【摘要】目的 评价干燥保存角膜片在真菌性角膜溃疡手术治疗中的作用。方法 对54例（54只眼）药物治疗无效的真菌性角膜溃疡患者采用无水甘油或无水氯化钙保存的角膜片，分别行板层角膜移植术及穿透性角膜移植术治疗，术中分别以5%碘酊烧灼植床表面及氟康唑原液或稀释液冲洗前房,以观察其治疗效果。结果 板层角膜移植组23例，1次手术成功者18例，2次手术成功者3例，手术成功率为91.3%；2例术后角膜炎复发，改行穿透性角膜移植术后炎症控制。穿透性角膜移植术组31例，1次手术成功者27例，4例因角膜炎未能控制或难治性青光眼行眼内容摘出或眼球摘除术。54例中，50例经手术治疗后角膜炎症控制，成功率为92.6%。结论 采用无水甘油或无水氯化钙保存的角膜片可对药物治疗效果不显或对现有药物耐药的真菌性角膜溃疡者行治疗性角膜移植术，可及时去除病灶、控制炎症、保存眼球，为再次增视性角膜移植术创造条件。对角膜溃疡病灶较浅者行板层角膜移植术，术中注意板层切除的深度，并应用5%碘酊烧灼植床表面；对病灶较深者，可视前房炎性反应的轻、重用氟康唑原液或稀释液冲洗前房，有助于手术成功率的提高。
Evaluation of the results of therapeutic lamellar keratoplasty and penetrating keratoplasty for fungal corneal ulcer
WANG Rongguang, ZOU Liuhe, DONG Dongsheng.
（Department of Ophthalmology, Affiliated Tong Ren Hospital, Capital Medical University, Beijing 100730，China）
【Abstract】 Objective To evaluate the effects of therapeutic lamellar and penetrating keratoplasty for fungal corneal ulcer. Methods Donor corneas preserved in pure glycerine or water-free calcium chloride were used in corneal transplantation for fungal corneal ulcers that were poorly responsive to the anti-fungal medical treatment, 5% iodine was used in lamellar keratoplasty to kill the fungi in the recipient bed, and diluted or original solution of fluconazole was used in penetrating keratoplasty to wash the anterior chamber. Results In the lamellar keratoplasty group, there were 23 cases; 18 cases were cured with one surgery and 3 cases were cured after second surgery, the success rate being 91.3%. There were 2 cases with recurrence of corneal inflammation, and the lesion was controlled by penetrating keratoplasty. The penetrating keratoplasty group included 31 cases, of them, 27 cases were cured with one surgery and 4 eyes were enucleated due to recurrent corneal inflammation or refractive glaucoma. In the total 54 cases, the inflammation was controlled in 50 cases after therapeutic corneal transplantation, success rate being 92.6%. Conclusions For those fungal corneal ulcers that are poorly responsive to anti-fungus eye drops, it is recommended to perform lamellar keratoplasty if the ulcer is located in the anterior 1/2 stroma, the key points of surgery are to remove the affected tissue completely and cauterize the recipient bed with 5% iodine. For deep ulcers or nearly perforative or perforated ulcers, diluted or original solution of diflucan is used to wash the anterior chamber during penetrating keratoplasty, that can help to improve the success rate.
【Key words】 Eye infection, fungal; Corneal ulcer; Keratoplasty, penetrating
近10余年来，国内已有诸多有关真菌性角膜病的药物及手术治疗的报告与眼部广谱抗生素及糖皮质激素眼液的应用有关。由于真菌的种类繁多，目前可以局部使用的抗真菌药物种类较少，而目前的抗真菌药物的眼内通透性又很差，所以在临床上经常遇到对现有药物治疗无效或耐药的情况。我们自1994年3月至1998年12月在无新鲜角膜材料情况下，对药物治疗无效的54例（54只眼）真菌性角膜溃疡患者根据角膜溃疡的大小及病灶的深浅采用干燥保存角膜片，分别行治疗性穿透性角膜移植术及板层角膜移植术，以期观察并评价其治疗效果，现报告如下。
资料与方法
一、对象
选择本院1994年3月至1998年12月收治的对药物治疗无效的真菌性角膜炎患者54例（54只眼），其中男32例，女22例。年龄14～71岁，平均37岁。植物性外伤者27例。
二、实验室检查
术前均行角膜溃疡刮片，真菌培养及药物敏感试验。其中镰刀菌29例，曲霉菌8例，青霉菌5例，余为白色念珠菌2例，球霉菌属3例，7例刮片可见菌丝，但真菌培养结果为阴性。54例中，26例对咪康唑或氟康唑敏感，但经临床应用无效。8例对咪康唑、氟康唑及克霉唑耐药。
三、手术分组
板层角膜移植术组23例，角膜溃疡直径4～7 mm，炎性浸润限于基质层前2/3。穿透性角膜移植术组31例，角膜溃疡深，其中角膜近穿孔或已经穿孔者9例。
四、手术方法
所用角膜材料均为我院眼库提供的无水甘油或无水氯化钙保存的干燥角膜片。
1.板层角膜移植术：植床边缘在溃疡边缘外1.0～1.5 mm处，分层行板层切除，第1层切除深度以将病灶组织基本切除为准，植床以5%碘酊烧灼，第2层切除深度以植床表面为正常组织为止，再次以5%碘酊烧灼植床，尤其应注意植床周边部及手术器械，以防止在缝合植片过程中将真菌播散至植床上。植床烧灼后以生理盐水冲洗，将复水后的角膜片制成大于植床0.25～0.50 mm的板层植片置于植床上，间断缝合16针，线头埋藏。
2.穿透性角膜移植术：植床大小的选择同板层移植术，植片直径大于植床0.5 mm，一般为7.5～9.0 mm。4例因术前角膜溃疡已累及全角膜，故行全角膜移植术。对术前前房积脓较多或虹膜表面有炎性渗出膜者，术中行氟康唑原液冲洗前房，将所有脓性渗出物冲洗干净，尤其注意房角处的渗出物，虹膜表面的膜样组织用显微无齿镊予以撕除。对瞳孔区有后粘连者行周边虹膜切除术。前房积脓少或虹膜反应较轻者术中以0.02%氟康唑稀释液冲洗。植床直径＜8 mm，溃疡位于角膜中央者行连续缝合，余均行间断缝合术。前房以生理盐水或消毒空气填充。
3.术后处理：术后局部滴用抗真菌及广谱抗生素眼液，口服或结膜下注射抗真菌药物。
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