病例10　72岁女性，右眼红痛20天。患者既往类风湿性关节炎病史

CASE 10　A 72-year-old female, with right eye redness and pain for 20 days. The patient has the history of rheumatoid arthritis

见图1-15。See Fig. 1-15.

鉴别诊断

Differential Diagnosis

◎ 边缘性角膜溃疡：是指近角膜缘处角膜基质的半月形炎症性病变，伴随角膜上皮缺损以及基质炎症浸润。多伴有全身免疫性疾病。

◎ Peripheral ulcerative keratitis (PUK): PUK is a type of crescent-shaped inf lammatory damage that occurs in the cornea limbus, always combined with an epithelial defect and the destruction of the peripheral corneal stroma. PUK may have a connection with systemic immune disease.

◎ 蚕食性角膜溃疡：是一种慢性疼痛性周边角膜溃疡性疾病，原因不明。溃疡起始于角膜缘，向周边及中央区进展，呈潜掘状。最后大部分角膜被血管化混浊的组织替代，残余角膜中央岛。

◎ Mooren ulcer: Mooren ulcer is characterized by painful peripheral corneal ulceration of unknown etiology. The ulcer extends circumferentially and centrally with a leading undermined edge. Cornea is replaced by a vascularized,opaque thinned tissue leaving behind a central island of cornea.

◎ Terrien角膜边缘变性：是一种少见的特发性的角膜周边变薄，通常双眼发病。

◎ Terrien marginal degeneration: Terrien marginal degeneration is a rare idiopathic peripheral corneal thinning that usually occurs in both eyes.

◎ 泡性角结膜炎：为眼部的非感染性疾病，是微生物抗原引起的免疫反应，引起角膜和结膜的结节样病变。

◎ Phlyctenular keratoconjunctivitis: It is an immune respond to microbial antigens to cause the corneal and conjunctival nodular lesions.

◎ 透明边缘性角膜变性：是一种非炎症性的扩张性角膜疾病，表现为周边角膜窄带样变薄，与角膜缘间隔1~2mm，是一种罕见的角膜疾病。

◎ Pellucid marginal degeneration: Pellucid marginal degeneration (PMD) is a non-inf lammatory ectatic corneal disease characterized by a narrow band of corneal thinning separated from the limbus by a relatively uninvolved area 1 to 2 mm in width. It is a rare corneal disorder.

病史询问

Asking History

◎ 询问是否有类风湿性关节炎、Wegener肉芽肿、复发性多软骨炎等全身免疫相关疾病。

◎ Asking the history of systemic diseases such as rheu ma toid arthritis, Wegener’s granuloma and recurrent polychondritis.

检查

Examination

◎ 视力下降。

◎ Visual acuity is decreased.

◎ 裂隙灯检查：角膜缘处角膜基质的新月形炎性浸润，伴随角膜上皮缺损和基质变薄。

◎ Slit-lamp examination: crescent-shaped inf la mmatory inf iltration that occurs in the limbal region of the cornea,combined with an epithelial defect and thinning of the peripheral corneal stroma.

实验室检查

Lab

◎ 全身自身免疫性疾病检查包括：全血细胞计数(CBC)、尿液镜检、抗核抗体(ANA)、抗中性粒细胞胞浆抗体(ANCA)、类风湿因子(RF)、抗环瓜氨酸肽(anti-CCP)、快速血浆反应素试验(RPR)、荧光密螺旋体抗体(FTAAbs)、胸部X线、结核菌素纯蛋白衍化物实验(PPD)、骶髂关节X线、鼻窦CAT扫描、乙肝及丙肝病毒检查。

◎ Systemic evaluation for underlying autoimmune dise ases may include: Complete blood count (CBC), urinalysis with microscopic analysis (UA&micro), antinuclear antibody (ANA), anti-neutrophil cytopl asm ic antibody(ANCA), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), rapid plas ma reagin (RPR), f luorescent treponemal ant ibody (FTA-Abs), chest X-ray, tuberculin purif ied protein derivative (PPD), sacroiliac joint X-ray,CAT scan of sinuses, hepatitis B virus, hepatitis C virus.

◎ 角膜微生物培养。

◎ Corneal microbial culture.

诊断

Diagnosis

边缘性角膜溃疡。

Peripheral ulcerative keratitis.

治疗

Management

◎ 无防腐剂的人工泪液，泪点塞或者泪点烧灼，角膜绷带镜可用于治疗干眼，促进角膜上皮化。

◎ Preservative free artif icial tears, closure of puncta with plugs or cautery, and bandage soft contact lens are used to treat associated dry eye and promote epithelialization of the ulcer.

◎ 氰基丙烯酸盐黏合剂可用于有穿孔风险的角膜溃疡。

◎ Cyanoacrylate adhesive may be applied to the ulcer bed to limit ulceration in cases of impending perforation.

◎ 局部抗生素用于预防细菌感染。

◎ Topical antibiotics are used to prevent bacterial sup erinfection.

◎ 局部使用免疫抑制剂和胶原酶抑制剂。

◎ Local immunosuppression, collagenase inhibitors.

◎ 全身免疫抑制剂。

◎ Systemic immunosuppression.

◎ 其他抗代谢药物：T细胞抑制剂，烷基化药物以及生物制剂。

◎ Steroid sparing agents include antimetabolites T cell inhibitors, alkylating agents and biologic agents.

◎ 手术治疗：适用于角膜穿孔，或者有穿孔风险的角膜溃疡。手术方式包括板层或穿透性角膜移植术、角膜 - 巩膜移植术。

◎ Surgery: Indications for surgical intervention include corneal perforation or excessive corneal thinning with impending perforation. Surgical options include lamellar keratoplasty, penetrating keratoplasty, as well as possible cornea-scleral keratoplasty.

患者教育和预后

Patient Education & Prognosis

◎ 边缘性角膜溃疡通常是全身疾病未得到控制的表现，需要全身免疫抑制治疗。

◎ Peripheral ulcerative keratitis is often a sign of an unco n t r o lled systemic disease requiring systemic immunosuppr e s s ion.

◎ 对于全身疾病未控制和反复发作的患者，预后差。有角膜穿孔风险的患者通常需要手术干预。

◎ The visual prognoses in patients with uncontrolled systemic disease and repeated attacked is poor. Surgical management for PUK is required in cases of impending corneal perforation.