大直径穿透性角膜移植治疗真菌性角膜炎术后复发和免疫排斥反应规律

The regularity of recurrent and immune rejection after large-diameter penetrating keratoplastyfor the treatment of fungal keratitis

目的观察分析大直径穿透性角膜移植（LDPK）治疗严重真菌性角膜炎（FK）术后复发和免疫排斥反应发生的特点和规律，为提高手术后植片的长期存活提供参考。方法回顾性病例研究。对2009年1月至2013年12月在青岛眼科医院行LDPK（植片直径大于9mm）治疗严重FK的70例（70眼）患者进行随访，随访时间为6～48个月，观察感染的菌种类型及其分布情况、术后真菌复发和植片免疫排斥反应的特点和规律。对裸眼视力（UCVA）、最佳矫正视力（BCVA）和植片存活情况等进行随访。结果70例患者发病至接受LDPK术的间隔时间为（23．7±11．7）d。真菌培养示首位菌种为镰刀菌属（72％）。LDPK术后，8例（11％）患者真菌复发，平均复发时间为（6．8±2．9）d。65例（93％）患者保存了眼球。26例（37％）患者术后1个月内发生内皮型免疫排斥，平均排斥发生时间为（17．8±5．1）d，21例经抗排斥治疗后植片恢复透明；5例遗留局部或全角膜植片混浊。至最后一次随访，39例（56％）患者角膜植片透明，植片内皮细胞密度平均为（1306±816）个／mm2，UCVA平均为4．0±3．8，BCVA平均为4．5±4．1。结论LDPK术后真菌复发和免疫排斥反应的时间差存在规律，这个时间窗对在术后2周应用糖皮质激素预防免疫排斥反应和防止复发有积极意义。

Objective To observe the characteristics and regularity of recurrent and immune rejection after large-diameter penetrating keratoplasty （LDPK） for the treatment of severe fungal keratitis; to provide a reference for improving the postoperative long-term survival of corneal grafts. Methods In a retrospective case series study, 70 patients （70 eyes） with severe fungal keratitis who underwent LDPK （≥9.0 mm） at Qingdao Eye Hospital between January 2009 and December 2013 were included. The follow-up after surgery ranged from 6 to 48 months. The fungal strains were identified, the characteristics and frequency of recurrent and immune rejection episodes were monitored and the long-term survival of corneal grafts was evaluated. Uncorrected visual acuity and best corrected visual acuity were recorded. Results The average time of onset for all patients was 23.7±11.7 days. Fungal cultures showed that the main fungus was fusarium （72%）. Postoperatively, 8 patients （11%） underwent recurrent fungal infection and the average recurrence time was 6.8±2.9 days. Sixty-five patients （93%） successfully maintained the structural integrity of the globe. The immunologic rejection occurred within one month after the surgery in 26 patients （37%） and the average rejection time was 17.8±5.1 days. Of these, 21 cases were treated in time, and the grafts became transparent after routine anti-rejection therapy, while the remaining grafts became partially or entirely opaque. Thirty-nine patients （56%） had a clear corneal graft at the last follow-up. Average endothelial cell density was1 306±816/mm2, average UCVA was 4.0±3.8, and average BCVA was 4.5±4.1. Conclusion LDPK is an effective surgical method in the management of severe keratitis with a high success rate in restoring anatomical integrity and providing useful vision. Postoperatively, there is a regularity in the duration of time between fungal recurrence and immune rejection, which indicates the use of glueocorticoids within 2 weeks after surgery to prevent recurrent and immune rejection episodes.