棘阿米巴角膜炎的诊断和治疗探讨
眼科研究 2000年第2期第18卷 临床研究
作者:金秀英 罗时运 杨宝铃 张文华 邹洋 李彬 李辽青 王正仪
单位:金秀英 罗时运 杨宝铃 张文华 邹洋 李彬 李辽青(100005 北京市眼科研究所);王正仪(北京热带医学研究所)
关键词:棘阿米巴;角膜炎;诊断;治疗;洗必泰;甲硝唑
摘要 目的探讨棘阿米巴角膜炎的临床与实验室诊断方法,寻找有效滴眼液用以治疗。方法观察分析25例棘阿米巴角膜炎感染各阶段的临床表现,通过角膜细胞学检查、阿米巴分离培养、角膜活检及组织病理学检查确诊,检测药物对棘阿米巴的抗原虫作用及临床疗效。结果感染自角膜上皮层开始,进行性侵入基质致盲。细胞学检查见包囊和/或滋养体(88.9%)。棘阿米巴培养阳性率57.9%。洗必泰、甲硝唑滴眼液治疗棘阿米巴角膜炎有良效。抗原虫治疗24例(25眼),治愈21眼,无复发。结论棘阿米巴角膜炎并非罕见,常因被误诊、误治导致视力丧失。重要的是早期诊断与抗原虫治疗。 分类号 R 772.21
Investigations on the diagnosis and treatment of acanthamoeba keratitis
Jin Xiuying,Luo Shiyun,Yang Baoling,et al.
Beijing Institute of Ophthalmology,Beijing 100005
Abstract ObjectiveTo establish accurate means for clinical and laboratory diagnosis of acanthamoeba keratitis(AK)and to find effective eye drops for the treatment of AK.MethodsThe clinical manifestations at each of the stages of AK infection in 25 cases were investigated.Corneal cytology,isolation and cultivation of the amoeba,corneal biopsy and histopathological examination were applied to ascertain the diagnosis.Some chemicals were tested in vitro as well as in clinical trial to see whether they were effective in treating the infection.ResultsThis series consisted of 25 cases (26 eyes),of which 8 eyes(30.8%) were related to wearing soft contact lens.The infection started from corneal epithelial layer and then spread progressively,slowly to the stroma to cause severe corneal inflammation and finally causing loss of vision.Corneal scrapings demonstrated the presence of cyst and/or trophozoite in 16(88.9%) out of 18 infected eyes.Isolations of acanthamoeba were recovered from 57.9% of corneal specimens.Chlorhexidine and metronidazole eye drops were found to be effective both in vitro and in clinical trials.Out of the treated 24 cases (25 infected eyes),21 eyes were completely cured without recurrence.ConclusionAt this site,AK is not a very rare infectious corneal disease.It is often been misdiagnosed and improperly treated.Early diagnosis and antiprotozoal therapy is important to control this infection and preserve sight.
Key word sacanthamoeba keratitis diagnosis treatment chlorhexidine metronidazole
