【摘要】 目的：观察羊膜移植术联合自体血清及那他霉素治疗真菌性角膜溃疡的临床效果。方法：农作物及植物所致真菌性角膜溃疡80例80眼，随机分成治疗组和对照组各40例，治疗组加用自体血清。两组对比观察角膜创面愈合及角膜瘢痕形成情况。所有病例于手术显微镜下彻底清创溃疡灶及坏死的角膜组织，取瑞济生物（8mm×10mm羊膜）基地膜面贴敷于溃疡面，再取（10mm×15mm）较大的生物羊膜覆盖其上。并以100尼龙线缝合固定。术后治疗组加自体血清球结膜下注射。结果：局部创面全部愈合69例69眼，11例未愈。治疗组术后6mo角膜瘢痕形成情况，平均视力明显优于对照组。两者比较差异有统计学意义(P<0.01)。结论：多层羊膜移植加自体血清结膜下注射治疗真菌性角膜溃疡疗效良好。
【关键词】 自体血清；那他霉素；角膜溃疡；真菌性；羊膜移植
Triple therapy of fungal corneal ulcer with autologous serum, bioamniotic membrane transplantation and NatamycinXiaoFeng Zhang, JingLin Cui, ShuJie Cao AbstractAIM: To observe clinical effects of the amniotic membrane transplantation combined with autologous serum and Natamycin treatment of fungal corneal ulcer. METHODS: Cropsand plantcaused 80 cases of fungal corneal ulcer (80 eyes) were randomly divided into treatment group and control group with 40 cases in each group, the treatment group was added with autologous serum. Corneal wound healing and corneal scar formation was observed in two groups. All patients underwent surgical debridement of ulcers and necrosis of the corneal tissue lesions under a microscope.Ruiji biological (8mm×10mm amniotic membrane) base membrane surface patching was taken on the ulcer surface, and (10mm×15mm) larger biological amniotic membrane was taken to cover it. They were sutured with 100 Nylon lines. The treatment group was added by subconjunctival autologous serum injection after surgery. RESULTS: All 69 eyes of 69 cases had local wound healed. Treatment group was better than the control group at corneal scar formation and average visual acuity 6 months after surgery The difference was statistically significant (P<0.01).CONCLUSION: Multilayer amniotic membrane transplantation plus subconjunctival injection of autologous serum treatment of fungal corneal ulcer is good.
KEYWORDS: autologous serum; Natamycin; corneal ulcers; fungal; amniotic membrane transplantation0 引言
真菌性角膜溃疡[1]，特别是农作物及植物外伤所致者，其发生率有逐渐增多的趋势，这可能与广谱抗生素及皮质类固醇药物的广泛应用有关，最常见的致病菌株为镰刀菌、曲霉菌、白色念珠菌，致盲率甚高[2]，治愈后角膜瘢痕形成也较严重，而且目前尚无确切有效的药物治疗。我们采用羊膜移植加自体血清及那他霉素治疗，取得较好的效果，报道如下。
1 对象和方法
1.1 对象
200402/200908收治住院真菌性角膜溃疡80例80眼，男59例，女21例，年龄17～72(平均34)岁。右眼36例，左眼44例，均为农民，有眼部农作物及植物外伤史。经溃疡面刮片于显微镜下找到真菌菌丝而确诊为真菌性角膜溃疡，病史最短3d，最长2mo，随机分成治疗组和对照组各40眼。80例均有眼红、眼痛及畏光症状，视力均仅有光感或手动，角膜溃疡范围 2～7mm。表面附有苔垢样坏死组织，溃疡周围可见卫星灶、羽毛状边缘及沟状凹陷，病灶处基质浸润浓密，有的伴有基质脓疡，累及后弹力层，角膜后表面经常贴附有白色浆糊状沉淀物(KP)[3]，均有不同程度的前房积脓(占前房1/5～4/5)，色白质稠。瑞济生物羊膜。规格：厚度0.1～0.3mm，面积8mm×10mm/ 10mm×15mm,无菌生理盐水浸泡（浸泡温度25～30℃），15min复水。
1.2 方法
术前在表面麻醉下刮除角膜面分泌物及菌苔，碘酊烧灼角膜溃疡面，冲洗，涂阿托品凝胶散瞳，那他霉素点眼。治疗组球结膜下注射自体血清，敷料遮盖。常规消毒铺巾，5g/L地卡因滴眼液表面麻醉，20g/L利多卡因球后麻醉。手术显微镜下彻底清除溃疡灶及周围水肿混浊的角膜组织，形成植床，20g/L碘酊涂抹创面,立即用生理盐水充分冲洗，根据溃疡面的范围取8mm×10mm生物羊膜修剪成植床大小的块状，基地面朝上贴敷于溃疡面[4]。如果病灶较深,则使用羊膜数层，其厚度参照周围健康角膜厚度，一般l～3层。再取10mm×15mm的羊膜覆盖于其外，仍以基底膜面贴敷。于角膜缘处以100尼龙线间断缝合固定。结膜下注射抗菌消炎药,阿托品0.2mg,加压包扎。术后2d后换药，每日以普拉洛芬滴眼液及那他霉素点眼液交替滴10次，7d后拆线。治疗组加用自体血清每日球结膜下注射。提取自体血清[5]:用采血试管抽取患者本人的静脉血液4～5mL，用4000转/min离心约 5mL，低温保存。用1mL注射器吸血清0.5～0.7mL备用。根据病情采用隔日球结膜下注射自体血清0.5～0.7mL。
2 结果
术后1wk羊膜呈灰白色水肿，拆线后1～2wk后角膜上皮愈合，6mo后治疗组角膜面光滑32例，角膜斑翳4例，角膜薄翳1例，3眼手术失败；对照组角膜表面光滑9例，斑翳8例，角膜薄翳15例，8眼手术失败。两组比较有统计学意义(P<0.01) 。随访6～12mo未见复发病例。
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