2015年 · 第51卷第09期

In the field of ophthalmology, the importance of vision is unknown, but some basic problems related to vision are rarely studied. "Exploring the Method of Correct Statistics of Eye Disease Vision Data and True and False Paracentric Dark Spots" in the Academic Debate Column of Chinese Journal of Ophthalmology, Issue 5, 2015^[1](hereinafter referred to as "Exploration") and "Discussion with the author of the article" Exploring the Method of Correct Statistics of Eye Disease Vision Data and True and False Paracentric Dark Spots ""^[2](hereinafter referred to as "Discussion") two articles, on "the nature of vision" carry on the thought-provoking discussion and discussion. The author thinks that the key of the problem lies in the understanding and understanding of "peripheral vision". In order to avoid "each speaks his own words", the main concepts involved and their interrelationships should be sorted out and clarified from the perspective of visual physiology, hoping to lead the discussion in depth and reach a consensus.

Trauma is one of the main causes of corneal ulcer. It is estimated that the number of blindness caused by eye injuries and corneal ulcers reaches 2 million worldwide every year^[1]There are few clinical reports on delayed corneal ulcer after corneal trauma repair. At present, there is no clear definition of "delayed corneal ulcer". The author defines it in this article as: corneal ulcer that occurs after a period of time (1 month or more) without signs of infection after corneal trauma and good wound healing. This study retrospectively analyzed 6 cases of delayed corneal ulcer after corneal trauma repair admitted to Tianjin Eye Hospital from February to November 2014. All of them achieved good therapeutic results after treatment. The pathogenic factors, treatment methods and efficacy of this disease are reported as follows.

The patient was a 51-year-old male. The inferior temporal field of the right eye was occluded for 6 months and gradually enlarged. FFA in an external hospital was diagnosed as hiatus retinal detachment, and the macula was not affected. At that time, the visual acuity of the right eye was 0.8, and the epidermal pad compression operation was performed. Postoperative visual acuity declined and the retina did not recover. Two months after operation, he came to Chengdu Aidi Eye Hospital for treatment. Admission examination: No obvious abnormalities were found on general physical examination. Eye examination: visual acuity 0.15 in right eye and 2.0 in left eye. No obvious abnormalities were observed in the left eye. In the right eye, except for the flat part of the inferior temporal retina, the rest of the retina was flat and detached, and there was no obvious spherical bulge (Figure 1,Figure 2）。 Pigmentation area after proto-scleral buckling surgery can be seen above the temporal. Repeated examination of indirect mirror, front mirror and three-sided mirror did not find the exact hole. A small circular depression can be seen above the center of the right eye papilla. Suspected congenital papilla fovea. FFA examination: In the pre-arterial and arterial stages, there was no fluorescence in the recesses. With time, the fluorescence in the recesses appeared and gradually increased. After the background fluorescence and intravascular fluorescence receded in the late stage, strong fluorescence accumulated in the recesses (Figure 3）。 OCT examination of the optic papilla revealed a fissure outside the inner wall of the fovea above the optic papilla communicating with the retinal neuroepithelium (Figure 4,Figure 5）。 Diagnosis: Congenital papillar fovea with serous detachment of the retina in the right eye. Treatment: Vitreous gas injection under local anesthesia, injection of C₃F₈0.8 ml. Rest in prone position. The retina was completely flat on the second postoperative day. Vision is manual in front of the eye. Immediately close the laser around the optic papilla for 2 to 3 times, and rest in the prone position. Visual acuity gradually recovered to 0.3 1 month after surgery. The retinal reattachment was good. OCT revealed complete macular reduction. Three months after surgery, the visual acuity was 0.5 in the right eye and 1.5 in the left eye. Mild vitreous opacity, complete retinal repatch, macular repatch (Figure 6,Figure 7)。 Four months after surgery, the right eye was 0.7, and the retinal reattachment was good.

