2016年 · 第52卷第08期

This issue focuses on the clinical and basic research of strabismus and amblyopia and pediatric ophthalmology. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Zhao Kanxing.

The patient was a 26-year-old male. He was injured by a beer bottle in his right eye for 6 days, and was admitted to the emergency department of ophthalmology of Wenling Hospital of Wenzhou Medical College on December 6, 2014. To diagnose contusion of the right eye, debridement and suture of the upper lid of the right eye, intramuscular injection of tetanus antitoxin and oral antibiotics were given. First follow-up visit on December 10. Eye examination: the visual acuity of the right eye is 0.1, the correction is not improved, and the visual acuity of the left eye is 1.0. The upper and lower eyelids of the right eye are blue and purple, the upper eyelid wound has been sutured, and the bulbar conjunctiva has thick bleeding; The cornea is transparent, there is no obvious exudation in the anterior chamber, there are a small amount of iris pigment epithelium granules on the temporal iris surface, and the lower iris surface can be seen to curl into a braid-shaped, dark brown iris pigment epithelium, which is adhered to the iris surface, the upper end is attached to the pupil margin, the lower end is free, and the edge is torn (FIG. 1A）； The pupil is round, dilated about 5 mm in diameter, and the direct and indirect light response is slow; No iris light leakage, negative iris light transmission, normal iris color and clear texture; The lens was transparent, the vitreous body was not obviously opaque, the optic nerve head was not edema, the posterior pole retina was edema, and the macular light reflex disappeared. Anterior segment of left eye normal (FIG. 1B）。 IOP: 12 mmHg (1 mmHg =0.133 kPa) in right eye and 13 mmHg in left eye. On the second follow-up visit on the 12th of the same month, the exfoliated iris pigment epithelium layer was curled into a mass and settled deep in the lower anterior chamber angle. UBM showed a central anterior chamber depth of 2.4 mm and normal lens position. The angle of the anterior chamber was wide at 12 o'clock, but slightly narrower at 3 o'clock and 9 o'clock. There was no angular recession and ciliary body detachment. At 12, 3 and 9 o'clock, the iris was thick and shortened, and the ciliary process was loose. At 6 o'clock, the iris was obviously thinner and uneven in thickness, and the pigment epithelium fell into the lower anterior chamber angle. Orbital CT examination revealed fracture of the medial wall of the right orbit. Clinical diagnosis: Iris pigment epithelium injury with partial exfoliation, traumatic mydriasis and retinal contusion in the right eye.

The child was a 5-year-old female. Mainly due to repeated redness, swelling and bulging of the upper lid of the left eye for more than one month, he was admitted to the Institute of Orbital Diseases of Armed Police General Hospital for treatment on December 30, 2013 with "left orbital tumor". In November 2013, the child developed redness, swelling and bulge of the left upper lid. He was treated with antibiotics, and the symptoms were slightly relieved, but they appeared again after stopping the drug. Multiple soft masses paraspinal were identified in December 2013 (Figure 1) and multiple hard nodules in the front of the neck, the local hospital diagnosed "acne tumor", without special treatment, the skin on the surface of the posterior anterior neck nodule spontaneously ruptured (Figure 2）。 In December 2013, the left upper lid was red, swollen and bulged again, and gradually aggravated. Orbital CT examination showed that irregular soft tissue density shadows were seen under the periosteum above the left external orbit, with unclear boundaries, and bone erosion was seen in the roof of the orbit and the lateral wall of the orbit (Figure 3）。 Orbital MRI showed that irregular soft tissue density shadows were visible above the left external orbit, with poor boundary, T₁Medium signal, T₂Moderate to high confounding signal, envelope enhancement, no significant enhancement in content (Figure 4）。 The children had no systemic symptoms such as low afternoon fever, night sweats, fatigue and weight loss. His father and uncle suffered from tuberculosis. Ophthalmological examination showed that the upper lid of the left eye was red and swollen, slightly drooping, and a swelling was raised on the outside and upper side, with unclear boundaries, soft texture, no tenderness, and poor mobility, about 0.3 cm ×0.8 cm in size; The eye position is correct, and the eyeball can move in all directions; Exophthalmos: right eye 14 mm, left eye 18 mm, orbital distance 90 mm; The conjunctiva was slightly edema, but no abnormalities were observed. Chest radiograph showed no obvious abnormalities in heart and lung. Blood Mycobacterium tuberculosis gamma interferon release test showed: IFN-gamma (interferon assay)>200 S/mLYM; A antigen (lymphocyte culture): positive; IFN-γ (interferon assay)>200 S/mLYM; B antigen (lymphocyte culture): positive. On January 2, 2014, a left orbital mass resection was performed under general anesthesia. A yellow-white rare mass was visible under the periosteum of the upper external orbit, which was soft and tender in texture. The bone wall above the external orbit was involved and eroded, and it was insect erosion and uneven (Figure 5）。 Postoperative pathological findings: granulomatous lesions with large necrosis, consistent with tuberculosis characteristics (Figure 6）。 Combined with the systemic manifestations, family history, test results and orbital pathology of the children, the diagnosis: (1) tuberculosis; (2) Tuberculous abscess of left orbit; (3) Paraspinal mass (tuberculosis to be drained); (4) Anterior neck mass (lymphatic tuberculosis to be drained). After 3 months of telephone follow-up, the child was given oral anti-tuberculosis drugs regularly. The redness and swelling of the eyelids subsided, the skin at the front of the neck healed, and the paraspinal mass shrank.

