第三章結(jié)膜病

DisordersoftheconjunctivaWhereisconjunctiva?瞼結(jié)膜球結(jié)膜穹隆結(jié)膜PalpebralconjunctivaBulbarconjunctivaFornicalconjunctivaRedeye=conjunctivitis?Themaincausesofaredeye:conjunctivitisepiscleritissubconjunctivalhemorrhagescleritiscornealdiseaseandtraumadryeyeanterioruveitisacuteglaucomablepharitis結(jié)膜炎總論疾病包括炎癥、外傷、先天性疾病和腫瘤最常見的是結(jié)膜炎癥Introductionofconjunctivitis

Thediseasescomprisesofinfection,trauma,congenitalabnormalitiesandtumours.Themostcommondiseaseisinfectionofconjunctivaltissue.結(jié)膜炎總論病因：復(fù)雜分類：內(nèi)源性和外源性感染性和非感染性微生物感染最常見，包括細菌、病毒、衣原體、真菌和寄生蟲；非感染因素包括物理性和化學(xué)性損傷免疫性因素和全身疾病也可以IntroductionofconjunctivitisEtiology：complicatedClassification：

Exogenous&EndogenousInfectious&Non-infectiousMicroorganisms:bacterial,viral,chlamydial,fungal,parasitic.Non-infection:physicalandchemicalImmunologic(allergic)Associatedwithsystemicdisease臨床表現(xiàn)

癥狀：眼部異物感、燒灼感、癢、流淚，累及角膜可出現(xiàn)畏光、視力下降、疼痛體征：分泌物：來源和分類水性、粘液性、膿性、粘液膿性結(jié)膜充血和水腫：球結(jié)膜充血和睫狀充血鑒別結(jié)膜濾泡結(jié)膜乳頭增生膜和假膜淋巴結(jié)腫大Clinicalfeatures

Symptoms:foreignbodysensation,burningsensation,itching,tearing,photophobia,painandblurredvisioninvolvedthecornea.Signs：Exudation：classificationHyperemiaandedema：ThecomparisonofciliarycongestionandconjunctivalcongestionFolliclesPapillaryhypertrophyMembraneandpseudomembranePreauricularlymphadenopathy結(jié)膜充血和睫狀充血鑒別睫狀充血角膜緣深層血管網(wǎng)深紅色固定近角膜緣明顯0.1%腎上腺素不變角膜、前房疾病結(jié)膜充血表面的結(jié)膜血管鮮紅色可推動近穹隆部明顯0.1%腎上腺素消失結(jié)膜、眼瞼疾病ThecomparisonofciliarycongestionandconjunctivalcongestionciliarycongestionLimbaldeepvascularnetworkDarkredFixedClosetolimbusNochangeafterinstillationof0.1%epinephrineDiseasesofcorneaandanteriorchamberconjunctivalcongestionSuperiorconjunctivalvesselsFreshredMovedClosetofornixDisappearafterinstillationof0.1%epinephrineDiseasesofconjunctivaandeyelids診斷臨床特點實驗室檢查：結(jié)膜刮片檢測革蘭染色吉姆薩染色結(jié)膜囊分泌物培養(yǎng)DiagnosisClinicalfindingsLaboratoryinvestigations：ConjunctivalscrapingGram’s&Giemsa’sstainCulture治療原則對因治療：局部＋全身分泌物多時可以沖洗結(jié)膜囊傳染性的應(yīng)注意切斷傳播途徑Principlesofmanagement

Drugs：Local＋systemicTheconjunctivalsacshouldbeirrigatedwithsalinesolution.Topreventspreadofthedisease,thepatientandfamilyshouldbeinstructedtogiveattentionpersonalhygiene.細菌性結(jié)膜炎急性細菌性結(jié)膜炎急性自限性，“紅眼病”，多于春秋季節(jié)致病菌：革蘭陽性球菌為主，表皮葡萄球菌和金黃色葡萄球菌起病急、眼紅、異物感、燒灼感、結(jié)膜充血，黏液膿性分泌物自限性。沖洗結(jié)膜囊，頻用抗生素眼水如0.3%氧氟沙星滴眼液注意洗手和個人衛(wèi)生BacterialconjunctivitisAcutebacterialconjunctivitisAcuteSelf-limited，“pinkeye”，springandautumnCause：G+coccus，Acuteonset、hyperemia、foreignbodysensation、burningsensation、conjunctivalinjection，moderatemucopurulentdischargeSelf-limited,conjunctivalsacirrigation,antimicrobialdrugshouldbegivenimmediately,0.3%ciprofloxacinPayattentiontopersonalhygiene.急性細菌性結(jié)膜炎

