【摘要】：目的：應用共焦顯微鏡觀察單純皰疹病毒性角膜炎(Herpes simplex virus endothelitis; HSK)內(nèi)皮型發(fā)病時角膜上皮細胞、角膜基質(zhì)、內(nèi)皮細胞及局部樹突狀細胞等的變化聯(lián)合眼前段OCT對角膜的形態(tài)學變化進行動態(tài)觀察,記錄藥物治療轉(zhuǎn)歸,并為調(diào)整臨床用藥提供依據(jù)。 方法：選擇與我院就診的HSK內(nèi)皮型患者30例(30眼),其中男性21例,女性9例,平均年齡55歲(17-69歲)。發(fā)病時間最短1周,最長2月,平均為20天。根據(jù)HSK內(nèi)皮型的分型,6例患者為扇形,其中4例有復發(fā)病史。17例為盤狀,其中8例為既往有單皰病毒性角膜炎反復發(fā)作史,3例患者伴有繼發(fā)性青光眼,2例患者伴有前房積膿。7例為彌散性,其中4例既往有單皰病毒性角膜炎反復發(fā)作史。入院后常規(guī)給予入院后常規(guī)給予抗病毒及抗免疫治療,眼壓升高者加用降眼壓藥物。裂隙燈顯微鏡常規(guī)檢查,記錄角膜水腫的范圍、內(nèi)皮面KP及皺褶等的變化。共焦顯微鏡檢查,分別于藥物治療前、治療7-14天、1月、3月時進行觀察,分析角膜上皮細胞、角膜基質(zhì)細胞、內(nèi)皮細胞及KP、樹突狀細胞(Dendritic cells, DCs)、炎性細胞的變化,并根據(jù)情況調(diào)整用藥。同時應用眼前段OCT觀察角膜的形態(tài)變化。 結(jié)果：裂隙燈顯微鏡檢查：扇形及盤狀HSK內(nèi)皮型患者恢復速度較快,一般于用藥7天角膜水腫基本消退,但可見到明顯的KP,連續(xù)治療2周后角膜可恢復透明,內(nèi)皮面KP明顯減少或消退。3例合并繼發(fā)性青光眼的患者均于7天內(nèi)眼壓降至正常范圍,停用降壓藥物后未見升高。2例伴有前房積膿的患者,與用藥3-5后積膿消失,未再次出現(xiàn)。彌散性HSK內(nèi)皮型患者恢復速度較慢,一般于用藥后10-14天角膜水腫基本消退,連續(xù)治療20-30天后角膜可恢復透明,內(nèi)皮面KP明顯減少或消退。30例患者隨訪期內(nèi)均無再次復發(fā)。 共焦顯微鏡檢查：上皮細胞層：細胞水腫,體積增大,排列疏松,細胞核呈高反光,有時見大量體積較小、強反光的炎癥細胞浸潤。藥物治療7-14天,上皮細胞排列規(guī)則,體積恢復正常,細胞核呈低反光,炎癥細胞明顯減少或消失。 樹突狀細胞：分布于角膜上皮細胞層、基底膜區(qū)、淺基質(zhì)層約44μm范圍內(nèi)。藥物治療前與治療后7-14天DCs無明顯變化：角膜水腫區(qū)可見大量DCs聚集,呈特征性的樹枝狀高亮反光結(jié)構(gòu),并可見遷移的DCs；周邊透明區(qū)DCs數(shù)量較多但樹突不明顯。隨病情好轉(zhuǎn),藥物治療后1月、3月觀察：樹突狀細胞數(shù)量減少,胞體及樹突狀反光逐漸降低,樹突縮小。各時期DC細胞的密度,藥物治療前、治療后7-14天、1月、3月分別為：(137±46)、(148±33)、(100±25)、(53±15)個/mm2,20例患者對側(cè)健眼DCs的密度為：29±5個/mm2。HSK發(fā)病組DC數(shù)量大于對照組,兩組之間的差異有統(tǒng)計學意義。藥物治療后DC數(shù)量減少,藥物治療后7-10天與藥物治療后1月、3月兩兩比較有統(tǒng)計學意義。 基質(zhì)層：基質(zhì)細胞普遍體積增大,胞體變形,細胞質(zhì)增多,胞內(nèi)大量高反光顆粒普遍體積增大,而胞質(zhì)反光較強,胞核與胞質(zhì)不易區(qū)分,部分患者淺基質(zhì)層難以分辨細胞形態(tài)。藥物治療1月,基質(zhì)層結(jié)構(gòu)規(guī)則,細胞核清晰可見,部分患者淺基質(zhì)形成瘢痕呈現(xiàn)無結(jié)構(gòu)狀態(tài)。 內(nèi)皮細胞層：藥物治療前水腫角膜區(qū)內(nèi)皮細胞無法成像,僅可見大量強反光團。透明區(qū)內(nèi)皮細胞呈激活狀態(tài),細胞核可見,。藥物治療7-14天可獲得較為清晰的角膜內(nèi)皮圖像：內(nèi)皮細胞水腫,六邊形結(jié)構(gòu)改變,內(nèi)皮細胞核可見并呈高反光,炎性細胞浸潤,點空樣改變等表現(xiàn)。藥物治療1月時：內(nèi)皮細胞水腫減輕,不規(guī)則六邊形細胞所占比例降低,炎細胞明顯減少,并可見贅疣形成。藥物治療3月時,內(nèi)皮細胞恢復六邊形結(jié)構(gòu),排列規(guī)則,部分患者仍可見少量贅疣及KP存在,角膜內(nèi)皮細胞密度2009.3±200個/mm2,對側(cè)健眼2456.00±382個/mm2,差異有統(tǒng)計學意義。 前段OCT檢查：治療前,角膜基質(zhì)層厚度明顯增加,反射強度較低且不均勻,內(nèi)皮面可見高反光團及皺褶形成,角膜測厚為：686.31±167.54μm。。藥物治療7-14天后,角膜基質(zhì)厚度降低,內(nèi)皮面高反光團消失或變小,無皺褶形成。1月時角膜內(nèi)皮面無高反光團,部分患者可見淺基質(zhì)殘留高密度的強反射帶,瘢痕形成,角膜測厚為：516.69±59.58μm。 結(jié)論：應用共聚焦顯微鏡聯(lián)合眼前段OCT對HSK內(nèi)皮型患者角膜各層進行活體的動態(tài)觀察,對進一步了解其藥物治療過程中的病理變化及指導治療,有效提高HSK內(nèi)皮型的診治水平,具有重要的臨床意義。
[Abstract]:AIM: To observe the changes of corneal epithelial cells, corneal stroma, endothelial cells and local dendritic cells during the onset of herpes simplex virus endothelitis (HSK) with confocal microscope, and to observe the morphological changes of cornea with OCT in the anterior segment of the eye. Provide basis for adjusting clinical medication.
