两性霉素B角膜基质和前房内注射治疗真菌性角膜脓肿

目的分析两性霉素B角膜基质联合前房注射治疗真菌性角膜脓肿的临床效果。方法回顾性分析我院真菌性角膜脓肿12例12眼,患者均有植物性外伤史,病灶均位于角膜深基质层或内皮面,共焦显微镜检查均见角膜基质内真菌菌丝。常规治疗无效后给予基质联合前房注射0.10g·L-1两性霉素B,其中,基质注射时为在角膜脓肿病灶边缘相对健康角膜处选取4～6个注射点,每点注射约0.02mL,前房注射时为一次性前房注入0.10mL。记录治疗前及治疗后视力、眼压、角膜情况、前房反应以及晶状体状况。术前及术后3个月行角膜内皮检查。结果 6眼1次注射后病灶缩小,未需重复注射病情痊愈;4眼行2～3次注射后病情控制;2眼1次注射后病情仍发展,改行球结膜瓣遮盖术痊愈。术后视力较术前平均提高1.3行。角膜内皮细胞密度治疗前为(2164±156)mm-2,治疗后3个月为(2218±262)mm-2,治疗前后差异无统计学意义(P=0.874)。1眼2次注射后晶状体混浊加重;1眼有一过性眼压升高;5眼治疗后24h前房反应明显,48h后消退。结论两性霉素B角膜基质联合前房注射可以有效治疗真菌性角膜脓肿。     

两性霉素B经三种途径给药后在角膜和房水中药物浓度的实验研究

背景角膜基质内注射或前房内注射两性霉素B治疗顽固的真菌性角膜炎取得较好疗效，但通过这2种途径给药后，药物在角膜和房水的浓度变化尚不清楚。目的探讨质量分数0．25％两性霉素B滴眼液点眼、1％两性霉素B注射液角膜基质内注射及1％两性霉素B注射液前房内注射3种途径给药后兔眼角膜和房水中的药物质量浓度变化。方法健康家兔45只按随机数字表法分为A、B、C3组，每组15只。A组、B组分别在角膜基质内和前房内单次注射10¨g两性霉素B注射液，C组兔眼机械法去除角膜上皮后用0．25％两性霉素B滴眼液点眼，每次50仙l，共6次，每次间隔5rain。分别于用药后30min、6h、1d、3d、7d各处死3只实验兔，获取房水和角膜组织，采用高效液相色谱法进行两性霉素B质量浓度的定量检测。结果在质量浓度0．10～100．00mtg／L范围内，两性霉素B的峰面积与吸收度之间具有良好的线性关系；0．10mg／L为其定量限质量浓度；药物在房水的回收率为89．1％～95．7％，在角膜中为81．4％～83．6％。用药后30rain、6h、1dA组角膜中的药物质量分数高于B组及C组，差异均有统计学意义（P〈0．05），高药物质量浓度可持续7d，超出绝大多数敏感真菌的MIC。。。用药后30min、6h、1dB组兔眼房水中的药物质量浓度高于A组及C组，差异均有统计学意义（P〈0．05）。C组1d内角膜和房水中均检测到明显药物浓度。结论兔眼角膜基质内注射及前房内注射两性霉素B可以提高药物在角膜及房水中的质量浓度，清除角膜上皮可以提高两性霉素B的角膜穿透力。     

链格孢菌性角膜炎一例

患者男性,45岁.因右眼石片击伤后眼红痛、异物感、畏光流泪并视力下降进行性加重1周,于2007年12月3日来南昌大学第二附属医院眼科门诊就诊.全身体检正常.眼部检查:视力右眼为眼前手动,左眼为0.8;右眼结膜混合性充血,角膜近瞳孔区偏下方町见一溃疡灶,呈灰白色,欠光泽,表面微隆起,被覆脓苔样物,溃疡面积大小约6 mm×6 mm,周边角膜尚透明,前房积脓(图1),眼后节情况窥不清.诊断:右眼真菌性角膜溃疡.行右眼角膜刮片培养检查,碘酊烧灼右眼角膜溃疡面,结膜下注射氟康唑注射液0.2 ml,依据病情次日或隔日再次给予相同治疗;局部交替频繁滴用两性霉素B眼液、氟康唑眼液及那他霉素眼液;全身静脉滴注氟康唑注射液200 mg,1次/日,1周后停用,治疗过程中密切注意肝肾功能变化.     

