病例6　52岁女性，主诉左眼眼红、眼痛1周

CASE 6　A 52-year-old female complaining of left eye redness and severe pain for one week

见图1-9。See Fig. 1-9.

鉴别诊断

Differential Diagnosis

◎ 弥漫性前巩膜炎：巩膜炎是以炎症细胞浸润、胶原破坏、血管改变为病理特征的巩膜炎症性疾病，可由自身免疫性疾病、代谢性疾病或感染引起，患者年龄偏大。巩膜炎分为前部及后部巩膜炎，其中前部巩膜炎最多见，约占98%。前部巩膜炎又分为两种类型：非坏死性及坏死性巩膜炎，以前者最多见。根据形态，非坏死性巩膜炎可分为弥漫性及结节性巩膜炎。坏死性巩膜炎在前部巩膜炎中约占13%。弥漫性前部巩膜炎典型症状为眼红、眼痛，常累及同侧头部或面部疼痛，可伴视力下降。典型体征为巩膜前段弥漫性充血，呈暗红色或蓝紫色，不因局部使用2.5%去氧肾上腺素而收缩变白，不能被棉签推动，伴表面结膜充血水肿，有局部压痛。

◎ Diffuse anterior scleritis: Scleritis is an inf lammation of the sclera characterized by cellular inf iltration, destruction of collagen and vascular remodeling, which is associated with autoimmune diseases, metabolic diseases or infection, patients tend to be older. Scleritis is classif ied as anterior scleritis and posterior scleritis. Anterior scleritis is the most common variety, accounting for about 98% of the cases. It is of two types: non-necrotising and necrotising. Non-necrotising scleritis is the most common, and is further classif ied into diffuse and nodular type based on morphology. Necrotising scleritis accounts for about 13% of anterior scleritis. Typical symptoms of diffuse anterior scleritis are redness, severe eye pain, which may radiate to the ipsilateral side of the head or face, and it may be accompanied with decreased vision. Typical signs are diffuse dark red or purple-bluish congestion in the anterior sclera that does not blanch with 2.5%phenylephrine drops, and cannot be moved with a cotton swab, accompanying with exterior conjunctival congestion,edema and local tenderness.

◎ 表层巩膜炎：这是巩膜表面血管结缔组织的炎症反应性疾病，导致巩膜表面血管充血，可被棉签推动，局部使用2.5%去氧肾上腺素后充血苍白消退。病灶通常位于睑裂区，呈局部弥漫性或结节性充血。患者多见于青中年，除眼红外，可有眼部轻微刺激症状及不适，通常不伴明显眼痛及视力下降，可反复发作，持续时间短，约2周左右，有自限性。

◎ Episcleritis: It is an inf lammatory disease of the vascularized connective tissue overlying the sclera, which reveals episcleral injection. The vessels can be moved with a cotton swab and can be constricted with topical 2.5% phenylephrine. The lesion is more common in the interpalpebral area and presents locally diffuse or nodular congestion. The patients are mainly young adults. The main symptom is redness, accompanying with mild irritation or discomfort without severe pain or decreased vision generally. Episcleritis is usually transient and selflimited within 2 weeks, but can recur.

◎ 感染性巩膜炎：通常由手术、创伤或周边组织感染（如感染性角膜炎、感染性眼内炎）引起，少数由全身性感染性疾病（如梅毒、结核病）引起的巩膜感染性疾病。典型表现为巩膜溃疡，巩膜脓肿伴脓性渗出，可见前房积脓。

◎ Infectious scleritis: It is an infection of the sclera. It is usually caused by surgery, trauma, or extension from contiguous infections, such as infectious keratitis or infectious endophthalmitis. It is less frequent associated with systemic infections such as syphilis and tuberculosis. Key clinical features include scleral ulcers, scleral abscesses with purulent exudates, and scleritis associated with hypopyon.

◎ 结膜炎：这是一类以结膜血管扩张、渗出为特征的疾病，可发生于任何年龄。主要临床症状包括眼红及眼部分泌物，可伴眼痛、眼异物感、眼痒等。结膜充血呈鲜红色，推之可移动，局部使用2.5%去氧肾上腺素后充血消退。睑结膜可受累，出现滤泡、乳头或假膜。

◎ Conjunctivitis: It is characterized by dilatation and exudation of conjunctival vessels at any age. The main clinical symptoms are redness and discharge, may accompanying with eye pain, foreign body sensation, itching,etc. Conjunctival hyperemia shows bright red hue and the expanded vessels are removable, which can be constricted with topical 2.5% phenylephrine. Tarsal conjunctiva often be involved in and associated with follicles, papillae or pseudomembrane appearance.

