重症化脓性角膜炎手术治疗的临床分析
摘要
目的
探讨重症化脓性角膜炎手术治疗的疗效,评价早期及适时手术干预治疗化脓性角膜炎的价值。
方法
对2006年1月至2009年12月在重庆医科大学附属第一医院眼科住院治疗的重症化脓性角膜炎部分病例进行手术治疗。包括细菌感染35例,真菌感染20例及混合感染6例,共61例(61眼); 7例术前角膜已穿孔,18例前房积脓超过1/3;手术方式:穿透性角膜移植(PKP)46例,板层角膜移植(LKP)8例,其它手术7例。随访3-12个月,观察眼球保存情况、术后视力变化、感染复发及其并发症。
结果
1.术后56例成功保住眼球,4例摘除眼球,1例失访;
2.术前78.7%(48例)视力小于0.02,其中有一半以上是仅有手动甚至光感视力,术后绝大部分视力有提高,51.8%(29例)视力大于0.02,有13例术后视力大于0.1;
3.感染复发6例,其中3例药物治疗无效、病情进展极快最终摘除了眼球,3例再次手术后保住眼球;
4.继发性青光眼7例,6例用药后眼压控制良好,1例因视功能丧失伴剧痛后摘除眼球;并发性白内障15例;
5.排斥反应17例, 3例行二次手术后稳定,1例因排斥放弃治疗。
结论
1、手术是治疗重症化脓性角膜炎的有效方式,其中主要是角膜移植特别是PKP对挽救重症角膜炎患者眼球,改善视功能有重要作用。
2、对重症化脓性角膜炎早期及适时进行手术治疗,大部分患者能挽救眼球,并不同程度的提高视力。
3、在角膜穿孔较小而无合适角膜材料情况下,用结膜瓣遮盖或羊膜移植(AMT)可以修复溃疡,为二次行光学性治疗创造条件。
Objective
To study the therapeutic effect of operation on severe suppurative keratitis and to evaluate the essentiality of early time and in time operation.
Methods
We choosed 61patients(61eyes) with refractory ruppurative keratitis which had been treated for operative therapy at the first affiliated hospital,Chongqing medical university, from Jan.2006 to Dec.2009.Including bacterial infection 35 eyes,fungal infection 20eyes,and mixed infection 6 eyes. 7eyes bad been perforated. 18eyes bad hypopyon exceed 1/3anterior chamber. Regular communicate with patients of post-operation .The follow-up ranged from 3-12months.The preservation of eyeballs, post-operative visual acuity and complications were documented.
Results
1 56 eyes were preserved after the operation,4eyes enucleated,1eye lost.
2 Most patients had a restoration of visual function,.
3 Infection recurred in 6 eyes,3 of which were controlled with sencondary operation,the others were enucleated because of the uncontrolled endophthalmitis.
4 7eyes occurred secondary glaucoma, the intraocular pressure of 6 eyes was controlled medically and surgically,1eye enucleated for severe pain and complete visual loss. Complicated cataract occurred in 15 eyes.
5 Graft rejection was observed in 17 eyes, 3received secondary corneal transplantation,1 eye refused further therapy.
Conclusion
1 Operation is an effective way for preservation of eyeballs and restoration of visual function in patients eyes with severe suppurative keratitis. Therapeutic keratoplasty especially penetrating keratoplasty may treat severe infectious keratitis effectively.
2 High cure rates are achievable and visual acuity is elevated by early time and in time operation on severe suppurative keratitis.
3 Amniotic membrane transplantation and conjunctival flap covering surgery are effective in promoting epithelialization and could be performed as an emergent procedure until a donor cornea is available.