The patient was a 36-year-old male. On December 19, 2013, he went to the Department of Ophthalmology, the First Affiliated Hospital of Nanjing Medical University due to visual loss in his left eye and discomfort for more than one month. The patient had a history of boxing injuries in both eyes and no history of systemic disease decades ago. Eye examination: visual acuity in the right eye was 1.0 and visual acuity in the left eye was 0.15. No obvious abnormalities were observed in the right eye. Mild conjunctival hyperemia in the left eye, nebulous edema of the cornea, medium-deep anterior chamber, brown retrocorneal precipitate (KP) (+), Tyndall sign, planktonic granules (+), round pupil, about 3 mm in diameter, sensitive to light reflection. The fundus of the eye is hazy, with a faint cup-to-disc ratio of 0.4, and the presence of macular central reflection. IOP: 15.4 mmHg (1 mmHg =0.133 kPa) in the right eye and 51.6 mmHg in the left eye. Gonioscopy showed that all quadrants of both eyes were wide angles, and no angular recession was observed. 2% carteolol hydrochloride eye drops, 0.2% brimonidine tartrate eye drops and 1% brinzolamide eye drops were administered to the left eye twice a day; Oral methazolamide tablets 50 mg, twice/d; Intravenous drip of 20% mannitol injection 250 ml, intraocular pressure fluctuated between 24.0 and 40.4 mmHg after 1 week of antihypertensive treatment once/d. ultrasound biomicroscope (UBM) examination showed that there were multiple cysts in the ciliary body of both eyes, and no ciliary epithelial hole or non-pigmented epithelial detachment was seen (Figure 1）。 Ocular B-ultrasound revealed flat retinal detachment in the left eye. After dilatation of the left eye, the trihedral mirror examination found that the peripheral retina was superficially detached from 8:00 to 12:00, and no hiatus was found. Preliminary diagnosis: Schwartz syndrome in the left eye. On January 9, 2014, the scleral surface condensation + fluid drainage + external compression of the left eye was performed under local anesthesia. Intraoperative anterior chamber puncture was performed to extract aqueous humor for later electron microscopy. Pressing the peripheral retina during operation revealed a sieve-shaped hole in the serrated edge above the nose. No intraocular pressure lowering drugs were used postoperatively, the intraocular pressure was 16.7 mmHg on day 1, the anterior chamber was clear, and the fundus examination showed complete repositioning of the retina. The intraocular pressure was 13.4 mmHg at 1 week postoperatively, and the visual acuity of the left eye was 1.0 at 20 days postoperatively. Retcam examination showed that the retina was flat and the compressed crest was high (Figure 2）。 The intraoperatively collected aqueous humor was electro-microscopically examined, and the external disc membrane of the optic cell was found, further confirming the diagnosis (Figure 3）。 Since the follow-up, the visual acuity, intraocular pressure and fundus are stable.

The patient was a 34-year-old male. On April 18, 2014, he came to the Department of Ophthalmology of Guangxi Zhuang Autonomous Region People's Hospital due to swelling and pain in his right eye with headache for 1 day. He had a history of type 2 diabetes for 6 years, and was treated with oral hypoglycemic drugs and subcutaneous insulin. The blood sugar control was not ideal, but routine fundus examination was not performed. Eye examination: visual acuity: 1.2 in right eye and 1.0 in left eye; IOP: 7.4 mmHg (1 mmHg =0.133 kPa) in the right eye and 9.8 mmHg in the left eye. Right eye conjunctiva hyperemia +, retrocorneal deposit + + +, aqueous humor opacity + +, pupil diameter 3 mm, direct and indirect light reflection sensitivity, crystalline lens transparency. No abnormalities were observed in the anterior segment of the left eye. Fundus examination of both eyes showed that the optic papilla was light in color with clear boundaries, and the fundus was scattered with hard exudation, microangioma and flaky bleeding. The arterial and venous blood vessels were light in color and showed a creamy appearance, and the arterial and venous blood vessels could not be distinguished. After asking about the medical history, the patient had been found to have fatty liver during physical examination, and suffered from acute pancreatitis in May 2013. After conservative treatment, his condition was stable. After admission, fundus photography, OCT, FFA, blood lipid, fasting blood glucose and abdominal ultrasound were examined. The results showed that the fundus image showed pale color and clear boundary of binocular optic papilla, scattered hard exudation, microangioma and patchy hemorrhage in the fundus, pale color of arterial and venous blood vessels, showing cream appearance, and arterial and venous blood vessels could not be distinguished (Figure 1）。 The results of OCT examination showed scattered punctate hyperreflex (hard exudation) in the neuroepithelial layer of the posterior pole of both eyes; Several mass hyperreflexes in the neuroepithelial layer, followed by obvious attenuation (hemorrhage); There were no vascular reflections in the choroidal layer (Figure 2）。 The results of FFA examination showed scattered microangiomas and patchy bleeding in the fundus of both eyes to obscure fluorescence, but no non-perfusion area and strong fluorescence of neovascularization were observed, showing moderate non-proliferative diabetic retinopathy (MNPDR) in both eyes (Figure 3）。 Peripheral blood showed a severe chyloid appearance, with total cholesterol 17.5 mmol/L, triglycerides 18.6 mmol/L, and fasting blood glucose 28.98 mmol/L. Abdominal ultrasound showed fatty liver and no abnormalities in pancreas. Diagnosis: Right eye iridocyclitis; Moderate nonproliferative diabetic retinopathy in both eyes; Binocular retinal lipidemia. After the diagnosis, in addition to the treatment of iridocyclitis, blood sugar and blood lipid reduction were treated concurrently. After 2 weeks of reexamination, the triglyceride was 10.1 mmol/L, the boundary of binocular papilla was clear, the color of arterial and venous blood vessels was normal, the hard exudation and bleeding were reduced compared with before treatment, and the retinal morphology returned to normal (Figure 4）。

