眼科学课件：结膜病

第三章结膜病

DisordersoftheconjunctivaWhereisconjunctiva?睑结膜球结膜穹隆结膜PalpebralconjunctivaBulbarconjunctivaFornicalconjunctivaRedeye=conjunctivitis?Themaincausesofaredeye:conjunctivitisepiscleritissubconjunctivalhemorrhagescleritiscornealdiseaseandtraumadryeyeanterioruveitisacuteglaucomablepharitis结膜炎总论疾病包括炎症、外伤、先天性疾病和肿瘤最常见的是结膜炎症Introductionofconjunctivitis

Thediseasescomprisesofinfection,trauma,congenitalabnormalitiesandtumours.Themostcommondiseaseisinfectionofconjunctivaltissue.结膜炎总论病因：复杂分类：内源性和外源性感染性和非感染性微生物感染最常见，包括细菌、病毒、衣原体、真菌和寄生虫；非感染因素包括物理性和化学性损伤免疫性因素和全身疾病也可以IntroductionofconjunctivitisEtiology：complicatedClassification：

Exogenous&EndogenousInfectious&Non-infectiousMicroorganisms:bacterial,viral,chlamydial,fungal,parasitic.Non-infection:physicalandchemicalImmunologic(allergic)Associatedwithsystemicdisease临床表现

症状：眼部异物感、烧灼感、痒、流泪，累及角膜可出现畏光、视力下降、疼痛体征：分泌物：来源和分类水性、粘液性、脓性、粘液脓性结膜充血和水肿：球结膜充血和睫状充血鉴别结膜滤泡结膜乳头增生膜和假膜淋巴结肿大Clinicalfeatures

Symptoms:foreignbodysensation,burningsensation,itching,tearing,photophobia,painandblurredvisioninvolvedthecornea.Signs：Exudation：classificationHyperemiaandedema：ThecomparisonofciliarycongestionandconjunctivalcongestionFolliclesPapillaryhypertrophyMembraneandpseudomembranePreauricularlymphadenopathy结膜充血和睫状充血鉴别睫状充血角膜缘深层血管网深红色固定近角膜缘明显0.1%肾上腺素不变角膜、前房疾病结膜充血表面的结膜血管鲜红色可推动近穹隆部明显0.1%肾上腺素消失结膜、眼睑疾病ThecomparisonofciliarycongestionandconjunctivalcongestionciliarycongestionLimbaldeepvascularnetworkDarkredFixedClosetolimbusNochangeafterinstillationof0.1%epinephrineDiseasesofcorneaandanteriorchamberconjunctivalcongestionSuperiorconjunctivalvesselsFreshredMovedClosetofornixDisappearafterinstillationof0.1%epinephrineDiseasesofconjunctivaandeyelids诊断临床特点实验室检查：结膜刮片检测革兰染色吉姆萨染色结膜囊分泌物培养DiagnosisClinicalfindingsLaboratoryinvestigations：ConjunctivalscrapingGram’s&Giemsa’sstainCulture治疗原则对因治疗：局部＋全身分泌物多时可以冲洗结膜囊传染性的应注意切断传播途径Principlesofmanagement

Drugs：Local＋systemicTheconjunctivalsacshouldbeirrigatedwithsalinesolution.Topreventspreadofthedisease,thepatientandfamilyshouldbeinstructedtogiveattentionpersonalhygiene.细菌性结膜炎急性细菌性结膜炎急性自限性，“红眼病”，多于春秋季节致病菌：革兰阳性球菌为主，表皮葡萄球菌和金黄色葡萄球菌起病急、眼红、异物感、烧灼感、结膜充血，黏液脓性分泌物自限性。冲洗结膜囊，频用抗生素眼水如0.3%氧氟沙星滴眼液注意洗手和个人卫生BacterialconjunctivitisAcutebacterialconjunctivitisAcuteSelf-limited，“pinkeye”，springandautumnCause：G+coccus，Acuteonset、hyperemia、foreignbodysensation、burningsensation、conjunctivalinjection，moderatemucopurulentdischargeSelf-limited,conjunctivalsacirrigation,antimicrobialdrugshouldbegivenimmediately,0.3%ciprofloxacinPayattentiontopersonalhygiene.急性细菌性结膜炎

Acutebacterialconjunctivitis

淋球菌性结膜炎由淋球菌引起通过生殖器－眼接触或生殖器－手－眼传播，成人多为自身感染，新生儿通过产道感染。临床表现：新生儿一般出生后1～3天发病，成人潜伏期为10小时至数天，症状猛烈，病情进展快，畏光流泪，眼睑高度水肿，有时形成膜或假膜。以大量脓性分泌物为特点，“脓漏眼”，可发生角膜穿孔

