穿透性角膜移植术治疗单纯疱疹病毒性角膜炎后复发的危险因素

Risk factors for recurrent herpes simplex keratitis after penetrating keratoplasty

目的研究单纯疱疹病毒性角膜炎在行穿透性角膜移植术（PKP）治疗后复发的危险因素，临床特征和治疗方式的选择。方法回顾性病例研究。回顾性分析2000年1月至2012年7月在青岛眼科医院因药物治疗无效行穿透性角膜移植术的单纯疱疹病毒性角膜炎患者329例（329眼）。观察分析其术后首次复发的情况，包括复发时间、复发类型、复发的危险因素以及复发后的治疗转归。PKP术后复发的相关危险因素的比较应用卡方检验。在一个回归模型中应用初始单变量分层分析以鉴定和选择复发的重要的相关因素。结果穿透性角膜移植术后有33眼（10％）复发，复发类型主要为上皮型，18例（54％），复发病灶主要集中于植片与植床交界处（63％），复发时间从2周到13年不等。复发的相关危险因素包括：免疫排斥（X2=47．09，P〈0．01）、继发性青光眼（X2=26．38，P〈0．05）、并发性白内障行白内障手术（x2=7．31，P〈0．05）、上呼吸道感染（X2=5．60，P〈0．05）、病灶累及角膜缘（x2=8．30，P〈0．05）。复发病例中上皮型有10例经单纯药物治疗有效，其余基质型和内皮型（包括由上皮型转化而来）有5例行结膜瓣覆盖术治疗，12例行单层或双层羊膜覆盖术，6例行二次PKP术。所有复发病例经药物或手术治疗后平均随访（24．6±5．4）个月，植片透明率达46％。结论免疫排斥、继发性青光眼（未行手术）、白内障手术、上呼吸道感染、病灶累及角膜缘，是穿透性角膜移植术后复发的危险因素，基于复发的临床特征和危险因素，选择合适的预防方式和治疗方式可有效控制复发。

Objective To evaluate the risk factors, clinical features, and treatment of recurrent herpes simplex keratitis after penetrating keratoplasty （PKP）. Methods This was a retrospective, interventional case series study. Three hundred twenty-nine patients （329 eyes） with herpes simplex keratitis who underwent penetrating keratoplasty at the Qingdao Eye Hospital between January 2000 and July 2012 were evaluated. All patients had fai]ed to respond to topical and systemic antivirus drug treatment before penetrating keratoplasty was performed. The medical records of each patient were reviewed retrospectively. The clinical features, including recurrence time, position, and type, were summarized. Appropriate topical and systemic antivirus treatment was determined for all patients based on the clinical features. If there was treatment failure, conjunctival flap covering, amniotic membrane transplantation, or penetrating keratoplasty was performed. Results Thirty-three patients （10%） experienced recurrence after penetrating keratoplasty. The recurrent type was mainly epithelial （54%） and 63% of the recurrences were at the border between donor and recipient tissues. Recurrence risk factors included immune rejection, secondary glaucoma, cataract surgery, upper respiratory tract infection, and lesions involving the limbus. Ten cases of the epithelial condition took a turn for the better simply with drug treatment; the remaining stromal and endothelial conditions （including changes from epithelial conditions） needed surgery： 5 cases of conjunctival flap, 12 cases of amniotic membrance transplantation, and 6 cases with PKP. With an average of 24.6±5.4 months for follow-up after treatment, 46% of the eyes had clear grafts. Conclusion Immune rejection,secondary glaucoma, cataract surgery, upper respiratory tract infection, and lesions involving the limbus are major risk factors for the recurrence of herpes simplex keratitis after penetrating keratoplasty. Based on the clinical features of recurrence, appropriate precautions and treatment options can help to control recurrent infection.