Methods: Thirty patients (30 eyes) with HSK endothelial type were selected, including 21 males and 9 females, with an average age of 55 years (17-69 years). There were 3 cases with secondary glaucoma and 2 cases with empyema in the anterior chamber. 7 cases were diffuse, of which 4 cases had a history of recurrent herpes simplex keratitis. Confocal microscopy was used to observe the changes of corneal epithelial cells, corneal stromal cells, endothelial cells and KP, dendritic cells (DCs), inflammatory cells before treatment, 7-14 days, 1 month and 3 months after treatment. At the same time, anterior segment OCT was used to observe corneal morphological changes.
Results: Slit lamp microscopy showed that the recovery rate of the patients with HSK endothelial type was faster than that of the patients with HSK endothelial type. Generally, the corneal edema subsided after 7 days of treatment, but obvious KP could be seen. After 2 weeks of continuous treatment, the cornea became transparent and the KP on the endothelial surface decreased or subsided significantly. The recovery rate of diffuse HSK endothelial type patients was slow, and the corneal edema basically subsided after 10-14 days of treatment. After 20-30 days of continuous treatment, the cornea could be restored to transparency, and the endothelial KP significantly decreased or subsided. No recurrence occurred during the follow-up period.
Confocal microscopy showed that the epithelial cell layer was edema, enlarged, loosely arranged, high reflective nucleus, and sometimes a large number of small, strongly reflective inflammatory cells infiltrated.
Dendritic cells were distributed in the epithelial layer, basement membrane area and superficial stroma of cornea within 44 microns. There was no significant change in DCs before and after treatment 7-14 days. There were a large number of DCs in the edema area of cornea with characteristic dendritic high reflective structure and migrating DCs. With the improvement of the disease, the number of dendritic cells decreased, the body and dendritic reflex gradually decreased, and the dendrites shrank. The density of DC cells in different periods before treatment, 7-14 days after treatment, 1 month and 3 months after treatment were (137 65507 The number of DCs in the group with (+5/mm2.HSK) was higher than that in the control group, and the difference between the two groups was statistically significant.
Stromal layer: the general volume of stromal cells increased, the body deformation, cytoplasm increased, a large number of high-reflective particles in the cell generally increased volume, and the cytoplasm was strong, the nucleus and cytoplasm were difficult to distinguish, some patients with superficial stroma difficult to distinguish cell morphology. Scar formation presents no structural state.
Endothelial cell layer: Before drug treatment, edema of corneal endothelial cells can not be imaged, only a large number of strong reflective masses can be seen. Inflammatory cell infiltration, dot-like changes and other manifestations. 1 month after treatment: endothelial cell edema reduced, irregular hexagonal cells decreased, inflammatory cells significantly reduced, and verrucous formation. 3 months after treatment, endothelial cells restored to hexagonal structure, regular arrangement, some patients still see a small number of verrucous and KP presence in the cornea. The density of skin cells was 2009.3 + 200 /mm2, and the contralateral healthy eyes were 2456 + 382 /mm2, the difference was statistically significant.
Before treatment, corneal stroma thickness was significantly increased, reflective intensity was low and inhomogeneous, high reflectors and folds were observed on the endothelial surface. Corneal thickness was 686.31 [167.54] micron. After 7-14 days of treatment, corneal stroma thickness decreased, high reflectors on the endothelial surface disappeared or diminished, and no folds formed. High reflective mass, some patients can see the residual high-density superficial stroma of strong reflex zone, scar formation, corneal thickness: 516.69 + 59.58 micron.
Conclusion: The dynamic observation of corneal layers in HSK patients by confocal microscope combined with ocular anterior segment OCT has important clinical significance for further understanding the pathological changes and guiding treatment in the course of drug therapy, and effectively improving the diagnosis and treatment of HSK endothelial type.
【學位授予單位】：濟南大學
【學位級別】：碩士
【學位授予年份】：2011
【分類號】：R772.21

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