GonococcalconjunctivitisDiplococcusNeisseriaGonorrhoeaeAvenerealgenitourinarytractinfectioninadults，neonatalconjunctivitisistransmittedfromthemotherduringdelivery.Clinicalfeatures：Presentationisusuallybetween1and3daysafterbirth.Theeyelidsareedematousandtender.Membraneandpseudomembraneformation.ProgressionrapidlyItischaracterizedbysevere,profuselypurulentexudate.Inseverecasecornealperforationcanoccur.诊断临床表现＋接触史＋结膜分泌物涂片治疗原则

局部：大量生理盐水冲洗全身：青霉素或头孢类，新生儿禁用喹诺酮类药物预防个人卫生隔离严格消毒患者的用品

淋球菌性结膜炎DiagnosisClinicalfindings＋contacthistory＋conjunctivalscrapingPrinciplesoftreatment

local：irrigatedwithmuchsalinesolutionsystemic：Penicilin&cefotaxime，NouseoffluoroquinolonetoneonatalconjunctivitisPreventionPersonalhygieneIsolationSterile

Gonococcalconjunctivitis新生儿淋球菌性结膜炎neonatalGonococcalconjunctivitisHaveabreak

衣原体性结膜炎

Chlamydialconjunctivitis

衣原体属包括沙眼衣原体种和鹦鹉热衣原体种沙眼衣原体可引起沙眼、包涵体性结膜炎和淋巴肉芽肿；鹦鹉热衣原体可引起鹦鹉热。衣原体的眼部感染是最广泛的，包括沙眼、成人包涵体性结膜炎和新生儿结膜炎沙眼衣原体抗原型A、B、Ba、C型可致沙眼，对四环素或红霉素最敏感，其次磺胺嘧啶、利福平沙眼

沙眼衣原体引起的慢性传染性眼病，睑结膜表面形成粗糙不平的外观形似沙粒而得名。病因：沙眼衣原体抗原型A、B、Ba、C型Trachoma

TrachomaisaninfectioncausedbyserotypeA、B、BaandCofChlamydiatrachomatis,whichisinitiallyachronicfollicularconjunctivitis.临床表现

症状：急性期异物感、畏光、流泪、有粘液或粘液性分泌物。数周后进入慢性期，症状消失。体征：急性期：眼睑红、结膜高度充血、睑结膜粗糙不平、上下穹隆结膜不满滤泡、耳前淋巴结肿大。慢性期：结膜慢性充血、睑结膜有乳头及滤泡形形成、角膜血管翳、内翻倒睫等。Clinicalfindings

Symptoms:Inacutestage,FBsensation,photophbia,tearing,mucousdischarge.Duringseveralweeksitprogressedintochronicstage.Signs

Acutestage:rednessofeyelids,hyperemiaofconjunctiva,tarsalandlimbalfollicles,tenderpreauricularnode.Chronicstage:formationofpapillaryhypertrophyandfollicles,pannus,entropionandtrichiasis.Tarsalfollicles后遗症和并发症睑内翻及倒睫上睑下垂睑球粘连角结膜干燥慢性泪囊炎角膜混浊Complications&SequelaeEntropionandtrichiasisptosisAdhesionofconjunctivaandeyeballKeratoconjunctivitisChronicdacryocystitisCornealopacification诊断沙眼的诊断至少要具备下列的两项：上睑结膜滤泡角膜缘滤泡及后遗症（Herbert小凹）典型的睑结膜瘢痕角膜缘上方血管翳实验室检查有助于确立沙眼的诊断。DiagnosisToestablishthediagnosisoftrachoma,patientsmusthaveatleasttwoofthefollowingsigns:SuperiorpalpebralconjunctivalfolliclesLimbalfolliclesandtheirsequelae(Herert’spits)Typicalconjunctivalscarringoftheuppertarsalconjunctiva.LimbalpannusThediagnosisisconfirmedbylaboratoryinvestigation.临床分期世界卫生组织（WHO）分期标准TF期（沙眼滤泡期）TI（沙眼炎症期）TS（沙眼瘢痕期）TT（沙眼倒睫期）CO（角膜混浊期）ClinicalgradingWorldHealthOrganization（WHO）gradingTF:trachomafollicleswithfiveormoreontheuppertarsalconjunctiva.TI:diffuseinfiltrationandpapillaryhypertrophyoftheuppertarsalconjunctivaobscuringatleast50%ofthenormaldeepvessels.TS:trachomatousconjunctivalscarringTT:trichiasisorentropionCO:cornealopacity