探讨重症化脓性角膜炎手术治疗的疗效,评价早期及适时手术干预治疗化脓性角膜炎的价值。
方法
对2006年1月至2009年12月在重庆医科大学附属第一医院眼科住院治疗的重症化脓性角膜炎部分病例进行手术治疗。包括细菌感染35例,真菌感染20例及混合感染6例,共61例(61眼); 7例术前角膜已穿孔,18例前房积脓超过1/3;手术方式:穿透性角膜移植(PKP)46例,板层角膜移植(LKP)8例,其它手术7例。随访3-12个月,观察眼球保存情况、术后视力变化、感染复发及其并发症。
结果
1.术后56例成功保住眼球,4例摘除眼球,1例失访;
2.术前78.7%(48例)视力小于0.02,其中有一半以上是仅有手动甚至光感视力,术后绝大部分视力有提高,51.8%(29例)视力大于0.02,有13例术后视力大于0.1;
3.感染复发6例,其中3例药物治疗无效、病情进展极快最终摘除了眼球,3例再次手术后保住眼球;
4.继发性青光眼7例,6例用药后眼压控制良好,1例因视功能丧失伴剧痛后摘除眼球;并发性白内障15例;
5.排斥反应17例, 3例行二次手术后稳定,1例因排斥放弃治疗。
结论
1、手术是治疗重症化脓性角膜炎的有效方式,其中主要是角膜移植特别是PKP对挽救重症角膜炎患者眼球,改善视功能有重要作用。
2、对重症化脓性角膜炎早期及适时进行手术治疗,大部分患者能挽救眼球,并不同程度的提高视力。
3、在角膜穿孔较小而无合适角膜材料情况下,用结膜瓣遮盖或羊膜移植(AMT)可以修复溃疡,为二次行光学性治疗创造条件。
Objective
To study the therapeutic effect of operation on severe suppurative keratitis and to evaluate the essentiality of early time and in time operation.
Methods
We choosed 61patients(61eyes) with refractory ruppurative keratitis which had been treated for operative therapy at the first affiliated hospital,Chongqing medical university, from Jan.2006 to Dec.2009.Including bacterial infection 35 eyes,fungal infection 20eyes,and mixed infection 6 eyes. 7eyes bad been perforated. 18eyes bad hypopyon exceed 1/3anterior chamber. Regular communicate with patients of post-operation .The follow-up ranged from 3-12months.The preservation of eyeballs, post-operative visual acuity and complications were documented.
Results
1 56 eyes were preserved after the operation,4eyes enucleated,1eye lost.
2 Most patients had a restoration of visual function,.
3 Infection recurred in 6 eyes,3 of which were controlled with sencondary operation,the others were enucleated because of the uncontrolled endophthalmitis.
4 7eyes occurred secondary glaucoma, the intraocular pressure of 6 eyes was controlled medically and surgically,1eye enucleated for severe pain and complete visual loss. Complicated cataract occurred in 15 eyes.
5 Graft rejection was observed in 17 eyes, 3received secondary corneal transplantation,1 eye refused further therapy.
Conclusion
1 Operation is an effective way for preservation of eyeballs and restoration of visual function in patients eyes with severe suppurative keratitis. Therapeutic keratoplasty especially penetrating keratoplasty may treat severe infectious keratitis effectively.
2 High cure rates are achievable and visual acuity is elevated by early time and in time operation on severe suppurative keratitis.
3 Amniotic membrane transplantation and conjunctival flap covering surgery are effective in promoting epithelialization and could be performed as an emergent procedure until a donor cornea is available.