棘阿米巴角膜炎(acanthamoeba keratitis)是致盲率极高的慢性进行性角膜炎,随着角膜接触镜应用和诊断技术提高病例报道日增[1~3]。此病常被误诊误治。棘阿米巴对一般抗微生物药不敏感,如延误诊断,不用抗原虫药控制感染则全角膜被破坏。国内对此病陌生,眼科原虫诊断、抗原虫眼药均属空白。我等继初步报道本病后[4,5],深入分析原虫眼感染各阶段的临床特征,完善诊断技术,体外筛选对棘阿米巴属虫株敏感的药物,配制抗原虫滴眼液。先后诊治棘阿米巴角膜炎25例(26眼),报道如下。
1 资料与方法
1.1 病例情况 北京同仁医院眼科门诊患者25例,男12例,女13例。年龄14~72岁(平均34.1岁)。单眼患者24人,双眼患者1人。被误诊为病毒性角膜炎16眼,细菌性角膜炎4眼,真菌性角膜炎3眼,不明病因3眼。曾用过多种药物平均治疗59.8天,后因恶化加重而转诊。既往无眼病史。患眼多为感染晚期,视力辨光感或数指17眼,0.1为6眼,0.2为3眼。戴角膜接触镜者8眼(30.8%),非戴角膜接触镜者18眼(69.2%)。
1.2 实验室检查 病灶刮取物涂片,Giemsa,Gram染色,乳酚棉蓝或KOH蓝墨水湿片光镜细胞学检查。常规细菌、真菌培养。病灶取材接种Page培基,滴大肠杆菌菌液28℃湿房培养原虫。前房积脓液涂片镜检、微生物培养。戴接触镜者的镜用物品微生物培养。角膜活检、病检及角膜组织块原虫培养。
1.3 药物体外实验检测抗原虫作用,配制抗原虫滴眼液及临床抗原虫治疗 试管法体外试验检测棘阿米巴虫株对碘酊,龙胆紫,来苏,硫柳汞,新洁尔灭,甲硝唑,洗必泰等敏感性。配制抗原虫滴眼液。用0.2%甲硝唑滴眼液联合甲硝唑口服或静点治疗8例。用0.02%洗必泰滴眼液或联合甲硝唑每半小时滴眼1次冲击治疗16例(17眼)。随症状缓解减少滴药次数,炎症消退后维持滴药2~3次/日,持续3~6月。阿托品扩瞳,一般抗生素滴眼防继发感染。服消炎痛。
2 结果
2.1 棘阿米巴感染角膜各阶段的临床表现分析 患眼皆急性发病,因眼红痛、畏光、流泪就医。开始视力无大影响,眼睑水肿、结膜充血、无分泌物。初表现上皮性角膜炎,光泽差,表面粗糙不平。裂隙灯下上皮层内见淡灰色细微点线状微隆起病灶,簇集或假树枝形排列,荧光素不着染或淡染,另见点状上皮剥脱。随上皮下出现斑、片状浸润,刺激症状明显,混合充血重。角膜旁中心区基质见向周边放射走行的纤细混浊。上皮层反复剥脱形成不规则形溃疡。角膜中周部基质弧、环形浸润、溃疡(图1),角膜缘肿胀、充血,视力锐减。角膜盘状浸润,中心浓密斑状混浊,进展为盘状溃疡(图2)。溃疡面粗颗粒状,浸润致密固着,边缘屡见沟状溶解。主病灶周围有时见卫星灶。虹膜充血、肿胀,前后粘连。重度前房反应,反复积脓、积血,多继发青光眼,并发晶状体混浊。病程中症状可短暂缓解随即进行性加重,常历时数月经年,最后全角膜混浊,溃疡、脓疡或后弹力层膨出、穿孔。患者诉重度眼痛(73.1%)而角膜知觉减退或消失(92.3%)。病初明确记载上皮性角膜炎11眼(42.3%)。上皮剥脱3眼(11.5%)。病程中先后表现浅基质浸润16眼(61.5%)。角膜神经周围炎4眼(15.4%)。地图状溃疡6眼(23.1%)。弧、环形浸润、溃疡15眼(57.7%)。盘状浸润、溃疡11眼(42.3%)。角膜缘炎4眼(15.4%)。虹膜睫状体炎23眼(88.5%),前房积脓11眼(42.3%),积血2眼(7.7%)。巩膜炎1眼(3.8%)。继发青光眼4眼(15.4%)。并发白内障2眼(7.7%)。膜细胞学检查未见包涵体、细菌或真菌。渗出细胞以中性粒细胞为主,屡见活化巨噬细胞。查见阿米巴包囊或/和滋养体16眼(16/18,88.9%)(图3)。普通细菌培养阴性19眼(19/22,86.4%)。真菌培养阴性22眼(22/22)。角膜刮取物分离培养出阿米巴11眼(11/19,57.9%)。3例戴接触镜患者的镜用生理盐水(3/4)及3例的镜盒(3/5)分离出阿米巴。虫株鞭毛试验未见梨形体,无鞭毛,滋养体及包囊的生物形态符合棘阿米属原虫。
2.3 角膜活检、病理检查见包囊、滋养体3眼(图4)。变性包囊、空囊周围中性粒细胞、巨噬细胞浸润、胶原溶解。角膜组织块培养2眼见棘阿米巴生长。
2.4 药物体外实验结果表明洗必泰有良好的杀灭棘阿米巴效果,甲硝唑也有一定的灭活作用。配制0.02%洗必泰,0.2%甲硝唑滴眼液治疗确诊的棘阿米巴角膜炎24例(25眼),治愈21眼(21/25,84%),平均治愈天数为60.9天,皆无复发。愈后视力(包括矫正视力)恢复正常10眼(47.6%),视力为0.1~0.3者6眼(28.6%)。辨手动、数指5眼(23.8%),其中2眼待白内障手术,3眼待角膜移植。未随诊4例。另1例未用抗原虫药治疗行角膜深板层切除,板层移植术,术后因感染失控而失败。
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