1、The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University 第十二章 葡萄膜疾病 UVEA DISEASES The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University 一、概述?葡萄膜由于富含血管和色素组织故又
2、称血管膜或色素膜。?包括虹膜、睫状体、脉络膜，故病变相互影响。?葡萄膜病是常见病，以炎症最为常见。The second hospital of Medical college,Xian Jiaotong University 概述?多发于青壮年，常合并糸统性自身免疫性疾病，病情反复，常引起严重的并发症。?病程：小于3个月为急性 大于3个月为慢性。The second hospital of Medical college,Xian Jiaotong University?按解剖部位分类?前葡萄炎Anterior uveitis?中间部葡萄炎Intermediate uveitis?后匍萄膜炎P
3、osterior uveitis?全葡萄膜炎Generalized uveitis 概述 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University 二、前葡萄膜炎Anterior uveitis?概述：?包括虹膜炎、虹膜睫状体炎和前部睫状体三种类型?是最常见类型，占我国葡萄膜炎总数的50%-60%?病因：大多数为内源性，例如细菌、病毒、风湿性疾病等，其次与外伤及手术有关 The second hosp
4、ital of Medical college,Xian Jiaotong University 前葡萄膜炎?症状：?刺激症状：眼痛、畏光、流泪、视物模糊?视力下降 The second hospital of Medical college,Xian Jiaotong University?体症：?睫状或混合性充血?角膜后沉着物KP?房水闪辉Aqueous flare?房水细胞?虹膜改变?瞳孔改变?晶状体改变?眼后段改变 前葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?睫状或混合性充血 前葡萄膜炎-体
5、征 The second hospital of Medical college,Xian Jiaotong University?角膜后沉着物?定义：炎症细胞或色素沉积在角膜后表面被称为 KP，其形成需要角膜内皮损伤和炎性细胞或色素细胞的同时存在?分类：粉尘状KP（淋巴/浆）羊脂状KP（类上皮/巨噬）色素性KP 前葡萄膜炎体征 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University The sec
6、ond hospital of Medical college,Xian Jiaotong University?房水闪辉Aqueous flare：在炎症时虹膜睫状体的血管扩张，大量的蛋白质或纤维素成分及炎性细胞渗出至房水中使房水变得混浊不清 前葡萄膜炎体征 The second hospital of Medical college,Xian Jiaotong University?前房细胞：?主要为炎性细胞?裂灯下表现为大小一致的灰白色颗粒?炎性细胞运动规律?前房积脓Hypopyon 前葡萄膜炎体征 The second hospital of Medical college,Xian
7、Jiaotong University?虹膜改变：?虹膜后粘连Posterior synechia of the iris?虹膜膨隆Iris bombe?虹膜前粘连Anterior synechia of the iris?房角粘连Goniosynechia 前葡萄膜炎体征 虹膜后粘连 虹膜膨隆，房角粘连 The second hospital of Medical college,Xian Jiaotong University?瞳孔改变：?梅花状、梨状、不规状瞳孔?瞳孔闭锁Seclusion of pupil?瞳孔膜闭Occlusion of pupil 前葡萄膜炎体征 The secon
8、d hospital of Medical college,Xian Jiaotong University?晶状体改变：?晶体表面环形色素?晶体表面斑块状色素?眼后段改变：?前玻璃体炎性细胞?偶见反应性黄班囊样水肿或视盘水肿 前葡萄膜炎体征 The second hospital of Medical college,Xian Jiaotong University?前葡萄膜炎并发症?继发性青光眼：?并发性白内障?低眼压和眼球蒌缩 前葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?诊断Diagnosis
9、：?诊断依据：睫状充血；KP；房水闪辉；瞳孔缩小；虹膜后粘连。其中以 KP 和房水闪辉阳性最为重要?仅有虹膜后粘连、晶体前表面色素沉着，有虹睫炎病史，而无睫状充血、KP 和房水闪辉等活动性病变则诊断为陈旧性虹睫炎?病因诊断困难，注意有无关节、消化道和免疫性疾病 前葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University 签别诊断 急性结膜炎 虹睫炎 急闭青光眼 充血 结膜性 睫状/混合 混合性 角膜 透明 透明KP 水肿 瞳孔 正常 小 大 眼压 正常 大多正常 高 前葡萄膜炎 The second hospita
