真菌性角膜炎(一)

簡介

       真菌性角膜炎是由致病真菌引起的、致盲率極高的感染性角膜病。中醫辨證根據其發病特點亦屬中醫“凝脂翳”、“濕翳”范疇。 真菌性角膜炎在臨床上較難診斷,容易誤診,常因治療不當而造成失明。一般情況下,真菌不會侵犯正常角膜,但當有眼外傷、長期局部使用抗生素、角膜炎癥及干眼癥等情況時,非致病的真菌就可能變為致病菌,引起角膜繼發性真菌感染。常見的致病菌為曲霉菌,其次是鐮刀菌、白色念珠菌、頭芽孢菌及鏈絲菌等。因致病菌種不同,角膜潰瘍形態不一。 真菌性角膜炎并非少見。夏秋農忙季節發病率高。在年齡與職業上,多見于青壯年、老年及農民。

發病病因

(1)多由致病真菌引起包括(鐮刀菌和曲霉菌、其他還有念珠菌屬、青霉菌屬和酵母菌等)

(2)眼部植物性外傷心史:常見有樹枝、甘蔗葉、稻草、麥芒等刺傷

(3)局部抵抗力下降:配戴角膜接觸鏡(軟性角膜接觸鏡和 OK鏡)可直接由角膜上皮糜爛或上皮擦傷引起真菌感染,也可以通過被真菌污染的保存液或清潔液引起感染

(4)機體免疫功能失調:與一些菌種的發病有關。如全身或局部長期使用廣譜抗生素、糖皮質激素或免疫抑制劑

臨床表現

       自覺有眼異物感、畏光流淚,視力減退癥狀,如果形成角膜侵潤灶呈白色或灰色,致密,表面欠光澤,呈牙膏樣或苔垢樣外觀,潰瘍周圍有膠原溶解形成的淺溝,或抗原抗體反應形成的免疫環。有時在角膜病灶旁可見偽足或衛星樣侵潤灶,病灶后可有斑塊狀纖維膿性沉著物。前房積膿,呈灰白色,粘稠或呈糊狀。真菌穿透性強,進入前房或角膜穿破時易引起真菌性眼內炎。

診斷要點

       根據角膜植物損傷史,結合角膜病灶的特征,可作出初步診斷。實驗室檢查找到真菌和菌絲可以確診。常用方法有角膜刮片Gram和Giemsa染色、10%-20%氫氧化鉀濕片刮片及培養均為陰性,而臨床又高度懷疑者,可考慮作角膜組織活檢。此外,免疫熒光染色、電子顯微鏡檢查和PCR技術也用于真菌角膜炎的診斷。角膜共焦顯微鏡作為非侵入性檢查,可直接發現病灶內的真菌病原體

中醫辨證要點: 真菌性角膜炎,辨證要點在于如何辨別風熱偏重、濕熱偏重,治療以祛風清熱解毒,清熱祛濕為主

鑒別診斷

       重癥的真菌性角膜炎,特別是鐮刀菌性角膜炎,由于發病急驟,常合并有前房積膿及角膜穿孔,經常被誤診為綠膿桿菌性角膜潰瘍,主要鑒別是:

1 、綠膿桿菌性角膜潰瘍:潰瘍呈淡綠色,表面濕潤而有光澤(由黏性壞死組織及分泌物構成),邊緣光滑,與正常角膜之間有浸潤水腫區。真菌性角膜炎具有典型的菌絲苔被病灶

2 、單純皰疹病毒:該病引起的壞死性角膜炎和棘阿米巴性角膜炎晚期盤狀基質膿瘍的臨床表現非??崴?,應通過病史及實驗室診斷加以鑒別。

預防

       預防是最關鍵的一步,因為患者絕大多數為農民,雖然整年均可發生,但主要集中在業夏收和秋收季節。 務必注意以下細節

1、養成良好的衛生習慣,勤洗手,常剪指甲

2、不要長期佩戴隱形眼鏡;更換隱形眼鏡時要小心

3、與急性結膜炎的預防相同,主要是切斷傳染源與注意眼和手的衛生

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