真菌性眼内炎的手术治疗与病原学研究

Research on the surgery treatment and etiology of fungal endophthalmitis

目的 探讨真菌性眼内炎的病原学诊断及治疗.方法 回顾性系列病例研究.总结分析2002年2月至2015年12月在北京协和医院眼科确诊为真菌性眼内炎的15例（15只眼）的临床表现、病原学诊断及治疗效果.男性3例,女性12例;平均年龄（45.8±15.3）岁.内源性真菌性眼内炎12例（12只眼）,外源性真菌性眼内炎3例（3只眼）.所有患者进行视力、眼前节、眼底像、B超检查.14只眼行玻璃体切除术,其中9只眼硅油填充,1只眼C3F8填充;1只眼行玻璃体腔注药术.取玻璃体液进行涂片,进行细菌培养基药物敏感性试验.术后平均随访15.0个月.结果 14例曾被误诊为葡萄膜炎,给予全身和眼局部糖皮质激素和（或）免疫抑制剂治疗,病情恶化.初诊视力：光感2只眼,眼前手动12只眼,0.1者1只眼.6只眼轻度前房炎性反应,4只眼中度前节炎性反应,5只眼重度前节炎性反应伴前房积脓.B型超声显示15只眼玻璃体炎性混浊,同时合并增生性玻璃体视网膜病变（PVR）11只眼,视网膜脱离10只眼,包括牵拉性视网膜脱离6只眼,渗出性视网膜脱离1只眼,视网膜脉络膜脱离3只眼.玻璃体液涂片10只眼找到真菌菌丝和孢子,12只眼培养结果：白色念珠菌6只眼,镰刀菌、近平滑念珠菌、淡紫拟青霉菌、土霉菌、木兰假丝酵母菌、曲霉菌各1只眼.根据病原学诊断,14只眼术中即刻给予两性霉素B玻璃体用药,术后9例患者全身给予氟康唑（口服或静脉输液）,2例患者静脉输注、口服伏立康唑,1例患者口服伊曲康唑.15只眼均局部点用两性霉素B眼液或氟康唑眼液.15只眼眼内炎均得到控制.视力提高6只眼,不变4只眼,下降5只眼.无光感3只眼,光感2只眼,眼前手动4只眼,眼前指数2只眼,0.01～0.04者2只眼,0.1～0.15者2只眼.5只眼视网膜在位,2只眼视网膜复位,2只眼视网膜未复位,6只眼出现复发性视网膜脱离,其中5只眼给予再次手术.最终10只眼视网膜在位,5只眼视网膜未复位.结论 真菌性眼内炎由于早期临床症状不明显容易误诊而延误治疗,故早期确诊是治疗的关键.玻璃体切除术联合玻璃体腔用药是治疗真菌性眼内炎的有效方法,玻璃体液涂片和培养阳性率高,根据病原学检测结果选择正确敏感的抗真菌药物可望最大限度挽救患者的眼球及视力.

Objective To evaluate the efficacy of vitrectomy and etiological diagnosis in the treatment of fungal endophthalmitis.Methods A retrospective survey was done on the clinical manifestation,etiological diagnosis and treatment efficacy of 15 patients （15 eyes） who had been diagnosed with fungal endophthalmitis at the inpatient department of Peking Union Medical College Hospital during 2002-2015.A total of 15 eyes of 15 patients,3 male and 12 female patients,were included in this study.The mean age of the patients was （45.8± 15.3） years.Among the 15 eyes,12 （12 patients） were diagnosed with endogenous fungal endophthalmitis and 3 （3 patients） were diagnosed with exogenous fungal endophthalmitis.Fourteen eyes have been misdiagnosed with uveitis,systematic or local application of glucocorticoid and/or immunosuppressor have been conducted on the patients which resulted in exacerbation.Baseline visual acuity：light perception in 2 eyes,hand movement for 12 eyes,and 1 eye of 0.1.Six eyes showed slight inflammatory reaction in anterior chamber,four eyes showed moderate inflammatory reaction in anterior chamber,while five eyes showed severe inflammatory reaction with hypopyon in anterior chamber.B-Scan ultrasound examination showed inflammatory vitreous opacity in all 15 eyes,combined proliferative vitreoretinopathy （PVR） were found in 11 eyes,retinal detachment were found in 10 eyes,which include 6 cases of tractional retinal detachment,1 case of exudative retinal detachment,and 3 cases of retinal and choroid detachment.Forty eyes underwent vitrectomy,1 eye underwent intravitreal injection.Nine eyes were processed with silicone oil tamponade,one eye was processed with C3F8 tamponade.At the beginning of the operation,vitreous fluids were collected for preparing smears which were later used for fungus culture and drug susceptibility testing.Results According to the smear results of vitreous fluid,fungal hyphae and spores were found in 10 eyes.The fungus culture indicated positive results in 12 eyes,including candida albicans in 6 eyes,fusarium,candida parapsilosis,paecilomyces lilacinus,asoergullus terreus,mulan candida and aspergillus in 1 eye respectively.Based on etiological diagnosis,14 eyes received amphotericin B intraocular injection during operation,and 9 patients received fluconazole （venous transfusion or oral administration）,2 patients received voriconazole through venous transfusion or oral administration,one patient received itraconazole through oral administration.All 15 eyes received local application of amphotericin B eyedrop or fluconazole eyedrop.The intraocular inflammations in all 15 eyes were mitigated.The visual acuity improved in 6 eyes,remained unchanged in 4 eyes,and reduced in 5 eyes.Postoperative visual acuity achieved 0.1 to 0.15 in 2 eyes,0.01 to 0.04 in 2 eyes,CF in 2 eyes,HM in 4 eyes,LP in 2 eyes,and NLP in 3 eyes.The retina of 5 eyes remained in position,the retina of 2 eyes reattached,the retina of 2 eyes failed to reattach.Recurrent retinal detachment happened in the other 6 eyes,5 of which received reoperation.Eventually,the retina of 10 eyes reattached,and the retina of the 5 eyes failed to reattach.Conclusions Vitrectomy is an effective method for treatment of fungal endophthalmitis.The positive rates of vitreous smear and fungus culture were really high.Application of sensitive anti-fungal drugs based on etiological diagnose can improve therapeutic level.