10、l of Medical college,Xian Jiaotong University?治疗Treatment-散大瞳孔?目的:?防止虹膜后粘连、瞳孔闭锁，以减少继发性青光眼?解除或减少虹膜括约肌和睫状肌痉挛，使其处于休息状态，刺激症状减轻，有利于病情的恢复。?促进睫状体的血液循环 前葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?常用药物：?炎症活动期给予 2%后马托品眼膏1836h?瞳孔散不大时给予强散瞳剂0.2ml 结膜下注射?炎症恢复期给予托品酰胺滴眼液 前葡萄膜炎治疗 The second
11、hospital of Medical college,Xian Jiaotong University?局部?0.5%考的松滴眼液点眼?庆大霉素2万u十地塞米松 5mg 结膜下注射?全身?0.9%NS250ml+D.X.M10mg静脉滴注?强的松：20mg,q.d.前葡萄膜炎-治疗 The second hospital of Medical college,Xian Jiaotong University?抗前列腺素类药物：?阿斯匹林0.5 tid?消炎痛25mg tid?病因治疗：?感染抗菌素?结核抗结核 前葡萄膜炎-治疗 The second hospital of Medical c
12、ollege,Xian Jiaotong University?并发症治疗?瞳孔阻滞导致的青光眼虹膜根切术?房角堵塞导致的青光眼滤过手术?并发性白内障只要光感光定位准确 ECCE+IOL 或PHACO+IOL?低眼压或眼球萎缩目前尚无有效治疗方法，必要时为维持眼球形态，作羟基磷灰石人工义眼台植入。前葡萄膜炎-治疗 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University 三、中间葡萄膜炎 Interm
13、ediate uveitis?概述?主要累及睫状体平坦部、玻璃体基底部、周边视网膜和脉络膜的炎症性和增殖性疾病?多见于儿童、40岁以下年轻人，常累及双眼，可先后或同时发病?1979 年国际葡萄炎研究组命名为中间葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?症状：轻者无，重则飞蚊症，视物模糊?体征：?眼前段：羊脂状/尘状KP，轻度房闪/房水中细胞。无睫状充血但儿童可?眼后段：玻璃体雪球状混浊，睫状体平坦部雪堤样改变，周边网膜静脉周围炎?易发生周边网膜血管炎及网膜脉络膜炎 中间葡萄膜炎 The second
14、 hospital of Medical college,Xian Jiaotong University 中间葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?并发症?黄斑囊样水肿:?并发性白内障：中间葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?诊断?根据典型的玻璃体雪球状混浊，睫状体平坦部雪堤样改变，周边网膜静脉周围炎即可诊断?对飞蚊症有加重倾向，不能以其它原因解释的晶体后囊下混浊或黄斑囊样水肿应结合三面镜，间
15、接检眼镜，检查，综合分析，作出诊断 中间葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?治疗?对症治疗为主?视力0.5 但伴有玻璃体混浊给予结膜下注射DXM5mg 或选用强的松20mg qd?网膜新生血管给予YAG 激光治疗?如炎症继续加重可用免疫抑制剂，环磷酰胺，环胞素治疗 中间葡萄膜炎 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Ji
16、aotong University 三、后葡萄膜炎(脉络膜炎)?概述?它包括了脉络膜、玻璃体后部及视网膜的炎性病变?脉络膜有睫状后动脉供血，可单独发病?视网膜外层由脉络膜供血，脉络膜视网膜炎，甚至视神经视网膜炎?按病灶分布，可分为局灶型、播散型及弥漫型 The second hospital of Medical college,Xian Jiaotong University 后葡萄膜炎?病因?感染性：如细菌，真菌，寄生虫和病毒?非感染性：如免疫性或过敏性及对坏死组织的炎性反应 The second hospital of Medical college,Xian Jiaotong Univ
17、ersity?临床表现?脉络膜炎时眼部症状轻。位于前方仅有黑影；后极部者，视物变形、中心视力减退?眼前段无充血及炎症改变?尘埃状及絮状玻璃体浑浊?活动期病灶灰黄色，视网膜水肿混浊?瘢痕期炎症消退，脉络膜萎缩，遗留色素脱失及瘢痕组织 后葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?并发症?黄斑水肿?视盘充血水肿?视网膜血管炎?视网膜脱离?眼球萎缩 后葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?鉴别诊断?眼内肿瘤：