The patient was a 66-year-old female. He was admitted to hospital on December 17, 2014 due to blurred vision in both eyes since childhood, which was aggravated for 1 year. The patient has not been diagnosed and treated with blurred vision since childhood, and has no history of wearing glasses. There was no surgery for ocular trauma and family history, and the parents were not close relatives. Systemic history: A history of hypertension for more than 20 years. The whole body examination showed no abnormalities. Ophthalmic examination: Visual acuity: 0.02 in right eye, anterior index in left eye. Correction does not improve. Transparent cornea in both eyes, moderate anterior chamber depth, atrial flash (-), clear iris texture, iris tremor, obvious subtemporal, round pupil, response to light (+). After mydriasis, the inferior temporal defect of the lens can be seen, the range is left>right, the suspensory ligament is intact and obviously increased, the lens cortex is gray-white and opaque, and the opaque at the defect is more obvious (Figure 1), no obvious opacity in the vitreous body, blurred fundus with leopard-shaped fundus changes, and atrophy of the choroid around the left eye papilla. Non-contact IOP: 18 mmHg (1 mmHg =0.133 kPa) in the right eye and 15 mmHg in the left eye. Auxiliary examination: right eye axis 25.5 mm, left eye axis 27.6 mm. UBM showed that the inferior temporal suspensory ligament was longer than the contralateral, and the lens edge in the defect area was rounded and blunt (Figure 2）。 OCT showed a lamellar macular hole in the left eye. Admission diagnosis: congenital lens defects in both eyes, complicated cataract in both eyes, and lamellar macular hole in the left eye.

The child was a 5-year-old male. On August 28, 2015, he went to the Department of Ophthalmology of Peking Union Medical College Hospital due to decreased visual acuity in his right eye and white deposits behind the cornea. Six months ago, the parents found the above symptoms and went to an external hospital. At that time, the eye examination showed that the visual acuity of the right eye was 0.08, the intraocular pressure was 22.5 mmHg (1 mmHg =0.133 kPa), corneal edema, retrocorneal precipitates (KP) (+ + +), aqueous humor flashes (+), planktonic bodies (+ +), and fundus blurred. Ocular B-ultrasound examination revealed vitreous opacity in the right eye. Aqueous humor cytology in the right eye revealed a large number of thawed tissue cells with unclear structure, a small number of inflammatory exudate cells and 100% neutrophils. Diagnosis: right eye viral uveitis, right eye corneal endotheliitis? Glucocorticoids and antiviral drugs were applied topically and systemically, but the efficacy was poor. Three months ago, he was referred to a superior hospital. On physical examination, the intraocular pressure of the right eye was 50.0 mmHg, and gray-white material deposition appeared in the anterior chamber. He was diagnosed as endophthalmitis of the right eye. Antifungal, antiviral and intraocular pressure lowering treatments were given, but no effect was seen, and visual acuity continued to decline. Retinal detachment of the right eye was found by ocular B-ultrasound 2 months ago. Right eye vitrectomy combined with silicone oil filling was performed in an external hospital, and the pathogenic test of intraocular specimens was negative. Subsequently, the patient went to the Department of Ophthalmology of Peking Union Medical College Hospital. Ocular examination: right eye visual acuity light perception, intraocular pressure T +2, mild protrusion of eyeball, mixed conjunctiva congestion, diffuse corneal edema, KP (+ +), aqueous humor flash (+), obscure plankton, posterior adhesion of part of the iris, anterior adhesion of part of the peripheral iris, and more white nodules on the surface of the iris (Figure 1), the lens is transparent, and the vitreous body and fundus of the eye are not clear. No obvious abnormalities were observed in the anterior segment and fundus of the left eye.