引文
[1]孙旭光.细菌性角膜炎治疗进展.中国医刊.2003,38(6):59-61
[2]张文华,潘志强,王智群等.化脓性角膜溃疡常见致病菌的变迁.中华眼科杂志.2002,38(1):8-12
[3] Xie L,Zhai H, Shi W. Penetrating keratoplasty for corneal perforations in fu-ngal keratitis.Cornea 2007;26:58-162
[4] Chowdhary A, Singh K. Spectrum of Fungal Keratitis in North India. Corn-ea, 2005,24(1):8-15
[5] Kalavathy CM, Parmar P, Kaliamurthy J, et al.Comparison of topical itraco-nazole 1% with topical natamycin 5% for the treatment of filamentous fungal keratitis. Cornea.2005,24:449–452
[6] Xie L, Zhai H, Zhao J,et al. Antifungal susceptibility for common pathogensof fungal keratitis in Shandong Province, China. Am J Ophthalmol. 2008 ,146(2):260-265
[7] Wei-Li Chen, Chun-Ying Wu, Fung-Rong Hu.et al. Therapeutic penetrating keratoplasty for microbial keratitis in Taiwan from 1987 to 2001. American Journal of Ophthalmology, 2004, 137(4):736-743
[8] Xie L, Dong X,Shi W et al.Treatment of keratitis by penetrating keratoplasty.Br J Ophthalmol,2001,85:1070-1074
[9] Xie L. Shi W. Liu Z. et al. lamellar keratoplasty for the treatment of fungalkeratitis[J].Cornea,2002,21(1):33-37
[10] Seng-Ei,J.Angus Scott,Prathiba Janardhanan,et al.Therapertic Keratoplasty for Advanced Suppurative Keratitis. American Journal of Ophthalmology 2007,143(5):755-762.e2
[11]史伟云,李绍伟,谢立信.板层角膜移植治疗真菌性角膜炎的临床疗效分析.中华眼科杂志.2002,38(6):347-350
[12] Mario Nubile, Paolo Carpineto, Manuela Lanzini. Multilayer amniotic memb-rane transplantation for bacterial keratitis with corneal perforation after hyperopic photorefractive keratectomy: Case report and literature review. Journal of Cataract & Refractive Surgery. 2007, 33(9):1636-1640
[13] C. Stephen Foster, Dimitri T. Azar, et al, Smolin and Thoft’s The Cornea: Scientific Foundations and Clinical Practice, 4th Edition, Philadelphia , Pa, Lippincott Williams & Wilkins, 2006;124:924
[14]史伟云,李素霞.结膜瓣遮盖术在重症角膜溃疡治疗中的临床价值.中华眼科杂志,2007,43:293-296
[15] Xie L, Zhai H, Shi W, et al.Hyphal Growth Patterns and Recurrence of Fu-ngal Keratitis after Lamellar Keratoplasty ,Ophthalmology, 2008, 115(6):983-987
[16]谢立信,翟华蕾.穿透性角膜移植术治疗真菌性角膜溃疡穿孔.中华眼科杂志.2005,41(11):009-1013
[17] Wusteman MC, Boylan S, Pegg DE. Cryopreservation of rabbit corneas in dimethyl sulfoxide. Invest Ophthalmol Vis Sci. 1997,38(10):1934-1943
[18] Bourne WM, Shearer DR, Nelson LR. Human corneal endothelial tolerance to glycerol, dimethylsulfoxide, 1,2-propanediol, and 2,3-butanediol. Cryobiology. 1994,31(1):1-9
[19] Hanada K, Igarashi S, Muramatsu O,et al. Therapeutic keratoplasty for corn-eal perforation: clinical results and complications. Cornea. 2008 ,27(2):156-60
[20] Ti SE, Scott JA, Janardhanan P,et al. Therapeutic keratopla-sty for advancedsuppurative keratitis. Am J Ophthalmol. 2007,143(5):755-762
[1] Xie L, Zhai H, Shi W. Penetrating keratoplasty for corneal perforations in fungal keratitis[J]. Cornea,2007,26(2):158-162.
[2] Xie L, Zhai H, Zhao J, et al. Antifungal Susceptibility for Common Pathogens of Fungal Keratitis in Shandong Province, China[J]. American Journal of Ophthalmology,2008,146(2):260-265.
[3] Li L, Wang Z, Li R, et al. In Vitro Evaluation of Combination Antifungal Activity against Fusarium Species Isolated from Ocular Tissues of Keratomycosis Patients[J]. American Journal of Ophthalmology,2008,146(5):724-728.
[4] Thiel M A, Zinkernagel A S, Burhenne J, et al. Voriconazole concentration in human aqueous humor and plasma during topical or combined topical and systemic administration for fungal keratitis[J]. Antimicrobial agents and chemotherapy,2007,51(1):239.
[5] Hariprasad S M, Mieler W F, Holz E R, et al. Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans[Z]. Am Med Assoc,2004.122,42-47.
