2018年 · 第54卷第06期

This issue focuses on the research progress of ocular surface diseases. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Huang Yifei.

In China, the diagnostic criteria and treatment plan of allergic conjunctivitis have lacked a unified understanding for a long time. Most ophthalmologists only rely on personal clinical experience for diagnosis and treatment, and the clinical effect is difficult to guarantee. In recent years, the diagnosis and treatment technology of ophthalmology in China has developed rapidly, and the basic and clinical research on allergic conjunctivitis has been deepened. It is necessary to standardize the diagnosis and treatment of allergic conjunctivitis by ophthalmologists in China in time. To this end, the Keratology Group of Ophthalmology Branch of Chinese Medical Association organized experts in the field of keratopathy in China, focusing on the hot spots of basic and clinical research of allergic conjunctivitis, based on the research results of evidence-based medicine at home and abroad, referring to the practical experience of experts, and after full discussion, expert consensus was reached.

The 2017 dry eye workshop (DEWS) II of the International Tear Film and Ocular Surface Association (TFOS) is the most cutting-edge and authoritative medical professional consensus on dry eye in the world. On the basis of the first edition of DEWS (DEWSⅠ), TFOS organized more than 150 top experts and scholars in the field of dry eye from many countries, and it took two and a half years to complete the clinical consensus. DEWS II in 2017 recorded new insights in the dry eye field after the promulgation of DEWS I. This consensus comprehensively explains the pathogenesis, pathophysiology, diagnosis and treatment of dry eye, and is a brand-new interpretation and another improvement of the understanding of dry eye. In 2013, the Keratology Group of Ophthalmology Branch of Chinese Medical Association issued the "Expert Consensus on Clinical Diagnosis and Treatment of Dry Eye (2013)" according to the characteristics of dry eye in China^[1]The diagnostic criteria and treatment principles of dry eye in China were pointed out. However, because there are not many research reports on the pathophysiology of dry eye in China, and the research is not in-depth enough, the pathophysiology of dry eye is not involved in the consensus of dry eye in China. Compared with DEWS II in 2017, there is still a gap in this aspect in China. In order to improve and deepen the clinical understanding of the pathogenesis of dry eye in China, this paper interpreted DEWS Ⅱ according to the research progress of pathophysiology of dry eye, and focused on the research results in this field after the promulgation of DEWS Ⅰ.

"Chinese Journal of Ophthalmology" published the 12th issue of 2016 "Expert Consensus on the Application of Glucocorticoid Ophthalmic Preparations in the Treatment of Corneal and Ocular Surface Diseases in China (2016)"^[1](hereinafter referred to as the Hormone Consensus). This consensus introduces expert opinions on the application of hormonal ophthalmic preparations in the treatment of corneal and ocular surface diseases from several aspects, such as commonly used clinical glucocorticoids (hereinafter referred to as hormones) ophthalmic preparations, their classification, indications, adverse reactions, use principles, contraindications, and application in common corneal and ocular surface diseases, which is of great significance to clinical ophthalmologists to understand and use hormonal ophthalmic preparations correctly. Study the Hormone Consensus carefully, and have questions about the application of hormone ophthalmic preparations in laser corneal refractive surgery. The following questions and opinions are put forward to discuss and discuss with experts and colleagues.

Thank you very much to readers for putting forward their own views and opinions through the study and understanding of the Expert Consensus on the Application of Glucocorticoid Ophthalmic Preparations in the Treatment of Corneal and Ocular Surface Diseases in China (2016) (hereinafter referred to as the Hormone Consensus). The positive response to the Hormone Consensus helps everyone better understand the application of glucocorticoid (hereinafter referred to as hormone) ophthalmic preparations in the treatment of corneal and ocular surface diseases, which is of great positive significance. Please refer to some answers to the discussion questions.