Acutebacterialconjunctivitis

淋球菌性結(jié)膜炎由淋球菌引起通過生殖器－眼接觸或生殖器－手－眼傳播，成人多為自身感染，新生兒通過產(chǎn)道感染。臨床表現(xiàn)：新生兒一般出生后1～3天發(fā)病，成人潛伏期為10小時至數(shù)天，癥狀猛烈，病情進展快，畏光流淚，眼瞼高度水腫，有時形成膜或假膜。以大量膿性分泌物為特點，“膿漏眼”，可發(fā)生角膜穿孔

GonococcalconjunctivitisDiplococcusNeisseriaGonorrhoeaeAvenerealgenitourinarytractinfectioninadults，neonatalconjunctivitisistransmittedfromthemotherduringdelivery.Clinicalfeatures：Presentationisusuallybetween1and3daysafterbirth.Theeyelidsareedematousandtender.Membraneandpseudomembraneformation.ProgressionrapidlyItischaracterizedbysevere,profuselypurulentexudate.Inseverecasecornealperforationcanoccur.診斷臨床表現(xiàn)＋接觸史＋結(jié)膜分泌物涂片治療原則

局部：大量生理鹽水沖洗全身：青霉素或頭孢類，新生兒禁用喹諾酮類藥物預(yù)防個人衛(wèi)生隔離嚴格消毒患者的用品

淋球菌性結(jié)膜炎DiagnosisClinicalfindings＋contacthistory＋conjunctivalscrapingPrinciplesoftreatment

local：irrigatedwithmuchsalinesolutionsystemic：Penicilin&cefotaxime，NouseoffluoroquinolonetoneonatalconjunctivitisPreventionPersonalhygieneIsolationSterile

Gonococcalconjunctivitis新生兒淋球菌性結(jié)膜炎neonatalGonococcalconjunctivitisHaveabreak

衣原體性結(jié)膜炎

Chlamydialconjunctivitis

衣原體屬包括沙眼衣原體種和鸚鵡熱衣原體種沙眼衣原體可引起沙眼、包涵體性結(jié)膜炎和淋巴肉芽腫；鸚鵡熱衣原體可引起鸚鵡熱。衣原體的眼部感染是最廣泛的，包括沙眼、成人包涵體性結(jié)膜炎和新生兒結(jié)膜炎沙眼衣原體抗原型A、B、Ba、C型可致沙眼，對四環(huán)素或紅霉素最敏感，其次磺胺嘧啶、利福平沙眼

沙眼衣原體引起的慢性傳染性眼病，瞼結(jié)膜表面形成粗糙不平的外觀形似沙粒而得名。病因：沙眼衣原體抗原型A、B、Ba、C型Trachoma

TrachomaisaninfectioncausedbyserotypeA、B、BaandCofChlamydiatrachomatis,whichisinitiallyachronicfollicularconjunctivitis.臨床表現(xiàn)

癥狀：急性期異物感、畏光、流淚、有粘液或粘液性分泌物。數(shù)周后進入慢性期，癥狀消失。體征：急性期：眼瞼紅、結(jié)膜高度充血、瞼結(jié)膜粗糙不平、上下穹隆結(jié)膜不滿濾泡、耳前淋巴結(jié)腫大。慢性期：結(jié)膜慢性充血、瞼結(jié)膜有乳頭及濾泡形形成、角膜血管翳、內(nèi)翻倒睫等。Clinicalfindings

Symptoms:Inacutestage,FBsensation,photophbia,tearing,mucousdischarge.Duringseveralweeksitprogressedintochronicstage.Signs

