病例3　64岁老年女性，发现左眼眼红伴异物感5年余

CASE 3　A 64-year-old female complaining of left eye redness and foreign body sensation for more than 5 years

见图1-4。See Fig. 1-4.

鉴别诊断

Differential Diagnosis

◎ 翼状胬肉：位于角膜上隆起的三角形纤维血管球结膜组织，基底位于角膜缘旁的结膜，尖端指向角膜中央。翼状胬肉通常是在角膜缘处与角膜缘粘连，而假性胬肉可累及球结膜、穹窿结膜或者睑结膜，跨越角膜而无粘连。

◎ Pterygium: It is a triangular f ibrovascular bulbar conjunctival tissue ingrowth over the limbus encroach onto the cornea. The base part of pterygium located in the bulbar conjunctiva near the corneal limbus and the tip pointing toward the center of the cornea. The pterygium adheres to the limbus, while the pseudopterygium is the adhesion of the tarsal conjunctiva, usually across the limbus without adhesion.

◎ 假性胬肉：常见原因包括眼部化学伤、手术、机械性眼外伤、瘢痕性结膜炎、周边角膜溃疡、严重感染性炎症或结膜瘢痕化等。假性胬肉通常跨过角膜缘处不形成粘连。该病可发生在角膜缘的任何位置，而翼状胬肉多发生在角膜的3：00位和9：00位。

◎ Pseudopterygium: It is the secondary changes due to the common causes including chemical injuries,surgery, eye trauma, scarring conjunctivitis, peripheral corneal ulcers, severe infectious inf lammation or cicatrizing conjunctivitis. The band of conjunctiva adheres to the cornea at its apex. The disease can occur at any position of corneal limbal, while pterygium occurs mostly at 3 o’clock and 9 o’clock of cornea.

◎ 睑裂斑：位于睑裂区靠近角膜缘的变性球结膜，为一呈水平带状、三角形或椭圆形隆起的灰黄色病灶，一般不侵犯角膜。

◎ Pinguecula: It is located on the bulbar conjunctiva near the limbus, not encroach onto the cornea. It is degenerative changes of bulbar conjunctival tissue. It can be ribbonshaped, triangular, or oval, which is a raised gray-yellow lesion, generally do not invade the cornea.

病史询问

Asking History

◎ 询问病程进展。

◎ Asking the onset and progression of the lesion.

◎ 询问眼部外伤史、化学烧伤史、眼部手术史。

◎ Asking the history of eye trauma, chemical burn, surgery.

◎ 询问是否长时间户外工作。

◎ Asking if he has been working outdoors for a long time.

◎ 询问疾病原发或术后复发。

◎ Asking if there was treatment with surgery previously.

检查

Examination

◎ 视力：较小的翼状胬肉多无症状，胬肉较大较厚时会引起角膜散光，侵及瞳孔区导致视力下降。

◎ Visual acuity: The smaller pterygium is asymptomatic, and the larger and thicker can cause corneal astigmatism, which invades the pupil area will cause vision loss.

◎ 裂隙灯检查：位于角膜浅层，逐渐向角膜中央生长的三角形纤维血管球结膜组织，基底位于角膜缘旁的结膜，尖端指向角膜中央。通常在角膜缘处与角膜缘粘连。常见于鼻侧，也可见鼻、颞两侧同时生长。静止期的胬肉头部平坦、体部不充血，血管少。进展期头部肥厚，体部明显充血。

◎ Slit-lamp examination: It is a triangular f ibrovascular bulbar conjunctival tissue which located in the superf icial layer of the cornea and ingrowth over the limbus encroach onto the cornea. The base part of pterygium located in the bulbar conjunctiva near the corneal limbus and the tip pointing toward the center of the cornea. It usually adheres to the limbus. It is common on the nasal side, and it can also be seen on both sides of the nasal and temporal. The pterygium in the resting period has a f lat head, no congestion in the body,and few blood vessels. In the advanced stage, the head is hypertrophic, and the body is obviously congested.

◎ 角膜地形图：胬肉覆盖部位可出现不规则角膜散光。

◎ Corneal topography: Irregular corneal astigmatism may appear in the pterygium covered area.

诊断

Diagnosis

翼状胬肉。

Pterygium.

治疗

Management

◎ 药物治疗：人工泪液可减轻患者眼部刺激感、异物感或干涩。局部点非甾体眼药水或短期激素类眼药水可减轻炎症反应、减轻结膜充血。对于相对早期或术后复发的翼状胬肉，局部可点免疫抑制剂类眼药水如环孢素可以帮助减缓增长速度。

◎ Medical treatment: Topical lubrication can help to release the irritation、foreign body sensation or dryness.Topical NSAID or short time steroids can reduce conjunctival inf lammation and congestion. Topical immunosuppressants such as ciclosporin can slow down but can not stop the progression of disease, which is suitable for early or recurrent cases.

◎ 手术治疗：对视力明显下降或有眼部症状影响正常生活的患者可行手术治疗。单纯翼状胬肉切除术复发率大概为80%。临床常采用翼状胬肉切除联合组织移植，如自体结膜移植术、角膜缘干细胞移植术、羊膜移植术等；组织植片移植手术中可联合丝裂霉素C减少复发率。

◎ Surgical treatment for patients with vision or symptom bothering patient normal life. Simple pterygium resection is associated with about 80% recurrent rate. Pterygia excision is often combined with tissue transplantation including autoconjunctival grate transplantation, corneal limbal stem cell transplantation, or amniotic membrane transplantation.Mitomycin C sometimes is used for adjunctive drug for graft technique.

患者教育和预后

Patient Education & Prognosis

◎ 户外配戴遮阳镜减少紫外线暴露。

◎ Advise patient to wear sunglasses to avoid ultraviolet exposure.

◎ 建议患者早期手术治疗，避免胬肉面积过大导致术后角膜散光或角膜中央区瘢痕。

◎ Follow-up and early treatment is advised to avoid postoperative astigmatism or central corneal scar caused by large area of lesion.