链格孢菌性角膜炎一例

患者男性,45岁.因右眼石片击伤后眼红痛、异物感、畏光流泪并视力下降进行性加重1周,于2007年12月3日来南昌大学第二附属医院眼科门诊就诊.全身体检正常.眼部检查:视力右眼为眼前手动,左眼为0.8;右眼结膜混合性充血,角膜近瞳孔区偏下方町见一溃疡灶,呈灰白色,欠光泽,表面微隆起,被覆脓苔样物,溃疡面积大小约6 mm×6 mm,周边角膜尚透明,前房积脓(图1),眼后节情况窥不清.诊断:右眼真菌性角膜溃疡.行右眼角膜刮片培养检查,碘酊烧灼右眼角膜溃疡面,结膜下注射氟康唑注射液0.2 ml,依据病情次日或隔日再次给予相同治疗;局部交替频繁滴用两性霉素B眼液、氟康唑眼液及那他霉素眼液;全身静脉滴注氟康唑注射液200 mg,1次/日,1周后停用,治疗过程中密切注意肝肾功能变化.     

氟康唑前房冲洗综合疗法治疗角膜外伤后真菌性角膜溃疡

目的 观察氟康唑前房灌注或前房注射治疗真菌性角膜溃疡的临床效果.方法 对11例(11眼)应用0.1％氟康唑液灌注式前房冲洗和0.5％甲硝唑静脉滴注及滴眼.结果 11例中10例感染控制,角膜病灶瘢痕修复.1例角膜病灶未完全修复自动出院.11眼中4眼视力提高:治疗后0.25者2眼;0.1、0.2者各1眼.其余患眼视力无提高(其中1眼行眼球摘除手术)未发现眼内组织中毒损害及角膜内皮损伤、失代偿等不良反应发生.结论 氟康唑液前房灌注或注射是治疗真菌性角膜炎的一种有效方法.     

角膜板层切除氟康唑角膜基质注射联合自体结膜移植治疗真菌性角膜炎

目的: 探讨角膜板层切除、氟康唑角膜基质注射、自体结膜移植三联术治疗中、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: 对我院2005-03/2010-06药物治疗效果不显著、病灶位于角膜中、浅层的真菌性角膜炎患者168例,大于病灶边缘0.5mm角膜刀板层切除病变角膜至基本透明,角膜基质注射2g/L氟康唑至水肿区大于病变区切缘约0.5mm,依病灶大小自患眼就近取带蒂结膜瓣连续缝合覆盖植床。术后第1d常规开放点眼,并观察角膜感染有无复发,注射造成水肿消退情况,结膜植片血运及患眼刺激症状,及视力变化。结果: 患者157眼成功实施三联手术治疗,占拟实施此术式患者93.5%;术后7d好转率96.2%,术后1mo,复发率3.8%,痊愈率95.5%,好转率0.6%;注射药物后角膜基质水肿平均消退时间为13.4h;术后1mo视力较术前提高者占24.8%,无明显变化者占58.0%,下降者占17.2%;角膜内皮损失率0～8%,平均2.9%;术后刺激症状:轻度87%,中度10%,重度3%;住院天数平均7.3d;住院费用平均2160元;术后3mo发现4例角膜轻微膨隆。结论: 角膜板层切除、氟康唑角膜基质注射、自体结膜移植三联术治疗早、中期真菌性角膜炎经济实用、疗效好、痊愈快,二期常规安全行光学性角膜移植术,对于经济条件差患者和角膜供体短缺地区,三联手术可作为首要选择。     

眼局部应用两性霉素B脂质体治疗外伤后真菌性角膜溃疡

目的观察眼局部应用两性霉素B脂质体治疗氟康唑无效的外伤后真菌性角膜溃疡的临床疗效。方法选择外伤后经角膜共焦显微镜及实验室检测确诊为真菌性角膜溃疡（溃疡直径≤5mm）27例（27眼）。其中角膜溃疡13例,角膜溃疡并前房积脓14例。在应用氟康唑治疗无效后应用两性霉素B脂质体滴眼以及前房注药治疗,同时进行常规溃疡面清创、碘酊烧灼治疗,观察其疗效。结果27眼中有22眼达到临床治愈,视力均较术前提高,5眼无效。此5眼中角膜溃疡中有1眼中途放弃治疗,1眼角膜穿孔后行角膜移植;前房积脓者中,1眼中途放弃、1眼行角膜移植;1眼行眼内容物摘除术。结论在早期快速诊断前提下,眼局部使用两性霉素B脂质体是目前治疗外伤后重症真菌性角膜溃疡有效方法之一。     