The patient was a male, 18 years old. On August 4, 2017, he underwent femtosecond laser small-incision lenticule extraction (SMILE) in an external hospital due to refractive error in both eyes. On the first day after surgery, the naked eye visual acuity of both eyes was 1.0. On the third day after surgery, he went to another hospital due to photophobia and tearing in his right eye and visual acuity decrease. He was given levofloxacin and other antibiotics without significant improvement. On August 10, 2017, he was transferred to the Department of Ophthalmology of Peking Union Medical College Hospital. Ophthalmological examination: The visual acuity of the right eye was manual, the left eye was 1.0, and the intraocular pressure measured by the finger was normal. Mixed conjunctival congestion in the right eye, localized white dense infiltration in the upper temporal area of the cornea, opacity and edema in the central area of the cornea, upper and lower infiltration of the capsular bag, melting and thinning of the corneal flap, massive inflammatory exudation in the anterior chamber, and empyema (Figure 1，Figure 2）。 Under confocal microscope, a large number of moderately and highly reflective necrotic tissue in the corneal stroma can be seen, which is intercalated with a large number of highly reflective inflammatory cells (Figure 3）。 Initial diagnosis: Infectious keratitis (bacterial) in the right eye after SMILE in both eyes. Considering the serious infiltration of the patient's corneal lesions and no significant improvement after using broad-spectrum antibiotics in other hospitals, the right corneal infection was removed on August 10, 2017. At the same time, the conjunctival sac and the tissue in the sac were taken for bacteriological culture and drug susceptibility. During the operation, the corneal flap ruptured when the original SMILE incision was irrigated by perfusion with amikacin balanced saline solution. The necrotic tissue on the stromal bed was scraped off, fully irrigated with amikacin balanced saline solution, and the surrounding residual corneal flap was reset. After completion, hydrophilic contact lenses were put on, and amikacin was injected subconjunctivally. Postoperatively, tobramycin eye drops and levofloxacin eye drops were alternately administered once in 15 minutes, gatifloxacin eye ointment 2 to 3 times/d, and ceftazidime intravenous infusion and atropine eye ointment were administered systemically 3 times/d. The results of bacteriological culture 3 days after operation showed streptococcal infection. After 1 week of treatment with sensitive antibiotics, the symptoms of photophobia and lacrimation were alleviated, the conjunctival congestion was improved, the hypema was absorbed, the corneal epithelium healed, and the central corneal scar remained (Figure 4）。 After the corneal infection is controlled, low-concentration glucocorticoids (loteprednol suspension eye drops twice a day) will be added to reduce the inflammatory response.

The patient, a 32-year-old man, went to the Department of Ophthalmology of Peking Union Medical College Hospital for the first time in February 2014 because he lost sight for nearly half a year after left eye trauma. The previous patient underwent two vitrectomies combined with silicone oil filling in an external hospital in September and October 2013 due to penetrating eyeball injury in his left eye. Retina detached again after silicone oil removal in the left eye in January 2014. When he visited our outpatient clinic in February 2014, he had visual acuity and light perception in his left eye, intraocular pressure of 4 mmHg (1 mmHg =0.133 kPa), aqueous humor flash (+ +), planktonic body (+ +), organized membrane in the pupil area, absence of lens, total retinal detachment with extensive fixed folds; The visual acuity of the right eye was 1.5, the intraocular pressure was 14 mmHg, and the anterior segment and fundus were roughly normal. On March 10, 2014, he underwent pupiloplasty + vitreous exploration + peeling + intraocular laser photocoagulation + silicone oil filling in his left eye. The postoperative inflammatory reaction was severe, and the periiris incision was closed. Twice neodymium yttrium aluminum garnet (Nd:YAG) laser periiris reaming was unsuccessful. In January 2015, he underwent peripheral iris resection of the left eye + tearing of organized membrane in the pupil area. At the reexamination one month later, the visual acuity of the left eye was 20 cm manually, the periiris incision was unobstructed, and the retina was in place. After that, the patient will be followed up in the future.

