412例真菌性角膜炎的回顾性分析

目的：对真菌性角膜炎患者的流行病学特征、实验室检查方法和结果及治疗效果进行分析,为真菌 性角膜炎诊治提供依据。方法： 回顾性系列病例研究。对2012年1月至2017年12月在冀中能源邢 台矿业集团总医院诊治的412例（412眼）真菌性角膜炎的流行病学特点、临床体征、病原学诊断方式、 结果及治疗效果采用Kruskal-Wallis H检验等统计学方法进行分析。结果：9-12月份是真菌性角膜 炎高发期,占全年患者总数的61.2%（252/412）。患病人群以农民为主,占59.5%（245/412）,植物性 外伤为首要病因者185例（44.9%）,其次为非植物性外伤86例（20.9%）。男女比例为1.82∶1。年龄 14～81（45.6±14.3）岁,41～60岁患者占53.9%（222/412）。真菌培养阳性率为88.8%（366/412）,高 于氢氧化钾湿片法[77.2%（318/412）],2种检测方式比较差异有统计学意义（χ2 =31.14,P<0.001）。 前几位的致病菌依次是镰刀菌属167例（40.5%）,链格孢菌属75例（18.2%）,曲霉菌属62例（15.0%）, 青霉菌属28例（6.9%）。真菌性角膜炎所致典型临床体征中以菌丝苔被最为常见（366例,88.8%）, 其次为伪足（224例,54.4%）、前房积脓（111例,26.9%）。镰刀菌属、链格孢菌属、曲霉菌属及青 霉菌属所致真菌性角膜炎的病情分级和预后水平比较差异均有统计学意义（Hc=40.676,P< 0.001; Hc=40.109,P<0.001）,显示镰刀菌属和曲霉菌属的病情分级重于链格孢菌属和青霉菌属,预后水平 也差于链格孢菌属和青霉菌属。结论：真菌性角膜炎患者呈逐年增多趋势;氢氧化钾湿片法和真菌 培养都是有效的诊断方法,镰刀菌属和曲霉菌属所致的真菌性角膜炎较链格孢菌和青霉菌引起的真 菌性角膜炎病情相对较重,且预后较差。     

真菌性角膜炎继发感染性眼内炎行眼内容物剜除术的临床特点及病原学分析

目的：分析真菌性角膜炎继发感染性眼内炎行眼内容物剜除术患者的临床特点及病原学特点。方法：回顾性系列病例研究。收集2012年1月至2021年12月于山东省眼科医院,因真菌性角膜炎继发感染性眼内炎,而行眼内容物剜除术的所有患者44例（44眼）。分析其病程及发病诱因、眼部及全身病史、临床表现、微生物培养及药物敏感试验结果。结果：纳入的44例患者占同期山东省眼科医院诊断为真菌性角膜炎患者总例数的2.15%。44例患者病程中位数为18.5 d,入院时44眼视力均为无光感,20 眼（45%）合并继发性青光眼。44眼均表现为全角膜溃疡,并累及角膜全层及角膜缘处,27眼（61%）合并前房积脓。微生物培养显示39眼（89%）真菌生长,其中镰刀菌属20眼（51%）,曲霉菌属8眼（21%）,链格孢霉属2眼（5%）;其他包括无孢霉4眼（10%）,谲诈腐霉菌2眼（5%）,尖端赛多孢霉1眼（3%）,帚枝霉1眼（3%）,多毛拟单孢瓶霉1眼（3%）。培养的菌种对两性霉素B、泊沙康唑、伏立康唑、伊曲康唑、5-氟胞嘧啶、氟康唑、阿尼芬净、米卡芬净、卡泊芬净等的最低抑菌浓度的几何均数依次为 1.597、1.338、1.926、3.291、64、189.699、1.36、1.16、1.23 μg/ml。结论：真菌性角膜炎继发感染性眼内炎行眼内容物剜除术的患者临床特征常表现为全角膜溃疡,致病菌除常见镰刀菌属、曲霉菌属、链格孢霉属外,其他如无孢霉、谲诈腐霉菌、尖端赛多孢霉等致病侵袭力较强的菌属也较为常见。     

