严重真菌性角膜炎患者就诊史调查分析

目的　分析真菌性角膜炎延误诊治的原因。方法　对 2 0 0 0年 1～ 12月山东地区 6 9例(6 9只眼 )因严重真菌性角膜炎行穿透性角膜移植术 (penetratingkeratoplasty ,PKP)或眼球摘除术患者的完整资料进行回顾性分析 ,调查内容包括发病原因、就诊时间、检查经过、诊断及治疗情况等 ,分析延误诊治的可能原因。结果　 6 3例行PKP ,6例行眼球摘除术。其中 5 2例角膜植片直径 >8 0mm。农民占就诊患者的 93%。患者就诊的基本程序为村卫生诊所、乡镇医院、县医院及市级以上医院。平均就诊时间为 2 2 9d。 5 4例 (78% )患者曾到县级医院就诊 ,确诊率为 2 4 % ;其中经角膜刮片检查 12例(2 2 % ) ,阳性率为 5 0 %。 30例在市级以上医院就诊 ,确诊率为 6 3% ;其中角膜刮片检查 2 2例 (73% ) ,阳性率为 73%。 35例 (46 % )术前应用抗真菌药物治疗 ,主要为氟康唑。结论　忽视基本诊断技术、缺乏有效眼科抗真菌药物和供体角膜材料、缺少角膜病专业医师是目前真菌性角膜炎延误诊治的主要原因。

A retrospective medical history analysis of the patients with severe fungal keratitis

Objective To investigate the cause of delayed diagnosis and treatment in severe fungal keratitis. Methods Retrospective analysis of the treatment history was performed in patients with severe fungal keratitis which attended to our hospital during 2000 to 2001. The main parameters evaluated were nature of access with the health care services, examinations undertaken, initiated treatment, and the time interval between presentation to each medical contact and to our center. Finally, the management undertaken at our center was evaluated. Results 69 patients (eyes) were enrolled into this investigation, of which 86%(59/69) was local residents in Shandong province, 93%(64/69) was farmer. Penetrating keratoplasty (PKP) were performed for 63 cases with a transplantation of donor cornea > 8.0 mm. However, 6 eyes were enucleated because of the severe endophthalmitis. Most of patients sought medical care following a same procedure: village and towns medical service, county hospital, city medical center. The time interval between the first medical contact and presentation to our center was 22.9 days on average.78%(54/69)patients attended to county hospitals, only 24%(13/54)patients got correct diagnosis of fungal keratitis. Smear examination had been undertaken only in 22%(12/54)of cases, the positive rate was 50%. In 30 patients who initially contact to city medical centers, 63%(19/30)was diagnosed as fungal keratitis,73%(22/30)was given smear examination with positive result of 73%(16/22). The positive rate of corneal scraping for fungus was 93%(64/69).46%(35/69)patients were prescribed antifungal agents of fluoconazole. Conclusion Several factors, including ignoring traumatic history and basic examination techniques, lacking of effective ophthalmic antifungal angents, cornea donor, without qualified ophthalmologists, lead to inappropriate management in fungal keratitis.