Acutestage:rednessofeyelids,hyperemiaofconjunctiva,tarsalandlimbalfollicles,tenderpreauricularnode.Chronicstage:formationofpapillaryhypertrophyandfollicles,pannus,entropionandtrichiasis.Tarsalfollicles后遺癥和并發(fā)癥瞼內(nèi)翻及倒睫上瞼下垂瞼球粘連角結(jié)膜干燥慢性淚囊炎角膜混濁Complications&SequelaeEntropionandtrichiasisptosisAdhesionofconjunctivaandeyeballKeratoconjunctivitisChronicdacryocystitisCornealopacification診斷沙眼的診斷至少要具備下列的兩項：上瞼結(jié)膜濾泡角膜緣濾泡及后遺癥（Herbert小凹）典型的瞼結(jié)膜瘢痕角膜緣上方血管翳實驗室檢查有助于確立沙眼的診斷。DiagnosisToestablishthediagnosisoftrachoma,patientsmusthaveatleasttwoofthefollowingsigns:SuperiorpalpebralconjunctivalfolliclesLimbalfolliclesandtheirsequelae(Herert’spits)Typicalconjunctivalscarringoftheuppertarsalconjunctiva.LimbalpannusThediagnosisisconfirmedbylaboratoryinvestigation.臨床分期世界衛(wèi)生組織（WHO）分期標準TF期（沙眼濾泡期）TI（沙眼炎癥期）TS（沙眼瘢痕期）TT（沙眼倒睫期）CO（角膜混濁期）ClinicalgradingWorldHealthOrganization（WHO）gradingTF:trachomafollicleswithfiveormoreontheuppertarsalconjunctiva.TI:diffuseinfiltrationandpapillaryhypertrophyoftheuppertarsalconjunctivaobscuringatleast50%ofthenormaldeepvessels.TS:trachomatousconjunctivalscarringTT:trichiasisorentropionCO:cornealopacity

我國1979年在全國第二屆眼科學(xué)術(shù)會議上制定的分期法：

Ⅰ期（進行期）即活動期。乳頭濾泡并存，上穹窿結(jié)膜組織模糊不清，有角膜血管翳。

Ⅱ期（退行期）退行期。自瘢痕開始出現(xiàn)至僅留少許活動病變。

Ⅲ期（完全結(jié)瘢期）活動病變完全消失，代之以瘢痕。此期已無傳染性。

臨床分期分級標準

根據(jù)活動性病變(乳頭和濾泡)占瞼結(jié)膜的總面積的多少，分為輕、中、重3級。占1／3面積以下者為(+)，占1／3～2／3者為(++)，占2／3以上者為(+++)。同時確定了角膜血管翳的分級法：將角膜分為4等分，血管翳侵入上1／4以內(nèi)者(+)，達1／4～1／2者為(++)，達1／2～3／4者為(+++)，超過3／4者為(++++)治療局部治療：0.1％利福平，0.5％金霉素，磺胺類滴眼液等，6周全身治療：急性期或嚴重的沙眼，全身抗生素并發(fā)癥治療：手術(shù)矯治內(nèi)翻矯正術(shù)角膜移植術(shù)Treatment

Topicaldropsorointments,includingpreparationsof0.1％rifampin,0.5％aureomycin,sulfonamidesfor6weeks.Systemicantibioticsisindicatedinacutestageorseverecase.complications：surgicalcorrection

沙眼衣原體：D～K型傳播途徑：尿道和陰道的分泌物及游泳等間接接觸，新生兒為經(jīng)母體的產(chǎn)道感染。特征：下瞼結(jié)膜和下穹隆結(jié)膜濾泡增生。診斷：臨床表現(xiàn)＋實驗室檢查治療：同沙眼包涵體性結(jié)膜炎

InclusionconjunctivitisiscausedbyCtrachomatisserotypeD-K.Transmission：adultsareusuallybyoralgenitalsexualpracticesorhandtoeyetransmission.Innewbornstheagentistransmittedduringbirthbydirectcontamination.Keyfeatures:theconjunctivaofbothtarsi-especiallythelowertarsus-havepapillaeandfollicles.Diagnosis:clinicalfindings+laboratoryfindingsManagement：sametotrachomaInclusionconjunctivitis包涵體性結(jié)膜炎

