摘要背景 感染性角膜炎是角膜病致盲的主要原因之一.对于药物治疗无效的严重感染性角膜溃疡患者若面临角膜穿孔甚至丧失眼球的危险时应首先考虑行穿透性角膜移植术(PKP).目前尚缺乏比较PKP治疗不同病原菌导致引起的严重感染性角膜溃疡患者疗效的研究. 目的 探讨不同病原菌引起的严重感染性角膜溃疡行PKP后的临床效果.方法 采用回顾性研究设计,对2008年1月至2014年1月于青岛大学附属医院确诊为严重感染性角膜溃疡且行PKP的患者210例221眼的临床资料进行分析,按照感染病原菌的种类将患眼分为真菌性角膜溃疡组(155眼)、细菌性角膜溃疡组(30眼)、病毒性角膜溃疡组(28眼)和棘阿米巴性角膜溃疡组(8眼),各组术眼术前不同等级视力的眼数分布相匹配.术后随访6 ～ 24个月,比较各组手术治疗的有效率、不同等级视力的眼数分布、角膜排斥反应发生率和病变复发率的差异. 结果 本组分析的病例中,真菌性角膜溃疡者居首位,为70.1％ (155/221),细菌性角膜溃疡占13.6％ (30/221),病毒性角膜溃疡占12.7％ (28/221),棘阿米巴性角膜溃疡占3.6％ (8/221).真菌性角膜溃疡组、细菌性角膜溃疡组、病毒性角膜溃疡组和棘阿米巴性角膜溃疡组行PKP的有效率分别为88.5％、86.7％、92.8％和75.0％,各组间差异无统计学意义(x2=4.022,P=0.259).细菌性角膜溃疡组和病毒性角膜溃疡组术后最佳矫正视力(BCVA)均明显好于真菌性角膜溃疡组,差异均有统计学意义(Z=-5.125、-7.504,均P＜0.001),病毒性角膜溃疡组术后BCVA明显优于细菌性角膜溃疡组,差异有统计学意义(Z=-3.189,P=0.001).随访中170眼患者角膜植片透明,有26眼角膜植片发生混浊和新生血管化,另有25眼植片周边部有少量新生血管长入,各组角膜植片不同透明程度的眼数分布差异无统计学意义(P=0.325).真菌性角膜溃疡组术眼术后排斥反应发生率分别为39.4％,明显高于细菌性角膜溃疡组的20％和病毒性角膜溃疡组的17.9％,差异均有统计学意义(P=0.043、0.029).随访期间真菌性角膜溃疡组术眼病变复发率为20.0％,明显高于细菌性角膜溃疡组3.3％和病毒性角膜溃疡组的3.6％,差异均有统计学意义(P=0.032、0.033).42.6％真菌性角膜溃疡眼术后首次发生排斥反应时间在术后3个月内,早于细菌性和病毒性角膜溃疡组. 结论 PKP是治疗严重感染性角膜溃疡的有效方法,4种常见的病原菌性角膜溃疡中,病毒性角膜溃疡术后BCVA最好,真菌性角膜溃疡术后排斥反应的发生率和复发率最高,且排斥反应发生较早.

abstractsBackground Refractory infectious keratitis is one of the leading causes of corneal blindness.Penetrating keratoplasty (PKP) is a primary approach to serious infectious keratitis patients who did not feasible to drug therapy.However, the comparative study on PKP outcomes of different pathogens-caused severe infectious keratitis is still lack at present.Objective This study was to evaluate the therapeutic effect of PKP on severe keratitis infected by fungus,bacteria,virus and acanthamoeba.Methods The clinical data of a total of 221 eyes of 210 patients who underwent PKP from severe infectious keratitis at Affiliated Hospital of Qingdao University from January,2008 to January, 2014 were retrospectively analyzed and reviewed.The patients were grouped to fungal infected group (155 eyes), bacterial infected group (30 eyes), virus infected group (28 eyes) and acanthamoeba infected group (8 eyes).The follow-up duration was 6-24 months.The effective rate of treatment, eyes in different graded visual acuities, rejected rate and recurrence rate were compared among different groups.Results The percentage of fungal keratitis was 70.1％ (155/221), and that of bacterial keratitis, virus keratitis and acanthamoeba keratitis was 13.6％ (30/221) ,12.7％ (28/221) and 3.6％ (8/221) ,respectively.The effective rates of PKP were 88.5％ ,86.7％ ,92.8％ and 75.0％ in the fungal infected group, bacterial infected group, virus infected group and acanthamoeba infected group, respectively, showing insignificant difference among the groups (x2=4.022, P =0.259).The postoperative best corrected visual acuity (BCVA) was better in the bacterial infected group than that in the fungal infected group or virus infected group (Z =-5.125,-7.504, both at P＜0.001) , and the postoperative BCVA in the virus infected group was superior to bacterial infected group (Z =-3.189,P =0.001).The grafts were clear in 170 post-PKP eyes, and corneal opacity and neovaseularization were observed in 26 eyes, and a few new blood vessels were seen in another 25 eyes after PKP.The number of eyes in different degree transparences was not significantly different among the groups (P =0.325).The rejected rate of grafts was 39.4％ in the fungal infected group,which was significantly higher than 20％ in the bacterial infected group and 17.9％ in the virus infected group (P =0.043,0.029).The recurrence rate of lesions was 20％ in the fugal infected group, 3.3％ in the bacterial infected group and 3.6％ in the virus infected group, showing significant differences between fugal infected group and bacterial infected group (P=0.032) as well as between fugal infected group and virus infected group (P =0.033).Rejected response occurred within 3 months after PKP in 42.6％ fungal-infected eyes, which was earlier than bacterial-and virus-infected eyes.Conclusions PKP is an effective treating approach to severe infectious keratitis.The postoperative BCVA is better in viral keratitis than that of bacterial keratitis or fungal keratitis.There is a higher rejection rate of grafts in fungal keratitis than that in bacterial keratitis or viral keratitis after PKP.