Objective: To investigate the treatment effect of keratectomy combined with intrastromal injection of voriconazole on fungal keratitis. Methods: Retrospective study. Ninety-eight fungal keratitis patients (98 eyes) were treated by keratectomy combined with intrastromal injection of voriconazole in Shandong Eye Hospital from January 2013 to May 2015. The corneal ulcers were mostly located in the paracentral or peripheral cornea, which incompletely blocked the pupil area. Slit lamp and anterior segment optical coherence tomography (AS-OCT) were used for lesion detection. The maximum lesion diameter was ≤5 mm, and the maximum depth was not more than half of the full corneal thickness. Because the anti-fungal drug treatment for 3-7 days was not effective, keratectomy was performed with intrastromal injection of voriconazole. The excision extension was 0.5 mm greater than the ulcer diameter, and keratectomy could be repeated until the infiltrative tissues were completely removed. Anti-fungal drug therapy was carried on after surgery. The wound healing and complications were observed. Results: All the subjects were diagnosed as fungal keratitis by corneal scraping and confocal microscopy. With an average lesion diameter of (3.72±1.23) mm, the corneal ulcers were located in the paracentral cornea in 30 patients (30.6%) and in the peripheral cornea in 68 patients (69.4%). The infiltrative depth of 74.5% of the cases detected by AS-OCT were ≤1/2 corneal thickness. The fungal keratitis in 95 cases was cured successfully. Conjunctival flap covering surgery (2 cases) and penetrating keratoplasty (1 case) were performed when the conditions were poorly controlled. Among the 95 cured cases, the ulcer healing time ranged from 3 to 19 days, and ≤7 days in more than half of the cases (48 cases). The average corneal thickness was (433.2±119.3) μm at 3 months, and the corneal endothelial cell density was (2 344.0±404.6) cells/mm(2). The uncorrected visual acuity was improved in 71(74.7%) eyes, of which 3 cases had a vision of 1.0. Conclusions: For fungal keratitis with a lesion diameter of<6 mm and a depth not more than half of the full corneal thickness, keratectomy combined with intrastromal injection of voriconazole could achieve ideal outcomes. The visual acuity recovered quickly, the therapy course was shortened, and the necessity of keratoplasty and other high risk surgeries was reduced. (Chin J Ophthalmol, 2017, 53: 682-688).
目的： 探讨角膜病灶切除联合基质内注射伏立康唑治疗真菌性角膜溃疡的临床疗效。 方法： 回顾性系列病例研究。收集2013年1月至2015年5月在山东省眼科医院应用角膜病灶切除联合基质内注射伏立康唑治疗的真菌性角膜溃疡患者98例（98只眼），其中男性71例，女性27例，年龄（51.9±11.5）岁。溃疡均位于角膜旁中央或周边部，未完全遮挡瞳孔区，裂隙灯显微镜结合眼前节光学相干层析扫描仪(AS-OCT)检查溃疡及浸润的深度≤1/2角膜厚度。入院后常规局部和全身使用抗真菌药物治疗3~7 d，如溃疡无明显好转或浸润加重，应用角膜病灶切除联合基质内注射伏立康唑的方法治疗。切除范围大于角膜溃疡直径0.5 mm，剥切深度略深于角膜浸润深度，彻底切除病灶后给予角膜基质内注射伏立康唑。观察角膜感染控制和角膜上皮愈合时间，随访有无真菌复发及视力变化等。 结果： 98例患者通过角膜刮片及共焦显微镜检查明确诊断为真菌性角膜溃疡，术前裂隙灯检查溃疡平均直径（3.72±1.23）mm；溃疡位于周边角膜的30例（30.6%），角膜旁中央68例（69.4%）。AS-OCT检查74.5%的患者感染浸润深度≤1/2角膜厚度。通过治疗95例（96.9%）患者感染得到控制，溃疡完全愈合，3例患者术后再次出现浸润，2例改行结膜瓣遮盖术，1例再次行穿透性角膜移植术。95例治愈患者角膜上皮愈合时间3~19 d，平均（8.58±3.87）d，溃疡愈合时间≤7 d的患者为48例（50.5%）。术后3个月病灶切除区域角膜平均厚度（433.2±119.3）μm，内皮细胞密度（2 344.0±404.6）个/mm(2)。71只眼（74.7%）视力较术前提高，达到1.0者3只眼。 结论： 角膜病灶切除联合基质内注射伏立康唑术对于直径小于6 mm，浸润深度不超过1/2角膜厚度的真菌性角膜溃疡可以快速控制感染，缩短药物治疗的时间，术后视力恢复快，减少了角膜移植和其他手术的必要性。（中华眼科杂志，2017，53：682-688）.
Keywords: Corneal stroma; Corneal ulcer; Eye infections, fungal; Injections, intraocular; Ophthalmologic surgical procedures; Voriconazole.