板层角膜移植术治疗真菌性角膜炎的临床疗效分析

目的：探讨板层角膜移植术治疗药物难以控制的中、浅层真菌性角膜炎的手术适应证及时机,并对其临床效果进行分析。方法：对临床确诊为真菌性角膜炎（病灶均位于角膜中浅层）且经抗真菌药物治疗无效的患者68例（68只眼）行板层角膜移植术,观察术后角膜真菌复发率、角膜植片透明率及角膜植片免疫排斥反应等情况,并对术中取下的病变角膜组织行真菌培养、菌属鉴定及组织病理学检查。结果：68例患者中,64例治愈,成功率为94％;随访观察6－36个月,植片全部透明,矫正视力为0．2－1．0;4例复发,复发率为6％。59例角膜组织标本真菌培养阳性,其中镰刀菌属41例,曲霉菌属8例,念珠菌属4例,青霉菌属2例,其他丝状菌属4例。61例病理切片行高碘酸－Schiff染色可见菌丝,57例菌丝均未超出病变角膜切片的深度和边缘,仅4例复发者可见菌丝达角膜组织切片全层,其中曲霉菌属3例,镰刀菌属1例。结论：板层角膜移植术是一种对经抗真菌药物治疗无效及溃疡直径较大或偏中心的中、浅层真菌性角膜炎患者具有治疗和复明作用的有效术式。     

天津地区角膜外伤后真菌感染的病原学调查分析

目的调查分析天津地区角膜真菌感染的病原菌种类。方法自2006年1月至2009年6月间,在天津市眼科医院采集角膜外伤后疑似真菌性角膜炎病变角膜标本170份,分别进行真菌直接涂片镜检和接种于沙保罗培养基进行真菌培养,对培养阳性者进行菌种鉴定。结果在170份角膜病变标本中,直接涂片镜检阳性98份,阳性率为57．65％。真菌培养阳性123株,阳性率为72．35％;涂片镜检和真菌分离培养的一致性为84．75％。其中镰刀菌属占66．67％,镰刀菌属中茄病镰刀菌占30．89％,尖孢镰刀菌占15．45％,串珠镰刀菌占13．82％。曲霉菌属占23．58％,曲霉菌属中黄曲霉菌占13．01％,烟曲霉菌占8．14％。结论镰刀菌属和曲霉菌属是天津地区眼部真菌感染的主要致病真菌。     

恩施地区外伤性真菌性角膜炎回顾性分析

目的 了解恩施地区外伤性真菌性角膜炎临床流行病学特点.方法 回顾性分析2009年7月至2013年6月恩施州中心医院收治的外伤性真菌性角膜炎病例.记录患者人口学特征、病史、职业、致伤原因、病程、先前诊断用药情况,来院后裂隙灯检查、微生物学检查、治疗方法、转归及随访结果,对资料进行分析.结果 4年间,69例（69眼）根据患病诱因、微生物学检查结果诊断为外伤性真菌性角膜炎.随访时间1 ～14个月.男51例,女18例,年龄27 ～71岁.农民64例.主要诱因为植物外伤.外院曾经过微生物学检查诊断为真菌性角膜炎2例.来院后沙氏培养基培养阳性67例,其中镰刀菌属54例（80.6％）,曲霉菌属10例（14.9％）.59例用药物治愈,清创及板层切除术8例,穿透性角膜移植术1例,眼球摘除1例.结论 恩施地区外伤性真菌性角膜炎首位病原体是镰刀菌属,多见于青壮年男性农民,植物外伤是主要原因,可导致严重视力损害.     