[6] Bunya V Y, Hammersmith K M, Rapuano C J, et al. Topical and oral voriconazole in the treatment of fungal keratitis[J]. American journal of ophthalmology,2007,143(1):151-153.
[7] Giaconi J A, Marangon F B, Miller D, et al. Voriconazole and fungal keratitis: a report of two treatment failures[J]. Journal of Ocular Pharmacology & Therapeutics,2006,22(6):437-439.
[8] Kernt M, Kampik A. Intracameral voriconazole: In vitro safety for human ocular cells[J]. Toxicology,2009,258(2-3):84-93.
[9] Torres H A, Hachem R Y, Chemaly R F, et al. Posaconazole: a broad-spectrum triazole antifungal[J]. The Lancet Infectious Diseases,2005,5(12):775-785.
[10] Schiller D S, Fung H B. Posaconazole: an extended-spectrum triazole antifungal agent[J]. Clinical Therapeutics,2007,29(9):1862-1886.
[11] Gubbins P O, Krishna G, Sansone-Parsons A, et al. Pharmacokinetics and safety oforal posaconazole in neutropenic stem cell transplant recipients[J]. Antimicrobial agents and chemotherapy,2006,50(6):1993.
[12] Krishnan-Natesan S, Chandrasekar P H, Manavathu E K, et al. Successful treatment of primary cutaneous Aspergillus ustus infection with surgical debridement and a combination of voriconazole and terbinafine[J]. Diagnostic Microbiology & Infectious Disease,2008,62(4):443-446.
[13] Durand M L, Kim I K, D Amico D J, et al. Successful treatment of Fusarium endophthalmitis with voriconazole and Aspergillus endophthalmitis with voriconazole plus caspofungin[J]. American journal of ophthalmology,2005,140(3):552-554.
[14] Anaissie E J. Diagnosis and therapy of fungal infection in patients with leukemia—new drugs and immunotherapy[J]. Best Practice & Research Clinical Haematology,2008,21(4):683-690.
[15] Gubbins P O, Mcconnell S A, Amsden J R, et al. Comparison of liposomal amphotericin B plasma and tissue concentrations following a single large (15 mg/kg) dose of daily (1 mg/kg) dosing. Abstr. 44th Intersci. Conf[J]. Antimicrob. Agents Chemother., abstr. A-33. American Society for Microbiology, Washington, DC,2004.
[16]徐楠,邹豪,温海, et al.两性霉素B聚氰基丙烯酸正丁酯纳米粒跨血脑屏障及抗隐球菌效力的研究[J].中国生物医学工程学报,2009,28(2).
[17]徐楠,邹豪,温海, et al.携两性霉素B的聚氰基丙烯酸正丁酯纳米粒对大鼠肝肾功能及血液系统的影响[J].中国真菌学杂志,2007,2(001):10-13.
[18] Rabinow B, Kipp J, Papadopoulos P, et al. Itraconazole IV nanosuspension enhances efficacy through altered pharmacokinetics in the rat[J]. International journal of pharmaceutics,2007,339(1-2):251-260.
[19] Hong J Y, Kim J K, Song Y K, et al. A new self-emulsifying formulation of itraconazole with improved dissolution and oral absorption[J]. Journal of Controlled Release,2006,110(2):332-338.
[20] Garcia-Valenzuela E, Song C D. Intracorneal injection of amphothericin B forrecurrent fungal keratitis and endophthalmitis[Z]. Am Med Assoc,2005.123,1721-1723.
[21] Prakash G, Sharma N, Goel M, et al. Evaluation of intrastromal injection of voriconazole as a therapeutic adjunctive for the management of deep recalcitrant fungal keratitis[J]. American Journal of Ophthalmology,2008,146(1):56-59.