Inclusionconjunctivitis病毒性結(jié)膜炎一種常見的結(jié)膜炎急性濾泡性結(jié)膜炎：流行性角結(jié)膜炎、流行性出血性結(jié)膜炎、單皰病毒性結(jié)膜炎等。相對的亞急性或慢性結(jié)膜炎：傳染性軟疣性瞼結(jié)膜炎、水痘－帶狀皰疹性瞼結(jié)膜炎、麻疹性角結(jié)膜炎等。病毒性結(jié)膜炎臨床表現(xiàn)差異較大，與病毒毒力和機體免疫狀況有關(guān)。ViralconjunctivitisViralconjunctivitis,acommonaffliction,canbecausedbyawidevarietyofviruses.Acutefollicularconjunctivitis:epidemickeratoconjunctivitis,epidemichemorrhagicconjunctivitis,herpessimplexvirusconjunctivitisandsoon.Subacuteorchronicconjunctivitis:molluscumcontagiosumblepharoconjunctivitis,varicella-zosterblepharoconjunctivitis,measleskeratoconjunctivitisandsoon.Severityrangesfromsevere,disablingdiseasetomild,rapidlyself-limitedinfection.流行性角結(jié)膜炎病因：腺病毒8、19和37型，傳染性強臨床表現(xiàn)：癥狀：角膜多有受累，異物感、水樣分泌物、疼痛、畏光、流淚等。體征：眼瞼水腫、瞼球結(jié)膜顯著充血、水腫并有結(jié)膜濾泡。耳前淋巴結(jié)腫大伴壓痛。早期角膜彌漫性點狀上皮性損害，繼續(xù)進展圓點狀灰白色上皮下炎性混濁，少數(shù)進展成淺基質(zhì)層點狀浸潤，圓形，邊界模糊，形態(tài)和大小一致，聚集成簇，又稱錢幣狀角膜炎。兒童有時有全身表現(xiàn)EpidemickeratoconjunctivitisEpidemickeratoconjunctivitisiscausedbyadenovirustypes8,19,29,and37.Clinicalfeatures：

Symptoms：FBsensation,waterydischarge,pain,photophobia,tearing,involvedcorneainmostcases.Signs：edemaoftheeyelids,conjunctivalhyperemiawithfollicles.Atenderpreauricularnodeischaracteristic.Diffusepunctateepithelialkeratitis,advancedtosubepithelialroundopacities.Inchildrentheremaybesuchsystemicsymptomsofviralinfectionasfever,sorethroat,diarrheaandsoon.診斷：根據(jù)急性濾泡性結(jié)膜炎伴發(fā)淺層點狀角膜炎，耳前淋巴結(jié)腫大伴壓痛，分泌物涂片鏡檢單核細胞增多等特點，即可診斷。治療：支持療法冷敷和血管收縮劑抗病毒滴眼液角膜基質(zhì)浸潤加用低濃度激素預(yù)防：注意隔離EpidemickeratoconjunctivitisDiagnosis：acutefollicularconjunctivitiswithsuperiorpunctatekeratitis,atenderpreauricularnode,scrapingshowingprimarymononuclearinflammatoryreaction.Treatment：thereisnospecifictherapyatpresent,butcoldcompresswillrelievesomesymptoms.Antiviralagentsisindicated.Corticosteroidsshouldbeavoidedduringacutestage,addedlowconcentrationcorticosteroidswhenstromaisinvolved.Prevention：isolationEpidemickeratoconjunctivitisEpidemickeratoconjunctivitisEpidemickeratoconjunctivitis流行性出血性結(jié)膜炎病因：70型腸道病毒，偶A24柯薩奇病毒臨床表現(xiàn)：自限性疾病，多為雙眼。畏光、流淚、眼紅、異物感和劇烈眼痛等，可有水樣分泌物、瞼結(jié)膜濾泡和結(jié)膜下出血?？捎卸傲馨徒Y(jié)腫大等，病初角膜上皮一過性、細小點狀的上皮性角膜炎。診斷：根據(jù)急性濾泡性結(jié)膜炎的癥狀，同時有顯著的結(jié)膜下出血，耳前淋巴結(jié)腫大等。治療及預(yù)防：同流行性角結(jié)膜炎。EpidemichemorrhagicconjunctivitisItiscausedbyenterovirustype70andoccasionallybycoxsackievirusA24.Clinicalfeature:self-limited,bilateral,photophobia,tearing,redness,FBsensation,pain,waterydischarge,palpebralconjunctivalfolliclesandsubconjunctivalhemorrhage.Preauricularnode,transientfinepunctateepithelialkeratitis.Diagnosis:onthebasisofacutefollicularconjunctivitis,markedsubconjunctivalhemorrhageandpreauricularnode.Treatment&prevention:asEpidemickeratoconjunctivitis流行性出血性結(jié)膜炎