湖北地区真菌性角膜炎病原体菌属分布及药物敏感性研究

目的研究湖北地区真菌性角膜炎患者眼部感染真菌的菌属分布及药物敏感性。方法对我院2004年8月至2009年7月送检的289份眼部标本进行真菌培养,并对真菌培养的阳性率、菌属分布及药物敏感性(分别采用法国梅里埃ATB FUN-GUS2试条及E-test法检测)进行回顾性分析。结果 289份眼部标本中,真菌培养阳性188株(65.1%)。感染真菌中镰刀菌属124株(66.0%),曲霉菌属16株(8.5%),链隔孢霉属、弯孢霉属及其他未知暗色孢科真菌共26株(13.8%)。镰刀菌属对两性霉素B、伊曲康唑、氟康唑敏感性分别为71.0%、29.0%、16.1%,曲霉菌属对这3种药物敏感性分别为25.0%、75.0%、25.0%,暗色孢科真菌分别为100.0%、85.7%、85.7%。ATB FUNGUS2试条与E-test法同时检测两性霉素B、伊曲康唑和氟康唑,这3种药物药敏结果的符合率分别为95.8%、93.8%和87.5%,经配对χ2检验,差异无统计学意义(P>0.05)。结论镰刀菌属是湖北地区主要的眼部致病真菌菌属,链隔孢霉属等暗色孢科真菌致病比例有升高趋势,上述致病菌属对两性霉素B敏感性最高。     

角膜致病性丝状真菌基因分型与临床意义分析

目的研究丝状真菌性角膜炎致病菌株的基因分型及临床意义。方法收集北京同仁医院眼科中心2006年1—12月经病原学检查诊断为丝状真菌性角膜炎的患者52例,对分离的致病菌株进行rDNAITS基因分型和形态学鉴定与分析,并对患者进行治疗和随访,分析基因分型与临床多因素的关系。结果基因分型与形态学鉴定种的一致率达90．3％。根据rDNAITS基因的亲缘关系,将52株丝状真菌分为4组：第1组22株（20株茄病镰刀菌和2株尖孢镰刀菌）;第2组12株（8株串珠镰刀菌、3株层生镰刀菌和1株雪腐镰刀菌）;第3组5株（4株少见眼部真菌和1株串珠镰刀菌）;第4组13株（10株曲霉菌属和3株链隔孢属）。第1组、第2组与第3组、第4组相比,患者发病时间、诱发因素、溃疡严重程度、抗真菌治疗的疗效比较,差异均有统计学意义（P=0．000,P=0．03,P=0．01,P=0．035）。结论rDNAITS基因分型能够准确地鉴定角膜丝状真菌,对于少见或鉴定困难的菌株具有明显的优势。由于菌株的基因型不同,丝状真菌性角膜炎的临床特点具有一定的差异。     

眼部主要感染真菌对两性霉素B和氟康唑的敏感度

目的探讨两性霉素B（amphomricin B）和氟康唑（fluconazole）这两种常见的抗真菌药物对眼科常见的致病真菌（镰刀菌属、念珠菌属、曲霉菌属）的体外抗菌活性。方法经刮片收集的眼部真菌感染58例。将标本接种于Sabouraud培养基中分离培养，阳性菌株42例。根据真菌培养的形态学特征和糖发酵、糖同化及硝酸盐还原试验，分离鉴定出镰刀菌属14例，念珠菌属14例，曲霉菌属9例，其他5例。共对37例这3株眼部体外培养真菌进行研究，amphotericin B和fluconazole体外单独用药时，用NCCLS推荐使用常量肉汤稀释法（M27-A，1997）进行真菌的药敏试验。分析方法采用t检验。结果Amphotericin B对镰刀菌属的最小抑菌浓度（MIC）50为0.55μg／ml，MIC90为2．50μg／ml；对念珠菌属的MICSO为0.68μg／ml，MICgO为2．90μg／ml；对曲霉菌属的MICSO为2．50μg／ml，MICgO为4．36μg／ml。而fluconazole对镰刀菌属和念珠菌属的MIC≥128μg／ml；对曲霉菌属的MIC50为1．32μg／ml，MIC90为2．68μg／ml。结论hmphotericinB对镰刀菌属和念珠菌属均有明显的体外抗菌活性（MIC〈8μg／m1），而fluconazole对曲霉菌属的抗菌活性高于amphoricin B，治疗眼部曲霉菌属感染应首选fluconazole。     

