马来西亚大学医学中心角膜溃疡的回顾分析
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首席医学网
2009年04月08日 16:31:04 Wednesday
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作者：A J Kadir A Samsudin A Fauzi Z Z Abidin 作者单位：马来西亚吉隆坡，马来亚大学医学院眼科
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【摘要】 目的：分析角膜溃疡的病例分布、危险因素、临床特点、微生物检查及预后结果。方法: 对200307/ 200604就诊于马来西亚大学医学中心的84例（87眼）患者进行研究，其中1例双眼发病，另1例曾因疱疹性角膜炎复发3次就诊。选入标准包括角膜上皮缺损、角膜基质浸润及炎症。 结果：患者84例中有男46例，女38例。主要是马来人(52%)。3个主要的危险因素是角膜接触镜的配戴(47%)，眼外伤(25%)及眼表疾病(24%)。在老年患者中，糖尿病(8%)及高血压(9%)是重要的系统性疾病。阳性为25%，而微生物培养阳性为73%。在各危险因素组中，绿脓杆菌是最常见的致病菌，在角膜接触镜配戴者中最高。耐庆大霉素革兰染色阴性菌有2例,耐青霉素表皮葡萄球菌有1例。75%的患者溃疡愈合，遗留角膜混浊。2mo后,54%的患眼最佳矫正视力>6/18，14%<3/60。3例患者需要行眼球摘除或剜除术。 结论：角膜接触镜配戴和眼外伤是青年人群中主要的可预防性危险因素，相反，眼疾是老年人中不可预防的危险因素。超过60%的培养阳性病例为革兰染色阴性菌。
【关键词】 角膜溃疡 角膜炎 马来西亚
INTRODUCTION
Retinoblastoma is the commonest primary intraocular malignant tumour in children. It usually presents before the age of 3 years[1]. It could be sporadic or familial. Familial cases tend to be bilateral and can be detected within 2 weeks after birth[2].
Part of the goal of managing retinoblastoma in the developed world include early detection and preservation of the eye with good vision[2,3]. The mortality from retinoblastoma is reported to be only 2%5%[1]. In many developing countries, however, due to late presentation poverty and inadequate facilities the goal of treatment is often to preserve life as the eye is almost invariably removed[4]. The current study examines the challenges in managing retinoblastoma in a developing country.
PATIENTS AND METHODS
The clinical and histopathological records of patients with retinoblastoma seen at University of Nigeria Teaching Hospital and Ebrans clinic both in Enugu, Nigeria over a 5year period (January 1998 to December 2002) were reviewed.
Data collected included patients age at diagnosis, sex, laterality, staging of tumour, family history and treatment modality. Data analysis was with EPIINFO version 6.0.
A four stage system of classification[5] was adopted for the study: 1)Quiescent stage with amaurotic cat eye reflex 2)Stage of increase of intraocular pressure. Tumour is confined to the eyeball but with glaucoma, megalocornea and intraocular inflammatory changes 3)Stage of extraocular extension involving the optic nerve. Spread is limited to the orbit 4)Distant metastasis to cervical lymph nodes, bones, central nervous system etc.
RESULTS
A total of 34 children had histologically proven retinoblastoma during the study period. Their age and sex distribution is shown in table 1. The earliest age at presentation was 5 months and the oldest age was 7 years. The mean age of males was 3.1±1.6 years and that of females was 2.4±1.2 years while overall mean age was 2.9±1.5 years. There was no statistically significant difference in the mean ages of males and females (t=1.2,P=0.3)
More males 25(74%) than females 9(26%) were affected, giving a male to female ratio of 1∶0.4. Only 6 patients had bilateral tumour. No positive family history of retinoblastoma was noted. The staging of the disease is as follows: stage 1, 3 patients (9%); stage 2, 8 patients (24%), stage 3, 13 patients (38%) and stage 4, 10 patients (29%).
Eleven patients (32.4%) had enucleation while 23 (67.6%) had exenteration. In the exenteration group, 5 patients presented earlier when the tumour was confined to the globe. Their parents, however, refused enucleation and only came back when tumour had spread to the orbit and became unsightly.
Postoperatively they were referred to paediatric oncology unit for chemotherapy.
DISCUSSION
Late presentation is a major challenge in management of
Table 1Age distribution of 34 children with retinoblastoma(%)
Age (years)SexMaleFemaleTotalPercent1123921031338393123541013511266101372026Total25934100
retinoblastoma in developing countries. Greater majority of the patients in our series presented at advanced stages with extraocular extension and orbital involvement. Most parents seek alternative medicine treatment modality first and resort to orthodox treatment when everything has failed.
In developed countries, initial detection of abnormalities in the eye suggestive of retinoblastoma by family members rather than physicians is associated with a higher incidence of enucleation[3]. Preservation of eye was greatly improved when physicians first detected the abnormalities. This, however, entailed serial examination under anaesthesia[2,3].
The serial examination under anaesthesia is designed for patients with family history of retinoblastoma. In the current series, none of the patients admitted a positive family history of the disease. This may stem from denial or ignorance. Moreover, most retinoblastoma patients in rural Africa do not survive to the age of reproduction.
Six patients (18%) had bilateral disease which is more often associated with familial disease. Unaffected parents of a child with bilateral retinoblastoma with no family history have a 40% chance of producing another affected child[1]. Such siblings should benefit from serial screening. This may not be achievable in rural Africa due to poverty. The patients and their caregivers travel several kilometres to get to the urban communities where the ophthalmologists practice. Although modern treatment modalities, such as photocoagulation, cryotherapy, external beam irradiation and episcleral radioactive plaque are not widely available in developing countries, enucleation at such early stages cures the patient of cancer[6].
The patients in this series were offered enucleation or exenteration and were subsequently referred to the paediatric oncology unit for chemotherapy. Cyclophosphamide, Vincristine, Methotrexate and Prednisolone were used. Carboplatin and Etoposide were not available. There is a need to provide these drugs. It is advocated that cancer patients in developing countries should be offered free treatment.
Extraocular disease whether to the orbit or central nervous system is associated with increased mortality[79]. Twentythree patients (68%) had exenteration because of spread to the orbit. Availability of effective cytotoxic agents can help achieve chemoreduction, enucleation rather than disfiguring extenteration can now be carried out[10]. After enucleation and excision of all visible residual orbital tumour, orbital radiotherapy followed by four more courses of chemotherapy is advocted[10]. Centres for radiotherapy are not widely available in Nigeria. Poverty is a limiting factor for referrals to such treatment centres. Also facilities for proper evaluation of these patients for metastatic disease such as technetium bone scan, CT scan or magnetic resonance imaging are not widely available. Another setback in the management of retinoblastoma in a developing country is failures in followup. There was no record of followup till death in any of the patients and this has made it difficult to assess the survival rate.
In conclusion, late presentation, poverty and unavailability of modern treatment facilities are some of the challenges in managing retinoblastoma in a developing country like Nigeria. Health education, early diagnosis and provision of modern treatment facilities will go a long way in improving the management of retinoblastoma in developing countries.
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