角膜放线菌病二例

角膜放线菌病是一种非常少见的感染性角膜病 ,因发病原因及临床表现与真菌感染相似 ,常误诊为真菌性角膜炎。我们收治 2例角膜放线菌病患者 ,经角膜刮片或细菌培养得到证实 ,现报告如下。例 1　男 ,5 7岁。因右眼被稻谷崩伤后 ,出现畏光、视力下降 2 4ｄ ,于 1997年 2月 9日入院。患者曾在外院拟诊为“右眼真菌性角膜炎” ,予以抗真菌药物治疗无效。体检未见异常。眼部检查 :视力右眼 0 0 2 ,左眼 1 2。右眼球结膜混合性充血 (++) ,角膜外下方可见 4ｍｍ× 3ｍｍ灰白色隆起病灶 ,边界不清 ,周围有白色颗粒样线状混浊 ,前房积脓 2ｍｍ。瞳孔…     

诺卡式菌性角膜炎表现为盘状角膜炎1例

目的:报告诺卡式菌属感染引起的盘状角膜炎病例1例。方法:病例报告。结果:患者,男,13岁,无角膜接触镜使用史,在小溪里游泳后,右眼疼痛伴视力下降2wk。最佳矫正视力:右眼6/30(0.2)。检查发现角膜基质存在形态规则的旁中心盘状浸润伴炎症反应。角膜敏感度下降。最初角膜刮片镜检行革兰氏染色阴性,棘阿米巴角膜刮片和培养阴性。诊断为病毒性盘状角膜炎,给予口服阿昔洛韦和局部使用激素眼药水。2wk后患者视力恶化伴角膜损伤加重,再次角膜取材刮片行革兰氏染色提示诺卡式菌属感染,按经验局部给予3g/L加替沙星眼药水后,临床效果明显。治疗6mo后,视力达到6/6仅在角膜中心留有少量角膜混浊。结论:诺卡式菌属感染延误诊断可以导致病情恶化。如果采用正确的治疗,诺卡式菌属感染引起的角膜炎可以恢复良好,仅留少量瘢痕,获得较好的视力。     

臭氧溶液对实验性真菌性角膜炎的治疗研究

目的探讨臭氧生理盐水对实验性真菌性角膜炎的治疗作用。方法在体外杀菌实验研究的基础上，进步观察臭氧水对兔结角膜组织的毒性作用；选定适宜浓度的臭氧液用于真菌性角膜炎的治疗研究，观察疗效。结果1．浓度高于6mg／L的臭氧生理盐液点眼，可损伤免眼结角膜组织。浓度为4mg／L的臭氧液点眼。对角膜无刺激作用。与生理盐水点眼相同。2．浓度为5mg／L臭氧液点眼，治疗兔真菌性角膜炎有效。结论适宜浓度的臭氧生理盐液对实验性真菌性角膜炎有治疗作用。可进一步引入临床治疗。     

Management of tunnel fungal infection with voriconazole

A 59-year-old woman presented 1 month after cataract surgery in the right eye with a stromal infiltrate at the site of the cataract surgery wound. The visual acuity was perception of light with accurate projection. Corneal scraping of the infiltrate revealed septate hyphae. There was no response to 6 weeks of therapy with topical fortified antibiotic agents and topical antifungal therapy in the form of natamycin 5%, amphotericin B 0.15%, and intracameral amphotericin B. The patient was started on oral voriconazole 200 mg twice daily and topical voriconazole 1% every hour, and resolution of the ulcer was noted within 3 days. At the 4-month follow-up, a visual acuity of 20/60 was achieved, with the formation of a vascularized corneal opacity superiorly. This case illustrates that topical and oral voriconazole may be used in the treatment of recalcitrant cases of fungal tunnel infections not responding to conventional antifungal therapy.     

