【作者】 马骁；

【导师】 刘早霞；

【作者基本信息】 吉林大学 ， 眼科学， 2004， 硕士

【摘要】 外伤化脓性眼内炎是开放性眼外伤的最严重并发症，国内外大量研究调查显示外伤后眼内炎的发病率约为3.3％～17％，若受伤环境为农村则发病率提高到30％。外伤时眼球破坏、异物残留、细菌毒力强、混合感染多以及前房和玻璃体积血等体征掩盖感染的早期症状而延误诊治等因素均是导致其预后较术后眼内炎更差的原因。外伤化脓性眼内炎一旦发生，大多来势凶猛，破坏性大，常以视力丧失、眼球萎缩告终，及时的诊断和治疗是挽救眼球、保存一定视力的关键。 为了评价玻璃体切割术联合晶体切除／白内障皮质吸出术对眼内炎的治疗效果及应用激素的效果，探讨不同手术时机对预后视力的影响及不同程度的外伤化脓性眼内炎治疗方法的选择，我们回顾性分析了我院2002年4月～2004年4月收治的41例41眼外伤化脓性眼内炎患者的治疗方案，其中男35眼，女6眼。年龄7～54岁。致伤原因：球内异物(43.9％)、注射器针头刺伤(9.76％)、铁丝刺伤(26.83％)、树枝刺伤(4.88％)、钝物致眼球破裂伤(14.63％)。伤后就诊时间6小时～30天。 对于5例炎症较轻者(前房水混浊、伴少量渗出，玻璃体混浊但可看见眼底红光反射，视力光感以上)给予静脉滴注、球周和球结膜下注射广谱抗生素及地塞米松治疗。对于30例中、重度眼内炎患者给予经睫状体平坦部三切口的闭 吉林大学硕士学位论文合式玻璃体切割术治疗，同时切除晶体(不保留囊膜)或行白内障皮质吸出，术中根据具体情况选择眼内填充物、灌注液中加入何种药物及是否应用巩膜环扎术、眼内光凝术。对于6例破裂严重、修复无望的盲眼，5例行眼内容宛g除和轻基磷灰石植入术，1例行眼球摘除术。术后随访3一6个月。结果35例患者治疗后眼球得以保留、炎症得到控制，视力有不同程度提高。视力在0.02一光感之间的23例进行玻璃体切割术治疗的患者，3天内手术者最终视力优于3天后手术者。 通过对本组病例治疗结果的分析，我们可以得到如下结论:(1)玻璃体切割术联合晶体切除/白内障皮质吸出术是治疗中、重度眼内炎的有效方法，手术应尽早进行。玻璃体切割术有如下优点:可立即清除眼内病原菌及其培养基、细菌毒素及炎性反应物;祛除或预防玻璃体机化对视网膜的粘连牵拉;有利于药物注入眼内及其在玻璃体内扩散;有球内异物或晶体破裂者(外溢的晶体皮质会为微生物生长提供营养)可一并摘除。术中应尽量切除病变玻璃体，直到在显微镜下看不见玻璃体内细小的漂浮物为止才能更好的控制感染。手术时机的延误会导致视网膜坏死、血管闭塞和外伤性PVR的发生。同时切除晶体或进行白内障皮质吸除术的原因为:外伤化脓性眼内炎多合并外伤性白内障;严重眼内炎的晶状体最终很少保持透明;去除晶体有利于扩大眼内操作空间和增加视野清晰度;晶体切除(不保留囊膜)有助于眼内细菌毒素及炎性反应物由前部小梁网排出。(2)灌注液中加入药物可代替玻璃体腔药物注射，成为玻璃体切割术有效的吉林大学硕士学位论文辅助治疗。因为在使用了硅油或C3Fs气体填充的眼内，再给予玻璃体腔药物注射易引起眼内药物浓度过高。灌注液中加入药物则可避免这样的问题，在气一液交换后，剩留的玻璃体腔内的液体中仍含有效药物浓度。(3)对于外伤性眼内炎的玻璃体切割术主张在巩膜赤道部常规作预防性巩膜环扎术。因为眼内炎的玻璃体切割术无法切除所有的玻璃体，特别是周边部玻璃体，加上外伤本身的增殖修复，术后经常发生牵拉性视网膜脱离。延误治疗的外伤性眼内炎治疗易发生外伤性PVR，亦需要巩膜环扎术。(4)眼内炎时血一眼屏障破坏，静脉滴注、球周和球结膜下注射能使轻度眼内炎的眼内达到有效药物治疗浓度，可代替单纯的玻璃体腔药物注射。玻璃体腔药物注射并发症太多，我们并不推荐使用。(5)外伤化脓性眼内炎中G+菌感染多见，推荐玻璃体腔内给予对所有G+菌均有效的万古霉素，不赞成联合给予对G一菌敏感的头抱他睫或阿米卡星(与万古霉素有协同作用)，因为越来越多的实验证实头抱他陡与万古霉素相混合时会产生沉淀，而氨基糖贰类抗生素(阿米卡星)即使在其治疗剂量也可能造成黄斑梗死和周围神经节细胞缺血坏死。所以我们认为待菌培养及药敏结果回报后再决定是否使用对G一菌敏感的抗生素更为安全稳妥。(6)眼内炎治疗的标准是同时控制感染和炎症。地塞米松可通过各种不同机制发挥眼内抗炎作用、抑制炎症引起的眼内纤维增生及后期的牵拉性视网膜脱离，所以治疗外伤化脓性眼内炎时，皮质类固醇激素的应用是必瓷的。对于全身禁忌应用皮质类固醇激素患者，推荐采取玻璃体腔内给予激素的方法，这样既有助于在关键时期 吉林大学硕士学位论文(眼内炎症只在最初的5一7天不断加重脚])控制炎症，又不会带来全身的副作用。(7)对于破裂严重、修复无望、无光感的眼内炎眼，为防止交感性眼炎的发生或眼内炎症向眼外扩散，可行眼球摘除术或眼内容刻除术。(8)外伤性眼内炎的菌培养阳性率一般较低，可能与患者在获取眼内标本前己使用了广谱抗生素及送检时间延迟有关。阳性率的高低还受检查更多还原

