严重真菌性角膜溃疡导致眼内炎的原因分析

目的 探讨避免治疗失败的临床策略.方法 对青岛眼科医院1999年1月至2008年12月期间收治的真菌性角膜溃疡导致眼内炎患者的发病原因、入院前治疗经过、临床特征和实验室检查结果进行回顾性分析.结果 47例眼内炎患者以农村居民(95.7%)为主.眼外伤是真菌性角膜溃疡的最主要病因(66.0%).3例患者在发病后曾应用激素药物.在患者首诊医院中,一级医院、二级医院和三级医院分别占68.1%、17.0%和14.9%.各级医院相应真菌性角膜溃疡正确诊断率分别为31.3%、62.5%和71.4%.患者从发病到入我院治疗平均时间为(29±23)d.镰刀菌属是最常见的致病菌属(91.5%),其中前3位菌种分别为茄病镰刀菌(48.9%)、尖孢镰刀菌(31.9%)和串珠镰刀菌(8.5%).21例患者进行了抗真菌药物敏感性试验,前三位敏感药物分别为那他霉素(88.9%)、伏立康唑(78.6%)和两性霉素(61.9%);前三位耐药药物分别为咪康唑(90.5%)、氟康唑(66.7%)和伊曲康唑(61.9%).结论 基层医院首诊正确诊断率低、非敏感药物使用和患者就诊不及时是真菌性角膜溃疡导致眼内炎的主要原因.提高基层医院诊疗水平,重视药物敏感性检测以及完善社会保障体系和转诊制度是避免治疗失败的有效措施.

Severe fungal corneal ulcer resulting in infectious endophthalmitis

Objective To analyze causes of serious fungal corneal ulcer resulting in infectious endophthalmitis and explore clinical strategies of avoiding the failure of antifungal therapy. Methods Etiological factors, pre-hospital treatments, clinical features and laboratory findings of 47 inpatients with fungal corneal ulcer resulting in endophthalmitis from January 1999 to December 2008 in Qingdao eye hospital were retrospectively reviewed. Results Rural residents (95.7%) dominated in 47 cases with a mean age of (49. 8 ± 10.1 ) years. Ocular trauma was the leading cause of fungal corneal ulcer ( 66. 0% ) . Three patients were ever treated with hormone drugs after the fungal infection. Primary, secondary and tertiary hospital accounted for 68. 1%, 17.0% and 14.9% among first medical consultation sites. Diagnostic accuracies of fungal corneal ulcer in three grade hospitals were 31.3%, 62.5% and 71.4%respectively. The average interval from the onset of disease to the admission into our hospital was (29 ±23 )days. The dominating pathogen was genus Fusarium ( 91.5% ) with F. solani (48. 9% ), F. oxysporum (31.9%) and F. moniliforme (8. 5% ). Antifungal drug sensitivity tests were performed in 21 patients.The first three sensitive drugs were natamycin (88. 9% ), voriconazole (78. 6% ) and amphotericin B(61.9%). The first three drug-resistant ones were miconazole (90. 5%), fluconazole (66. 7% ) and itraconazole (61.9%). Conclusion Main causes of fungal corneal ulcer resulting in infectious endophthalmitis included lower diagnostic accuracies of first medical consultation in primary hospitals,abuses of non-sensitive drug and delayed treatment of patients. Improving clinical capabilities of doctors in primary hospitals, emphasizing antifungal drug susceptibility tests, and consummating the social security system and the referral system could be effective measures to avoid therapeutic failures.