 3mm diameters and light reflex was normal. The intraocular lens was in the capsular bag. The fudus could not be seen clearly.
二、辅助检查
Accessory Examinations
B超示双眼玻璃体混浊，网膜在位。
右眼角膜内皮细胞计数：2462.7个/mm2,
左眼角膜内皮细胞计数：1888个/mm2
B scan showed vitreous opacity, no detachment of retina.
Endothelium cell count:
OD:2462.7 cells/mm2
OS:1888 cells/mm2
三、初步诊断
Impression
1.双眼 角膜炎 药物毒性？
2.双眼 睑板腺功能不全
3.双眼 人工晶状体眼
1.Keratitis(dug toxicity?)OU
2.Meibomian glands dysfunction OU
3.Pseudophakia eye OU
四、治疗经过
Treatment Process
入院第一天停用所有抗病毒及抗炎药物予倍然ou qid 立宝舒ou qn 营养角膜，并给予睑板腺清洁治疗qd ，患者对立宝舒不良反应较重，出现明显眼部刺激症状，故停用，予角膜接触镜保护上皮治疗，观察角膜变化，入院第三天患者眼痛等症状略减轻，给予自体血清点眼，营养角膜，促进上皮愈合治疗，病情好转，入院第九天，患者角膜上皮已愈合，但存在上皮粗糙，基质浸润，故加用FML os qid 减轻基质水肿，自体血清点眼治疗13天后停用，用药改为FML os bid 减轻基质水肿，倍然ou qid营养角膜, 出院时眼部情况：右眼远视力1.2，左眼远视力0.4，右眼角膜鼻侧可见愈合线，略粗糙，上皮下haze ，左眼角膜上皮完整粗糙，可见愈合线，基质已无浸润，情况稳定。
All the anti-viral and anti-inflammatory eye drops were discontinued on the first day of admission to our hospital. And Bion tears and Liposic were given for both eyes. Cleaning of the Meibomian glandular orifice was performed every day. But the patient felt eye pain after the Liposic was given. So we stopped Liposic and used the soft contact lens to protect the corneal epithelium. On the 3rd day of admission, the symptoms were slightly relieved. And autologous serum was givin to promote the growth of the corneal epithelium. On the 9th day of admission corneal epithelium healed. However, the epithelium became rough with stromal edema. So Fluorometholone(FML) eye drops was given 4 times a day for the aim of alleviation stormal edema. Her symptoms gradually were resolved. And the medications were gradually tapered. On the day of discharge, her visual acuity was 1.2 in the right eye and 0.4 in the left eye. Slit-lamp examination showed that corneal epithelium healing line and slightly rough epithelium with sub-epithelium haze in the right eye. And the epithelium of left eye was intact with healing line.
五、查房记录
Discussion
刘慧医师：根据病史及眼部检查，初步诊断为药物毒性角膜炎。患者在外院被诊断为病毒性角膜炎及给予十余种抗病毒，抗菌，泪液等药物治疗，双眼症状无明显好转，且逐渐加重；考虑患者白内障术后2个半月，持续点用抗病毒及抗菌药物，外源性感染的机会很小，故考虑药物毒性角膜损伤，应停用其现用药物，观察角膜变化。
Dr. Liu Hui: According to the patient’s history and eye examination, the impression diagnosis was drug toxicity keratitis. The patient was diagnosed as viral keratitis in the local hospital and was given more than 10 different types of anti-viral and bacterial eye drops and artifical tears, withoutsymptoms resolved. The patient has been performed with the cataract surgery for 2 months and the incidence of exogenous infection was very low. So drug toxicity keratitis should be considered. All the anti-inflammation eye drops should be stopped.
杨瑞波医师：病毒性角膜炎往往有上呼吸道感染病史，常见的单纯疱疹性角膜炎可表现为特征性的树枝状损伤，抗病毒药物治疗有效，药物毒性反应抗病毒治疗无效，甚至病情加重，角膜药物毒性反应表现为浅层点状角膜上皮病变，随着用药时间的延长和毒性的加大，点状染色可呈弥漫状，或片状，部分患者可表现为假树枝状膨大的特征，严重者可出现角膜溶解或穿孔。
Dr. Yang Rui-Bo: Viral keratitis was usually secondary to upper respiratory viral infection. Herpes simplex keratitis revealed a characteristic dendritic ulcer and anti-viral medications were effective. However, anti-viral eye drops was no effect and even worse for the drug toxicity keratitis. The manifestation of drug toxicity keratitis was superficial punctiform corneal epithelium erosions, along with increasing toxicity of medication for prolonged using. Some patients manifested as pseudo-dendritic infiltration. In the severe cases the dissolution and perforation of cornea may occur.
魏瑞华副主任：超声乳化术术后角膜反应一般术后立即出现角膜轻中度水肿，无点状上皮损害，随着时间延长水肿逐渐消退，而药物毒性反应是术后使用抗生素后出现角膜上皮改变，随着时间延长病变加重。
Dr. Wei Rui-Hua: After phacoemulsification surgery, corneal reaction usually appeared with mild to moderate edema, without the epithelium punctiform erosions. And the edema would be resolved gradually. But the drug toxicity reaction was corneal epithelium lesions after prolonged using antibiotics.
赵少贞主任：根据病史及眼部检查，同意目前诊断。药物毒性反应是用药过量是引起的机体生理功能和结构的病理变化，患者长期使用抗生素滴眼液可出现毒性反应，引起毒性反应的常见滴眼液有：氨基糖苷类，氟喹诺酮类，氯霉素等，其毒性作用可能与该类药物抑制细胞的蛋白质合成，诱导角膜基质细胞凋亡，滴眼液中的防腐剂亦可以引起药物毒性反应。白内障术后应尽量选择药物毒性小的抗生素滴眼液，严格掌握给药次数，用药种类及使用期限。
Prof. Zhao Shao-Zhen: According to the history and examination, I agreed with the diagnosis. Drug toxic reaction was that excess use of the medications lead to pathological changes of organism physiological function and structures. The patient had long-term use of topical antibiotics which caused toxic reaction. The medications which commonly were associated with toxic reaction included: Aminoglycosides, Fluoroquinolone, Chloromycetin, et al.These medications may inhibit cell protein synthesis and include keratocyte apoptosis. Ocular medication preservatives could also cause the drug toxic reaction. After cataract surgery, low toxic effect topical antibiotics should be given as possible and the doctor should strictly control the administration, medication type and duration.
入院第一天角膜染色可见右眼角膜中央区愈合线粗线状着染，左眼角膜弥漫着染
On the 1st day of admission, corneal stained with florescence showed thick epithelial healing line in the right eye and diffuse central staining of epithelium in the left eye.
8-22
od
图 1
入院第四天
4th day of admission
入院第六天
6th day of admission
入院第十一天
11th day of admission
入院第十六天
16th day of admission
