2016年 · 第52卷第06期

This issue focuses on the clinical and basic research of glaucoma. The responsible editorial committee responsible for the planning, composition and review of this issue is Editor-in-Chief Wang Ningli.

Glaucoma drainage valve implantation is an effective surgical method for the treatment of refractory glaucoma with multiple failures^{[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15]}。 The surgical procedure is more complicated than trabeculectomy, and postoperative complications, such as shallow anterior chamber, exposure of the conjunctival surface of the drainage tube, contact of the drainage tube with the cornea or blockage by the iris, and advancement of the position of the drainage disc, are also common. In order to improve the success rate of glaucoma drainage valve implantation and reduce the occurrence of postoperative complications, experts from the Glaucoma Group of Ophthalmology Branch of Chinese Medical Association reached a consensus on the operating specifications of glaucoma drainage valve (single-disc valve) implantation after discussion.

Glaucoma is the first irreversible blinding eye disease in China. The prevalence rate of people over 40 years old exceeds 2.6%. At present, there are about 15 million patients, of which 2.25 million to 4.5 million will be blinded by it^[1]。 Glaucoma has become one of the major public health problems that seriously endanger the visual health of our people.

The patient was a 53-year-old male. On January 8, 2005, he came to Shenzhen Eye Hospital for treatment due to sudden decline of vision in his right eye and exophthalmos for 1 week. The patient was previously in good health. General physical examination showed no abnormalities, and thyroid function was normal. Eye examination: the visual acuity of the right eye is manual in front of the eye, which cannot be corrected, and the visual acuity of the left eye is 1.5. Goldman tonometer measured intraocular pressure: 18 mmHg (1 mmHg =0.133 kPa) in the right eye and 17 mm Hg in the left eye. Height of palpebral fissure in heads up: 8 mm in right eye and 8 mm in left eye. There is no delay in both upper eyelids. There was no redness and swelling in both eyelids, and no conjunctiva congestion. The refractive interstitium of the right eye is transparent, the pupil is round, about 4 mm in diameter, the direct response to light is slow, the indirect response to light is normal, and there are no abnormalities in the fundus. No abnormalities were observed in the left eye. The right eyeball is slightly protruding forward, and the exophthalmos is 17.5 mm in the right eye, 15.5 mm in the left eye, and the orbital distance is 100 mm. Both eyes are in straight position and movement is coordinated. F-VEP and P-VEP in the left eye were normal, while F-VEP P in the right eye was normal₁₀₀The incubation period of the wave was moderately delayed and the amplitude was moderately decreased compared to the left eye. Orbital CT examination showed that the lateral rectus muscle, medial rectus muscle and inferior rectus muscle of the right eye were obviously spindle-shaped hypertrophy in the abdomen, the lower rectus muscle was the most serious, and the muscle stop was normal. Orbital MRI revealed obvious fusiform hypertrophy in the abdomen of the lateral rectus, medial rectus and inferior rectus of the right eye (FIG. 1A), the inferior rectus is the most severe (FIG. 1B), T₁WI showed medium-high signal, T₂WI showed medium signal, obvious enhancement, and the muscle stop end was normal. Preliminary diagnosis: External muscle hypertrophy of the right eye. Cause to be investigated: thyroid-related ophthalmopathy of the right eye (grade VI)?

