結(jié)膜病培訓(xùn)講義

1、結(jié) 膜 疾 病Disease of the conjunctiva目的與要求 了解結(jié)膜的解剖 熟悉各種充血的特點(diǎn)及其臨床意義 掌握細(xì)菌及病毒引起的急性結(jié)膜炎，并了解春季結(jié)膜炎 認(rèn)識(shí)沙眼的危害及其傳播途徑，掌握沙眼的診斷和鑒別診斷、并發(fā)癥及防治辦法 了解結(jié)膜干燥癥、翼狀胬肉的分類(lèi)及處理原則內(nèi)容 結(jié)膜的解剖 結(jié)膜炎總論 細(xì)菌性結(jié)膜炎 急性卡他性結(jié)膜炎 慢性卡他性結(jié)膜炎 淋菌性結(jié)膜炎 衣原體性結(jié)膜炎 變態(tài)反應(yīng)性結(jié)膜炎 泡性眼炎 春季卡他性結(jié)膜炎 病毒性結(jié)膜炎 流行性角結(jié)膜炎 流行性出血性結(jié)膜炎 結(jié)膜干燥癥 結(jié)膜變性及其他結(jié)膜病結(jié)膜的解剖 半透明粘膜組織 分三部分 瞼結(jié)膜 球結(jié)膜 穹隆結(jié)膜 血管 眼瞼

2、動(dòng)脈弓結(jié)膜后動(dòng)脈 眼動(dòng)脈肌支睫狀前動(dòng)脈角膜緣血管網(wǎng)結(jié)膜上穹窿結(jié)膜上穹窿結(jié)膜囊結(jié)膜囊結(jié)膜下穹窿結(jié)膜下穹窿結(jié)膜充血和睫狀充血的鑒別結(jié)膜充血睫狀充血鮮紅色深紅色近穹隆明顯近角膜緣明顯可隨結(jié)膜移動(dòng)不隨結(jié)膜移動(dòng)滴0.1%腎上腺素消失滴0.1%腎上腺素不消失結(jié)膜炎，干眼癥，瞼緣炎等角膜炎，前葡萄膜炎炎，青光眼等The Red Eye混合充血睫狀充血結(jié)膜充血General description of conjunctivitis The most common ocular disorder Etiology Infection of microorganism Physical injuries Che

3、mical injuries Allergic disorder Immunological disorder Nutritional deficiencyGeneral description of conjunctivitis classification According to the cause Bacterial, chlamydial, viral, fungal, allergic conjunctivitis According to the course Acute, subacute and chronicGeneral description of conjunctiv

4、itisClinical manifestation Symptoms Foreign body sensation, burning sensation, itching Tearing, pain and photophobia when cornea is involved Physical sign Conjunctival hyperemia and edema Increase of secretion Bacterial: serous,mucous and purulent Viral: watery or serous Allergic one or xerophthalmi

5、a: ropy filamentousGeneral description of conjunctivitisClinical manifestation Symptoms foreign body sensation,burning sensation,itching tearing,pain and photophobia when cornea is involved Physical sign conjunctival hyperemia and edema increase of secretion Bacterial: serous,mucous and purulent vir

6、al: watery or serous allergic one or xerophthalmia: ropy filamentousGeneral description of conjunctivitisClinical manifestation Physical signsubconjunctival hemorrhagepapillary hyperplasia palpebral conjunctival epitheliumfollicular formation accumulation of lymphocyte beneath the conjunctival epith

7、elium, seen in chlamydial and drug-induced conjunctivitisGeneral description of conjunctivitisClinical manifestation Physical sign Pseudomembrane or membrane of the palpebral conjunctiva The exudation rich in fibrin from palpebral conjunctiva Pseudomembrane: in baby and children, adenoviral, neonata

8、l inclusion, streptococcal conjunctivitis True membrane: diphtheritic conjunctivitis Preauricular lymphadenectasis with tenderness viral conjunctivitisGeneral description of conjunctivitisExamination and diagnosis Clinical examination Cytologic examination Smear of conjunctiva and scaling smear of c

9、onjunctiva Bacteriological examination Bacterial culture and drug sensitive test Virus isolation and its antigenic detectionGeneral description of conjunctivitisPrinciple treatment General principles Remove pathogenic cause Take local phamacotherapy as major Systemic treatment as supplement if neces

10、sary Instillation of eyedrops Instillation of ointment Washing of conjunctival sac Systemic treatment Prevention Bacterial conjunctivitis Acute catarrhal conjunctivitis Chronic catarrhal conjunctivitis Hyperacute bacterial conjunctivitisAcute catarrhal conjunctivitis “pink eye”, in spring and autumn