◎ 急性前葡萄膜炎：主要症状有眼红、眼疼、畏光及视力下降等。典型体征有睫状充血、角膜后沉着物(KP)、房水闪辉、房水细胞等。充血呈深红色，环绕角膜缘，推之不移动。

◎ Acute anterior uveitis: The main symptoms are redness,eye pain, photophobia, and decreased vision. Typical signs are ciliary f lush, keratic precipitates (KP), aqueous f lare and aqueous cell. Ciliary f lush is dark red and immovable,which surrounds the limbus.

◎ 炎性睑裂斑：黄白色、扁平或轻微隆起的结膜炎症性病变，病变多发于鼻侧或颞侧。结缔组织由病变部位延伸至角膜缘，但不累及角膜。病灶周边结膜充血，通常双眼发病。

◎ Inf lamed pinguecula: yellow-white, f lattened or slightly elevated conjunctival inf lammatory lesion adjacent to the nasal or temporal side of the limbus and usually occurring in both eyes. Connective tissue extends from the lesion to the limbus, but does not involve the cornea. Surrounding conjunctival injection may be associated.

◎ 角膜接触镜性眼病：可由角膜接触镜沉淀物、镜片过紧或护理液毒性反应等角膜接触镜配戴时的相关问题导致，出现畏光、异物感、眼痛、眼红、视力下降、不耐受角膜接触镜等症状。角膜接触镜配戴者须关注。

◎ Contact lens-related problems: May be caused by contact lens deposits, tight lens syndrome or toxicity reactions to contact lens solution. Symptoms are photophobia, foreign body sensation, pain, red eye, decreased vision, contact lens intolerance. Must be considered in all contact lens wearers.

病史询问

Asking History

◎ 眼部症状出现及进展情况，除了眼红、眼痛（可放射至同侧面颊及头部），是否伴随视力下降、畏光、眼部分泌物等症状。

◎ It is imperative to ask about the onset and progre s s ion of ocular symptoms, such as eye pain (which may radiate to the ipsilateral side of the cheek or head), redness, decreased vision, photophobia and discharge, etc.

◎ 既往是否有自身免疫性疾病（如结节病、类风湿性关节炎等）、结核病、代谢性疾病等，有无头痛、过敏史、眼部外伤史或手术史。

◎ Patients should also be asked about a history of autoim mune diseases (such as sarcoidosis, rheumatoid arthritis,etc), tuberculosis, metabolic diseases; the history of hea d ac he, allergies, eye trauma and surgery.

◎ 是否有角膜接触镜配戴史。

◎ And the history about wearing contact lens.

◎ 该病例合并类风湿性关节炎。

◎ This case has rheumatoid arthritis.

检查

Examination

◎ 视力：可能伴渐进性或急性视力下降。

◎ Visual acuity: decreased vision onset may be gradual or acute.

◎ 眼压：根据不同病因，可能出现眼压升高。

◎ IOP: Depending on the etiology, intraocular pressure may increase.

◎ 巩膜外观检查：巩膜炎在自然光或室内呈现紫蓝色充血外观，检查时须提拉眼睑以便明确充血范围。

◎ Sclera appearance examination: Scleritis is best detected as purple-bluish congestion by examining the sclera under natural or room light; retracting the lids helps determine the extent of involvement.

◎ 裂隙灯检查：除检查充血部位及特征外，应注意排除有无睑结膜充血、滤泡乳头，有无角膜内皮KP、房水闪辉、房水细胞等表现。局部使用2.5%去氧肾上腺素后观察充血是否变白消退，有助鉴别巩膜炎与表层巩膜炎，前者点药后充血不消退，后者相反。

◎ Slitlamp examination: In addition to characteristic congestion, the below signs, such as tarsal conjunctival congestion, follicles, papillae, corneal endothelial KP, aqueous f lare, aqueous cell and other relative manifestations should also be noted. Scleritis may be differentiated from episcleritis by using 2.5% phenylephrine drops, which causes blanching of the blood vessels in episcleritis, but not in scleritis.

◎ 眼底检查：怀疑后部巩膜炎时，应进行眼底检查。

◎ Fundus examination: should be performed when posterior scleritis is suspected.

◎ 眼球按压检查：充血部位是否有压痛。

◎ Press eyeball: to check if there is tenderness over the area of scleral congestion.

◎ 怀疑后部巩膜炎时，行以下检查。

◎ Perform the following examinations when posterior scleritis is suspected.

