病例16　34岁女性，主诉左眼畏光、疼痛、异物感、流泪伴视力下降3天

CASE 16　A 34-year-old female complaining of photophobia, pain, foreign body sensation, tearing and diseased vision in left eye for 3 days

见图1-25、图1-26。See Figs. 1-25 and 1-26.

鉴别诊断

Differential Diagnosis

◎ 树枝状角膜炎：是单纯疱疹病毒性角膜炎中的最常见类型。它通常是由角膜上皮细胞中存在的活病毒引起的单眼病症（在免疫功能低下的患者和特应性患者中可为双侧发病）。早期角膜上皮层出现点状或簇状的灰白色、微隆起的针尖样浸润。1~2天后，浸润扩大融合，形成典型的树枝状溃疡。树枝状末端呈球状膨大。荧光素钠染色可见中央深绿色溃疡，病灶边缘淡绿色包绕。常见症状有眼红、眼痛、畏光、流泪及视力下降。该病易反复发作并导致角膜敏感度降低。

◎ Dendritic keratitis: Is the most common type of herpes simplex keratitis. It is a usually unilateral condition caused by the presence of live virus within corneal epithelial cells.(It also can be bilateral, especially in immunocompromised patients and those with atopy. ) Early corneal epithelial layer shows punctate gray and raised needle-shape inf iltration. After 1 to 2 days, the inf iltration expand and merge to form a typical dendritic ulcer. Each dendritic branch has spherically terminal bulb. After stained with f luorescein, the central part of the ulcer shows dark green because epithelium defect and the peripheral part shows light green. Common symptoms include unilateral redness,eye pain, photophobia, tearing and decreased vision. The disease tend to recur and can lead to corneal sensitivity decrease.

◎ 假树枝状角膜病变：可见于带状疱疹病毒性角膜炎、棘阿米巴性角膜炎、复发性角膜上皮糜烂及药物毒性角膜上皮病变等疾病中，鉴别如下。

◎ Pseudodendritic keratopathy: Can be seen in her pes zoster virus keratitis, acanthamoeba keratitis, rec urrent corneal epithelial erosion and drug-induced toxic keratopathy. The different is below.

带状疱疹病毒性角膜炎(HZK)：角膜特征性表现为假树枝状角膜炎、基质炎或神经麻痹性角膜炎。角膜上皮病变区荧光素钠染色不如HSK明显，且无树枝末端球状膨大的特征性表现。同时HZK通常伴同侧鼻翼、额部和 / 或头顶部皮肤的疱疹或疱疹后瘢痕，且常伴疱疹后神经痛或神经感觉异常。以上两大特点有助于与HSK鉴别。

Herpes zoster keratitis (HZK): The cornea is cha ra cterized by pseudodendritic keratitis, stromal inflammation,or neuroparalytic keratitis. Corneal ep ithelial lesions are stained with less f luorescein than HSK, without characteristic terminal bulb at each ending of the branch.HZK patients usually have rashes or scars on forehead,scalp and tip of nose accompanying with postherpetic neuralgia or neur o s e nsory abnormalities. The two characteristics above are helpful for identif ication.

棘阿米巴性角膜炎：在疾病的早期可有假树枝状角膜病灶，其上皮病变是隆起性而非溃疡性，且无树枝末端球状膨大的特征性表现。患者常有角膜接触镜配戴史、眼异物史或外伤史，眼痛剧烈，且症状与体征程度不相符，属于慢性病程。角膜刮片镜检或共聚焦显微镜检查可见典型棘阿米巴包囊。

Acanthamoeba keratitis: In the early stage, pseud odendritic corneal lesions are raised and not ulcerative, without characteristic terminal bulb at each ending of the branch.Patients often have a history of wea r ing corneal contact lens,corneal foreign body or tra u ma. Eye pain is often very sharp,while the signs are not so severe, which lead to inconsistent sym p toms and signs. Corneal scraping staining and con focal microscope are very useful to f ind typical acant h a m o eba cysts.

复发性角膜上皮糜烂：病因复杂多样，常见病因有前部角膜营养不良、角膜擦伤、角膜变性、角膜屈光手术及糖尿病等。表现为反复发生的急性眼痛、畏光、异物感和流泪。角膜上皮糜烂区在愈合过程中可呈现假树枝状或地图状外观，但无树枝末端球状膨大的特征性表现。

Recurrent corneal epithelial erosion: The causes are complex. Common causes include anterior corneal dyst rophy, corneal abrasion, corneal degeneration, corneal refractive surgery and diabetes mellitus. It is characterized by recurrent acute eye pain, ph o t o phobia, foreign body sensation and tearing. The erosion area may present a pseudodendritic or geog r a p hic-shaped appearance during healing, but without characteristic spherical terminal bulb at each ending of the branch.

药物毒性角膜上皮病变：眼局部不合理用药所引起的角膜组织病理性改变，多由药物本身或防腐剂引起的角膜细胞毒性或变态反应。早期表现为局限性或弥漫性的上皮浸润糜烂，后期可发展至假树枝状角膜上皮溃疡，若继续不合理用药，可发展至基质溃疡乃至穿孔。该类疾病特点为：在原发病基础上，通常有明确的长期点药史或短期多种眼药高频次点药史；角膜荧光素钠染色除了溃疡区着染外，周围角膜上皮也被着染。

Drug-induced toxic keratopathy: It is a severe path ological changes of cornea caused by unreasonable local drug application on the eyes. The eyedrops and preservatives inside may cause corneal cytotoxicity or allergic reaction.In the early stage, local or diffuse epithelial inf iltration appear. While in the later stage, erosion can develop into pseudodendritic ulcer. If the unreasonable treatment is continued, the pseudodendritic ulcer can develop into stromal ulcer and even perforation. Patients commonly have a history of long-term or high-frequency application of multiple eyedrops for their primary diseases. Not only the ulcer, but also the surrounding corneal epithelium is abnormal and can be stained with f luorescein.