18、根据超声波、X线、FFA 区别?老年性黄斑盘状变性?脉络膜渗漏：此脱离部位随体位改变?视网膜色素变性 后葡萄膜炎 The second hospital of Medical college,Xian Jiaotong University?治疗?理想治疗：病因?非特异性治疗法：如伴前节炎症，散瞳、睫状肌麻痹剂、局部激素；后葡萄膜炎及全葡萄膜炎需全身激素治疗；非甾体类抗炎剂；免疫抑制剂?最好是病因治疗，原因不明、病情严重者可试用广谱抗生素 后葡萄膜炎 The second hospital of Medical college,Xian Jiaotong UniversityThe secon
19、d hospital of Medical college,Xian Jiaotong University 四、全葡萄膜炎?累及前、中、后、整个葡萄膜的炎症称为全葡萄膜炎?治疗同上 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University 五、几种常见的特殊葡萄炎?强直性脊椎炎?Behcet 病?交感性眼炎?Fuchs 综合症 The second hospital of Medical colle
20、ge,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University?强直性脊椎炎Ankylosing sopndylitis?是一种病因不清、主要累及轴骨骼的特发性炎症疾病，并发急性前葡萄炎，发于青壮年男性。?往往双眼交替性发作，易复发。?诊断：主诉腰骶部疼痛?治疗：同前葡萄膜炎 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,
21、Xian Jiaotong University?Behcet 病?定义：一种以复发性葡萄膜炎、口腔溃疡、皮肤多形性损害、生殖器溃疡为特征多系统受累的疾病。?临床表现?眼部损害?口腔溃疡?皮肤损害?生殖器溃疡 The second hospital of Medical college,Xian Jiaotong University?国际Behcet 病研究组诊断标准?1.复发性口腔溃疡（一年至少复发三次）?2.下面4项中出现2项即可确诊?A.复发性生殖器溃疡或生殖器瘢痕?B.前后葡萄膜炎，玻璃体内细胞或网膜血管炎?C.皮肤结节性红斑，假毛囊炎，痤疮样结节?D皮肤过敏反应阳性 Behcet病
22、 The second hospital of Medical college,Xian Jiaotong University Behcet病?治疗：?前段受累-阿托品点眼?糖皮质激素，一般为20-30mg/d?免疫抑制剂：环胞霉素 A 5mg（kg.d）?并发性白内障、继发性青光眼在炎症完全控制下可考虑手术 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University?交感性眼炎Sympathetic
23、 ophthalmia?概念：指发生于一眼穿通伤或内眼术后的双侧肉芽肿性葡萄膜炎称为交感性眼炎?受伤眼称为诱发眼；另一眼侧称为交感眼?病因：主要由外伤或手术造成眼内抗原暴露并激发自身免疫应答所致 The second hospital of Medical college,Xian Jiaotong University 交感性眼炎?临床表现：?可发生于外伤或手术后5d至56年内，但多发生于2周至2个月内。?一般发病隐匿，为肉芽肿性炎症，可表现为前葡萄膜炎、后葡萄膜炎、中间葡萄膜炎和全葡萄膜炎，其中以全葡萄膜炎为多见。The second hospital of Medical college
24、,Xian Jiaotong University?诊断：?眼球穿通伤或内眼手术史对此病诊断有重要价值（与Vogt-小柳原田病鉴别的重要依据）?FFA 可见视网膜色素上皮和脉络膜水平的多灶性渗漏及染料积存的现象，可伴有视盘染色。交感性眼炎 The second hospital of Medical college,Xian Jiaotong University?治疗：?对眼前段受累者，可给予糖皮质激素点眼和睫状肌麻痹剂等治疗；对于表现为后葡萄膜炎和全葡萄膜炎者，则应选择糖皮质激素口服或其他免疫抑制剂。交感性眼炎 The second hospital of Medical college,
25、Xian Jiaotong University?预防?眼球穿通伤后及时修复创口，避免葡萄膜嵌顿及预防感染，对此病可能有预防作用。?关于摘除伤眼是否有预防作用，尚有争议。对有望保存视力和眼球者，应尽可能修复伤口。对修复无望的眼球破裂，可慎行眼球摘除术。交感性眼炎 The second hospital of Medical college,Xian Jiaotong UniversityThe second hospital of Medical college,Xian Jiaotong University?小结：?前葡萄膜炎临床表现、诊断、治疗、并发症?Behcet 病、交感性眼炎概念