Epidemichemorrhagicconjunctivitis免疫性結(jié)膜病結(jié)膜組織的免疫學(xué)特點正常球結(jié)膜的免疫學(xué)特點：球結(jié)膜是一個經(jīng)常發(fā)生免疫學(xué)反應(yīng)的組織。富含各種免疫成分和細胞結(jié)膜的超敏反應(yīng)：Ⅰ型超敏反應(yīng)過敏性結(jié)膜炎Ⅱ型超敏反應(yīng)瘢痕性類天皰瘡Ⅲ型超敏反應(yīng)邊緣性角膜潰瘍Ⅳ型超敏反應(yīng)接觸性皮炎、接觸性角膜炎，角膜移植排斥反應(yīng)免疫性結(jié)膜炎枯草熱結(jié)膜炎又稱季節(jié)性過敏性結(jié)膜炎，屬Ⅰ型超敏反應(yīng)臨床表現(xiàn)：多有過敏性鼻炎或哮喘等其他特應(yīng)性疾病。接觸致敏原后迅速發(fā)病，瘙癢、眼瞼紅腫、球結(jié)膜充血水腫、粘液性滲出。劇烈瘙癢是特征。診斷：臨床表現(xiàn)，結(jié)膜刮片查嗜酸性粒細胞治療:遠離過敏原局部冷敷局部抗組胺與縮血管細胞膜穩(wěn)定劑嚴重可用糖皮質(zhì)激素脫敏療法ImmuologicconjunctivitisHayfeverconjunctivitisKnownasseasonalallergicconjunctivitis,hypersensitivityreactiontypeⅠClinicalfeatures:Thediseaseiscommonlyassociatedwithallergicrhinitisorasthma.Thepatientscomplainsofitching,tearing,chemosisandrednessoftheeyes.Theremaybeasmallamountofropydsicharge.Extremeitchingisthekeyfeature.Diagnosis：clinicalfindings.Eosinophilsaredifficulttofindinconjunctivalscrapings.Treatment:toeliminateantigencoldcompresseslocalvaso-constrictorsandhistamine-blockingagentsCromolynSteroids

春季角結(jié)膜炎春季卡他，是一種反復(fù)發(fā)作的，季節(jié)性，免疫性角結(jié)膜病。20歲以下青少年多見，男性，雙眼。病因：Ⅰ、Ⅳ型超敏反應(yīng)共同作用的結(jié)果。臨床表現(xiàn)：眼部奇癢、畏光、流淚、異物感、可有大量粘液性分泌物。分3型：瞼結(jié)膜型：主要在上瞼結(jié)膜。典型的瞼結(jié)膜扁平粗大乳頭，呈鋪路石癢，球結(jié)膜呈典型的暗紅色。角膜緣型：角膜緣充血，結(jié)節(jié)，呈膠凍樣外觀。混合型診斷：典型的病史＋體征治療：輕度用抗組胺藥中度肥大細胞穩(wěn)定劑嚴重糖皮質(zhì)激素或環(huán)孢霉素VernalkeratoconjunctivitisThedisease,alsoknownas“springcatarrh”,isanuncommonbilateralallergicdiseasethatusuallybeginsintheprepubertalyearsandlastsforseveralyears.Causes：hypersensitivityreactiontypeⅠ,ⅣClinicalfeatures：extremeitching,photophobia,FBsensation,ropydischarge.Theupperpalpebralconjunctivaoftenhasgiantpapillaethatgiveacobblestoneappearance.Insomecases,themostprominentlesionsarelocatedatthelimbus,wheregelatinousswellingsarenoted.Diagnosis：typicalsymptomsandsignsTreatment：Mild:histamine-blockingagentsModerate:cromolynSevere:steroidsorcyclosporine泡性角結(jié)膜炎病因：結(jié)膜，角膜組織對內(nèi)源性微生物蛋白質(zhì)變態(tài)反應(yīng)引起的局部病變，本病多發(fā)生于兒童及青少年，特別是營養(yǎng)不良

。癥狀：輕者僅有異物感及流淚，累及角膜出現(xiàn)畏光、流淚、刺痛及眼瞼痙攣等臨床分型：泡性結(jié)膜炎、泡性角膜炎、泡性角結(jié)膜炎。診斷及治療PhlyctenularconjunctivitisPhlyctenularconjunctivitisisadelayedhypersensitivityresponsetomicrobialproteins.

