共聚焦显微镜在其他角膜病中的应用

第八节　共聚焦显微镜在其他角膜病中的应用

一、干眼症

干眼症亦称角结膜干燥症,是极为常见的眼表疾病,是指任何原因引起的泪液质和量或动力学异常导致的泪膜不稳定,并伴有眼部不适症状,眼表组织病变为特征的一大类疾病的总称(图4-75)。如仅有眼部不适症状而无眼表损伤的体征,称为干眼症。如同时伴有眼表损伤,称为干眼病。

图4-75　干眼症患者的裂隙灯像

注:角膜上皮点状染色,泪河变浅

在共聚焦显微镜下,干眼症患者一般表现为眼表各层上皮细胞特别是鳞状上皮细胞增生,上皮细胞呈应激状态,细胞核突出;部分患者可伴有上皮下神经改变,如神经增粗、分支增多、走行不规则等。这些均为干眼症在共聚焦显微镜下的常见表现(图4-76)。

A.角膜浅表鳞状上皮细胞增生,排列密集,细胞核明显突出,细胞呈激活状态,并可见胞体高亮的脱落细胞(箭头)

B.角膜基底层上皮细胞胞体增大,细胞核突出(箭头),细胞呈激活状态

C.角膜基底层上皮细胞间隙增大,细胞核突出(箭头),细胞呈激活状态

D.角膜上皮(下方)-基质(上方)交界处可见上皮下神经明显增粗,走行尚规则

E.角膜上皮下神经明显增粗,排列密集,伴少量朗格汉斯细胞浸润(箭头)

F.角膜上皮下神经明显增粗,伴少量朗格汉斯细胞浸润(箭头)

G.角膜上皮下神经明显增粗,伴少量朗格汉斯细胞浸润(箭头)

图4-76　共聚焦显微镜观察干眼症患者角膜(A～D为X 1 000, NIDEK CS系列;E～F为X 800, HRT系列)

二、眼类天疱疮

眼类天疱疮可导致黏蛋白缺乏性干眼病。本病常隐匿发病,有眼红、异物感、流泪、畏光等症状。双侧发病,病程反复。典型体征为下方睑球粘连、下穹窿缩窄(图4-77)。

A.角膜广泛新生血管,中央角膜基质部分溶解

B.可见广泛结膜瘢痕

图4-77　眼类天疱疮患者的裂隙灯像

在共聚焦显微镜下,患者角膜除存在角膜各层上皮细胞增生、激活的干眼病共同表现外,还可见角膜、结膜炎症细胞浸润,并常累及基质。基质细胞呈激活状态,有时可见基质瘢痕形成。由于角膜基质层透光性下降,内皮细胞形态大多较模糊(图4-78)。

A.结膜内见大量炎症细胞浸润

B.角膜上皮纵切面,可见眼表各层上皮细胞特别是表层鳞状上皮细胞增生,各层上皮细胞呈激活状态,细胞核突出

C.角膜翼状细胞胞体增大,细胞核突出(箭头),细胞呈激活状态

D.角膜基底细胞增生,细胞密集,细胞核突出(黑色箭头),细胞呈激活状态,并可见少量圆形高反光炎症细胞浸润(白色箭头)

E.基质细胞呈明显激活状态,胞体相互交织呈致密网状

图4-78　共聚焦显微镜观察眼类天疱疮患者的角膜(X 800,HRT系列)

三、Sjögren综合征

Sjögren综合征是一组由自身免疫性疾病引起的综合征。除了干眼症的眼部表现外,还包括角结膜干燥,口腔、鼻腔及生殖道黏膜干燥和结缔组织病。

Sjögren综合征多发生于绝经期妇女,眼部主要表现为一系列干眼症状,但病情严重程度重于普通的干眼症患者(图4-79)。 Sjögren综合征的病理检查表现以泪腺中大量淋巴细胞浸润、泪液分泌功能破坏为特征,可致泪液生成不足性干眼病。病变晚期,腺泡组织被大量的纤维结缔组织所取代。

图4-79　Sjögren患者的裂隙灯像注:角膜荧光染色后可见角膜上皮广泛糜烂

在共聚焦显微镜下,Sjögren综合征患者除存在角膜各层上皮细胞增生、激活等的干眼病共同表现外,还可见角膜、结膜炎症细胞浸润,并常累及基质。基质细胞呈激活状态,有时可见前弹力层和基质沉积物(图4-80)。

A.角膜浅表上皮细胞增生,细胞核突出(黑色箭头),细胞呈激活状态;并可见少量圆形高反光炎症细胞浸润(白色箭头)

B.角膜基底层上皮细胞增生,细胞核突出(黑色箭头),细胞呈激活状态;并可见少量圆形高反光炎症细胞浸润(白色箭头)

C.角膜基底层上皮细胞排列紊乱,细胞核突出,细胞呈激活状态。基底膜反光增强,局部皱褶(箭头)

D.角膜上皮基底膜可见不规则形态高反光沉积物(白色箭头),上皮下神经纤细,走行紊乱,可见断端(黑色箭头)

E.角膜基质细胞呈明显激活状态,胞体相互交织呈致密网状

F.角膜基质混浊,背景反光较强,基质细胞间可见细针状高反光沉积物(箭头)

图4-80　共聚焦显微镜观察Sjögren患者的角膜(X 800,HRT系列)

四、类风湿关节炎伴发干眼病

类风湿关节炎是常见的全身性结缔组织病,常伴发干眼病。共聚焦显微镜下,患者除存在角膜各层上皮细胞增生、激活等的干眼病共同表现外,还常伴有上皮下神经数量增多、减少、分支增多、走行紊乱等,有时可见前弹力层和浅基质层沉积物、瘢痕(图4-81)。

A.角膜基底细胞增生,细胞密集,细胞核明显突出,细胞呈激活状态

B.上皮下神经明显增粗,数量增多,分支增多,相互交联。不伴明显炎症细胞浸润

C.上皮下神经分支明显增多,相互交联呈网状

D.上皮下神经明显减少,未见分支,伴中量朗格汉斯细胞浸润

E.前弹力层界面高反光瘢痕组织(箭头),瘢痕处神经走行中止

F.患者对侧眼前弹力层界面高反光瘢痕组织(箭头),瘢痕处神经走行中止

G.患者对侧眼浅基质层,可见高反光瘢痕组织(箭头)

图4-81　共聚焦显微镜观察类风湿关节炎伴干眼病患者的角膜

(X 800,HRT系列)

五、丝状角膜病变

干眼病可引起丝状角膜病变。患者局部角膜上皮细胞卷成丝状物,一端附在角膜表面,另一端呈游离状态。自觉症状有异物感及眼痛。裂隙灯下可见角膜表面挂有细丝状物,以上方角膜较多见(图4-82)。共聚焦显微镜下可见多枚脱落的角膜上皮细胞卷成一高反光条索,顶端悬浮,末端连于角膜上皮层内(图4-83)。

A.角膜上皮呈丝状剥脱,附着于角膜表面

B.钴蓝光下卷丝清晰可见(箭头处)

图4-82　丝状角膜病变患者的裂隙灯像

图4-83　共聚焦显微镜观察丝状角膜病变患者的角膜(X 800,HRT系列)

注:多枚脱落的角膜上皮细胞卷成一高反光条索,顶端悬浮,末端连于角膜上皮层内(箭头)

(乐琦骅　徐建江　洪佳旭　郑天玉　朱文卿)

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