难治性蚕蚀性角膜溃疡合并坏死性巩膜炎的临床治疗

Clinical analysis of the treatment for refractory Mooren＇s ulcer combined with necroscleritis

目的分析探讨全身应用免疫抑制剂联合手术治疗合并坏死性巩膜炎的难治性蚕蚀性角膜溃疡的疗效。方法回顾性系列病例研究。山东省眼科医院2004年1月至2011年7月诊治的伴有坏死性巩膜炎的严重蚕蚀性角膜溃疡者7例（7眼）。治疗原则：①药物治疗：口服环孢素胶囊和强的松片，根据病情减量维持半年，无复发时停用。局部应用1％环孢素滴眼液和妥布霉素地塞米松滴眼液，4次／d，逐渐减量维持。②手术治疗：巩膜坏死范围〈1／4象限者，行巩膜修补术；角膜溃疡范围≤全角膜1／2者，行部分板层角膜移植术：角膜溃疡范围〉全角膜1／2者或巩膜坏死范围〉1／2象限者均行结膜瓣遮盖术。术后3个月内每半个月复查1次，之后每个月复查1次至术后1年，1年后每2个月复查1次。结果7例中有3例行结膜瓣遮盖术，4例行部分板层角膜移植术联合巩膜修补术。行结膜瓣遮盖术的3例患者术后结膜瓣血运好，溃疡愈合，眼表稳定，随访期间未见原发病复发。行部分板层角膜移植术联合巩膜修补术的4例，随访期间3例未见原发病复发，1例因自行停药1．5个月，巩膜自溶再次人院，给予巩膜修补术联合药物治疗，随访2年未见复发。随访期内7例患者未见角膜移植术后免疫排斥反应的发生，未见因药物副作用所致停药。结论全身应用免疫抑制剂联合手术治疗伴有坏死性巩膜炎的难治性蚕蚀性角膜溃疡有效，全身和局部联合应用免疫抑制剂可以明显提高手术成功率。

Objective To evaluate the efficacy of using immunosuppressive agents and surgery for refractory Mooren＇s ulcer combined with necroscleritis. Methods In a retrospective study, 7 patients who were diagnosed with refractory Mooren＇s ulcer combined with necroscleritis between January 2004 and July 2011 at Shandong Eye Hospital were included. The treatment for the patients was determined by the following principles： first, oral cyclosporin A and prednisone were administered for half a year based on the condition, glucocoreieoid eye drops and cyelosporin A eye drops were used four times daily and reduced according to the condition; second, when the corneal ulcer area was smaller than half the area of the cornea, lamellar keratoplasty was performed; and when the area of the scleral necrosis was less than 1/4 quadrant, seleral neoplasty was performed; the remaining patients underwent eonjunctival flap surgery. Patients were followed up twice a month for 3 months, once a month for 1 year and every two months thereafter. Results Three eyes were treated with conjunctival flap, and these 3 eyes recovered ocular surface stabilization. No recurrence was observed in these 3 patients during the follow-up period. The other 4 eyes were treated by lamellar keratoplasty combined with seleral neoplasty. In these patients, recurrence was discovered in 1 patient who had stopped using the systemic drugs. Scleral neoplasty was performed again on this patient, and postoperative medications were continued. No recurrence was observed. No significant complications related to drug use were observed in any patient during the study period. Conclusion The treatment of immunosuppresive agents and surgery are effective in patients with refractory Mooren＇s ulcer combined with necroseleritis. Using systemic and partial immunosnppresive agents can effectively decrease the incidence of recurrence.