病史询问

Asking History

◎ 明确眼部症状出现及持续时间，眼痛是否剧烈。

◎ Determent the onset and duration of ocular symp t o ms,eye pain is severe or not.

◎ 眼周皮肤是否有异常感觉：痛觉、针刺感或感觉迟钝等。

◎ Ask about any abnormal sensation in the skin around the eyes: Pain, pinprick feeling or dullness of skin sensation, etc.

◎ 既往是否反复出现类似症状，有无其他眼部病史、角膜外伤史、眼部手术史及角膜接触镜配戴史；有无长期点药或近期频繁使用多种眼药史；有无全身免疫性疾病史及糖尿病史。

◎ Any history of similar symptoms previously. Any other primary eye diseases, or corneal trauma, ocular surgery,wearing contact lenses, etc. Any history of long-term eyedrops treatment or application of multiple eyedrops frequently. Any history of systemic immunity diseases or diabetes mellitus.

◎ 近期有无发热史。

◎ Does the patient have a fever recently?

检查

Examination

◎ 视力：发病后视力急速下降。

◎ Visual acuity: Always decreases rapidly after the attack of the disease.

◎ 裂隙灯检查：可见单个或多个分支、边缘凸起、末端是球茎形状的溃疡性上皮病变。溃疡扩大可形成“地图状”，可被荧光素染色。在上皮病灶下方可见被称为“鬼影状树枝”的前基质混浊。检查是否有角膜基质浸润、内皮炎、葡萄膜炎、急性视网膜坏死和血管炎。

◎ Slit lamp examination: Single or multiple branching,ulcerating epithelial lesions with raised edges and terminal bulb formation. Enlargement of ulcers can lead to the formation of a “geographic” ulcer, which can be stained with f luorescein. Anterior stromal haze called “ghost dendrites” may develop below the epithelial lesions. Check if there is stroma inf iltration, endothelitis, uveitis, acute retinal necrosis and vasculitis.

◎ 角膜荧光素染色：角膜着染呈树枝状，分支末端呈球形膨大，以资与其他假树枝性角膜病变鉴别。

◎ Corneal f luorescent stain: The stain of terminal bulb at each ending of branch is easy to differential pseudodendritis.

◎ 角膜知觉检查：复发病例可有角膜知觉减退。

◎ Corneal sensation: Weaken or disappear in patients with recurrent onset.

◎ 皮肤及颜面检查：观察眼周皮肤是否有疱疹，是否沿三叉神经第一支、第二支支配区域分布，以排除带状疱疹病毒性角膜炎。

◎ Skin and face inspection: Check periocular skin blister lesion distribution (CN V1 and V2 region) to distinguish from HZK infection.

实验室检查

Lab

◎ 角膜及房水病毒PCR检测：存在假阴性率，尤其对已经接受抗病毒药物及激素治疗的患者。

◎ PCR detection of corneal and aqueous viruses: False negative rate exists, especially for patients who have received antiviral drugs and steroids therapy.

◎ 角膜刮片镜检及培养：对于存在上皮缺损者，可进行该检查，有助于排除其他感染性角膜炎。

◎ Corneal scraping for microscopy and culture (if epithelial defect exists): To exclude other infectious keratitis.

诊断

Diagnosis

单纯疱疹病毒性角膜炎（上皮型）- 树枝状溃疡。

Herpes simplex epithelial keratitis-dendritic ulcer.

治疗

Management

◎ 急性期治疗原则：控制病毒在角膜内复制，减轻炎症反应引起的角膜损伤。首选局部抗病毒药物治疗：阿昔洛韦(ACV)、更昔洛韦(GCV)滴眼液或眼膏。用药期间监控药物副作用。

◎ Principles of treatment in acute phase: Control virus replication in cornea, reduce corneal injury caused by inf lammatory reaction. Prefer topical antiviral therapy:acyclovir (ACV), ganciclovir (GCV) eye drops or eye ointments. Monitor side effect.

◎ 联合抗细菌眼药预防继发细菌感染。

◎ Combined with antibacterial eyedrops to prevent secondary bacterial infection.

◎ 辅助人工泪液治疗，促进上皮愈合。

◎ Application of artif icial tears to promote epithelial healing.

◎ 为减少病毒向角膜基质蔓延，可酌情刮除病灶区上皮联合抗病毒药物以利病毒清除。

◎ To prevent the process of the virus goes into the corneal stroma, debridement of the lesion can be considered, and applied with antiviral drugs to facilitate virus clearance.

患者教育和预后

Patient Education & Prognosis

◎ 预后通常较好，但该病易复发，须在严格随诊下规范接受治疗。

◎ The prognosis is good, but easy to recur, stand a rdized treatment under strict follow-up is very important.

◎ 角膜上皮可愈合或形成角膜云翳，一般对视力影响较小；若病情进展，则会发展为地图状角膜溃疡或向角膜基质层发展。

◎ Corneal epithelium can heal or form corneal nebula,which generally have less impact on vision; while if the disease progresses, it will develop to geographic or stromal keratitis.

◎ 改善不良生活及用眼习惯，增强机体抵抗力，有助于减少复发。

◎ Improve living and eye using habits, proper physical exercise can enhance the body immunity and reduce the recurrence rate.