[2]张文华,潘志强,王智群等.化脓性角膜溃疡常见致病菌的变迁.中华眼科杂志.2002,38(1):8-12
[3] Xie L,Zhai H, Shi W. Penetrating keratoplasty for corneal perforations in fu-ngal keratitis.Cornea 2007;26:58-162
[4] Chowdhary A, Singh K. Spectrum of Fungal Keratitis in North India. Corn-ea, 2005,24(1):8-15
[5] Kalavathy CM, Parmar P, Kaliamurthy J, et al.Comparison of topical itraco-nazole 1% with topical natamycin 5% for the treatment of filamentous fungal keratitis. Cornea.2005,24:449–452
[6] Xie L, Zhai H, Zhao J,et al. Antifungal susceptibility for common pathogensof fungal keratitis in Shandong Province, China. Am J Ophthalmol. 2008 ,146(2):260-265
[7] Wei-Li Chen, Chun-Ying Wu, Fung-Rong Hu.et al. Therapeutic penetrating keratoplasty for microbial keratitis in Taiwan from 1987 to 2001. American Journal of Ophthalmology, 2004, 137(4):736-743
[8] Xie L, Dong X,Shi W et al.Treatment of keratitis by penetrating keratoplasty.Br J Ophthalmol,2001,85:1070-1074
[9] Xie L. Shi W. Liu Z. et al. lamellar keratoplasty for the treatment of fungalkeratitis[J].Cornea,2002,21(1):33-37
[10] Seng-Ei,J.Angus Scott,Prathiba Janardhanan,et al.Therapertic Keratoplasty for Advanced Suppurative Keratitis. American Journal of Ophthalmology 2007,143(5):755-762.e2
[11]史伟云,李绍伟,谢立信.板层角膜移植治疗真菌性角膜炎的临床疗效分析.中华眼科杂志.2002,38(6):347-350
[12] Mario Nubile, Paolo Carpineto, Manuela Lanzini. Multilayer amniotic memb-rane transplantation for bacterial keratitis with corneal perforation after hyperopic photorefractive keratectomy: Case report and literature review. Journal of Cataract & Refractive Surgery. 2007, 33(9):1636-1640
[13] C. Stephen Foster, Dimitri T. Azar, et al, Smolin and Thoft’s The Cornea: Scientific Foundations and Clinical Practice, 4th Edition, Philadelphia , Pa, Lippincott Williams & Wilkins, 2006;124:924
[14]史伟云,李素霞.结膜瓣遮盖术在重症角膜溃疡治疗中的临床价值.中华眼科杂志,2007,43:293-296
[15] Xie L, Zhai H, Shi W, et al.Hyphal Growth Patterns and Recurrence of Fu-ngal Keratitis after Lamellar Keratoplasty ,Ophthalmology, 2008, 115(6):983-987
[16]谢立信,翟华蕾.穿透性角膜移植术治疗真菌性角膜溃疡穿孔.中华眼科杂志.2005,41(11):009-1013
[17] Wusteman MC, Boylan S, Pegg DE. Cryopreservation of rabbit corneas in dimethyl sulfoxide. Invest Ophthalmol Vis Sci. 1997,38(10):1934-1943
[18] Bourne WM, Shearer DR, Nelson LR. Human corneal endothelial tolerance to glycerol, dimethylsulfoxide, 1,2-propanediol, and 2,3-butanediol. Cryobiology. 1994,31(1):1-9
[19] Hanada K, Igarashi S, Muramatsu O,et al. Therapeutic keratoplasty for corn-eal perforation: clinical results and complications. Cornea. 2008 ,27(2):156-60
[20] Ti SE, Scott JA, Janardhanan P,et al. Therapeutic keratopla-sty for advancedsuppurative keratitis. Am J Ophthalmol. 2007,143(5):755-762
[1] Xie L, Zhai H, Shi W. Penetrating keratoplasty for corneal perforations in fungal keratitis[J]. Cornea,2007,26(2):158-162.
[2] Xie L, Zhai H, Zhao J, et al. Antifungal Susceptibility for Common Pathogens of Fungal Keratitis in Shandong Province, China[J]. American Journal of Ophthalmology,2008,146(2):260-265.
[3] Li L, Wang Z, Li R, et al. In Vitro Evaluation of Combination Antifungal Activity against Fusarium Species Isolated from Ocular Tissues of Keratomycosis Patients[J]. American Journal of Ophthalmology,2008,146(5):724-728.
