类风湿相关性角膜病变的个体化临床治疗

Individualized therapy for patients with rheumatic keratopathy

目的：分析探讨使用抗类风湿药物联合手术个体化治疗类风湿相关性角膜病变的疗效。方法回顾性系列病例研究。山东省眼科医院2008年1月至2013年11月间诊治的类风湿相关性角膜病变14例（17只眼）。治疗原则：据病例的临床特征合理选择药物联合手术的个体化治疗方案。①药物治疗：选择口服及局部抗类风湿药物，术后逐渐减量并维持应用。②手术治疗：病灶深度介于角膜1／2～3／4，或深度＜1／2且病变范围超过全角膜1／4象限者，选择结膜瓣遮盖术或羊膜移植术（ AMT）；角膜溃疡深度＞全厚度3／4者，选择部分板层角膜移植术（ LKP）或穿透性角膜移植术（ PKP）。泪液缺乏者联合结膜瓣遮盖术或睑裂缝合术。随访治疗后1年间的病情变化。结果14例均处于类风湿活动期；8只眼病灶位于角膜旁中央，9只眼位于角膜缘；病灶深度2只眼未及1／2，10只眼达1／2～3／4，5只眼超过3／4；病灶面积未及角膜1／4共11只眼，1／2至1／4之间3只眼，1／2以上3只眼。均接受药物联合手术治疗，行AMT术5只眼，结膜瓣遮盖术6只眼，部分LKP术4只眼，PKP术2只眼，其中5只眼因泪液缺乏联合结膜瓣遮盖术或睑裂缝合术；治疗后较前增视8只眼（47．1％）；病变区树突细胞持续存在。随访1年中15只眼病情平稳，2只眼再次发病。结论类风湿相关性角膜病变与全身病情相关，病灶范围局限而深，伴树突细胞长期分布，且泪液分泌功能差；根据临床特征选择个体化的药物联合手术治疗方案，利于保存眼球及视力。

Objective To analyze the efficacy of individualized therapy by using anti-rheumatic drugs and surger-ies for patients with rheumatic keratopathy .Methods In a retrospective study, 14 patients（17 eyes） who were diagnosed with rheumatic keratopathy between January 2008 and November 2013 in Shandong Eye Hospital were included.The thera-py for the patients was determined by the corneal status：first, some oral anti-rheumatic drugs and eye drops were used based on the condition, and the dosage was adjusted after surgery;second, when the ulcer depth was deeper than 3/4 cor-nea, lamellar keratoplasty or penetrating keratoplasty was performed; the remaining patients underwent either conjunctival flap surgery or amniotic membrane transplantation based on the ulcer location, depth and area.Someone accepted extra conjunctival flap surgery or tarsorrhaphy for lack of tear.Their symptom changes were tracked during the following one year.Results All the rheumatoid patients have a seizure during keratopathy;corneal ulcers of 8 eyes were on the central, and 9 eyes were on the limbus.The ulcer depth of 2 eyes were less than 1/2 corneal thickness, 10 eyes were between 1/2 and 3/4 thickness, and 5 eyes were deeper than 3/4 thickness.The ulcer area of 11 eyes were less than 1/4 quadrant, 3 eyes were between 1/4 and 1/2 quadrant, and 3 eyes were larger than 3/4 quadrant.All the 17 eyes were treated by indi-vidualized therapy, with amniotic membrane transplantation （5 eyes）, conjunctival flap surgery （6 eyes）, lamellar kerato-plasty （4 eyes） , and penetrating keratoplasty （2 eyes） .There were 5 eyes accepted extra conjunctival flap surgery or tar-sorrhaphy for lack of tear.Visual acuity in 8 eyes （47.1%） was improved after treatment.Long-term distribution of den-dritic cells was found by confocal.There were 2 eyes occurred palindromia.Conclusion Rheumatic keratopathy is associ-ated with systemic disease.Its lesions scope is limited and deep accompanied with long-term distribution of dendritic cells and poor tear.Therefore, selecting individualized therapy is benefit for preserving eyes and vision.