The patient was a 50-year-old male. Due to blurred vision in his right eye for 2 months, he came to Tianjin Eye Hospital in November 2011. Both eyes of the patient underwent phacoemulsification and cataract aspiration with IOL implantation 4 years ago. The operation went smoothly and there were no postoperative complications. High myopia in both eyes, no family genetic history, hypertension, arthritis, and no other systemic or ophthalmic history. Ocular examination: right eye, best corrected visual acuity (BCVA) 0.3, cornea and anterior chamber normal, IOL position normal, uniform milky white liquid opacity between IOL and posterior capsule, no obvious opacity in posterior capsule (FIG. 1A), and no obvious abnormalities were observed in the fundus. A non-contact tonometer (NCT) measured intraocular pressure of 20 mmHg (1 mmHg =0.133 kPa). Left eye, BCVA 1.0, IOL position positive, remaining no abnormalities, intraocular pressure 19 mmHg. B-ultrasound and fundus fluorescence angiography in both eyes showed no abnormalities. The axial length was 28.2 mm in the right eye and 28.1 mm in the left eye. Diagnosis: Liquid posterior cataract in right eye, IOL eyes in both eyes, and high myopia in both eyes. The right eye was given 0.1% flumerone eye drops and diclofenac sodium eye drops 4 times/day for 1 week. After 1 week, there was no remission. After Nd-YAG laser, the capsule was incised in a circular way, and milky white liquid was released into the vitreous body. The above two eye drops were continued for 2 weeks after laser surgery. There were no postoperative complications. One week after the operation, the BCVA of the right eye was 0.9. The white opacity disappeared under the slit lamp microscope, and the anterior capsule lacrimal fibrosis (FIG. 1B), no significant uveal inflammation, NCT 19 mmHg. The refractive status did not change significantly before and after laser treatment.