11、, sporadic or epidemic Clinical finding Acute onset(1-3days) Both eye Tearing, foreign body and burning sensation Conjunctival hyperemia, purulent secretion, palpebral swelling, spots of subconjunctival hemorrhage Ill process: 2 weeks Treatment Prevention Chronic catarrhal conjunctivitis EtiologyBac

12、terial infection Acute-chronic or infection of bacterial with weak toxicityNon-infectious Environment factorsDustChemical smoke or gas Irritating eye drugsComplicated from other disordersChronic catarrhal conjunctivitis Clinical finding Chronic onset, both eye Itching, foreign body and asthenopia or

13、 no symptoms Conjunctival hyperemia Mucous secretion Papillary and follicle hyperplasia Treatment Give management according to different causes Gonococcal conjunctivitis Hyperacute purulent conjunctivitis with the strongest infectivity and large destructibility Etiology: Diplococcus gonorrhoeae Adul

14、t: auto infection Children: touch infection Newborn: direct infectionGonococcal conjunctivitis Clinical findings Incubation period: 10h-2, 3d, acute onset Opthalmalgia, photophobia, tearing Swelling of the eyelids Palpebral and bulbar hyperemia and chemosis Secretion: serous-bloody-purulent 濃漏眼 Infl

15、ammatory pseudomembrane Preauricular lymphadenectasis Corneal ulcer and perforationGonococcal conjunctivitis Diagnosis Clinical findings Lab examination(Gram stain, G- diplococcus) Treatment topical and systemic one is the same important Prevention Be isolated to avoid infection and epidemicChlamydi

16、al conjunctivitisTrachoma Chlamydia is microorganism between bacterium and virus Chlamydia trachomatis: antigen: ABCBa DEFGHIJK trachoma genitourinary system inclusion conjunctivitis Chlamydia is sensitive to tetracyclin or erythromycinTrachoma A chronic, infectious keratoconjunctivits Named from ro

17、ugh, uneven appearance on the surface of palpebral conjunctiva that looks like sand Our country: before 1950s: the first cause of blindness 1955: separated the pathogen after 1970s: decreased greatly now: remote districts Developing countries of the Asian-African areaTrachoma(clinical findings) Comm

18、only occurred in children and juvenile, with bilateral acute or subacute onset Incubation time: 5-14d(children), 7d(average) Acute or subacute stage(1-2mon): photophobia, tearing, foreign body sensation Palpebral and bulbar conjunctival hyperemia Ropy secretion Papillary hyperplasia, follicles forma

19、tion Corneal epithelitis Be cured without scar leftTrachoma(clinical findings) Chronic stage: superinfections or concomitant bacterial infections Conjunctival hyperemia Ropy secretion Papillary hyperplasia, follicles in upper fornix and palpebral conjunctiva conjunctival thickening scar white luster

20、 like tenden Corneal epithelitis Trachomatous pannusTrachoma (classification) I Stage progressive stage papillae and follicles, upper fornix is blurred, corneal panus II Stage regressive stage scar,a little active lesion III Stage complete scar, no active cicatricial stage lesion and infectivityChla

21、mydial conjunctivitisTrachoma(sequela and complication) Entropion and trichiasis Blepharoptosis Symblepharon (lower fornix) Parenchymatous xerosis of conjunctiva Chronic dacryocystisis Corneal opacityChlamydial conjunctivitisTrachoma(diagnosis) 1)the vessels of upper fornix and palpebral conjunctiva

22、 are blurred, congested, papillary hyperplasia or follicle formation or both 2)corneal pannus 3)scar 4)trachomatous inclusion Diagnosis on the basis of the first plus one of other three antigenic testTrachoma (differential diagnosis) Chronic follicular conjunctivitis 1)follicles in lower palpebral /

23、fornix conjunctiva, no fusion tendency, translucent, conjunctiva is not thickened 2)no scar and corneal pannus. Spring catarrh 1)papillae are large and flat, no lesion on upper fornix 2)no cornea pannus 3)eosinophil cells in secretion smear Inclusion conjunctivitis 1)follicles in lower palpebral and

24、 fornix conjunctiva 2)no corneal pannus and scar.Trachoma (treatment) Topical tetracyclin, erythromycin Systemic sulfadiazine, rifampin Operative: sequelae and complication SAFE Surgery Antibiotic Facial cleanliness Environmental improvementAllergic conjunctivitisVernal conjunctivitis(spring catarrh

25、) A seasonal disease, also named spring catarrh, with recurrence in warm spring, summer, commonly seen in youth (male) with age under 20 years, bilateral, relapses every year. Etiology: unclear, immunologic disorder (type I of allergic reaction) sensitinogen: plant pollen, dust, animal furfurous, fe