B超：巩膜壁是否有厚度改变。后部巩膜炎，B超可显示眼球后壁T形征。

B-scan: check the changes in the thickness of the scleral wall.B-scan detect T signe, which help to differential posterior scleritis.

眼底光学相干断层扫描(OCT)：是否有脉络膜皱褶和视网膜下液。

Posterior segment OCT: check choroidal folds and subretinal f luid.

荧光素眼底血管造影(FFA)：了解眼底血管渗漏情况（后巩膜炎可有视网膜血管多发针尖样渗漏）。

Fundus f luorescein angiography: check the leakage of vessels in the fundus (posterior scleritis can have retinal vascular pinpoint leakage).

实验室检查

Lab

◎ 血常规、免疫学检查（红细胞沉降率、C反应蛋白、类风湿因子、抗核抗体等），排除是否合并自身免疫性疾病或感染；血清尿酸检测，排除是否合并痛风。

◎ Complete blood count, immunologic tests (blood sedimentation, C-reactive protein, rheumatoid factor,antinuclear antibodies, etc) should be done in order to rule out the autoimmune diseases or infection. Uric acid should be tested if gout is suspected.

◎ 若怀疑感染，进一步行涂片镜检及培养。

◎ If infection is suspected, further scraping for microscopy examination and culture should be performed.

诊断

Diagnosis

弥漫性前部巩膜炎。

Diffuse anterior scleritis.

治疗

Management

◎ 局部治疗：轻症患者可考虑激素类滴眼液，可联合局部非甾体抗炎药。严重巩膜炎及坏死性巩膜炎时应禁用局部激素。

◎ Topical treatment: Mild cases can use cortico s t er oids eye drops, combined with topical non-steroidal antiinf lammatory drugs (NSAIDs). Corticosteroids is never for severe scleritis and necrotizing scleritis.

◎ 若合并葡萄膜炎及眼底病变，给予相应治疗。

◎ If the patients are combined with uveitis or fundus diseases, the corresponding treatments should be provided.

◎ 全身治疗：眼部病情较重或合并明确的活动性全身免疫性疾病者，可联合全身药物治疗。

◎ Systemic treatments: for severe scleritis or whom accompanying with active systemic immune diseases.

口服非甾体抗炎药：如氟比洛芬、吲哚美辛、萘普生等，缓解炎症性疼痛。

Oral NSAIDs: f lurbiprofen, indomethacin or naproxen can be applied for relieving inf lammatory pain.

口服激素：非甾体抗炎药无效时，考虑激素治疗。视病情变化，持续口服激素1~2周后，逐渐减量使用。其间配合补充钾和钙，以预防骨质疏松；激素用量较大者可考虑应用静脉注射激素3日后改为口服。

Systemic corticosteroids: steroids therapy should be considered when oral NSAIDs is ineffective. According to the changes of disease, the patients should maintain steroids treatment for 1 to 2 weeks, then taper the dosage slowly. Potassium and calcium should also be supplemented to prevent osteoporosis during steroids treatment. The patients who need a high dosage of steroids can be considered the intravenous corticosteroids for 3 days and then replaced by oral way.

免疫抑制剂：上述方案治疗不佳或激素用量较大者，可在相关专科医师指导下使用免疫抑制剂（如环磷酰胺、硫唑嘌呤、环孢素等），联合应用可降低口服激素剂量。

Immunosuppressive therapy: if above treatments are ineffective or in the case of a large dosage of steroids treatment, immunosuppressants (e.g., cyclophosphamide,azathioprine, cyclosporine) can be chosen under the specialized guidance to reduce the dose of steroids.

◎ 控制活动性全身免疫性或代谢性疾病。

◎ Control active systemic immune diseases or metabolic diseases.

◎ 其他：若确诊为感染性巩膜炎，选择敏感性抗生素，并慎重选择激素及免疫抑制剂。

◎ Others: sensitive antibiotics should be used in infectious scleritis cases and in that condition, steroids and immunosuppressants should be considered carefully.

患者教育和预后

Patient Education & Prognosis

◎ 本病病程持续较久，可持续1个月以上，可复发。须规范持续治疗，定期眼科复查。

◎ Diffuse anterior scleritis can last for more than 1 month and tend to recur. Patients should have a standardized continuous treatment under strict follow-up.

◎ 积极控制原发病，预后情况在很大程度上取决于原发全身性疾病是否得到充分治疗及控制。注意观察用药期间有无产生副作用，必要时定期复查免疫指标。

◎ Actively control of the primary diseases. The prognosis depends greatly on whether the primary systemic disease can be treated adequately. Pay attention to the side effects of the drugs, and test the immune indexes regularly if necessary.