Therapeutic effect of intracameral amphotericin B injection in the treatment of fungal keratitis

PURPOSE: To study the therapeutic efficacy of intracameral amphotericin B (ICAMB) injection in the treatment of fungal keratitis. METHODS: Fourteen patients with fungal keratitis received ICAMB, 10 microg/0.1 mL (group A), and 17 patients received conventional treatment only (group B). Visual acuity, time to hypopyon disappearance, time to epithelial defect closure, time to final improvement, and final outcome were analyzed and compared between the 2 groups. The concentration of amphotericin B in the aqueous humor after injection was measured using high-performance liquid chromatography. RESULTS: The mean final visual acuity (log MAR) was 1.6 +/- 1.1 in group A and 1.3 +/- 1.4 in group B (P = 0.24). The mean time to disappearance of hypopyon, epithelial defect closure, and final improvement was 9.4 +/- 9.4, 19.8 +/- 10.4, and 26.6 +/- 9.2 days in group A and 26.7 +/- 21.3 (P = 0.03), 32.6 +/- 22.8 (P = 0.08), and 52.8 +/- 38.2 days (P = 0.04) in group B, respectively. At the last follow-up, treatment success was achieved in 92.9% of group A and 82.4% of group B (P = 0.38). The mean concentration of intracameral amphotericin B was 601.6 +/- 51.3 ng/mL at 6 hours, 98.8 +/- 43.1 ng/mL at 1 day, 57.0 +/- 11.6 ng/mL at 3 days, and 52.3 +/- 8.3 ng/mL at 7 days after injection. CONCLUSIONS: ICAMB seems to be effective in reducing time to disappearance of hypopyon and final improvement in the treatment of fungal keratitis.     

Fungal keratitis after nonpenetrating glaucoma surgery

PURPOSE: The purpose was to report a case of fungal keratitis that occurred following viscocanalostomy. METHODS: A 63-year-old man who underwent viscocanalostomy in his left eye presented with pain, redness, watering, and a decrease in visual acuity. Slit lamp examination showed teardrop-like stromal infiltration of the superior cornea. Corneal and conjunctival scrapings were obtained and a corneal biopsy was performed. RESULTS: Microscopic examination of smears demonstrated no bacteria and fungi. Corneal biopsy revealed dichotomously branching, septate hyphae suggestive of Aspergillus species. Culture identified no microorganism. The patient responded to amphotericin B treatment and the corneal infiltration resolved, leaving a plaquelike corneal scar. CONCLUSION: Fungal keratitis may occur after viscocanalostomy, but prompt diagnosis and treatment can preserve the eye.     

深基质真菌性角膜炎综合治疗方案的疗效评估

目的：探讨基于角膜基质内注射伏立康唑的综合治疗方案对感染灶浸润深度达1/2角膜基质以上的 深基质真菌性角膜炎的有效性和安全性。方法：回顾性临床研究。选择2013年3月至2017年7月 于温州医科大学附属眼视光医院行角膜基质内注射伏立康唑治疗的深基质真菌性角膜炎患者62例 （62眼）的资料进行分析。观察指标包括年龄、溃疡直径、治愈率、复发率以及并发症情况等,注射 术后至少随访6个月;并根据角膜基质内注药效果将患者分为单纯角膜基质内注药有效组和单纯角 膜基质内注药无效组。采用独立样本t检验及卡方检验对数据进行统计分析。结果：62例患者的溃 疡直径为2.8～11.0（5.5±2.1）mm,患者发病到就诊时间为2 d～2年（44.2±98.6）d,其中6例患者主 诉病史超半年,56例患者发病到就诊时间为（21.2±13.6）d;术后随访6～36（10.5±7.5）个月。单纯 角膜基质内注射伏立康唑治愈42例（42眼）;1例（1眼）患者角膜基质注药有效后为提高视力行角膜移 植;单纯角膜基质内注射伏立康唑无效19例（19眼）,联合行结膜瓣覆盖治疗后,治愈11眼,需再行 角膜移植8眼,其中2眼术后复发。该综合治疗方案治愈率为85.5%,复发率为3.2%。单纯角膜基质 内注药有效组溃疡直径小于单纯角膜基质内注药无效组,差异有统计学意义（t=-2.199,P=0.032）。 术中及术后随访均未见并发症。结论：角膜基质内注射伏立康唑对常规药物治疗无效的深基质真菌 性角膜炎有良好的疗效并且安全性较高。而对于病灶范围广泛的患眼,单纯角膜基质内注药疗效欠 佳,联合结膜瓣覆盖治疗可提高治愈率。     

The Effect of a Comprehensive Treatment Regimen for Deep Stromal Fungal Keratitis