The patient was a 36-year-old male. Due to the abnormality of fundus in both eyes found by physical examination, he went to the Affiliated Optometry Hospital of Wenzhou Medical University in December 2015. The patient had poor visual acuity at night, good visual acuity during the day and no other ocular discomfort since childhood. The patient had no history of systemic disease, both parents were in healthy health, were not married by close relatives, and had no history of similar eye disease in the family. Ophthalmologist physical examination: naked visual acuity of right eye 0.5, -1.00 DS corrected to 1.0; Left eye naked visual acuity 1.0, -0.50 DC ×160° corrected to 1.0. IOP was 15.0 mmHg (1 mmHg =0.133 kPa) in the right eye and 17.1 mmHg in the left eye. There was no protrusion of the eyeballs in both eyes, the eye position was right, the eye movement was good, and there was no obvious abnormality in the anterior segment of both eyes. The dilated pupil examination of the fundus shows that the vitreous body is transparent, the optic disc is light in color, the boundary is clear, the cup-to-disc ratio is about 0.3, there is no abnormality in the flow of blood vessels, and the artery/vein is about 2:3. Diffusely distributed white spots are seen from the posterior pole of the retina to the equator, starting from the edge of the optic disc on the nasal side, starting from the outside of the vascular arches above and below the macular area on the temporal side, and reaching the equator. The spots are most dense at the edge of the posterior pole and gradually decrease to the periphery; The white spots are uniform in size, symmetrically distributed in both eyes, similar in diameter to the retinal arterioles, and located below the retinal blood vessels. There is no pigmentation in the whole retina, and there is reflection in the fovea (Figure 1）。 Auxiliary examination: OCT examination showed no obvious abnormalities in the scanning range of the macular area of both eyes, and the foveal shape was acceptable. White spot lesions in the peripheral retina were located in the retinal pigment epithelium, showing cluster-like protuberances and passing through the ellipsoid area (Figure 2）。 Visual field examination: There were no obvious abnormalities in the visual field of both eyes. Fluorescein sodium fundus angiography: normal arm-retina circulation time in both eyes, diffuse hyperfluorescence in the retina outside the macular area, no obvious correspondence with spots, and weakened background fluorescence, no fluorescence leakage in late stage (Figure 3）。 Indocyanine green fundus angiography: Choroidal circulation is normal, and there is a boundary between the posterior pole of the fundus and its periphery in the early stage, and it is more obvious in the late stage (Figure 4）。 electroretinogram (ERG): Dark vision: The amplitude of A and b waves in both eyes decreased. Photopia: Right eye: A and b wave amplitude decreased; Left eye: A wave amplitude normal, b wave amplitude decreased. Reexamination of ERG after 3 h of dark adaptation showed: darkopia: the amplitude of A and b waves in both eyes was normal; Photopia: normal A wave in both eyes, decreased b wave amplitude (Figure 5）。 Diagnosis: White dotted fundus in both eyes, the patient is recommended to be followed up regularly.

The patient was a 39-year-old male. Because of the inconsistent color of his eyes since childhood, he went to Weifang Eye Hospital. Family history of similar eye disease denied. Eye examination: visual acuity right eye 0.8 (-0.50 DS-1.25 DC ×120° =1.2), left eye 0.2 (-1.00 DS-1.50 DC ×65° =1.2), with intraocular pressure of 20 mmHg in both eyes (1 mmHg =0.133 kPa); The cornea of the right eye is transparent, the anterior chamber is middle and deep, the aqueous humor is clear, the iris is brown-black, the texture is clear, the pupil is round, the light response is sensitive, the lens is transparent, the retina is orange-yellow, the optic disc boundary is clear and acceptable, C/D is about 0.3, the blood vessels run normally, and the foveal reflection is visible; The cornea of the left eye is transparent, the anterior chamber is medium-deep, the aqueous humor is clear, the iris is light blue, the texture is clear, the pupil is round, and the light response is sensitive, the lens is transparent, the retina is bright red, the optic disc boundary is clear and acceptable, C/D is about 0.3, the blood vessels run normally, and the foveal reflection is visible (Quintessence Picture 1,Quintessence Picture 2,Quintessence Picture 3）。 Clinical diagnosis: congenital heterochromatic iridis in left eye^{[1,2,3,4,5,6]}。