病例1 16岁女孩，主诉眼干眼红异物感
CASE 1 A 16-year-old female complaining of dryness and foreign body sensation of both eyes
见图1-1。See Fig. 1-1.
图1-1 A.睑缘肥厚、毛细血管扩张和后睑缘炎伴睑板腺口阻塞（黑箭头），结膜充血，角膜缘新生血管，下方血管翳呈铲形，侵入角膜组织（蓝箭头）；B.鼻面部血管扩张，痤疮形成。Fig. 1-1 A. pachyblepharosis and telangiectasia with posterior blepharitis with capping of meibomian orif ices(black arrow), conjunctiva congestion，peripheral corneal neovascularization, spade-shaped inf iltrates along the advancing vascular border(blue arrow); B. facial telangiectasia, papule and pustule formation.
鉴别诊断
Differential Diagnosis
◎ 眼酒渣鼻：眼酒渣鼻是一种炎症性眼部疾病，患者通常伴随皮肤酒渣鼻，其特征是面部持续性红斑、毛细血管扩张、丘疹和脓疱。累及眼睑，可见睑缘充血，睑缘皮肤伴随结痂和鳞屑样改变，睑板腺开口扩大，毛细血管扩张，睑板腺发炎或睑板腺囊肿；结膜充血或混合充血，严重者可累及角膜，发生角膜炎。角膜受累通常始于角膜下1/3处，表现为浅表点状角膜炎。
◎ Ocular Rosacea is an inf lammatory eye condition that often affects those who have rosacea of the skin, which is characterized by persistent erythema, telangiectasia,pimples and pustules on the face. Patients with blepharitis can see hyperemia, the skin around the blepharon can have crusts and scales, the opening of meibomian gland is enlarged, capillary is expanded, meibomian gland inf lammation or meibomian gland cyst; the conjunctiva is hyperemia or mixed hyperemia. In serious cases, the cornea can be affected and keratitis can occur. Corneal involvement typically starts with superf icial punctate keratitis in the inferior third of the cornea.
◎ 睑板腺功能障碍：多见于老年，症状无特异性，包括眼红、眼部烧灼感、异物感、干燥感、刺激感、痒、视疲劳、视力波动、流泪等。睑缘常增厚，可伴红斑、过度角化等体征，睑缘后层出现自后向前的永久性血管扩张，睑板腺开口有白色角质蛋白堵塞而凸起变形，挤压后分泌物呈泡沫样、颗粒样或牙膏样。不伴面部皮肤改变。
◎ Meibomian gland dysfunction (MGD): commonly seen in the elderly. The symptoms are nonspecif ic,including redness, burning sensation, foreign body sensation, dryness, irritation, itching, visual fatigue, visual f luctuation, tearing, etc. Lid margin is often thickened,accompanied by erythema, hyperkeratosis and other signs. The posterior lid margin presents a permanent vasodilatation from posterior to anterior. The opening of the meibomian gland orif ice is blocked by white keratin and hump deformed. The secretions are foam, granule or toothpaste. Do not combine with facial dermatology disorders.
◎ 泡性角结膜炎：一般单眼发病，轻微异物感，累及角膜则症状加重。反复发作后疱疹可向中央进犯，新生血管长入，称为束状角膜炎，痊愈后遗留带状薄翳，根据典型的角膜缘或球结膜处实性结节样小泡，周围充血等症状可正确诊断。
◎ Phlyctenulosis: often one eye involved, slight foreign body sensation, corneal involvement will aggravate the symptoms.After repeated attacks, herpes may invade into the center and new blood vessels grow in, which is called fascicular keratitis. After recovery, shingles and pannus are left. It can be correctly diagnosed according to typical symptoms such as solid nodular vesicles at cornea edge or bulbar conjunctiva,peripheral congestion.
◎ 边缘性角膜炎：由对葡萄球菌外毒素和细胞壁蛋白的超敏反应引起，抗原 - 抗体复合物沉积于角膜缘（抗原从泪膜扩散，抗体从血管中扩散），伴继发性淋巴细胞浸润。病原学培养可呈阴性，但金黄色葡萄球菌常能从眼睑边缘分离出来。
◎ Marginal keratitis：caused by a hypersensitivity reaction against staphylococcal exotoxins and cell wall proteins with deposition of antigen-antibody complexes in the peripheral cornea (antigen diffusing from the tear f ilm, antibody from the blood vessels) with a secondary lymphocytic inf iltration.The lesions are culture-negative but S. aureus can frequently be isolated from the lid margins.
病史询问
Asking History
◎ 眼部出现症状的时间及是否有反复；询问皮肤酒渣鼻的病史及治疗。
◎ Asking the onset, duration and recurrent of symptoms.Asking the history and treatment of facial rosacea.
◎ 询问外伤史及其他全身病史。
◎ Asking trauma and other system disorders.
检查
Examination
◎ 视力、眼压。
◎ Vision, IOP.
◎ 裂隙灯检查：双眼上、下睑睑板腺开口情况，睑板腺腺体分泌物性状，睑缘形态及血管化情况，以及结膜充血情况。角膜缘血管翳及角膜浸润灶。
◎ Slit lamp examination：the opening of meibomian gland orif ice, the secretions of meibomian gland, the shape of meibomian margin, and conjunctival congestion of the upper and lower eyelids of both eyes. Check the vasculization of eyelid margin. Peripheral corneal neovascularization and inf iltration.
◎ 干眼检查：角膜荧光素钠染色检查角膜是否有浅层点状角膜炎，泪膜破裂时间，泪液分泌试验。
◎ Dry eye examination: corneal f luorescein staining to check superf icial punctate keratitis and tear f ilm break-up time, Schirmer test.
◎ 眼科医师在患者就诊时应关注面部皮肤情况，是否存在毛细血管扩张、丘疹和脓疱形成、鼻炎、鼻赘和面部潮红等。
◎ Facial observation: Facial telangiectasia, papule and pustule formation, rhinophyma and facial f lushing may occur.
实验室检查
Lab
◎ 皮肤科检查：行毛囊螨虫镜检。
◎ Dermatological examination: microscopical examination of hair follicle mites.
◎ 睑缘及结膜囊细菌培养，眼睑毛囊螨虫镜检。
◎ Bacterial culture of blepharon and conjunctival sac，microscopical examination of blepharon mites.
诊断
Diagnosis
眼酒渣鼻。
Ocular Rosacea.
治疗
Management
◎ 避免接触过敏原。局部治疗包括清洁睑缘，使用无防腐剂人工泪液、抗生素等，如红霉素眼膏或妥布霉素眼膏。
◎ Topical treatment including lid margins cleaning，preservatives free lubricants and topical antibiotics，such as erythromycin ointment or tobramycin ointment.
◎ 伴角膜炎时须慎用糖皮质激素，除外感染因素非常必要。
◎ It is necessary to use glucocorticoids when cornea was involved, except for infection factors.
◎ 皮肤面严重受累时需要联合皮肤科共同治疗，全身使用抗生素，主要是四环素类，多西环素或米诺环素，是大多数酒渣鼻患者的首选药物。
◎ Systemic antibiotics, primarily the tetracyclines,particularly doxycycline and minocycline, are the drugs of choice for most rosacea individuals with facial problem.
患者教育和预后
Patient Education & Prognosis
◎ 眼酒渣鼻是一种多因素疾病，症状可控，但可反复发作，彻底治愈较困难。
◎ Ocular Rosacea is a multifactor disease with controllable symptoms. It is prone to recur and difficult to cure completely.