课题背景：真菌性角膜溃疡是目前位于感染性角膜疾病首位的疾病，真菌性角膜炎临床症状不典型，大多为混合性感染，并且临床上没有确切有效的抗真菌药物。近年来，由于抗菌素和激素的滥用，真菌性角膜溃疡无论在诊断和治疗上，都是临床很棘手的疾病。穿透性角膜移植是目前临床上能挽救眼球和视力并且能有效治疗真菌性角膜溃疡的方法。

应用要点：采用穿透性角膜移植术治疗高危真菌性角膜溃疡，观察术后视力变化和真菌复发、植片排斥、继发性青光眼、并发性白内障等并发症的发生情况。结果提示对于保守治疗无效的高危真菌性角膜溃疡患者，如果注重围手术期的处理、术中操作的技巧性以及术后的合理用药，可有效地减少复发率及术后并发症发生率。

同行评价：文章使用穿透性角膜移植方法，并在手术前后采用药物治疗真菌性角膜溃疡，具有创新性，对于临床治疗有一定应用意义。

摘要

背景：单纯药物治疗高危真菌性角膜溃疡效果不佳，目前穿透性角膜移植已是挽救眼球和视力的主要手段。
目的：观察穿透性角膜移植治疗高危真菌性角膜溃疡的随访结果。
设计、时间及地点：回顾性病例分析，于2000-01/2005-01在青岛大学医学院附属医院眼科完成。
对象：选择在青岛大学医学院附属医院行穿透性角膜移植的高危真菌性角膜溃疡患者36例(36眼)，其中9例穿孔，前房积脓25例，术前合并白内障6例，合并青光眼3例。
方法：移植前给予抗真菌联合抗细菌治疗，36例患者均在入院4 d内完成了穿透性角膜移植，术后局部和全身给予抗炎和抗真菌药物治疗，随访6~24个月。
主要观察指标：观察移植后视力变化和真菌复发、植片排斥、继发性青光眼、并发性白内障等并发症的发生情况。
结果：①36例患者中13例随访6~12个月，17例随访13~18个月，6例随访19~24个月。②35例患者（97%）成功地保存了眼球，34例(94%)患者视力有不同程度提高。③移植后4例患者(11%)真菌复发，其中3例药物治疗后治愈，1例摘除眼球；13例患者(36%)植片发生排斥，其中10例经抗排斥治疗植片转为透明，3例因药物治疗无效而行二次穿透性角膜移植术；3例患者(8%)植片发生溃疡，其中2例治愈，1例因合并角膜内皮功能失代偿而行再次穿透性角膜移植；5例患者(14%)继发青光眼，眼压均得到成功控制；4例患者(11%)发生并发性白内障，其中2例行白内障摘除。其余患者移植后随访期间眼部情况稳定，植片保持透明。最终随访时，32例患者(89%)角膜植片透明。
结论：对于保守治疗无效的高危真菌性角膜溃疡患者，穿透性角膜移植是挽救眼球和视力的有效方法。
关键词：角膜移植；角膜溃疡；真菌病

赵桂秋，姜楠，杜兆东，梁涛，杨姗姗. 穿透性角膜移植治疗高危真菌性角膜溃疡36例：同期非对照随访[J].中国组织工程研究与临床康复，2008，12(18):3457-3460
[www.zglckf.com/zglckf/ejournal/upfiles/08-18/18k-3457(ps).pdf]

Penetrating keratoplasty for treating high-risk mycotic corneal ulcer in 36 cases: A concurrent non-control follow-up study

Abstract

BACKGROUND: Outcomes of drug alone for treating high-risk mycotic corneal ulcer are not satisfactory. Penetrating keratoplasty (PKP) has been the main methods to retrieve eyeball and sight at present.
OBJECTIVE: To evaluate the follow-up efficacy of PKP for treatment of high-risk mycotic corneal ulcer.
DESIGN, TIME AND SETTING: A retrospective case analysis was performed at the Department of Ophthalmology, Affiliated Hospital, Medical College, Qingdao University from January 2000 to January 2005.
PARTICIPANTS: Totally 36 patients (36 eyes) with high-risk mycotic corneal ulcer undergoing PKP were selected at the Affiliated Hospital, Medical College, Qingdao University. Nine of them were perforated, twenty-five were hypopyon, six had combined cataracta preoperatively, and three of them were combined with glaucoma.
METHODS: The patients were treated with antifungal and antibacterial treatment preoperatively, and all of them were given PKP within 4 days after admission. After surgery, antifungal and antibacterial treatments were performed locally and systemically. Follow-up was conducted for 6-24 months.
MAIN OUTCOME MEASURES: Postoperative visual acuity and complications such as, fungus recurrence, implant rejection, secondary glaucoma, complicated cataracta.
RESULTS: Of the 36 patients, 13 patients were followed up for 6-12 months, 17 patients were followed up for 13-18 months, and 6 patients were followed up for 19-24 months. A total of 35 out of 36 patients (97%) preserved the eyeballs and the visual acuity improved in 34 patients (94%). Fungal infection recurred in 4 eyes (11%), 3 of which were controlled with antifungal medication and 1 was enucleated. Graft rejection was observed in 13 eyes (36%), 10 of which recovered transparent with medication and 3 received secondary PKP. Three (8%) eyes had graft ulceration, 2 of which were cured and the other one was regrafted because of severe endothelial cell loss. Five (14%) eyes had secondary glaucoma, and the intraocular pressure was controlled medically and surgically. Complicated cataract occurred in 4 (11%) eyes, 2 of which underwent cataract extraction. Most complications were controlled successfully. At last follow-up, 32 grafts (89%) were transparent.
CONCLUSION: For patients with high-risk mycotic corneal ulcer, the conservative therapy was uneffective, but PKP is an effective approach for preservation of eyeballs and restoration of visual function.

Zhao GQ, Jiang N, Du ZD, Liang T, Yang SS. Penetrating keratoplasty for treating high-risk mycotic corneal ulcer in 36 cases: A concurrent non-control follow-up study.Zhongguo Zuzhi Gongcheng Yanjiu yu Linchuang Kangfu 2008;12(18):3457-3460(China) [www.zglckf.com/zglckf/ejournal/upfiles/08-18/18k-3457(ps).pdf]