Objective: To evaluate the efficacy and safety of a comprehensive treatment regimen based on intrastromal voriconazole injection in the treatment of deep stromal fungal keratitis in which the lesion has infiltrated more than half of the corneal stroma. Methods: This was a retrospective study. Sixty-two patients (62 eyes) with deep stromal fungal keratitis who underwent intrastromal voriconazole injection were selected at the Eye Hospital, Wenzhou Medical University from March 2013 to July 2017. Age, the diameter of the ulcer, cure rate, recurrence rate, complications, etc., were measured. All the patients were followed up for at least 6 months. Sixty-two patients were divided into an effective group (EGII) and an ineffectivegroup (IGII) based on the effect of the pure intrastromal voriconazole injection. The data were analyzed by an independent samples t-test and Chi-square test. Results: The 62 patients had ulcer diameters ranging from 2.8 to 11.0 (5.5±2.1)mm. The time from onset to treatment for the 62 patients ranged from 2 days to 2 years (44.2±98.6)days. Six patients sought treatment more than half a year after onset, and the remaining 56 patients had an onset time of 21.2±13.6 days. All patients were followed up for 6 to 36 (10.5±7.5)months. Forty-two patients (42 eyes) were cured by pure intrastromal voriconazole injection, 1 patient (1 eye) underwent a corneal transplant to improve vision after intrastromal voriconazole injection was effective; 19 patients (19 eyes) underwent conjunctival flap coverage after the injection failed. Combined with conjunctival flap coverage, 11 eyes were cured, 8 eyes required corneal transplants, and 2 patients relapsed after corneal transplants. The cure rate of the comprehensive treatment regimen was 85.5%, and the recurrence rate was 3.2%. The EGII group had a smaller ulcer diameter than the IGII group, and the difference between the two groups was statistically significant (t=-2.199, P=0.032). There were no complications during or after the operation. Conclusions: Intrastromal voriconazole injection has a safe and beneficial effect on deep stromal fungal keratitis that does not respond to conventional drugs. For eyes with a wide range of lesions, the effect of pure intrastromal voriconazole injection was not good, but the cure rate can be improved when treatment is combined with conjunctival flap coverage.     

Scytalidium keratitis: case report in a human eye

PURPOSE: To describe the presentation and treatment of a case of an atypical reticular corneal infiltrate with surrounding immune-like ring in a young woman caused by Scytalidium fungal species. METHODS: Interventional case report describing the clinical appearance, course, and treatment of Scytalidium keratitis. RESULTS: A 21-year-old female equestrian with a history of soft contact lens wear was noted to have persistent keratitis and photophobia of the right eye after an injury with a volleyball. Although initially culture negative and responsive to topical steroids, the keratitis persisted, and repeat corneal scrapings and cultures revealed Scytalidium species. Treatment with topical amphotericin B 0.15% and oral fluconazole 200 mg twice daily eradicated the infection, and the patient had a final best-corrected visual acuity of 20/20. CONCLUSION: Scytalidium species fungal organisms can cause an indolent keratitis. Intensive oral and topical antifungal therapy was successful in eradicating the infection.     

Successful treatment of Paecilomyces lilacinus endophthalmitis after foreign body trauma to the cornea

PURPOSE: To report the successful treatment of a patient with Paecilomyces lilacinus endophthalmitis infection after foreign body (FB) trauma to the cornea. METHODS: A 30-year-old man presented to us with a corneal abscess and iritis 2 months after removal of a metal corneal FB. Initial corneal biopsy culture was negative. Treatment with topical 5% natamycin, 0.9% fortified gentamycin, and 5% cephalothin hourly was commenced. As a result of developing signs of endophthalmitis, two more biopsies were taken, a week apart, from the vitreous and anterior chamber, successively. The last biopsy yielded positive microbiologic results of the specious Paecilomyces lilacinus. Intravitreal injection of 50 microg/0.5 mL of amphotericin was administered during the vitreal biopsy. Soon after isolating the specious Paecilomyces lilacinus, the following treatment was administered: 200 mg of itraconazole bd by mouth, 5% topical natamycin every hour, 2 mg/mL of topical fluconazole every 2 hours, three anterior chamber injections of 0.35 mL of 0.1% fluconazole and two amphotericin B injections to the anterior chamber of 50 microg/0.5 mL each. RESULTS: There appeared to be no sign of infection 6 months after initial treatment. A large, dense scar existed in the medial part of the cornea only. The pupil was secluded. The patient's visual acuity was 6/21. The eye was comfortable and all topical antifungal medication was ceased.