A 41-year-old male was seen in the Department of Ophthalmology of the Second Affiliated Hospital of Nanchang University on October 16, 2012 due to red eyes, half-month vision loss and dizziness. He had a history of chronic bronchitis for more than 20 years in the past. One month ago, he was treated in an outside hospital for cough and fever, and was discharged after his condition improved. In the past half month, my conscious vision has gradually declined, so I came to the Second Affiliated Hospital of Nanchang University for treatment. Physical examination: blood pressure 120/70mmHg, clear consciousness, thin physique, crimson face, lips and palms, correct facial features of the head, soft neck, widening of intercostal space in the thorax, scattered dry rales in both lungs, no wet rales, heart rate 80 beats/min, uniform rhythm, soft abdominal wall, no enlargement of liver and spleen, and no pathological signs in the nervous system. Eye examination: the visual acuity of the right eye was 0.1, the visual acuity of the left eye was 0.5, and the correction did not improve. IOP was 15 mmHg (1 mmHg =0.133 kPa) in the right eye and 14.5 mmHg in the left eye. There was no abnormality in the eye position, conjunctiva and sclera of both eyes were congested, blood vessels were dilated, the cornea was transparent, the anterior chamber was middle-deep, and the lens was transparent. Funduscopy showed congestion and edema of the optic head, blurred boundary, thin retinal artery, arteriovenous ratio of about 2:5, arteriovenous crossover compression sign was obvious, the retinal vein was highly dilated and dark purple, the vein diameter was uneven, and the distal vein at the arteriovenous crossover was enlarged and appeared sausage-like. Multiple scattered retinal spots and patchy hemorrhage were seen on the retina (Figure 1）。 FFA examination showed that the dye development and reflux time were significantly prolonged, the boundary of binocular papilla was not clear, the small blood vessels on its surface were dilated and fluorescein leaked, the retinal veins were generally dilated and dilated in a sausage-like manner, and a large number of scattered circular hemorrhage of different sizes were seen in the omentum to block fluorescence. In the later stage, some vein walls were stained, and the papilla was intensely fluorescent (Figure 2）。 OCT examination showed obvious thickening of the retinal nerve fiber layer around the optic papilla in both eyes. Chest X-ray showed chronic bronchitis, bronchiectasis, emphysema. White blood cells 3.61×10⁹/L, red blood cells 7.23×10¹²/L, hemoglobin 300g/L, platelets 78×10⁹/L. After consultation with the hematology department, the bone marrow image was further examined. The result was polycythemia bone marrow image, and the JAKI/V617 fusion gene was positive. Diagnosis: emphysema, secondary polycythemia with fundus alterations.

The patient was a 55-year-old female. Because of the discovery of conjunctival mass in both eyes for 2 years, he went to Tianjin Eye Hospital. There were no obvious abnormalities in the whole body examination. Eye examination: the naked eye visual acuity of both eyes was 1.0; The conjunctiva of both eyes is shown inQuintessence Picture 1； Anterior segment and fundus examination of both eyes showed no obvious abnormalities; Mild vitreous opacity in both eyes. Excision of conjunctival masses in both eyes was performed. Excised tissues were examined by immunohistochemistry: CD20 (+ +), CD79a (+), CD3 scattered cells (+), CD5 scattered cells (+), CD7 scattered cells (+), CD38 (–), CD43 (+), Ki-67 focal and scattered cells (+) (Quintessence Picture 2）。 Histopathological diagnosis: small cell B-cell lymphoma of the conjunctiva in both eyes.

The patient was a 24-year-old male. Because the right eye mass was found for 45 days, he went to Tianjin Eye Hospital. Eye examination: visual acuity in the right eye was 1.0; The bulbar conjunctiva was slightly congested, and two pink pedicled neoplasms were visible on the surface of the medial canthus conjunctiva, which were papillary and soft (Quintessence Picture 1A), a mass was seen in the upper eyelid conjunctiva, with dilated blood vessels and congested eyelid conjunctiva (Quintessence Picture 1in B); The cornea is transparent; No other obvious abnormalities were seen in the anterior segment of the eye; Fundus examination showed no obvious abnormalities. Clinical diagnosis: Multiple papilloma of the right eye.