眼部真菌感染的病原学及体外药物敏感性分析

目的 分析4年间眼部感染的真菌菌属分布及其体外药物敏感性。方法 收集2179份眼部标本进行分离培养，对真菌培养阳性率、菌属的种属分布、菌属的季节分布及年龄与性别分布进行回顾性分析；同时分析培养阳性的真菌对常用抗真菌药物的敏感性。结果 共培养阳性菌株681株，阳性率为31．25％，其中镰刀菌属394株（57．86％），曲霉菌属116株（17．03％）。培养阳性的标本中，角膜591株（86．78％）、房水29株（4．26％）、结膜22株（3．23％）、玻璃体22株（3．23％）、泪囊1株（0．15％）、其他16株（2．35％）。体外药物敏感性观察发现，镰刀菌中368株对那他敏感（93．40％），曲霉菌中107株对伊曲康唑敏感（92．24％）。结论 镰刀菌属及曲霉菌属仍是我国北方主要的眼部致病真菌菌属；镰刀菌对那他霉素最敏感，曲霉菌对伊曲康唑最敏感。     

糖尿病真菌性角膜炎患者临床特征、病原学特点及预后的回顾性分析

背景 真菌性角膜炎在中国的发病率较高,是感染性角膜病致盲的主要原因之一,而糖尿病真菌性角膜炎患者也随之逐年增多,其治疗和转归不同于单纯真菌性角膜炎患者,目前对于该病的研究相对缺乏. 目的 分析糖尿病真菌性角膜炎的临床特征、病原学特点及预后情况,为临床诊疗提供依据.方法 回顾性分析2000年1月至2012年1月在青岛大学医学院附属医院诊治的87例糖尿病真菌性角膜炎患者的临床资料,并与同期纳入的40例无全身病真菌性角膜炎患者的人口学特征、临床症状、病原学检查、预后情况进行比较.结果 糖尿病真菌性角膜炎患者多有血糖控制不良现象和外伤的诱因,其植物性外伤引起者占36.8％,与无全身病真菌性角膜炎组的57.5％相比所占比例下降,差异有统计学意义（χ^2=6.06,P＜0.05）.糖尿病真菌性角膜炎组患者以61 ～70岁年龄段居多,无全身病真菌性角膜炎组以51 ～60岁年龄段居多.糖尿病真菌性角膜炎患者的职业分布仍然以从事农业生产人员和体力工人为主,分别占34.5％和26.4％,糖尿病病史平均为（13.0±4.9）年.实验室检查发现,糖尿病真菌性角膜炎患者感染的真菌种类以镰刀菌属最多,占60.0％,曲霉菌属和念珠菌属各占20.0％,其中念珠菌感染所占比例明显高于无全身病角膜炎患者组的10.0％,差异有统计学意义（χ^2=3.92,P＜0.05）.根据病灶感染特征和辅助检查结果综合考虑进行个体化诊疗后,糖尿病真菌性角膜炎患者组的治愈率为46.0％,低于无全身病真菌性角膜炎组的62.5％,差异有统计学意义（χ^2=5.48,P＜0.05）,而无效率为14.9％,明显高于无全身病真菌性角膜炎组的5.0％,差异有统计学意义（χ^2=5.47,P＜0.05）.结论 糖尿病真菌性角膜炎患者有其自身的特点,糖尿病可能是真菌性角膜炎发病的一个重要危险因素,持续的高血糖水平影响了该病的人口学?     