The patient was a 58-year-old male. He was admitted to hospital on January 18, 2011 due to the discovery of a mass in the left orbit for 2 years. When the patient washed his face 2 years ago, he accidentally found a small nodular mass on his left lower eyelid, about 1 cm in diameter. He did not have any other discomfort and had not been treated. The mass gradually grew, and now he felt obviously grown. He was admitted to hospital for treatment. The left face of the patient was blue-gray since childhood, and the area did not change significantly. Admission examination: the superficial lymph nodes of the whole body were not palpable and swollen, and the skin on the left face appeared blue-gray (Figure 1), the visual acuity of both eyes was 1.0, no abnormalities were found in the right eye examination, the skin of the lower eyelid of the left eye was raised, and a medium mass with a diameter of about 2 cm could be palpable subcutaneously, which could be pushed into the orbit, the conjunctiva was blue-gray, and no abnormalities were found in the anterior segment of the eyeball and fundus examination. Auxiliary examination: Orbital CT examination showed a nodular soft tissue density shadow in the soft tissue of the left lower eyelid, with a clear boundary and uneven density, about 1.0 cm ×1.5 cm in size, no abnormalities in the bone quality of the eyeball and orbital wall, and no abnormalities in the right orbit (Figure 2）。 Orbital B-ultrasound examination showed that a solid lesion of approximately 13.0 mm ×14.8 mm could be detected at the left inferior orbital margin, with clear boundaries, a small number of punctate weak echoes could be seen in it, and no obvious blood flow signal could be seen by color Doppler. Preliminary diagnosis: left orbital tumor. After admission, all examinations were completed. After no surgical contraindications, left lateral canthotomy and conjunctival approach orbital tumor resection was performed under local anesthesia. During the operation, it was found that the tumor was located in the fat below the orbit, and a large number of pigment cells were seen in the surrounding fat. The border of the tumor was clear, black, and there was no obvious envelope. It was completely removed, and the inside was black when dissected (Figure 3）。 Return of postoperative pathological findings: left orbital malignant melanoma (Figure 4）。 The patient was advised to undergo enucleation of the contents of the orbit of the left eye, but the patient refused to undergo enucleation of the contents of the orbit due to good vision in the left eye and was discharged. After 3 years of follow-up, the patient was in good health, and there was no recurrence after reexamination of orbital CT.

A 51-year-old female was seen in our hospital on September 27, 2013 due to an increase in secretion for 1 week 8 months after recanalization of the left lacrimal duct. She had a history of persistent epiphora in both eyes for 5 years and pus in her right eye for 1 year. She had undergone 3 lacrimal duct probing operations in another hospital. After treatment, the above symptoms did not improve and she was admitted to our hospital. endoscopic endonasal dacryocystorhinostomy (EE-DCR) was performed by a skilled surgeon in our hospital, and the symptoms of bilateral epiphora and right epiphora disappeared after operation. Eight months later, the patient appeared yellow-white discharge in his left eye after exertion, which was the heaviest in the morning, and the eyelid could be closed when the discharge was high. Orbital CT showed an open bone window at the left ostomy and no significant inflammation in the paranasal sinuses (Figure 1）。 Endoscopic examination showed that the anastomosis was open, without obvious granulation tissue around it, and a large amount of yellow-white purulent secretion was seen inside and outside the anastomosis (Figure 2）。 There was no obvious resistance to lacrimal duct irrigation. Considering the left EE-DCR postoperative infection, systemic cefazolin sodium intravenous drip, local levofloxacin, tobramycin, 0.1% flumetrolone and other eye drops combined with tobramycin and dexamethasone to irrigate the lacrimal duct treatment, no obvious improvement. The patient's ocular and nasal secretions were taken for bacterial and fungal smears and cultures, as well as drug sensitivity tests. It was found that Klebsiella pneumoniae and Streptococcus pneumoniae were growing, and they were sensitive to levofloxacin lactate. Levofloxacin lactate was given 0.3 g intravenous drip twice a day. After 5 days of anti-infective treatment, the eyelid secretions were significantly reduced. Endoscopic nasal examination was performed again, and secretion was still visible at the anastomosis. The lacrimal duct probe was used to explore the anastomosis, and the hyperplastic nasal mucosa tissue closed the anastomosis below, resulting in the formation of residual lacrimal sac below (Figure 3), combined with the above anatomical characteristic changes, the diagnosis of lacrimal pool syndrome was revised. The hyperplastic nasal mucosal tissue was resected under endoscopic local anesthesia, the pouch was opened, and Merogel (hyaluronic acid, Xomed, USA) was placed on the surgical wound (Figure 4）。 The eyelid and anastomotic discharge disappeared 3 days after surgery, and the phenomenon of tearing and pus did not appear again after 9 months of follow-up (Figure 5）。

