周某某，男，28岁 Mr. Zhou, 28-years old, male patient 一．病例特点 General Information 主诉 右眼视物模糊、疼痛、畏光、流泪伴异物感7天 Chief Complaint A 28-year-old male presented with blurred vision, pain, photophobia and foreign body sensation in the right eye for 7 days. 病史 现病史：病人于9个月前开始无明显诱因经常发现右眼视物模糊伴异物感，于外院诊断为“病毒性内皮炎”点眼水治疗后好转，之后用药不规律，反复发作。7天前视物模糊及异物感加重，并伴有流泪、畏光、疼痛，曾在我院门诊检查，诊断为“右眼角膜内皮炎”，5天前点药时触碰角膜后，症状加重。今为进一步治疗来诊。我院门诊以“右眼角膜内皮炎”收入院治疗。发病以来，精神好，饮食，睡眠和大小便均正常。 既往史：房间隔缺损修补术后16年 个人史：生于原籍，无明确疫区、疫水接触史，无不良嗜好。 婚育史：28岁结婚，未育，家人体健 家族史:否认家族性遗传病史 Medical History History of present illness(HPI): The patients experienced decreased vision and FB sensation in the right eye 9 months ago. He was diagnosed with viral endotheliitis. The symptoms were shortly relived after administration of eye-drops but with frequent recurrences. The blurriness and FB sensation was worsened in the last week, with severe lacrimation, photophobia and ocular pain. Past History and systemic review were unremarkable. 眼部检查 右眼：远视力0.6,眼压19.3mmHg。外眼正常，结膜充血，巩膜无黄染及充血。角膜全层轻度水肿，瞳孔缘下方上皮水肿，伴中央区0.5ⅹ0.5mm上皮缺损，其周围1ⅹ2mm基质浸润，内皮面皱褶，内皮面可见细尘样KP，前房深度可，房闪（+），虹膜纹理清，瞳孔圆，直径3mm，光反射存，晶状体透明，眼底视盘界清色可，血管走形可，余未见明显异常。左眼：远视力1.0,眼压18.5mmHg。检查未见明显异常。 Ocular Examination:
二．初步诊断 Initial Diagnosis 右眼角膜内皮炎 Right eye Endotheliitis 三．治疗经过 Treatments 入院第一天考虑角膜内皮炎大部分与病毒感染有关，故应用全身抗病毒治疗及局部激素治疗，予阿昔洛韦0.5g bid ivdrip, 典必殊滴眼液 od qid，典必殊膏od qd；入院第二天考虑为上皮与基质贴附不良与基底膜功能差有关，故刮除病变上皮边缘，予佩戴角膜接触镜促进角膜上皮生长；入院第四天患者眼痛、异物感症状减轻，角膜上皮基本对合，粗糙 ，轻肿，加用更昔洛韦凝胶od tid 局部抗病毒治疗；入院第六天患者症状进一步减轻，角膜上皮可见愈合线，粗糙，内皮面KP消失，期间出现眼压升高，考虑与激素应用相关，调整激素用量联合降眼压药物后，眼压恢复正常；入院第十八天发现角膜上皮粗糙较前局限，但中央上皮缺损，基质轻肿，考虑患者持续角膜上皮粗糙，长时间无健康上皮生长与基底膜营养不良相关，予自体血清od R6C治疗，后观察角膜上皮逐渐愈合，一周后出院，角膜上皮完整，局部粗糙，基质无明显浸润。 On Day 1, Acyclovir 0.5g ivdrip bid was administered to lower viral load, Tobradex eye drop qid and Tobradex ointment qd were used to reduce inflammation. On Day 2, debridement of the loosened epithelium and soft contact lens was used to hasten the epithelialization. Two days later, the patient experienced decreased pain and FB sensation, and closure of the initial epithelial defect was observed. Gancyclovir gel tid was then added to eradicate the virus. On Day 6, the patient reported further improvement of previous symptoms, and the KPs underlying the endothelium disappeared. During the following two weeks, IOP of the right eye was elevated several times, but was finally controlled within normal range after tapering steroid eye drops. However, punctate erosions and swollen of the epithelium were constantly presented. On Day 18, a central epithelial defect together with stromal edema was noticed. Autologous serum tears R6C were then added to improve the condition. The persistent epthithelial defect responded well to the autologous serum therapy. The healing process of the cornea lasted for one week, leaving only mild haze with no visible infiltrate. 四．查房记录 Discussion 刘慧医师：根据患者既往9个月病史，反复发作，角膜全层轻度水肿，角膜后细尘样KP，皱褶，上皮缺损等表现，考虑为右眼角膜内皮炎。 Dr. Liu Hui: With previous HSV infection history, the patient developed corneal stromal edema with keratic precipitates, overlying stromal, epithelial edema, and iritis. Based on the above findings, the patient was diagnosed with endotheliitis in the right eye. 杨瑞波主治医师：结合眼部检查及病史，同意目前诊断。角膜内皮炎的诊断，缺乏特异性指标，目前主要根据临床表现及体征进行诊断。其临床特点为：视力显著下降，角膜深基质水肿及角膜后沉着物，大多数患者前房反应轻微，少数患者有严重的虹膜睫状体反应。 Dr. Yang Rui-Bo: Currently there is no specific examination to verify endotheliits, and the diagnosis of corneal endotheliitis mainly relies on clinical findings. The characteristics of endotheliitis include significantly decreased vision, corneal stromal edema, and KP. The majority of the patients develop mild inflammation in the anterior chamber, some may present with severe iridocyclitis, though. 