1、2006年年7月月5日日 白内障术后2月 治疗:ACV 1.0DXM 5mg无防腐剂人工泪液可乐必妥1%环孢霉素 眼水0.02%FMT2006年年7月月24日日 7.8 停ACV针,改口服ACV 2#5/日 7.10 丽科明和 自体血清 7.11 改0.02%FMT为典必殊qid 7.21 出院可乐必妥 BID1%CSA BID人工泪液 QID典必殊 tidACV 2#5/日2006年年8月月2日日2006年年8月月16日日2006年年10月月17日日右眼白内障术后2月左眼白内障术后1个半月综合治疗2月后 容易和排斥反应混淆 术后应该至少口服ACV3月以上 出现排斥反应时，加用口服ACV 如果
2、有上皮病变或者植片溶解，局部不能用激素。尽量减少局部用药 丽科明、无防腐剂人工泪液、自体血清 局部低浓度激素0.02%氟美瞳 必要时用1%CSA 全身口服ACV 口服激素 病情严重，可静脉注射ACV1.0+DXM5mg 无菌性溃疡 病毒引起的基底膜的破坏，使得上皮不能生长 分为点状上皮糜烂和神经营养性溃疡 早期表现为角膜表面不规整，无光泽 椭圆形，边缘光滑的 溃疡底部呈灰白色混浊，边缘光滑增厚，甚至基质溶解变薄，导致角膜穿孔 配戴高含水量可过夜的隐形眼镜（Advance Acuve 2 weeks Johnson&Johnson）戴镜期间用抗生素眼水 2次/日 预防感染 如果没有隐形眼镜，间断
3、隔天涂抗生素眼膏后加压包扎 使用不含防腐剂的人工泪液（瑞新、倍然等）6次/日 酌情使用低浓度的激素（如0.02%氟美瞳）12次/日 有虹睫炎时适当散瞳（东莨菪碱）2次/日 同时口服抗病毒药物 基质有溶解穿孔的倾向，可羊膜移植或组织粘合剂粘贴，必要时角膜移植累及上皮层、基质和内皮层Stromal diseaseControl of trigger mechanisms of recurrent病情严重，可静脉注射ACV1.general acyclovirrisk of recurrence is 12%to 19%02%FMT为典必殊qidDebridement2006年10月17日Proph
4、ylaxis for postPK patients with history of HSV keratitisscattered KP over the entire cornea with overlying diffuse stromal edemaIn severe cases,a dense,retrocorneal plaque of inflammatory cells accompanied by hypopyon may be seen自体血清如果有上皮病变或者植片溶解，局部不能用激素。minute,raised,clear vesicles累及上皮层、基质和内皮层Immun
5、e stromal(interstitial)keratitisidoxuridine(IDU)Dendritic keratitisbranching,linear lesion with terminal bulbs and swollen epithelial borders that contain live virus溃疡底部呈灰白色混浊，边缘光滑增厚，甚至基质溶解变薄，导致角膜穿孔2006年年8月月28日日2006年年9月月5日日2006年年9月月16日日 尽量减少局部用药 丽科明、无防腐剂人工泪液、自体血清 局部低浓度激素0.02%氟美瞳 必要时用1%CSA 全身口服ACV 口服
6、激素 治疗性隐形眼镜 羊膜移植 I.Infectious epithelial keratitisA.Cornea vesiclesB.Dendritic ulcerC.Geographic ulcerD.Marginal ulcer II.Stromal keratitisA.Necrotizing stromal keratitisB.Immune stromal(interstitial)keratitis III.EndotheliitisA.DisciformB.DiffuseC.Linear minute,raised,clear vesicles in the early sta
7、ges of a recurrence Within 24 hours,the vesicles coalesce to form the typical dendritic and geographic ulcers branching,linear lesion with terminal bulbs and swollen epithelial borders that contain live virus stains positive for fluorescein epithelial lesion that extends through the basement membran
8、e associated with the previous use of topical corticosteroids results from active viral disease like dendritic ulcer proximity to limbus,accompanying blood vessels,unique clinical features anterior stromal infiltrate underlying the ulcer and adjacent limbal injection dendritic ulcer overlying the st
9、romal infiltrate more symptomatic more intense and longer lasting disease Some patients require topical corticosteroids HSV marginal ulcer Moderate disciform endotheliitis丽科明、无防腐剂人工泪液、自体血清02%FMT为典必殊qid2006年10月17日Infectious epithelial keratitisTopical antiviralsNecrotizing stromal keratitis丽科明、无防腐剂人工
10、泪液、自体血清白内障术后HSK病例1No corticosteroidsEndotheliitisthinning and perforationIn severe cases,a dense,retrocorneal plaque of inflammatory cells accompanied by hypopyon may be seenMild disciform endotheliitis without prior corticosteroid useStromal diseaseDNA hybridization techniquesTopical corticosteroid
11、sHerpes simplex disciform keratitisanterior stromal infiltrate underlying the ulcer and adjacent limbal injectionControl of trigger mechanisms of recurrentboth corticosteroids and antiviral agents direct viral invasion of the corneal stroma clinical findings are necrosis,ulceration,and dense infiltr
12、ation of the stroma with an overlying epithelial defect thinning and perforation retained viral antigen within the stroma Stromal infiltration immune ring stromal neovascularization，sectoral stromal edema without stromal infiltrate keratic precipitates(KP),overlying stromal and epithelial edema,and
