鞏膜炎

簡介:

       鞏膜為一細胞與血管均少,大部由膠原組成的組織。其表面為球結膜及球筋膜所覆蓋,不與外界環境直接接觸,所以很少患病。據多數學者統計其發病率僅占眼病患者總數的0.5%左右。由于鞏膜的基本成分的膠原性質,決定了其病理過程緩慢及所致的膠原紊亂難于修復。眼球是膠原的“窗口”,因此鞏膜炎(scleritis)常是全身結締組織疾病的眼部表現。

分類:

根據炎癥侵犯鞏膜或表層鞏膜組織中的部位,癥狀及預后,一般公認將鞏膜炎分為以下類型

(一)表層鞏膜炎 :早表層鞏膜炎在臨床上分為兩型:

1.單純性表層鞏膜炎(simple episcleritis)2.結節性表層鞏膜炎(nodular episcleritis)

(二)深層鞏膜炎:⑴彌漫性前鞏膜炎(diffuse anterior scleritis) ⑵結節性前鞏膜炎(nodular anterior scleritis) ⑶壞死性前鞏膜炎(necrotizing anterior scleritis)

臨床癥狀:

       后鞏膜炎最常見的癥狀有程度不同的疼痛、視力減退、眼紅,但也有一些人沒有明顯癥狀或僅有這些癥狀中的一種。重癥病例有眼瞼水腫、球結膜水腫、眼球突出或復視或兩者皆有。癥狀與眼眶蜂窩組織炎難以區別。

鑒別診斷:

       其鑒別點在于本病的水腫程度較蜂窩織炎為明顯,而蜂窩織炎的眼球突出,則又較后鞏膜炎為顯著。疼痛輕重不等,有的甚輕,有的極度痛苦,常與前部鞏膜炎受累的嚴重程度成正比。病人可能主訴眼球本身痛或疼痛涉及眉部、顳部或顴顳部。視力減退是常見的癥狀,其原因是伴有視神經視網膜病變。有些人主訴由于近視減輕或遠視增加而引起視力疲勞,這是后鞏膜彌漫性增厚導致眼軸縮短,更換鏡片可使癥狀緩解。臨床和病理方面均可見,后鞏膜炎病人都有前部鞏膜受累,表現有穹窿部淺層鞏膜血管擴張、斑片狀前鞏膜炎、結節性前鞏膜炎。也可沒有眼部充血。但有疼痛和眼充血的病史,或可能已局部用過皮質類固醇治療。眼球突出、上瞼下垂和眼瞼水腫,可見于重癥鞏膜周圍炎,這種炎癥常擴散到眼外肌或眼眶。因眼外肌炎癥可有眼球轉動痛或復視。這些癥狀合并在一起就被稱為鞏膜周圍炎、鞏膜球筋膜炎和急性前部炎性假瘤。此外還有一種病變更為表淺,表現為明顯的眼球筋膜炎,而鞏膜則無明顯炎癥,James稱之為膠凍性眼球筋膜炎。球結膜呈半膠凍狀橙紅色水腫,如魚肉狀,觸之稍硬,壓迫時有輕度凹陷,病變可延伸到角膜緣,而眼內仍然正常。但亦有嚴重者,病變可侵及鞏膜而成為膠凍狀鞏膜炎。

眼底病變:

①界限清楚的眼底腫塊:局限性鞏膜腫脹區可引起脈絡膜隆起。通常圍以同心的脈絡膜皺褶或視網膜條紋。這類炎癥結節常伴有眶周圍疼痛,但也可以患病而無明顯癥狀在常規檢查中才發現。

②脈絡膜皺襞、視網膜條紋和視盤水腫:這是鞏膜炎的主要眼底表現。病人常伴有輕度疼痛或穹窿部眼球表層血管充血。鄰近視盤之鞏膜炎癥,偶可致視盤水腫。

③環形脈絡膜脫離:有些病例鄰近鞏膜炎病灶處可見略呈球形的脈絡膜脫離,但環形睫狀體脈絡膜脫離更常見。

④滲出性黃斑脫離:青年女性后鞏膜炎可致后極血-視網膜脫離,這種脫離只限于后極部。眼底熒光血管造影可見多處針尖大小的滲漏區。超聲掃描顯示眼后極部各層變厚和眼球筋膜水腫。 基于上述,Benson(1982)指出,對原因不明的閉角型青光眼、脈絡膜皺褶、視盤水腫、界限清楚的眼底腫塊、脈絡膜脫離和滪性視網膜脫離等,均應想到此病的可能。西醫常規治療不再贅述

魏醫生的中醫辯證經驗:

       中醫認為鞏膜炎屬于火疳范疇,多由心肺積熱、火毒侵襲、風濕內擾、婦女血熱等引起,病因病機是肺熱蘊結,導致肺失肅降,氣血瘀滯。

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