Bernauer W, Langenauer U M
Universität Zürich und OMMA Praxisgemeinschaft, Zürich.
Klin Monbl Augenheilkd. 2006 May;223(5):353-6. doi: 10.1055/s-2006-926557.
Chronic conjunctivitis and keratoconjunctivitis account for a significant ocular morbidity. Early diagnosis and appropriate management are essential to avoid persisting structural damage and visual loss. In children, the correct diagnosis is frequently delayed because of the low individual experience with pediatric ocular inflammation, the uncommon clinical manifestations and the rarity of some conditions. This study aims to identify the problems associated with the diagnosis of chronic pediatric (kerato-)conjunctivitis.
48 consecutive tertiary referrals (median age: 8.5 years) with chronic conjunctivitis or keratoconjunctivitis were studied. The ocular inflammation of all patients was denoted by their referring ophthalmologists as "chronic conjunctivitis refractory to therapy". The median time since disease onset was 23 months (range: 3 - 118). On average, 2.8 (range: 2 - 5) ophthalmologists were seen before the final diagnosis was made. A standardized protocol was used to classify and diagnose the ocular inflammation. Laboratory investigations were carried out to confirm the diagnosis in 20 out of 48 patients.
In 33 out of 48 patients treatment failure was due to an inappropriate diagnosis. The most frequent diagnosis were Staphylococcus-associated inflammation (n = 21) and vernal keratoconjunctivitis (n = 12). Viral infection causing molluscum contagiosum was the most frequent condition that was missed (n = 7). Ligneous conjunctivitis (n = 2) was not recognised by the 9 ophthalmologists who were previously in charge of the treatment. Significant corneal involvement was found in 24 (50 %) patients.
History taking and a thorough clinical examination of the entire ocular surface allow the correct diagnosis of and therapy for chronic surface inflammation in almost all pediatric patients. Subtle clinical changes have to be sought actively to avoid misdiagnosis. Such changes include lesions in the anterior lid margin, collarettes, follicules, papillae, and superficial punctate keratopathy.
慢性结膜炎和角结膜炎是导致眼部发病率显著升高的重要原因。早期诊断和恰当治疗对于避免持续性结构损伤和视力丧失至关重要。在儿童中，由于儿科眼部炎症方面的个人经验不足、临床表现不常见以及某些病症较为罕见，正确诊断常常被延迟。本研究旨在确定与慢性儿童（角）结膜炎诊断相关的问题。
对48例连续转诊的慢性结膜炎或角结膜炎患者（中位年龄：8.5岁）进行了研究。所有患者的眼部炎症被其转诊的眼科医生诊断为“治疗难治性慢性结膜炎”。自疾病发作以来的中位时间为23个月（范围：3 - 118个月）。在做出最终诊断之前，平均每位患者看过2.8（范围：2 - 5）位眼科医生。采用标准化方案对角部炎症进行分类和诊断。对48例患者中的20例进行了实验室检查以确诊。
48例患者中有33例治疗失败是由于诊断不当。最常见的诊断为葡萄球菌相关性炎症（n = 21）和春季角结膜炎（n = 12）。导致传染性软疣的病毒感染是最常被漏诊的病症（n = 7）。9位之前负责治疗的眼科医生均未识别出木样结膜炎（n = 2）。24例（50%）患者发现有明显的角膜受累。
详细的病史采集和对整个眼表进行全面的临床检查，几乎能让所有儿童患者的慢性眼表炎症得到正确诊断和治疗。必须积极寻找细微的临床变化以避免误诊。这些变化包括睑缘前部病变、结膜环、滤泡、乳头以及浅层点状角膜病变。