真菌性角膜炎的临床转归及影响因素分析

背景 真菌性角膜炎预后差,致盲率高,了解影响真菌性角膜炎预后的主要危险因素有助于选择适宜的干预手段,对改善真菌性角膜炎临床转归至关重要. 目的 研究真菌性角膜炎对不同治疗方法的临床预后及其影响因素.方法 采用系列病例观察研究设计,纳入2013年1月至2014年1月在河南省眼科研究所确诊的真菌性角膜炎患者267例267眼,所有患眼均行裂隙灯显微镜检查、激光扫描共焦显微镜检查、真菌培养及病灶标本药物敏感性试验.对所有患眼均先采用联合抗真菌药物疗法,然后根据药物敏感性试验结果调整药物治疗方案.如药物治疗效果不佳,则根据病情择行角膜病灶切除联合结膜瓣移植术、板层角膜移植术或穿透角膜移植术.对患眼的临床预后情况进行分级,分析患眼病情转归的影响因素. 结果 267眼真菌性角膜炎患者中,抗真菌药物治疗后痊愈者185眼,药物治愈率为69.29％;60眼药物治疗后根据病情选择不同的手术进行治疗,真菌感染病灶得到控制,22眼因难治性青光眼或最终行眼内容物摘除术而丧失视功能,临床总体治愈率为91.76％.真菌培养结果显示,曲霉菌和镰刀菌为常见致病真菌.与其他菌种感染性角膜炎相比,曲霉菌感染角膜炎药物治愈率最低,不同菌种感染角膜炎患者药物治愈率总体比较差异有统计学意义(x2=11.350,P=0.002).曲霉菌感染角膜炎患者临床预后最差,不同菌种感染性角膜炎的不同等级预后眼数总体比较差异有统计学意义(H=31.285,P=0.013).真菌培养阳性患者药物治愈率为71.8％,明显高于真菌培养阴性患者的62.5％,差异有统计学意义(x2=8.75,P＜0.01);敏感药物数≥2种的角膜炎患者药物治愈率为77.5％,敏感药物数＜2种的角膜炎患者药物治愈率为52.3％,差异有统计学意义(x2=9.63,P＜0.01);2个组间不同等级临床预后眼数分布比较差异有统计学意义(H=24.281,P=0.021).真菌性角膜炎的病灶面积＞16 mm2、前房积脓＞2 mm、药物敏感性试验敏感药物数＜2种及致病菌种为镰刀菌或曲霉菌均为影响真菌性角膜炎临床预后的危险因素(均P＜0.05).结论 体外药物敏感性试验能较好地指导真菌性角膜炎的临床药物治疗,病灶面积＞16 mm2、前房积脓＞2 mm、药物敏感性试验敏感药物数＜2种及致病菌种为镰刀菌或曲霉菌者预后较差.     

Fluoroquinolone therapy in Mycobacterium chelonae keratitis after lamellar keratectomy

PURPOSE: To characterize a rabbit model of Mycobacterium chelonae keratitis after lamellar keratectomy and assess the effectiveness of fluoroquinolone therapy. SETTING: University Laboratory, University of California, Irvine, California, USA. METHODS: Twenty-eight New Zealand white rabbits had unilateral lamellar keratectomy with placement of 2.5 x 10(5) colony-forming units of log-phase M chelonae under each flap. Eyes (7 per group) were randomized and treated with sterile balanced salt solution, gatifloxacin 0.3%, ciprofloxacin 0.3%, or levofloxacin 0.5% 4 times daily. Two masked observers examined all eyes on days 2, 5, and 7 and weekly for 4 weeks. Severity of disease and bacterial culture results were the main outcomes measured. The means and standard deviations were calculated, and differences between the groups were statistically analyzed. RESULTS: All eyes developed clinical disease. At the time the rabbits were killed, eyes treated with balanced salt solution, ciprofloxacin, levofloxacin, and gatifloxacin were culture positive in 6 (85.7%), 7 (100%), 6 (85.7%), and 3 (42.9%) of 7 eyes per group, respectively. Frequency of positive culture and the severity of clinical disease in gatifloxacin-treated eyes were significantly less (P < .05) than in the other groups combined. CONCLUSIONS: The rabbit model of M chelonae keratitis was successfully developed in our study. A fourth-generation quinolone (gatifloxacin) showed the best performance among the fluoroquinolones tested in our experimental approach. The fourth-generation fluoroquinolone, gatifloxacin, could be effectively used for the treatment of mycobacterial keratitis.     