我国1979年在全国第二届眼科学术会议上制定的分期法：

Ⅰ期（进行期）即活动期。乳头滤泡并存，上穹窿结膜组织模糊不清，有角膜血管翳。

Ⅱ期（退行期）退行期。自瘢痕开始出现至仅留少许活动病变。

Ⅲ期（完全结瘢期）活动病变完全消失，代之以瘢痕。此期已无传染性。

临床分期分级标准

根据活动性病变(乳头和滤泡)占睑结膜的总面积的多少，分为轻、中、重3级。占1／3面积以下者为(+)，占1／3～2／3者为(++)，占2／3以上者为(+++)。同时确定了角膜血管翳的分级法：将角膜分为4等分，血管翳侵入上1／4以内者(+)，达1／4～1／2者为(++)，达1／2～3／4者为(+++)，超过3／4者为(++++)治疗局部治疗：0.1％利福平，0.5％金霉素，磺胺类滴眼液等，6周全身治疗：急性期或严重的沙眼，全身抗生素并发症治疗：手术矫治内翻矫正术角膜移植术Treatment

Topicaldropsorointments,includingpreparationsof0.1％rifampin,0.5％aureomycin,sulfonamidesfor6weeks.Systemicantibioticsisindicatedinacutestageorseverecase.complications：surgicalcorrection

沙眼衣原体：D～K型传播途径：尿道和阴道的分泌物及游泳等间接接触，新生儿为经母体的产道感染。特征：下睑结膜和下穹隆结膜滤泡增生。诊断：临床表现＋实验室检查治疗：同沙眼包涵体性结膜炎

InclusionconjunctivitisiscausedbyCtrachomatisserotypeD-K.Transmission：adultsareusuallybyoralgenitalsexualpracticesorhandtoeyetransmission.Innewbornstheagentistransmittedduringbirthbydirectcontamination.Keyfeatures:theconjunctivaofbothtarsi-especiallythelowertarsus-havepapillaeandfollicles.Diagnosis:clinicalfindings+laboratoryfindingsManagement：sametotrachomaInclusionconjunctivitis包涵体性结膜炎

Inclusionconjunctivitis病毒性结膜炎一种常见的结膜炎急性滤泡性结膜炎：流行性角结膜炎、流行性出血性结膜炎、单疱病毒性结膜炎等。相对的亚急性或慢性结膜炎：传染性软疣性睑结膜炎、水痘－带状疱疹性睑结膜炎、麻疹性角结膜炎等。病毒性结膜炎临床表现差异较大，与病毒毒力和机体免疫状况有关。ViralconjunctivitisViralconjunctivitis,acommonaffliction,canbecausedbyawidevarietyofviruses.Acutefollicularconjunctivitis:epidemickeratoconjunctivitis,epidemichemorrhagicconjunctivitis,herpessimplexvirusconjunctivitisandsoon.Subacuteorchronicconjunctivitis:molluscumcontagiosumblepharoconjunctivitis,varicella-zosterblepharoconjunctivitis,measleskeratoconjunctivitisandsoon.Severityrangesfromsevere,disablingdiseasetomild,rapidlyself-limitedinfection.流行性角结膜炎病因：腺病毒8、19和37型，传染性强临床表现：症状：角膜多有受累，异物感、水样分泌物、疼痛、畏光、流泪等。体征：眼睑水肿、睑球结膜显著充血、水肿并有结膜滤泡。耳前淋巴结肿大伴压痛。早期角膜弥漫性点状上皮性损害，继续进展圆点状灰白色上皮下炎性混浊，少数进展成浅基质层点状浸润，圆形，边界模糊，形态和大小一致，聚集成簇，又称钱币状角膜炎。儿童有时有全身表现EpidemickeratoconjunctivitisEpidemickeratoconjunctivitisiscausedbyadenovirustypes8,19,29,and37.Clinicalfeatures：

