手术联合两性霉素B脂质体治疗重症真菌性角膜溃疡

Operation Combined With Liposomal Amphotericin B Intraocular Injection.Treating Refractory Keratomycosis

目的观察手术联合两性霉素B脂质体治疗重症真菌性角膜溃疡的临床疗效。方法选择经实验室、角膜共焦显微镜及眼B超确诊的氟康唑治疗无效的重症真菌性角膜溃疡患者64例（64只眼）（溃疡直径〉5mm），其中合并前房积脓34例（34只眼），合并前房积脓继发青光眼18例（18只眼），合并前房积脓并发眼内炎12例（12只眼）（波及前1／2玻璃体9只眼，波及后部3只眼）。应用两性霉素B脂质体全身及局部药物治疗，分别联合自体结膜瓣遮盖术、治疗性穿透性角膜移植、治疗性眼前段重建等手术治疗，观察其疗效。结果行自体结膜瓣遮盖术16例；治疗性穿透性角膜移植39只眼；治疗性眼前段重建手术治疗9例。所有病例均同时进行两性霉素B脂质体前房冲洗，其中联合玻璃体注药7例。角膜溃疡、前房积脓34例中，无效3例；角膜溃疡、前房积脓并继发青光眼18例中，无效8例（其中3例治疗中途放弃）；角膜溃疡、前房积脓并发眼内炎12例中，无效4例（其中2例治疗中途放弃）。临床总有效率76．57％。结论手术联合两性霉素B脂质体治疗重症真菌性角膜溃疡，取得了较好的临床疗效，可以缩短病程、挽救患者眼球，是治疗重症真菌性角膜溃疡的有效方法之一。同时强调真菌性角膜溃疡早期快速诊断是有效治疗的重要前提。

Objective To To evaluate the efficacy of operation combined with amphotericin B injection in the keiatomycosis which not responding to conventional antifungal therapy.Methods Records of 64 patients who were clinical diagnosed with fiangal keratitis from November, 2005 to June, 2007 were retrospectively reviewed.All patients did not respond to initial treatment with topical and intravenous fluconazole, 34 cases （ 34 eyes） of 64 patients had hypopyon, and 18 cases （ 18 eyes ）with secondary glaucoma, 12 cases （ 12 eyes） with endophthalmitis, 9 eyes related with anterior 1/2 vitreous, 3 eyes related with posterior segment.All patients received operation combined with Liposomal amphotericin B intraocular injection.Results Sixteen cases were carried out modified conjunctival flap microsurgery, 39 cases were carried out penetrative keratoplasty, 9 cases were carried out anterior segment reconstruction surgery.Among 34 eyes, visual acuity was improved in 26 eyes, 8 eyes did not respond which include 2 eyes with keratomycosis that gived up treatment, 3 eyes with hypopyon, and 3 eyes with endophthalmitis.Conclusions Surgery combined with liposomal amphotericin B treatment of severe fungal corneal ulcers is the one effective treatment method.Better clinical efficacy can be achieved, may shorten the course, save the patient eye.Early and rapid diagnosis is an important prerequisite for effective treatment of fungal corneal ulcer.