The effectiveness of a topical antibiotic irrigating solution in a model of staphylococcal keratitis after lamellar keratectomy

PURPOSE: To create a model of Staphylococcus aureus keratitis after lamellar keratectomy; to assess the toxicity of an antibiotic irrigating solution on the corneal stromal bed; and to test the chemotherapeutic effectiveness of a topical antibiotic, both alone and with an antibiotic-containing irrigating solution in preventing S. aureus keratitis after lamellar keratectomy. METHODS: The right eye of each of 38 rabbits were used in this study. In 18 eyes, a lamellar flap was created with a microkeratome, and an inoculum of S. aureus (either 1,000, 5,000, or 50,000 CFUs) was instilled under each flap; the eyes were examined for signs of infection and inflammation at 24 and 48 hours. In another five eyes, a lamellar flap was created in the same manner and the stromal bed was irrigated with 0.3% ofloxacin; the eyes were assessed for ocular inflammatory changes and evidence of crystalline deposits. Finally, in each of 15 additional eyes, 1,000 CFUs of S. aureus were instilled under a lamellar flap to create experimental infectious keratitis. The keratitis was treated according to three regimens: irrigation of the stromal bed with sterile balanced salt solution; irrigation of the stromal bed with 0.3% ofloxacin, followed by application of topical ofloxacin four times a day; application of topical ofloxacin only, four times a day. Eyes were examined for infection and ocular inflammatory changes at 24 and 48 hours. RESULTS: Staphylococcus aureus keratitis can consistently be produced under the stromal flap by inoculation of relatively few organisms. Irrigation of the stromal bed with commercial-strength topical ofloxacin does not appear to be toxic to the stromal bed, with no evidence of crystalline precipitates of the antibiotic. In our model of infectious keratitis after lamellar keratectomy, both topical ofloxacin alone and the combination of topical ofloxacin and irrigation of the stromal bed with 0.3% ofloxacin were effective at preventing S. aureus keratitis. However, the combined treatment of antibiotic irrigation plus topical antibiotic was more effective at preventing inflammation than topical ofloxacin alone.CONCLUSIONS: In this model of S. aureus keratitis after lamellar keratectomy, irrigation of the stromal bed with antibiotic plus topical antibiotic appears to be both safe and effective for preventing infection.     

Fluoroquinolone therapy in multiple-drug resistant staphylococcal keratitis after lamellar keratectomy in a rabbit model

PURPOSE: To assess the effectiveness of a fourth-generation fluoroquinolone for prophylaxis against multiple drug-resistant staphylococcal keratitis after lamellar keratectomy in a rabbit model. DESIGN: Experimental study. METHODS: Twenty-eight New Zealand white rabbits underwent unilateral lamellar keratectomy using a manual microkeratome followed by the placement of 1000 colony-forming units (CFUs) of log-phase Staphylococcus aureus bacteria under each flap. Eyes (seven in each group) were randomized and treated with one of the following agents: sterile balanced salt solution, gatifloxacin (0.3%), ciprofloxacin (0.3%) or levofloxacin (0.5%) immediately and 6, 12, and 18 hours after surgery. Inflammation was graded by two masked observers at 24 and 48 hours, and the presence or absence of infectious infiltrates was determined. The means and standard deviations were calculated, and differences among the groups were statistically analyzed. RESULTS: There were no flap complications encountered during surgery. Eyes treated with ciprofloxacin, levofloxacin, and balanced salt solution developed infectious infiltrates in five of seven eyes per group. Gatifloxacin-treated eyes did not develop clinical infection and exhibited lower mean inflammation scores (P <.01 compared with the other groups). CONCLUSION: The fourth-generation fluoroquinolone, gatifloxacin, is an effective prophylaxis against the development of keratitis after lamellar keratectomy in rabbits with an organism resistant to methicillin, levofloxacin, and ciprofloxacin.     