Symptoms：FBsensation,waterydischarge,pain,photophobia,tearing,involvedcorneainmostcases.Signs：edemaoftheeyelids,conjunctivalhyperemiawithfollicles.Atenderpreauricularnodeischaracteristic.Diffusepunctateepithelialkeratitis,advancedtosubepithelialroundopacities.Inchildrentheremaybesuchsystemicsymptomsofviralinfectionasfever,sorethroat,diarrheaandsoon.诊断：根据急性滤泡性结膜炎伴发浅层点状角膜炎，耳前淋巴结肿大伴压痛，分泌物涂片镜检单核细胞增多等特点，即可诊断。治疗：支持疗法冷敷和血管收缩剂抗病毒滴眼液角膜基质浸润加用低浓度激素预防：注意隔离EpidemickeratoconjunctivitisDiagnosis：acutefollicularconjunctivitiswithsuperiorpunctatekeratitis,atenderpreauricularnode,scrapingshowingprimarymononuclearinflammatoryreaction.Treatment：thereisnospecifictherapyatpresent,butcoldcompresswillrelievesomesymptoms.Antiviralagentsisindicated.Corticosteroidsshouldbeavoidedduringacutestage,addedlowconcentrationcorticosteroidswhenstromaisinvolved.Prevention：isolationEpidemickeratoconjunctivitisEpidemickeratoconjunctivitisEpidemickeratoconjunctivitis流行性出血性结膜炎病因：70型肠道病毒，偶A24柯萨奇病毒临床表现：自限性疾病，多为双眼。畏光、流泪、眼红、异物感和剧烈眼痛等，可有水样分泌物、睑结膜滤泡和结膜下出血。可有耳前淋巴结肿大等，病初角膜上皮一过性、细小点状的上皮性角膜炎。诊断：根据急性滤泡性结膜炎的症状，同时有显著的结膜下出血，耳前淋巴结肿大等。治疗及预防：同流行性角结膜炎。EpidemichemorrhagicconjunctivitisItiscausedbyenterovirustype70andoccasionallybycoxsackievirusA24.Clinicalfeature:self-limited,bilateral,photophobia,tearing,redness,FBsensation,pain,waterydischarge,palpebralconjunctivalfolliclesandsubconjunctivalhemorrhage.Preauricularnode,transientfinepunctateepithelialkeratitis.Diagnosis:onthebasisofacutefollicularconjunctivitis,markedsubconjunctivalhemorrhageandpreauricularnode.Treatment&prevention:asEpidemickeratoconjunctivitis流行性出血性结膜炎

Epidemichemorrhagicconjunctivitis免疫性结膜病结膜组织的免疫学特点正常球结膜的免疫学特点：球结膜是一个经常发生免疫学反应的组织。富含各种免疫成分和细胞结膜的超敏反应：Ⅰ型超敏反应过敏性结膜炎Ⅱ型超敏反应瘢痕性类天疱疮Ⅲ型超敏反应边缘性角膜溃疡Ⅳ型超敏反应接触性皮炎、接触性角膜炎，角膜移植排斥反应免疫性结膜炎枯草热结膜炎又称季节性过敏性结膜炎，属Ⅰ型超敏反应临床表现：多有过敏性鼻炎或哮喘等其他特应性疾病。接触致敏原后迅速发病，瘙痒、眼睑红肿、球结膜充血水肿、粘液性渗出。剧烈瘙痒是特征。诊断：临床表现，结膜刮片查嗜酸性粒细胞治疗:远离过敏原局部冷敷局部抗组胺与缩血管细胞膜稳定剂严重可用糖皮质激素脱敏疗法ImmuologicconjunctivitisHayfeverconjunctivitisKnownasseasonalallergicconjunctivitis,hypersensitivityreactiontypeⅠClinicalfeatures:Thediseaseiscommonlyassociatedwithallergicrhinitisorasthma.Thepatientscomplainsofitching,tearing,chemosisandrednessoftheeyes.Theremaybeasmallamountofropydsicharge.Extremeitchingisthekeyfeature.Diagnosis：clinicalfindings.Eosinophilsaredifficulttofindinconjunctivalscrapings.Treatment:toeliminateantigencoldcompresseslocalvaso-constrictorsandhistamine-blockingagentsCromolynSteroids

春季角结膜炎春季卡他，是一种反复发作的，季节性，免疫性角结膜病。20岁以下青少年多见，男性，双眼。病因：Ⅰ、Ⅳ型超敏反应共同作用的结果。临床表现：眼部奇痒、畏光、流泪、异物感、可有大量粘液性分泌物。分3型：睑结膜型：主要在上睑结膜。典型的睑结膜扁平粗大乳头，呈铺路石痒，球结膜呈典型的暗红色。角膜缘型：角膜缘充血，结节，呈胶冻样外观。混合型诊断：典型的病史＋体征治疗：轻度用抗组胺药中度肥大细胞稳定剂严重糖皮质激素或环孢霉素VernalkeratoconjunctivitisThedisease,alsoknownas“springcatarrh”,isanuncommonbilateralallergicdiseasethatusuallybeginsintheprepubertalyearsandlastsforseveralyears.Causes：hypersensitivityreactiontypeⅠ,ⅣClinicalfeatures：extremeitching,photophobia,FBsensation,ropydischarge.Theupperpalpebralconjunctivaoftenhasgiantpapillaethatgiveacobblestoneappearance.Insomecases,themostprominentlesionsarelocatedatthelimbus,wheregelatinousswellingsarenoted.Diagnosis：typicalsymptomsandsignsTreatment：Mild:histamine-blockingagentsModerate:cromolynSevere:steroidsorcyclosporine泡性角结膜炎病因：结膜，角膜组织对内源性微生物蛋白质变态反应引起的局部病变，本病多发生于儿童及青少年，特别是营养不良