The patient was a 45-year-old male. He was admitted to our hospital on June 27, 2014 due to repeated redness, swelling and pain in his right eye, accompanied by visual loss for 1 month. One month before admission, the patient showed redness, swelling and pain in the right eye, blurred vision, conscious right eyelid skin fever, slightly limited eyeball rotation, tearing, dizziness, general fatigue and discomfort, nasal congestion, purulent discharge. After treatment with glucocorticoid eye drops and intraocular pressure lowering eye drops in other hospitals, it improved slightly, but the symptoms of the right eye recurred and gradually worsened. Irregular fever began to occur 10 days ago, with a body temperature of 38.5~40.0 ℃, and systemic anti-inflammatory treatment was ineffective. 20 days ago, due to nasal congestion, purulent discharge and sneezing for 1 month, he was diagnosed with nasal septum deviation in another hospital and underwent nasal septum correction. Since then, he has complained that bilateral nasal congestion has not improved and continues to worsen, with intermittent and repeated epistaxis, which can stop itself. Since the onset of the disease, the spirit, appetite and sleep are poor, the urine and defecation are normal, and the physical strength has decreased. Prior health, family members have no history of tumors.

The patient was a 61-year-old female. Because of visual loss and pain in his left eye for more than 1 year, he went to the Department of Ophthalmology, Affiliated Hospital of Guizhou Medical University. Suffering from rheumatoid arthritis for more than 9 years without systemic treatment; 3 years of steroid glaucoma in both eyes, 3 years after anti-glaucoma surgery in the right eye and 1 year after anti-glaucoma surgery in the left eye. Both father and sister suffer from rheumatoid arthritis. Eye examination: left eye naked visual acuity was 0.12, corrected visual acuity was 0.3; Intraocular pressure is 8.0 mmHg (1 mmHg =0.133 kPa); conjunctival hyperemia and edema; Scleral fusion was observed at 3 mm from the limbus in the supranasal quadrant (Quintessence Picture 1In a), about 8 mm ×8 mm, the pigment membrane is exposed, only a thin layer of epithelium is seen on it, fluorescein staining (-), the filter vesicles next to it are pale, the scleral melt foci spread to the scleral flap, and the scleral flap is partially melted; A strip-like white infiltration was observed in the stromal layer of the supranasal limbus, stained with fluorescein (-) (Quintessence Picture 1in B); The center of the cornea is transparent, the retrocorneal sediment (+ +), the aqueous humor flashes (+ +), the upper periiris incision is patent, the iris texture is poor, the pupil is dilated, the diameter is about 6 mm, and the lens is moderately opaque; The vitreous body is flocculate and turbid, the fundus is blurred and the color of the optic papilla is light, the cup-to-disc ratio is 0.3, the ratio of arteriovenous diameters is 1:2, and the foveal reflection is dark. Clinical diagnosis: scleral uveoma secondary to necrotizing scleritis in the left eye; Secondary uberitis of left eye; Postoperative anti-glaucoma in both eyes.

The patient was a 21-year-old male. He went to Tianjin Eye Hospital because his left eye was blurred for more than 4 months after being injured by a fist. Eye examination: naked eye visual acuity was 0.1 for the right eye and 0.02 for the left eye; The corrected visual acuity was 1.0 in the right eye, but no improvement in the left eye; IOP in both eyes normal; Anterior segment examination in both eyes was roughly normal; No obvious abnormalities were found in the right fundus, and the left fundus was foundQuintessence Picture 1。 For the OCT examination, seeQuintessence Picture 2。 Clinical diagnosis: blunt contusion of left eye; Choroidal laceration of left eye; Macular hole in left eye; Macular hemorrhage in the left eye.