Signs:conjunctivalphlyctenuleusuallyproduceonlyirrigationandtearing,butcornealandlimbalphlyctenulesareusuallyaccompaniedbyintensephotophobia.

Classification：phlyctenularconjunctivitis,phlyctenularkeratoconjunctivitis,phlyctenularkeratitis

Stevens-Johnson綜合癥也稱重癥多形性紅斑，是一種急性的，可能致命的皮膚和粘膜炎癥水皰樣病變，主要與服用某些藥物或某些微生物感染有關(guān)。其發(fā)病機制為免疫復(fù)合物沉積在皮膚和結(jié)膜基質(zhì)引起的超敏反應(yīng)。眼部急性期嚴重的，雙側(cè)彌漫性結(jié)膜炎，有卡他性、膿性、出血性滲出膜或假膜形成。晚期并發(fā)癥包括結(jié)膜瘢痕化、倒睫、瞼內(nèi)翻、淚液缺乏。Stevens-JohnsonsyndromeErythemamultiformemajorisadiseaseofthemucousmembranesandskin.Theskinlesionisanerythematous,urticarialbullouseruptionthatappearssuddenlyandisoftendistributedsymmetrically.Bilateralconjunctivitis,oftenmembranous,isacommonmanifestation.Thepatientscomplainsofpain,irrigation,discharge,andphotophobia.Thecorneaisaffectedsecondarily,andvascularizationandscarringmayseriouslyreducevision.TransientconjunctivitisandlidcrustingwithoutsequelaeSeveremembranousorpseudomembranousconjunctivitisFocalfibroticpatchesandoccasionallysymblepharonMetaplasticlashes其他眼部瘢痕性類天皰瘡移植物抗宿主疾病Sjogren綜合癥MiscellaneousconjunctivitisOcularcicatricialpemphigoidGraft-versus-hostdiseaseSjogrensyndrome

變性性結(jié)膜病瞼裂斑

黃白色，無定形樣沉積的結(jié)膜變性性損害，出現(xiàn)在瞼裂區(qū)近角膜緣的球結(jié)膜上皮下。

病因：紫外線和光化學(xué)性暴露

臨床表現(xiàn)：瞼裂部位接近角膜緣處的球結(jié)膜，三角形略隆起的斑塊，基底向角膜。

治療：一般不需治療，注意有無干眼。影響外觀、反復(fù)慢性炎癥或干擾角膜接觸鏡的配戴時可以考慮手術(shù)切除。DegenerativediseasesoftheconjunctivaPingueculaCauses：ultravioletlightandphotochemicalexposureClinicalfeatures：Theyappearsasyellowish&whitishtriangularnodulesonbothsidesofthecorneaintheareaofthepalpebralaperture.Treatment:Ingeneral,notreatmentisrequired,butincertaincasesofcosmeticreason,recurrentpingueculitisordifficulttowearcontactlenssurgerymaybemade.瞼裂斑Pinguecula翼狀胬肉

瞼裂區(qū)肥厚的球結(jié)膜及其下的纖維血管組織呈三角形向角膜侵入，形態(tài)似翼狀。病因：不明，可能與紫外線照射、氣候干燥、接觸風(fēng)塵有關(guān)系，近地球赤道和戶外工作的人群發(fā)病率高臨床表現(xiàn)：多數(shù)無癥狀，偶有充血、不適，延及角膜會引起散光，遮蓋瞳孔區(qū)影響視力。單眼或雙眼，鼻側(cè)多見鑒別診斷：與外傷引起的假性胬肉相鑒別。PterygiumApterygiumisatriangularsheetoffibrovasculartissuewhichinvadesthecornea.Theetiologyisnotwellelucidated.Thecausesmaybeultravioletlight,drying,andwindyenvironments,sinceitiscommoninpersonswhospendmuchoftheirlivesoutofdoorsinsunny,dusty,