。症状：轻者仅有异物感及流泪，累及角膜出现畏光、流泪、刺痛及眼睑痉挛等临床分型：泡性结膜炎、泡性角膜炎、泡性角结膜炎。诊断及治疗PhlyctenularconjunctivitisPhlyctenularconjunctivitisisadelayedhypersensitivityresponsetomicrobialproteins.

Signs:conjunctivalphlyctenuleusuallyproduceonlyirrigationandtearing,butcornealandlimbalphlyctenulesareusuallyaccompaniedbyintensephotophobia.

Classification：phlyctenularconjunctivitis,phlyctenularkeratoconjunctivitis,phlyctenularkeratitis

Stevens-Johnson综合症也称重症多形性红斑，是一种急性的，可能致命的皮肤和粘膜炎症水疱样病变，主要与服用某些药物或某些微生物感染有关。其发病机制为免疫复合物沉积在皮肤和结膜基质引起的超敏反应。眼部急性期严重的，双侧弥漫性结膜炎，有卡他性、脓性、出血性渗出膜或假膜形成。晚期并发症包括结膜瘢痕化、倒睫、睑内翻、泪液缺乏。Stevens-JohnsonsyndromeErythemamultiformemajorisadiseaseofthemucousmembranesandskin.Theskinlesionisanerythematous,urticarialbullouseruptionthatappearssuddenlyandisoftendistributedsymmetrically.Bilateralconjunctivitis,oftenmembranous,isacommonmanifestation.Thepatientscomplainsofpain,irrigation,discharge,andphotophobia.Thecorneaisaffectedsecondarily,andvascularizationandscarringmayseriouslyreducevision.TransientconjunctivitisandlidcrustingwithoutsequelaeSeveremembranousorpseudomembranousconjunctivitisFocalfibroticpatchesandoccasionallysymblepharonMetaplasticlashes其他眼部瘢痕性类天疱疮移植物抗宿主疾病Sjogren综合症MiscellaneousconjunctivitisOcularcicatricialpemphigoidGraft-versus-hostdiseaseSjogrensyndrome

变性性结膜病睑裂斑

黄白色，无定形样沉积的结膜变性性损害，出现在睑裂区近角膜缘的球结膜上皮下。

病因：紫外线和光化学性暴露

临床表现：睑裂部位接近角膜缘处的球结膜，三角形略隆起的斑块，基底向角膜。

治疗：一般不需治疗，注意有无干眼。影响外观、反复慢性炎症或干扰角膜接触镜的配戴时可以考虑手术切除。DegenerativediseasesoftheconjunctivaPingueculaCauses：ultravioletlightandphotochemicalexposureClinicalfeatures：Theyappearsasyellowish&whitishtriangularnodulesonbothsidesofthecorneaintheareaofthepalpebralaperture.Treatment:Ingeneral,notreatmentisrequired,butincertaincasesofcosmeticreason,recurrentpingueculitisordifficulttowearcontactlenssurgerymaybemade.睑裂斑Pinguecula翼状胬肉

睑裂区肥厚的球结膜及其下的纤维血管组织呈三角形向角膜侵入，形态似翼状。病因：不明，可能与紫外线照射、气候干燥、接触风尘有关系，近地球赤道和户外工作的人群发病率高临床表现：多数无症状，偶有充血、不适，延及角膜会引起散光，遮盖瞳孔区影响视力。单眼或双眼，鼻侧多见鉴别诊断：与外伤引起的假性胬肉相鉴别。PterygiumApterygiumisatriangularsheetoffibrovasculartissuewhichinvadesthecornea.Theetiologyisnotwellelucidated.Thecausesmaybeultravioletlight,drying,andwindyenvironments,sinceitiscommoninpersonswhospendmuchoftheirlivesoutofdoorsinsunny,dusty,