13、iritis the presence of HSV I antigen in corneal endothelial cells three forms:disciform,diffuse,and linear KP iritis edema from endothelial decompensation sensitive to topical corticosteroids Herpes simplex disciform keratitis scattered KP over the entire cornea with overlying diffuse stromal edema
14、iritis In severe cases,a dense,retrocorneal plaque of inflammatory cells accompanied by hypopyon may be seen branching,linear lesion with terminal bulbs and swollen epithelial borders that contain live virusbranching,linear lesion with terminal bulbs and swollen epithelial borders that contain live
15、virusModerate diffuse endotheliitisscattered KP over the entire cornea with overlying diffuse stromal edemavidarabine or AraAHSV blepharitisTopical corticosteroidsminute,raised,clear vesiclesProphylaxis for postPK patients with history of HSV keratitis2006年10月17日Diffuse endotheliitisWithin 24 hours,
16、the vesicles coalesce to form the typical dendritic and geographic ulcersControl of trigger mechanisms of recurrentAll cases of linear endotheliitis如果有上皮病变或者植片溶解，局部不能用激素。EndotheliitisA.Primary HSV infection典必殊 tid Diffuse endotheliitis line of KP KP can be sectoral or,in some cases,circumferential e
17、dema between the KP and the limbus KP located at the leading edge of the edema both corticosteroids and antiviral agents Linear endotheliitis thorough ophthalmic examination viral culture:slow Cytologic examination of specimens stained with Giemsa or Wright stains,Multinucleated giant cells,nonspeci
18、fic,intranuclear inclusions Immunologic tests:The Herpchek,Virogenlatex agglutination,enzyme immunofiltration,and the 1hour enzyme linked immunoassay can detect HSV antigen in cell culture and direct specimens within 5 hours electron microscopy DNA hybridization techniques Serum antibody titers:diag
19、nosis of primary infection Debridement Drug therapy Surgical Control of trigger mechanisms of recurrent Dendritic keratitis Wound cottontipped applicator No topical iodine or ether Cycloplegic With antiviral idoxuridine(IDU)vidarabine or AraA trifluridine(F3T)Cyclocytidine(CC)acyclovir bromovinyldeo
20、xyuridine(BVDU):Europe general acyclovir HSV blepharitis HSV conjunctivitis Infectious epithelial keratitis Prophylaxis for corticosteroid treatment of immune stromal keratitis(drop for drop with topical corticosteroid)Primary HSV infection Selected cases of severe diffuse endotheliitis Selected cas
21、es of severe iridocyclitis/trabeculitis Linear endotheliitis Immunocompromised patients Pediatric patients refractory to topical medications Prophylaxis against recurrent infectious epithelial keratitis Prophylaxis for postPK patients with history of HSV keratitis Advantages:inhibition of cellular i
22、nfiltration and opacification and scarring,inhibition of the release of toxic enzymes,and inhibition of neovascularization Disadvantages:exacerbation and spread of active viral infection,enhancement of collagenolytic enzyme,corneal thinnning Marginal keratitis Moderate immune stromal keratitis Moder
23、ate disciform endotheliitis Moderate diffuse endotheliitis Moderate iridocyclitis/trabeculitis Severe immune stromal keratitis Severe disciform endotheliitis Severe diffuse endotheliitis All cases of linear endotheliitis Severe iridocyclitis/trabeculitis HSV conjunctivitis Infectious epithelial kera
24、titis Mild immune stromal keratitis without prior corticosteroid use Mild disciform endotheliitis without prior corticosteroid use Mild diffuse endotheliitis without prior corticosteroid use PKP:inactive for many months risk of recurrence is 12%to 19%rejection and recurrent LKP:low success rates,risk of reactivation