Diffuse lamellar keratitis associated with carboxymethylcellulose sodium 1% after laser in situ keratomileusis

PURPOSE: To investigate the association between the use of carboxymethylcellulose sodium 1% (Celluvisc) (Allergan, Inc.) during laser in situ keratomileusis (LASIK) and the development of diffuse lamellar keratitis (DLK). SETTING: Outpatient surgery center, Detroit, Michigan, USA. METHODS: In this retrospective case series, the postoperative clinical course and surgical outcomes in 30 eyes of 15 consecutive patients who had LASIK with the use of Celluvisc were reviewed. All patients had primary LASIK, and the incidence and severity of DLK were analyzed. RESULTS: Diffuse lamellar keratitis developed in 24 of the 30 eyes (80.0%) in which Celluvisc was used before the keratectomy (P = <.0001, Fischer exact test). Sixteen eyes (66.7%) had stage 1, and 8 (33.3%) had stage 2. Diffuse lamellar keratitis was diagnosed in most cases (91.6%) on postoperative day 1. All inflammation resolved after treatment with intense topical corticosteroids. CONCLUSIONS: Celluvisc used immediately before the keratectomy in LASIK was highly associated with the development of DLK.     

Comparison of topical itraconazole 1% with topical natamycin 5% for the treatment of filamentous fungal keratitis

PURPOSE: To compare the clinical efficacy of itraconazole 1% eyedrops with a standard therapy regimen (natamycin 5% eyedrops) for topical monotherapy of fungal keratitis. METHODS: Patients presenting with suspected uniocular microbial keratitis over a period of 12 months (January to December 2002) underwent detailed clinical examination and microbiological investigation. One hundred consecutive patients with direct smear- and/or culture-proven fungal keratitis were enrolled in the study after obtaining informed consent. The ulcers were categorized as severe or nonsevere. The first 50 consecutive patients received primary therapy with topical natamycin hourly, and the next 50 consecutive patients received topical itraconazole hourly. The primary efficacy criteria were the physician's judgment of clinical success, cure rate, and the rate of treatment failure. RESULTS: The diagnosis of fungal keratitis was established by positive microscopy and culture findings in 88 patients and by positive microscopy alone in 12 patients. Species of Fusarium, Aspergillus, and Curvularia were the principal isolates. Thirty-six (72%) of 50 patients (28 of 37 with nonsevere keratitis and 8 of 13 with severe keratitis) showed a favorable response to primary natamycin therapy (mean duration, 20.5 days), while 30 (60%) of 150 patients (25 of 38 with nonsevere keratitis and 5 of 12 with severe keratitis) exhibited a favorable response to primary itraconazole therapy (mean duration, 23.1 days). In keratitis due to Fusarium spp, 19 (79%) of 24 patients showed a favorable response to natamycin, which was significantly greater than the 8 (44%) of 18 patients who showed a favorable response to itraconazole (P < 0.02). However, no such difference was evident in keratitis due to Aspergillus spp or Curvularia spp; in keratitis due to Aspergillus spp, favorable responses were noted in 6 (54.5%) of 11 patients receiving natamycin and 5 (50%) of 10 patients receiving itraconazole, while in keratitis due to Curvurlaria spp, such responses occurred in both patients receiving natamycin and in 8 (89%) of 9 patients receiving itraconazole. Both antifungal formulations were generally well tolerated with no obvious adverse effects. CONCLUSIONS: Topical natamycin should continue to be considered as the treatment of choice for filamentous fungal keratitis; when natamycin is unavailable, topical itraconazole therapy could be used, particularly if the infections are due to Aspergillus or Curvularia spp.     

板层角膜切除术联合那他霉素治疗真菌性角膜溃疡的临床及病理研究

目的：研究板层角膜切除术联合那他霉素治疗真菌性角膜溃疡的临床疗效及组织病理学基础。方法：选取2009-12/2011-11真菌性角膜溃疡患者32例32眼,角膜病变未累及内皮层,行角膜板层切除联合那他霉素滴眼治疗,观察记录治疗前后视力、角膜情况、病程、并发症及致病菌种类,对切除组织行组织病理学检查。结果：治疗前视力≤0.05者20眼,～0.3者11眼,〉0.3者1眼。板层切除术后联合那他霉素治疗痊愈28例（87.5%）,治愈时间7～32（平均13.2±8.5）d,痊愈时视力≤0.05者5眼,～0.3者8眼,〉0.3者15眼。病情控制不良改行角膜移植术者4例。31例真菌培养阳性（96.9%）,其中镰刀菌18例,曲霉菌属8例,链格孢霉3例,未知菌属2例。病理学检查显示溃疡灶中有多量中性粒细胞浸润,过碘酸-希夫（PAS）染色显示角膜组织中菌丝多数位于角膜浅层,并呈与板层胶原纤维平行方向生长,但也有少数呈斜形或垂直生长方式,侵及切除组织全层。不同菌属之间菌丝在角膜中生长方式无明显差异。结论：对于病变未累及全层的真菌性角膜溃疡患者,及时行板层角膜切除术可大大提高那他霉素药物治疗有效性,缩短病程,恢复视力。     

