真菌性角膜炎板层角膜移植术后复发的临床研究

Clinical study on the recurrence of fungal keratitis after lamellar keratoplasty

目的探讨板层角膜移植术（LKP）治疗真菌性角膜炎术后真菌复发的特点、诊疗方法及危险因素。方法采用非随机回顾性系列病例研究。收集1998年1月至2005年7月在山东省眼科研究所青岛眼科医院经LKP治疗确诊的真菌性角膜炎患者218例（218只眼），术前详细询问病史，术中选用大于病灶0．5mm的环钻，采用深板层剖切，个别病例加以术中镜检，术后观察真菌的复发特点，对复发者进行药物与手术治疗，并比较在不同菌属和术前给予糖皮质激素或免疫抑制剂治疗、以及有前房积脓或内皮斑等危险因素存在下行LKP术后的复发情况。结果术后2周有17例（7．80％）真菌复发，其中15例在术后第1周；复发主要表现为局部刺激症状加重、植床中央或边缘出现菌丝浸润灶。17例复发病例均成功行穿透性角膜移植术（PKP）治愈。危险因素分析：曲霉菌属LKP术后复发率（19．23％）高于镰刀菌属（5．63％）（P=0．0323），术前应用糖皮质激素或免疫抑制剂治疗的病例行LKP术后复发率（21．70％）较高（P=0．0219），术前前房积脓或内皮斑的病例LKP术后复发率（17．02％）较高（P=0．0134）。结论LKP治疗真菌性角膜炎的术后复发主要在术后1周内；曲霉菌属、术前经糖皮质激素或免疫抑制剂治疗以及前房积脓或内皮斑等是其危险因素；术中灵活应用手术技巧等可能是降低复发率的有效途径。

Objective To study the characters, diagnosis, treatment and risk factors of the recurrence of fungal keratitis after lamellar keratoplasty （LKP）. Methods In this nonrandomized retrospective case series, two hundred and eighteen cases of fungal keratitis were undertaken partial LKP from January 1998 to July 2005. The case history was inquired in detail preoperatively. A trephine with diameter 0. 5 mm larger than the area of fungal infection was used to incise the lamellar corneal ulcer, and the hyphae of some cases were inspected with microscope during the operation. The recurrence of fungal keratitis was observed after the surgery. Medical treatment and/or operation were used in the management of recurrent cases. The risk factors for the recurrence of fungal keratitis after LKP, such as fungal species, glucocorticoid or immunosuppressant therapy, hypopyon or endothelial plague, were also analyzed. Results Seventeen cases（7.80% ） recurred within 2 weeks after surgery and mainly （ 15 cases） within 1 week. The recurrence displayed with increased local irritation and hypha infiltration on recipient LKP bed. All recurrent fungal infections were controlled by performing penetrating keratoplasty （PKP）. Risk factor analysis ： （ 1 ） The recurrent rate of Aspergillus infection （ 19. 23% ） was higher than that in Fusarium infection （5.63%） （P = 0. 0323 ）. （2） The recurrence rate of cases treated with glucocorticoid or immunosuppressant preoperatively （21.70%） was much higher than that in non-treated cases （6. 15% ） （ P = 0. 0219）. （3） The recurrence rate of cases with hypopyon or endothelial plague preoperatively （ 17.02% ） was much higher than that without these signs （5.26%） （ P = 0. 0134）. Conclusions The recurrence of fungal keratitis after LKP occurs mainly within the 1st week. Aspergillus infection, glucocorticoid or immunosuppressant therapy, hypopyon or endothelial plague are the risk factors for LKP.