[4] Thiel M A, Zinkernagel A S, Burhenne J, et al. Voriconazole concentration in human aqueous humor and plasma during topical or combined topical and systemic administration for fungal keratitis[J]. Antimicrobial agents and chemotherapy,2007,51(1):239.
[5] Hariprasad S M, Mieler W F, Holz E R, et al. Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans[Z]. Am Med Assoc,2004.122,42-47.
[6] Bunya V Y, Hammersmith K M, Rapuano C J, et al. Topical and oral voriconazole in the treatment of fungal keratitis[J]. American journal of ophthalmology,2007,143(1):151-153.
[7] Giaconi J A, Marangon F B, Miller D, et al. Voriconazole and fungal keratitis: a report of two treatment failures[J]. Journal of Ocular Pharmacology & Therapeutics,2006,22(6):437-439.
[8] Kernt M, Kampik A. Intracameral voriconazole: In vitro safety for human ocular cells[J]. Toxicology,2009,258(2-3):84-93.
[9] Torres H A, Hachem R Y, Chemaly R F, et al. Posaconazole: a broad-spectrum triazole antifungal[J]. The Lancet Infectious Diseases,2005,5(12):775-785.
[10] Schiller D S, Fung H B. Posaconazole: an extended-spectrum triazole antifungal agent[J]. Clinical Therapeutics,2007,29(9):1862-1886.
[11] Gubbins P O, Krishna G, Sansone-Parsons A, et al. Pharmacokinetics and safety oforal posaconazole in neutropenic stem cell transplant recipients[J]. Antimicrobial agents and chemotherapy,2006,50(6):1993.
[12] Krishnan-Natesan S, Chandrasekar P H, Manavathu E K, et al. Successful treatment of primary cutaneous Aspergillus ustus infection with surgical debridement and a combination of voriconazole and terbinafine[J]. Diagnostic Microbiology & Infectious Disease,2008,62(4):443-446.
[13] Durand M L, Kim I K, D Amico D J, et al. Successful treatment of Fusarium endophthalmitis with voriconazole and Aspergillus endophthalmitis with voriconazole plus caspofungin[J]. American journal of ophthalmology,2005,140(3):552-554.
[14] Anaissie E J. Diagnosis and therapy of fungal infection in patients with leukemia—new drugs and immunotherapy[J]. Best Practice & Research Clinical Haematology,2008,21(4):683-690.
[15] Gubbins P O, Mcconnell S A, Amsden J R, et al. Comparison of liposomal amphotericin B plasma and tissue concentrations following a single large (15 mg/kg) dose of daily (1 mg/kg) dosing. Abstr. 44th Intersci. Conf[J]. Antimicrob. Agents Chemother., abstr. A-33. American Society for Microbiology, Washington, DC,2004.
[16]徐楠,邹豪,温海, et al.两性霉素B聚氰基丙烯酸正丁酯纳米粒跨血脑屏障及抗隐球菌效力的研究[J].中国生物医学工程学报,2009,28(2).
[17]徐楠,邹豪,温海, et al.携两性霉素B的聚氰基丙烯酸正丁酯纳米粒对大鼠肝肾功能及血液系统的影响[J].中国真菌学杂志,2007,2(001):10-13.
[18] Rabinow B, Kipp J, Papadopoulos P, et al. Itraconazole IV nanosuspension enhances efficacy through altered pharmacokinetics in the rat[J]. International journal of pharmaceutics,2007,339(1-2):251-260.
[19] Hong J Y, Kim J K, Song Y K, et al. A new self-emulsifying formulation of itraconazole with improved dissolution and oral absorption[J]. Journal of Controlled Release,2006,110(2):332-338.
[20] Garcia-Valenzuela E, Song C D. Intracorneal injection of amphothericin B forrecurrent fungal keratitis and endophthalmitis[Z]. Am Med Assoc,2005.123,1721-1723.
[21] Prakash G, Sharma N, Goel M, et al. Evaluation of intrastromal injection of voriconazole as a therapeutic adjunctive for the management of deep recalcitrant fungal keratitis[J]. American Journal of Ophthalmology,2008,146(1):56-59.