病例21　68岁，女性，右眼红、眼疼、畏光流泪1个月

CASE 21　A 68-year-old female complaining of redness, pain, photophobia and tearing of right eye for 1 month

见图1-36。See Fig. 1-36.

鉴别诊断

Differential Diagnosis

◎ 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。该病早期为角膜缘炎症和结膜及表层巩膜的水肿，角膜炎症早期为灰白色水肿，病变的角膜部位距离角膜缘2~3mm，可在4~12个月快速进展，累及全周角膜。溃疡被血管化组织覆盖。溃疡通常为新月形，最终只残余混浊的角膜中央岛。临床上根据病情分为两种类型。第一种类型：单眼发病，症状轻到中度，治疗效果好。第二种类型：双眼发病，临床症状重，治疗效果差。

◎ Mooren’s ulcer (MU): Mooren’s ulcer is charac t e rized by painful peripheral corneal ulceration of unknown etiology. The disease generally begins with intense limbal inf lammation and swelling in the episclera and conjunctiva. Corneal changes begin 2 to 3 mm from the limbus, f irst appearing as grey swellings that rapidly furrow, and then proceeding circumferentially and centrally over 4 to 12 months. The bed of the furrow becomes vascularized. These ulcers are often described as crescent-shaped and can leave behind either an opaque,edematous central cornea. There are two types: The f irst is usually unilateral, with mild to moderate symptoms, and generally responds well to treatment. The second type is bilateral, with relatively more pain and generally a poor response to therapy.

◎ Terrien角膜边缘变性：是一种少见的特发性的非炎症性的角膜周边变薄，单眼或者不对称的双眼发病，可伴随角膜新生血管、混浊以及脂质沉着。病变可引起角膜逆规性散光。

◎ Terrien marginal degeneration: It is an uncommon but distinct variety of marginal thinning of the cornea. It causes a slowly progressive non-inf lammatory, unilateral or asymmetrically bilateral peripheral corneal thinning and is associated with corneal neovascularization, opacif ication and lipid deposition. Degeneration may lead to a high degree of against-the-rule or oblique astigmatism.

◎ 边缘性角膜溃疡：是一种炎症性疾病，最终引起周边角膜变薄。该病通常伴随自身免疫性疾病，包括类风湿性关节炎、结节性多动脉炎、炎症性肠病、胶原血管病、系统性红斑狼疮(SLE)、复发性软骨炎、多血管炎肉芽肿、Churg-Strauss综合征。

◎ Peripheral ulcerative keratits (PUK): It is a group of inf lammatory diseases whose f inal common pathway is peripheral corneal thinning. PUK has been associated with many autoimmune disorders, including: Rheumatoid arthritis, polyarteritis nodosa, inf lammatory bowel disease,collagen vascular diseases, systemic lupus erythematosus(SLE), relapsing polychondritis, granulomatosis with polyangiitis, Churg–Strauss syndrome.

病史询问

Asking History

◎ 疾病的起病及进展。

◎ 是否有类风湿等免疫性疾病。

◎ Asking the history of onset and progression, and all above system diseases like rheumatoid arthritis or other immune system disease.

眼部检查

Examination

◎ 视力下降。

◎ Visual acuity was decreased.

◎ 裂隙灯检查：最初表现为周边角膜灰白色新月形浸润，继而上皮缺损，基质融解，发展成为周边角膜溃疡，溃疡起始于角膜缘，向周边及中央区进展，呈潜掘状，最后大部分角膜受侵犯，残余混浊的角膜中央岛。

◎ Slit lamp examination: Typically, Mooren’s ulcer begins as a crescent-shaped gray-white inf iltrate in the peripheral cornea, which progresses to epithelial breakdown and stromal melting eventually developing into corneal ulcer.Corneal ulcer that begins near the limbus and progresses circumferentially and centrally. Eventually most of the cornea is invaded, leaving the central island of the cornea cloudy.

实验室检查

Lab

◎ 全血检查：全血细胞计数、红细胞沉降率、类风湿因子、抗核抗体、抗中性粒细胞胞浆抗体、胸部及骶髂关节X线检查、肝功能等。

◎ Complete blood test: Blood cell counts, erythr o cyte sedimentation rate, rheumatoid factor, ant i n u clear antibody,antineutrophil cytoplasmic antibodies, X-ray examination of chest and sacroiliac joint, liver enzymes, etc.

◎ 通过微生物学检查排除感染性角膜炎。

◎ Infectious etiologies should be excluded by appr o p riate microbiology.

诊断

Diagnosis

蚕食性角膜溃疡。

Mooren’s ulcer.

治疗原则

Management

◎ 药物治疗：局部糖皮质激素，局部免疫抑制剂，全身免疫抑制剂。

◎ Medical approaches: Topical corticosteroids, local and systemic immunosuppression.

◎ 手术治疗：结膜切除、羊膜移植术、板层或全层角膜移植术。

◎ Surgical approaches: Conjunctival resection, amniotic membrane transplantation, lamellar keratoplasty, and penetrating keratoplasty.

患者教育和预后

Patient Education & Prognosis

◎ 蚕食性角膜溃疡是一种慢性、痛性、进展溃疡性角膜炎，此病病因不明确，病程长、易反复。临床过程以及预后与疾病的类型和程度相关。

◎ Mooren’s ulcer is a painful, progressive, chronic ulcerative keratitis. The course of Mooren’s ulcer is long and repeatedly.The clinical course, response to therapy, and eventual prognosis of this disease are related to the disease pres e ntation.