真菌性角膜炎1414例临床分析

A clinical analysis of 1414 cases of fungal keratitis

目的探讨真菌性角膜炎(FK)的临床特征及诊断和治疗方法。方法回顾性系列病例研究。收集2006年1月至2016年10月于山东省眼科研究所青岛眼科医院就诊的1414例(1414只眼)真菌性角膜炎患者的资料,对其人口学特征、致病诱因、发病时间、实验室检查方法和结果、临床特征及治疗方案进行分析。结果1414例FK患者中,男性877例(62.0%),女性537例(38.0%);年龄(53.71±11.72)岁,40~60者874例(61.8%)。1174例(83.0%)患者来自山东省,其余主要来自长江以北各省。患者职业以农民(1211例,占85.6%)为主,发病时间以秋冬季为主。从发病到于我院就诊的时间为1~74 d,942例(67.1%)患者在症状出现后8~30 d于我院就诊。角膜损伤为主要危险因素,其中以植物外伤最为多见(367例,26.4%)。1365只患眼通过氢氧化钾湿片直接镜检法查出菌丝,诊断阳性率为96.5%,1270只患眼通过共焦显微镜查出菌丝,诊断阳性率为89.8%。973只患眼(68.8%)的角膜溃疡灶刮取物和(或)术后的病变角膜组织培养出真菌,其中以镰刀菌属最多见595例(61.1%),其次为链格孢霉菌属184例(18.9%)、曲霉菌属119例(12.2%)。603例(42.7%)为浅中基质浸润者,614例(43.4%)为深基质浸润者,197例(13.9%)为全层浸润。角膜溃疡灶直径以4~6 mm最为多见725例(51.6%),其次为<4 mm 372例(26.4%)、>6 mm 302例(22.0%)。498例(35.2%)合并前房积脓,34例(2.4%)合并角膜穿孔,58例(4.1%)合并眼内炎。1198例(84.8%)患者接受手术治疗,其中包括416例(29.4%)行穿透性角膜移植术,408例(98.1%)治愈;199例(14.1%)行板层角膜移植术,193例(97.0%)治愈;532例(37.6%)角膜溃疡清创术,494例(92.8%)治愈。215例(15.2%)患者接受了单纯药物治疗,147例(68.4%)治愈。56例(3.9%)最终失去眼球,包括54例眼内容物摘除术和2例眼球摘除术。结论FK的发病人群多为在农村居住的中老年群体。镰刀菌仍是山东地区最主要的FK病原体。角膜刮片氢氧化钾涂片直接镜检法可早期、快速诊断FK。对浅中基质浸润的患者,角膜溃疡清创术是一种便捷有效的治疗手段。对深基质浸润的患者,角膜移植术是最有效的治疗手段。

Objective To discuss clinical features and treatments of fungal keratitis,and to provide statistical data for clinical therapy and increase the therapeutic effects.Methods This is a retrospective case series study.An analysis was performed by collecting patients′demography features,risk factors,onset time,lab results,clinical features and treatment from 1414 cases of fungal keratitis from January 2006 to October 2016 in Qingdao Eye Hospital,Shandong Eye Institute.Results In the 1414 cases(1414 patients),1174 patients(83.0%)came from different areas in Shandong Province,and the rest mainly from provinces on the north of Yangtze River.The age was 40 to 60 years in 874 cases(61.4%).The onset time was often in autumn and winter.The average duration between the onset and treatment was 1 to 74 days;942 patients(67.1%)visited our hospital in 8-30 days after the appearance of the symptoms.Corneal trauma was the most common risk factor,especially injury by plants(367 cases,26.4%).The positive rate of direct microscopic examination of potassium hydroxide wet mounts was 96.4%.The positive rate of confocal microscopy was 89.8%.Fungi were detected in corneal ulcer scrapings and(or)diseased corneal tissues obtained during surgery from 973 patients(68.8%).Most of the fungi were Fusarium(595 cases,61.1%),followed by Alternaria(184 cases,18.9%)and Aspergillus(119 cases,12.2%).There were 603 cases(42.7%)of superficial and middle stromal infiltration,614 cases(43.4%)of deep stromal infiltration and 197 cases(13.9%)of full-thickness corneal infiltration.Diameters of the corneal ulcer lesion were mostly between 4 and 6 mm(725 cases,51.6%),followed by<3 mm(372 cases,26.4%)and>6 mm(302 cases,22.0%).Hypopyon was combined in 498 cases(35.2%),corneal perforation in 34 cases(2.4%),and endophthalmitis in 58 cases(4.1%).Surgery was performed in 1198 cases(84.8%),including penetrating keratoplasty in 416 cases(29.4%),lamellar keratoplasty in 199 cases(14.1%),and corneal ulcer debridement in 532 cases(37.6%),with an effective rate of 98.1%(408 cases),97.0%(193 cases)and 92.8%(494 cases),respectively.Two hundred and fifteen cases(15.2%)were treated with medical therapy alone,of which 147 cases(68.4%)were cured.Fifty-six patients(3.9%)finally lost their eye balls,including 54 cases of evisceration and 2 cases of ophthalmectomy.Conclusions Fusarium is the main causative agent of fungal keratitis in Shandong Province.Direct microscopic examination of potassium hydroxide wet mounts is a simple,rapid and effective test method.Early diagnosis can be made if the result of corneal ulcer scraping examination is positive.Antifungal drug treatments can be done in early onset time.If the drug efficacy is poor or the patient′s condition gets worse,immediate surgery is the key to controlling fungal keratitis.(Chin J Ophthalmol,2020,56:286-293)