【Abstract】 Posttraumatic infectious endophthalmitis is the most serious complications of ophthalmic trauma.The overall frequency estimated by large statistic data is approximately from 3.3% to 17%,but is reported to be 30% after rural penetrating trauma. Posttraumatic infectious endophthalmitis differs from postoperative and endogenous endophthalmitis both in its causative microorganisms and in its poorer visual prognosis. The poorer visual prognosis with posttraumatic endophthalmitis is probably attributable to the combination of ocular injury, the different spectrum of infecting microbes and a delay in treatment. The rapid initiation of therapy is the key to save globe and maintain certain visual acuity after posttraumatic infectious endophthalmitis.In order to evaluate the effect of the combination of vitrectomy and cataract surgery with corticosteroids used in the treatment of severe endophthalmitis, to evaluate the effect of surgical time in final visual acuity and to explore what kind of therapeutic methods should be choosed to treat various intensity posttraumatic infectiouis endophthalmitis,we retrospectively analysed 41 eyes diagnosed as posttraumatic infectiouis endophthalmitis from our hospital between April 2002 to April 2004.35 eyes are male while 6 eyes are female. All patients were followed up for 3 to 6 months.Among tramatic cause ,foreign body is the most common cause (43.9%). Subconjunctival,systemic and topical antibioticswith corticosteroids were used in the treatment of five minor cases whose aqueous humor and vitreous were turbid but the red reflect light of fundus could be seen and visual acuity were above light perception. The combination of vitrectomy and lens surgery was used in the treatment of thirty moderate and severe cases. Enucleation with hydroxyapatite implantation was used in the treatment of six patients whose eyeballs had serious ruptured and were unable to be repaired. Finally,34 patients’ infectious syndrom were controlled and achieved better final visual acuity.We also found that the patients treated with vitrectomy in 3 days achieved better visual acuity than those above 3 days.Because blood-ocular barrier may not be intact in an inflamed eye,subconjunctival, systemic and topical administration of antibiotics can get an therapeutic concentrations within the eye.we don’t recommend using intravitreal injection in minor cases because it has too many complications.To reduce the destructive effect of the significantinflammation that coexists with infection in endophthalmitis,we recommend using systemic, topical and subconjunctival,corti--costeroids in combination with antibiotics, provided that no co--ntraindications exist. Corticosteroids can reduce the intr-aocular inflammatory process and secondary complications associated with microbial endophthalmitis,such as retinal detachment. Many experiments found that the use of intravitreal dexamethasone (400 mg) had no potential retinal toxicity,and it is a good method to treat the patients with contraindications ininitial stage of endophthalmitis,without any side effect.Vitrectomy has the potential advantages of removing theinfecting organism and associated toxins, removing vitreous membranes that could lead to retinal detachment and improvingintraocular distribution of antibiotics.So vitrectomy is necessary in severe cases of endophthalmitis. Extracting cataract whichcaused by tramau or opacity due to severe infections will help to increase the acuity and the field of operation.In addition, lensectomy can accelerate the associated toxins and inflammatory substances removing from eye through trabecular reticulum. Therefore,we think that vitrectomy with lens surgery is the most effective method in the treatment of severe posttraumatic endophthamitis,and recommend operator to plus scleral encircling to prevent tractional detachment of retina. Adding medicine in persusate to take place of intravitreal injection will help to avoid medicine concentration exceeding within eye i更多还原