真菌性角膜炎板层角膜移植术后复发的临床研究

目的 探讨板层角膜移植术(LKP)治疗真菌性角膜炎术后真菌复发的特点、诊疗方法及危险因素.方法 采用非随机回顾性系列病例研究.收集1998年1月至2005年7月在山东省眼科研究所青岛眼科医院经LKP治疗确诊的真菌性角膜炎患者218例(218只眼),术前详细询问病史,术中选用大于病灶0.5mm的环钻,采用深板层剖切,个别病例加以术中镜检,术后观察真菌的复发特点,对复发者进行药物与手术治疗,并比较在不同菌属和术前给予糖皮质激素或免疫抑制剂治疗、以及有前房积脓或内皮斑等危险因素存在下行LKP术后的复发情况.结果 术后2周有17例(7.80%)真菌复发,其中15例在术后第1周;复发主要表现为局部刺激症状加重、植床中央或边缘出现菌丝浸润灶.17例复发病例均成功行穿透性角膜移植术(PKP)治愈.危险因素分析:曲霉菌属LKP术后复发率(19.23%)高于镰刀菌属(5.63%)(P=0.0323),术前应用糖皮质激素或免疫抑制剂治疗的病例行LKP术后复发率(21.70%)较高(P=0.0219),术前前房积脓或内皮斑的病例LKP术后复发率(17.02%)较高(P=0.0134).结论 LKP治疗真菌性角膜炎的术后复发主要在术后1周内;曲霉菌属、术前经糖皮质激素或免疫抑制剂治疗以及前房积脓或内皮斑等是其危险因素;术中灵活应用手术技巧等可能是降低复发率的有效途径.     

Treatment of advanced acanthamoeba keratitis with deep lamellar keratectomy and conjunctival flap

PURPOSE: To describe whether deep lamellar keratectomy with a conjunctival flap is effective for the treatment of Acanthamoeba keratitis. METHODS: Two patients (three eyes) had at least a 4-week history of painful keratitis misdiagnosed as herpetic keratitis and bacterial keratitis. Both patients were started on multiple topical antiamoebic drugs after Acanthamoeba infection was confirmed. No improvement was observed after 3-4 weeks. Surgery was then performed. Peribulbar anesthesia was given, and the infected tissue was removed by deep lamellar keratectomy. A bipediculate conjunctival flap was put in place and secured with interrupted 10-0 nylon sutures. RESULTS: Both patients experienced immediate pain relief. The infection was controlled and all medications were tapered. There were neither necrosis nor retraction of the flap. Final examination revealed a Best-corrected visual acuity (BCVA) of 20/100 in each eye in the patient described in case number one at 30 months, and 20/100 in the patient described in case number two at 13 months. CONCLUSION: Deep lamellar keratectomy with a conjunctival flap is a suitable approach to help control the infection and to help relieve pain in patients with advanced Acanthamoeba keratitis.     

Corneal biopsy in the diagnosis of keratomycosis

In two patients, a 55-year-old man and a 49-year-old man, who had fungal keratitis initially undiagnosed by corneal scrapings the condition was successfully diagnosed by corneal biopsy. We compared corneal biopsy specimens and corneal scraping in the diagnosis of keratomycosis in rabbits with experimental bilateral fungal keratitis caused by Fusarium solani, Aspergillus fumigatus, and Candida albicans. Corneal scrapings disclosed three specimens (30%) positive for Candida, five (50%) for Fusarium, and six (60%) for Aspergillus keratitis, whereas corneal biopsy specimens showed fungal elements of Fusarium, Aspergillus, and Candida in all inoculated eyes.