姜洋 李莹 王忠海 罗岩 金玉梅

　　作者单位：100730 北京，中国医学科学院北京协和医院眼科

　　姜洋，Email：jiangyangpumch@126.com，联系电话：010-69151668

　　通信作者：李莹，Email：liyingpumch@sohu.com北京协和医院眼科李莹

　　国家自然科学基金项目81170826     

　　【摘要】 目的 分析重症单纯疱疹病毒性角膜炎延误治疗原因及综合治疗效果分析。设计 回顾性病例系列。研究对象2008年09月至2010年12月北京协和医院眼科就诊的重症单疱病毒性角膜炎患者100例（102眼）。方法 对研究对象中52例（53眼）具有完整既往诊治资料患者进行回顾性分析，调查内容包括既往诊治时间、既往诊断及治疗情况，分析延误治疗的可能原因。所有患者视病情应用口服更昔洛韦0.5~1.0 g 每日3次，联合局部更昔洛韦眼用凝胶每日4次抗病毒治疗，并结合患者个体病程、病损情况联合应用低浓度激素0.1％氟米龙滴眼液每日3~6次或口服泼尼松龙20~30 g每日1次；视病情联合应用睫状体松弛剂复方托吡卡胺每日1~3次；角膜存在溃疡、角膜上皮不完整者，预防性应用抗生素滴眼液每日3次；所有病例联合人工泪液及角膜保护剂治疗。治疗前与治疗后1周、2周及4周随访，评估睫状充血、角膜浸润、角膜混浊、角膜水肿、角膜后弹力层皱褶以及角膜后沉着物情况，评价治疗有效率与治愈率。疗效评价应用。主要指标 延误治疗的可能原因，睫状充血、角膜浸润、角膜混浊、角膜水肿、角膜后弹力层皱褶以及角膜后沉着物情况，治疗有效率与治愈率。结果 12例（23.08%）患者误诊为单纯虹膜炎仅应用激素治疗未予抗病毒药物治疗，其中2例误诊为单纯虹膜炎伴角膜带状变性，另有1例误诊为虹膜角膜内皮综合征。32例（61.54%）患者未明确诊断角膜炎类型，其中24例（75%）患者仅应用抗生素治疗完全未应用抗病毒药物。伴有虹膜炎症、小梁网炎症的患者中24例（66.67%）未用激素及睫状肌松弛剂。1例伴小梁网炎眼压继发性升高患者被给予毛果芸香碱每小时1次治疗。应用系统综合治疗后患者体征均有好转，治疗后1、2、4周与治疗前6项体征的（体征评分？请分别具体描述）（补充于观察项目与时间）差异存在统计学意义. F值分别为231.543，136.700，106.031，58.323，19.183，60.590；P值均为0.000）。治疗后随访1年，4例（3.92%）患者复发，3例（2.94%）患者病情控制情况下角膜变薄，未见其他不良情况。结论 重视原发病诊断以及综合治疗是有效治疗重症单纯疱疹病毒性角膜炎的重要保证。

　　The analysis of the causes of treatment effect delay and the comprehensive treatment effect in severe herpes simplex viral keratitis

　　Jiang Yang  Li Ying  Wang Zhong-hai  Luo Yan  Jin Yu-mei

　　From the Chinese Academic of Medical Science, Department of Ophthalmology, Peking Union Medical College Hospital; 100730, Bei Jing, China;

　　Jiang Yang: Email：jiangyangpumch@126.com, Telephone:010-69156366

　　Corresponding author: Li Ying  Email：liyingpumch@sohu.com, Telephone:010-69156366

　　Foundation item: National Natural Science Foundation of China ( No: 81170826 )

　　【Abstract】 Objective  to investigate the cause of delayed diagnosis and treatment of severe herpes simplex keratitis(HSK) and to evaluate the clinical values of comprehensive HSK．Design  retrospective case study. Participants  102 eyes of 100 patients with severe HSK attended to our hospital from September 2008 to November 2010. Methods  retrospective analysis of treatment history was performed in 52 patients(53 eyes) with full record, evaluating the diagnosis and treatment. Ganciclovir were administered 0.5g-1.0g 3 times per day orally and 4 times per day locally combined with 0.1% fluorometholone eye drops3 times per day or 20g-30g prednisolone once orally and tropicamide (ciliary body relaxant ) 1-3 times per day according to the condition. Preventive antibiotics were administered in cases with ulcer and incomplete epithelium, while eye protectants in all cases. Signs were evaluated before and after the therapy 1st week，2nd week and 4th week. Curative effect was analyzed by repeated measure with analysis of variance. Main Outcome Measures  causes of treatment effect delay; ciliary congestion, corneal infiltration, corneal opacity, corneal edema, folding of the Descemet membrane and keratic precipitates; effective and curative rate. Results  12 (23.08%) of severe HSK cases were misdiagnosed as iritis administered with steroid without antiviral drug, 2 patients were misdiagnosed as iritis combined with band degeneration of cornea and 1 patient as iridocorneal endothelial syndrome. Keratitis type of  32(61.54%) cases was not clarified,24(75%) of which were administered with antibiotics without antiviral drug.24(66.67%) patients who suffered iritis or trabecular meshwork inflammation were not administered with steroid or ciliary body relaxant.1patients suffered secondary ocular hypertension caused by trabecular meshwork inflammation was administered with pilocarpine every hour. After the administration，the conditions improved significantly at 1st week，2nd week and 4th week(F=231.543，136.700，106.031，58.323，19.183，60.590；P value=0.000). In the 1 year follow-up observation,  4(3.92%) of patients developed recurrence and 3(2.94%) of patients got their cornea become thin even with the condition under control. No other adverse condition was observed. Conclusion  It is the important guarantee to cure severe herpes simplex viral keratitis that attention should be paid to original disease diagnosis and comprehensive treatment.

　　【Keyword】herpes simplex keratitis; retrospective study; ganciclovir; comprehensive treatment