魏瑞华副主任医师：角膜内皮炎一般认为与自体免疫和病毒感染有关，病因尚不清楚，可能由于角膜内皮收到病毒或其他因素的损失发生结构改变后受到机体免疫系统攻击发生的反应，HSV-I及水疱带状疱疹病毒是引起角膜内皮炎的主要病毒，目前公认的治疗方案是皮质类固醇激素联合抗病毒药物，可全身及局部用药。抗病毒药首选阿昔洛韦，重症患者可给与阿昔洛韦注射液注射。此病有复发倾向，治愈后应继续巩固治疗1-2个月。 Dr. Wei Rui-Hua: The exact pathogenesis of endotheliitis in HSV is unknown. It appears that reaction at the level of the endothelium is immunologic because of the clinical findings of KP and iritis. That resolution usually can be obtained with topical corticosteroids further supports the immunologic nature of this condition. The role of live virus also has been speculated as contributing to this clinical entity, and one immunohistologic study of tissue from patients with previous disciform endotheliitis comfirmed the presence of HSV-1 antigen in corneal endothelial cells. The recommended therapy usually combines the use of anti-viral agents and corticosteroids, systemically or topically. Acyclovir is still the mainstay of systemic treatment for HSV infection. Recurrence of endotheliitis is common; therefore, the topical medications should be continued until the inflammation is quiet for several months. 赵少贞主任医师：该患者也出现了持续性上皮缺损（PED）。治疗PED的主要策略有：去除睑裂闭合不全，睑内翻，倒睫或慢性睑缘炎等眼睑异常；以无防腐剂人工泪液或者泪点塞积极治疗干眼。其他物理性治疗还包括包扎性角膜接触镜及睑裂缝合，均可减轻瞬目对角膜上皮造成的机械性力量，减少上皮剥脱。除此之外，近年来发现羊膜移植对PED也有较好疗效。 自体血清促进角膜上皮愈合的具体机制尚不清楚。一般认为血清中含有一些促进上皮修复的生长因子，如EGF,维生素A，TGFβ以及纤连蛋白等。血清中还含有P物质及胰岛素样生长因子，因而有可能解释自体血清对PED的治疗作用。 Dr. Zhao Shao-Zhen: In this case, the patient developed persistent epithelial defect (PED) in combination with endotheliitis in the right eye. The strategies of treatment for PED include removal of any identifiable aetiologies and promotion of epithelial healing. Any lid abnormalities present such as lagophthalmos, entropion, trichiasis, or chronic blepharitis should be corrected accordingly. Dry eyes should be treated with frequent application of preservative-free medications. Punctal occlusion can preserve natural tears. Other mechanical aids to facilitate epithelial healing include bandage contact lens (BCL) and tarsorrhaphy. Both can reduce the mechanical stress of blinking and desquamation of the corneal epithelium. In recent years, amniotic membrane transplantation has also been shown to be useful in the treatment of refractory PED. The exact mechanism of action of autologous serum tears in the promotion of epithelial healing is unknown. It is postulated that essential growth factors for epithelial healing are present. These factors include EGF, vitamin A, TGF β, and fibronectin. In addition, neuropeptides such as substance P and insulin-like growth factors are present in the serum.These findings may account for the beneficial effect from autologous serum tears in the treatment of PED 入院第三天 3rd day of admission
图1 右眼结膜充血减轻，角膜瞳孔区下方原上皮缺损处新生上皮长出，其中央区仍裂隙状上皮缺损，内皮皱褶 Figure 1 shows decreased conjunctival injection with re-epithelialization in the central cornea on Day 3. Notice the remaining linear defects of the epithelium and the endothelial folds. 入院第九天 9th day of admission
图2 角膜上皮大致对合，内皮面皱褶较前减少，KP（-），前房深度可，房闪（-） Figure 2 shows incomplete closure of the epithelial defects on Day 9. Endothelial folds were reduced. KP and chamber flares were no longer presented. 入院第二十天 20th day of admission
图3（9-2），运用自体血清点眼后， 右眼角膜上皮愈合。 Figure 3 shows complete closure of PED with the use of autologous serum tears on Day 20. 入院第二十六天 26th day of admission
图4 右眼角膜完全修复，遗留轻微云翳。 Figure 4 shows the healed cornea with mild haze on Day 26. |
