病例5 85岁女性，右眼间断性异物感、眼痛、流泪伴视物模糊半年余
CASE 5 A 85-year-old female complaining of right eye blurry vision with intermittent foreign body sensation, pain and tearing for more than half a year
见图1-7。See Fig. 1-7.
图1-7 角膜弥漫性水肿，可见中央区上皮大泡样隆起Fig. 1-7 Corneal diffuse edema, bullae in the central area
鉴别诊断
Differential Diagnosis
◎ 大泡性角膜病变：患者多有内眼手术史（最多见于白内障术后人工晶状体眼或无晶状体眼伴玻璃体疝接触角膜内皮）、Fuchs角膜内皮营养不良（图1-8）、青光眼病史等。角膜内皮细胞数量明显降低或内皮功能下降致失代偿。视力下降，角膜上皮雾状水肿，单个或多发大泡，大泡易破裂导致突发的异物感、疼痛、畏光、流泪等症状，随着上皮修复，症状可缓解，该病可反复发生。
◎ Bullous keratopathy: Most of the patients with bullous keratopathy have the histories of intraocular surgery(IOL eye or aphakic eye with vitreous hernia contacting endothelium), or Fuchs corneal endothelial dystrophy(Fig. 1-8), or glaucoma, etc. The quantity of corneal endothelial cells signif icantly decreased led to endothelium dysfunction and severe cornea edema. The cornea appears hazy or opaque which also reduces vision. Single or multiple bullae in the corneal epithelium rupture easily which trigger sudden foreign body sensation, eye pain,photophobia and tearing. The symptom can be improved with the epithelium repaired. But the process occurs repeatedly.
◎ 角膜上皮剥脱：角膜上皮剥脱通常与外伤、严重干眼有关，患者多眼疼、流泪及睁眼困难，裂隙灯显示局部上皮缺损。
◎ Corneal epithelial exfoliation: This disease is usually related to trauma and severe dry eye. The patient complains of painful, tearing and difficulty opening eyes. Certain part of epithelium defect can be examined using a slitlamp.
◎ 角膜内皮炎：角膜内皮炎是原发于角膜内皮的炎症导致角膜功能障碍，病毒感染及自身免疫反应是主要发病原因，裂隙灯可见角膜水肿、角膜后沉着物以及轻度前房反应。
◎ Corneal endotheliitis: The inf lammation originates from endothelium and can lead to corneal endothelium dysfunction. Virus infection such as herpes, and autoimmune reaction are the main causes. Corneal edema, keratic precipitates and mild anterior chamber reaction can be observed by a slitlamp.
病史询问
Asking History
◎ 疾病出现的时间、是否反复、是否患有其他眼部疾病（青光眼、慢性葡萄膜炎、Fuchs角膜内皮营养不良等）。
◎ Asking the duration of disease, similar episodes, other eye diseases (glaucoma, chronic uveitis, Fuchs endothelial dystrophy, etc).
图1-8 共聚焦显微镜下可见角膜内皮细胞增大水肿，六边形结构不清，伴类圆形高反光赘疣Fig. 1-8 Endothelial cells enlarged and swol len, the hexagonal structure was unclear, ac com panied by round high ref lective excrescence
◎ 是否有眼部手术史（白内障手术或其他眼内手术）及家族病史（Fuchs角膜内皮营养不良有家族遗传倾向）。
◎ The history of eye surgery (cataract surgery or other intraocular surgery), the family medical history (Fuchs endothelial dystrophy).
检查
Examination
◎ 视力：雾视，一般晨起重，下午可以改善。严重患者刺激症状明显，难以睁开眼睛。病程较长者，基质层混浊明显，视力显著降低。
◎ Visual acuity: Foggy vision is the most severe in the morning in mild cases and can be improved in the afternoon. In severe cases, the irritation symptoms are obvious and it is difficult to open eyes. In cases with a long course of disease, the stromal layer is turbid and the visual acuity is signif icantly reduced.
◎ 裂隙灯检查：角膜上皮呈雾状，可伴单发或多发大小不等的上皮水泡，角膜基质增厚水肿，后部角膜不清或混浊。病程持续者，角膜基质新生血管长入，基质层逐渐混浊。
◎ Slitlamp examination: The corneal epithelium is foggy,with single or multiple epithelial vesicles of different size,stroma edema and thickening. The deep layer of cornea unclear or opacity. As the course of the disease continues,some signs occur including neovascularization into stroma and stromal layer opacity gradually.
实验室检查
Lab
◎ 角膜共聚焦显微镜：角膜内皮细胞计数通常低于500个 /mm2，共聚焦显微镜显示角膜内皮细胞异常增大，如伴Fuchs角膜内皮营养不良可见角膜内皮细胞间大小不一、类圆形高反光赘疣，大量赘疣可融合，内皮细胞增大、失去多边形结构，甚至结构不清。
◎ Confocal microscope: Endothelial cell density usually less than 500/mm2, abnormal endothelial cells enlargement.The patient with Fuchs endothelial dystrophy has some special signs including different sizes of corneal endothelial cells, round-like highly ref lective excrescence, a large number of verruca can be fused, abnormal endothelial cell swell, lose polygonal structure or even unclear structure.
◎ 基因检测：Fuchs角膜内皮营养不良的患者可行基因检测。
◎ Gene detection: It is available for Fuchs endothelial dystrophy patient.
诊断
Diagnosis
大泡性角膜病变。
Bullous keratopathy.
治疗
Treatment
◎ 高渗剂：50%葡萄糖溶液或5%盐水局部滴用可减轻角膜水肿。
◎ Hypertonic solution(50% hypertonic glucose, 5%normal saline)can reduce corneal edema.
◎ 抗生素眼药水或眼药膏可预防感染。
◎ Antibiotic eye drops or ointment to prevent infection.
◎ 人工泪液、角膜营养类滴眼液及角膜绷带镜可缓解眼部刺激症状，促进上皮愈合。
◎ Artif icial tears, corneal nutrition eye drops and bandage contact lens can relieve eye irritation symptoms and pr om ote epithelial healing.
◎ 手术治疗包括角膜内皮移植术、穿透性角膜移植术、角膜层间烧灼术以及结膜瓣覆盖术。
◎ Surgical treatment includes corneal endothelial transp l antation, penetrating keratoplasty, corneal lamellar cauterization and conjunctival f lap covering.
患者教育和预后
Patient Education & Prognosis
◎ 该疾病病因是各种原因导致的角膜内皮细胞数量降低或功能下降致角膜内皮失代偿。疾病不可逆，非手术治疗只可缓解症状，不能提高角膜内皮细胞数量或提高视力。
◎ The etiology of this disease is corneal decom p e n s ation caused by the decrease of corneal endothelial cells number or function. The disease is irreversible, non-surgical treatment can only alleviate symptoms, can not increase the number of corneal endothelium cells, or improve vision.
◎ 疾病最终为角膜混浊并形成瘢痕，症状或可减轻。对仍有潜在视力的患者，可选择角膜内皮移植手术缓解症状并提高视力。但对于因青光眼等严重疾病导致的角膜内皮失代偿，提高视力的可能性较小。
◎ The outcome of the disease may be corneal op a cif ica tion and scarring, the symptoms may be reli ev ed. For patients who still have potential vision, cor neal endothelial transplantation can be selected to relie ve symptoms and improve vision. But for end ot helial decompensation caused by serious diseases such as glaucoma, it is less likely to improve vision.