A 49-year-old female was admitted to the Institute of Orbital Diseases of the General Hospital of the Armed Police on March 18, 2014 due to the discovery of a mass above the right orbit for 2 years. In September 2010, the patient felt that his right eye was red and swollen with eye pain. He went to the local hospital and was given symptomatic treatment with infusion (the specific medication was unknown). After treatment, the patient felt that his right eye pain was relieved. In September 2011, the patient felt that a flat bulge could be palpable above the right orbit and at the root of the medial nose. He went to the local hospital for a CT examination, which was considered to be "internal carotid aneurysm". In October 2011, he underwent embolization of internal carotid aneurysm under general anesthesia, but the postoperative symptoms did not improve. In January 2014, the patient suddenly developed headache without obvious trigger, accompanied by nausea and vomiting, the mass above the right orbit and the medial nasal root was significantly larger than before, and the right eyeball was obviously prominent with external and inferior displacement. He went to the Institute of Orbital Diseases of Armed Police General Hospital. Ophthalmological examination: the naked eye visual acuity of the right eye was 0.3, and the correction did not improve. The right eyelid is swollen and ptotic, covering about 1/2 of the pupil. A tortuous tubular mass can be palpable above the right orbit and at the root of the medial nose, which is soft and pulsatile, and a blowing-like murmur can be smelled, consistent with the pulse. The eyeball is obviously prominent, externally displaced, and externally oblique about 45°. The eyeball can not turn internally past the midline, and the movement in the remaining direction is almost fixed. Exophthalmos: right eye 17 mm, left eye 10 mm, orbital distance 95 mm. The bulbar conjunctival vessels in the upper part of the right eye were tortuous and dilated, the pupil was round and dilated, about 5 mm in diameter, and the direct and indirect light reflection disappeared. No abnormalities were found in the anterior and posterior segments of the remaining eye (Figure 1）。 Fundus examination: The vein was slightly dilated, but no abnormalities were found. Orbital pressure (+ +). Syphilis (+). Color Doppler ultrasound showed tortuous and thickened superior vein of the right eye, with a maximum internal diameter of about 12.8 mm, and CDFI showed venous blood flow spectrum. Orbital CT showed thickening of the right superior vein, thinning of the ipsilateral sphenoid greater wing bone, enlargement of the ipsilateral supraorbital fissure, and widening of the cavernous sinus (Figure 2）。 Orbital MRI showed thickening of the superior vein in the right eye, T₁Medium signal, T₂Moderate and low signal, obvious enhancement, ipsilateral cavernous sinus obvious enhancement, optic nerve obvious compression, medial displacement (Figure 3）。 Admission diagnosis: thickening of the superior vein of the right eye; Right internal carotid cavernous fistula; right supraorbital fissure syndrome; Post-cavernous fistula embolization of the right internal carotid artery.

The patient was a 27-year-old male. She suffered from intermittent blurred vision in her right eye for 3 years with headache, and went to Baoding Yinghua Eye Hospital on December 11, 2014. History of hypertension and epilepsy denied. General physical examination: A large number of densely distributed reddish papules were seen on bilateral cheeks and mandibles (Figure 1), 3 depigmented spots were seen on the skin of both lower limbs (Figure 2）。 Eye examination: naked visual acuity of both eyes 0.8, corrected visual acuity 1.0; No abnormalities were seen in the anterior segment of the eye; Yellow-white nodular lesions were seen in the right fundus immediately above the optic papilla and in the nasal retina, with clear boundaries, slight bulge, and uneven surface, covering part of the retinal blood vessels (FIG. 3A）； The left fundus was roughly normal. Autofluorescence: the right eye lesion showed nodular hyperfluorescence (FIG. 3B）。 OCT examination: the lesion was located between the retinal layers, the nerve fiber layer was thickened, and the retinal tissue in the inner layer of the lesion surface was smooth and undulating; The lesion was a cystic hyporeflex, with a large number of punctate hyperemission around the hyporeflex, which was erosion-like (Figure 4）。 Skull MRI examination was performed in February 2014: patchy long T was seen in the cortex of bilateral frontal lobe, right parietal lobe, right occipital lobe and left temporal lobe₁Long T₂Signal shadow, fluidattenuated inversion recovery (FLAIR) showed high signal; Patchy long T was seen under bilateral frontal cortex₁Long T₂Signal, FLAIR showed high signal; There were no abnormalities in the morphology, size and signal of sulcus, fissure, cistern and ventricle; No obvious enhancement was observed in the lesions of enhanced scan. Cranial magnetic resonance angiography showed no obvious abnormalities. Clinical diagnosis: tuberous sclerosis complex (TSC); retinal astrocytic hamartoma (RAH) of the right eye.

The patient was a 64-year-old female. Due to blurred vision for 3 to 4 months, he went to Tianjin Eye Hospital. History of trauma and systemic medical history are denied. Eye examination: visual acuity was 0.8 for the right eye and 0.03 for the left eye; There was no obvious abnormality in the anterior segment examination of both eyes; For left fundus examination, seeQuintessence Picture 1In A, the ICGA inspection is shown inQuintessence Picture 1Medium B, OCT examination is shown inQuintessence Picture 1Medium C. Clinical diagnosis: Age-related maculopathy type II neovascularization in the left eye.