26、ather, sun light temperature, antigenic components of microorganismsAllergic conjunctivitisVernal conjunctivitis (Clinical findings) Symptom:extreme itching Sign 1)palpebral type: papillary hyperplasia in the upper palpebral conjunctiva that like oval flat cobblestone, eosinophillia in secretion 2)c

27、orneal limbal type: collid tubercles at the corneal limbus 3)mixed type:Allergic conjunctivitisVernal conjunctivitis Treatment: 1)self-limited, no vision affected 2)general treatment: keep away proble sensitinogen 3)medical treatment: natrii cromoglycas corticosteroid Allergic conjunctivitis Immedia

28、ted allergic antigen: pollen, contact lens, etc. Delayed one: various drug Clinical findings: immediate type: dermatitis of palpebral skin, blepharitis, mild infiltrative conjunctivitisAllergic conjunctivitis Lab examination: degenerative epithelial cell, few polynuclear cells and mononuclear cells

29、in secretion Treatment: 1)find out and get rid of sensitinogen 2)corticosteroid 3)3% boric solution 4)anti-allergic agentsAllergic conjunctivitisphlyctenular keratoconjunctivitis Etiology Delayed reaction to protein of microorganism Mostly to mycobecterium tuberculosis and staphylococcus aureus Clin

30、ical findings Herpetic tubercle may appear on the bulbar conjunctiva or limbus Treatment Topical steroid dropsViral conjunctivitisEpidemic keratoconjunctivitis Acute onset, strong infectivity, may be sporadic or epidemic Etiology: adenovirus, type 8, 19, 29 and 37.Viral conjunctivitisEpidemic kerato

31、conjunctivitis(EKC) Clinical findings Incubation period: 5-7d Foreign body sensation, itching, pain, photophopia and tearing Palpebral edema, conjunctival hyperemia and chemosis, less and watery secretion, follicles in palpebral and fornix conjunctiva, preauricular lymphadeectasis and tenderness Be

32、cured after one week exacerbate: superfial punctate keratitisViral conjunctivitisEpidemic keratoconjunctivitis Diagnosis: Acute folliclar cinjunctivitis superfial punctate keratitis preauricular lymphadenectasis neutrophial Treatment: no specific drug Antiviral:topical(mainly) and systemic-acyclic A

33、ntibioticViral conjunctivitisEpidemic hemorrhagic conjunctivitis Fulminant epidemic ocular infections Etiology Entero-virus type 70, picornavirus Coxsackie virus type A 24Viral conjunctivitisEpidemic hemorrhagic conjunctivitis Clinical findings Incubation period: 24hr Ill course: self-limited, 10d o

34、r shorter Ophthalmagia, foreign body sensation, photophopia and tears Eyelid and conjunctiva red and swollen, watery secretion, follicular hyperplasis of palpebral conjunctiva, patchy hemorrhage on bulbar conjunctiva, preauricular lymphadenectasis Transient fine punctate epithelial keratitisTears,te

35、ars film and xerosisTears Mainly produced by the lacrimal gland and conjunctival goblet cells. Volume: 5-9ul Major organic component: protein albumin, globulin, lysozyme immunoglobulin (IgA,IgG,IgE) Main ions: K+Na+Cl- A little Lipin, glucose, urea PH: 5.20-8.35(7.35) isotonicTears,tears film and xe

36、rosisTears film Tear film Tears form a thin layer (about 7-10um thick), composed three layers: lipid, watery, mucous layer. Functions Cover and fill in corneal surface, to make the cornea be a smooth optic interface Moisten and protect corneal and conjunctival epithelium Inhibit the growth of microo

37、rganism through mechanical and antimicrobic effect Supply necessary nutrient to the corneaTears,tears film and xerosisprimary tear dysfunction any abnormality of involved component in tear film, deficiency of tear secretion or its abnormal distribution or maintenance Rubbing and foreign body sensati

38、on, drying and burning sensation Conjunctival hyperemia, mucous filamentous secretion, papillary hyperplasia, filamentous keratitis Schirmer test, rupture time of the tear film, fluorescein staining of corneal epitheliumTears,tears film and xerosisXerosis of conjunctiva Epithelial xerosis dificency

39、of vitamin A, when complicated with corneal epithelial xerosis called xerophthalmia Xerosis of conjunctivae Parenchymatosa caused by topical ocular disorder 1)cicatricial xerosis of conjunctiva 2)exposure keratoconjunctival xerosis Keratoconjunctivitis sicca an autoimmune disorder, Sjogren syndromeT

40、ears,tears film and xerosisXerosis of conjunctiva Treatment: 1)etiological treatment 2)treatment against deficiency of tear secretionOther common conjunctival disordersPterygium Etiology: unclear, outdoor work Clinical findings: 1)hypertrophic bular conjunctiva and its subconjunctival tissue invade onto the cornea with the shape o