2017年 · 第53卷第08期

This issue focuses on the clinical and basic research of ocular tumor orbital disease. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Fan Xianqun, Department of Ophthalmology, Ninth People's Hospital affiliated to Shanghai Jiaotong University School of Medicine.

The patient was an 82-year-old female. On November 3, 2014, I went to the Department of Ophthalmology of Shaoxing People's Hospital because the painless mass in the upper lid of my left eye increased rapidly for more than 3 months. Ocular examination: A strip-shaped mass, about 25 mm ×8 mm ×5 mm, was seen near the upper eyelid margin of the left eye, pink, with clear borders, soft texture and smooth surface, with telangiectasia, no tenderness and ulceration (Figure 1), the palpebral conjunctiva has no bulge; The visual acuity is 0.6 in the right eye and 0.5 in the left eye; When looking up, the upper eyelid edge of the left eye is located at the upper edge of the pupil; The lenses of both eyes were opaque, and there were no obvious ocular abnormalities. Systemic examination: No obvious preauricular, head and neck lymph nodes were palpable, blood pressure 138/82 mmHg (1 mmHg =0.133 kPa), and electrocardiogram showed premature ventricular contractions. Past: history of hypertension for many years, oral medication to control blood pressure is basically normal, denying diabetes, leukemia, organ transplantation and the use of immunosuppressants; No obvious abnormalities were found in laboratory and radiological auxiliary examinations; The patient is a farmer and has been engaged in agricultural labor for a long time; There is no history of similar disease in the family. On November 5, 2014, the left upper eyelid mass was resected under local anesthesia. Pathological examination showed that the tumor cell nest was located in the dermis and spread to the subcutaneous tissue under low magnification, and there was no connection with the epidermis. The tumor cells were round or oval, evenly distributed (Figure 2）； High power microscope shows that the tumor cytoplasm is very little, and there are many mitotic phenomena (Figure 3）； Immunohistochemical examination revealed cytokeratin 20 (CK20) (FIG. 4A), neuron specific enolase (NSE) (FIG. 4B), chromaffin A and CD56 were all positive, and carcinoembryonic antigen, human leukocyte common antigen, and anti-melanoma specific monoclonal antibody (HMB45) were all negative. Diagnosis: Merkel cell carcinoma of left upper eyelid (stage II/T₂N₀M₀), left eye ptosis (mechanical), cataract in both eyes, hypertension, premature ventricular contractions. Because of the patient's personal reasons, radiotherapy (referred to as radiotherapy for short) and other treatments are abandoned after surgery. At 3 months follow-up, no local recurrence and distant metastasis were observed.

The patient was a 27-year-old female. He was admitted to the Department of Ophthalmology of the First Affiliated Hospital of Zhengzhou University on August 29, 2014 due to recurrence for 15 days 1 month after resection of inner and inferior conjunctival mass in his left eye. One month ago, the patient underwent resection of the inner and inferior conjunctival mass in the left eye in the local hospital, and the postoperative pathological diagnosis was spindle cell tumor. 15 d ago, the lesion recurred and gradually increased to a cord-like mass. Admission examination: the visual acuity of the right eye was 1.0, and no abnormalities were found in the examination of eyeball and orbit; The visual acuity of the left eye was 1.0, and the medial conjunctiva showed a longitudinal cord-like mass, enlarged lacrimal mons, and it was hard to touch (Figure 1), the medial angle of the upper eyelid was swollen and hypertrophic, the lateral movement of the eyeball was slightly limited, the lacrimal duct was irrigated smoothly, the area of the lacrimal sac was compressed without pus, and no abnormalities were found in the eye examination. Bilateral submandibular lymph nodes were not swollen. CT examination: Long soft tissue density shadow on the medial side of the anterior part of the left orbit, the lesion involved the eyeball wall and medial rectus muscle, and the adjacent bone was not damaged (Figure 2）。 Admission diagnosis: recurrent space-occupying lesions of left medial canthus and anterior orbit.

The patient was a 23-year-old female. On February 1, 2015, he went to the strabismus and pediatric ophthalmology clinic of Suzhou Ideal Eye Hospital due to the discovery of intermittent outward deviation of his left eye for half a year. The patient complained of outward deviation of the left eye intermittently in the past six months, no diplopia, and no restriction of eye movement. He denied a history of head trauma, metabolic disease and vascular disease, and his previous binocular vision was roughly normal. Initial diagnosis: Distant vision: 1.0 in right eye, 0.8 in left eye, subjective optometry: flat light in right eye, -0.50 DC ×145° =1.0 in left eye. Slit lamp microscopy showed clear refractive interstitium and normal fundus in the right eye. There was no obvious congestion in the bulbar conjunctiva of the left eyelid, a small cloud was seen in the center of the cornea (a corneal foreign body had occurred, and the patient complained that the visual acuity of the left eye did not decrease after the injury), and the rest of the anterior segment and fundus were normal. Eye position: 33 cm reflecting light, orthogonal or right eye fixation, left eye-15°L/R slight; Degree of strabismus by prism covering method (naked eye): 33 cm: right eye fixation-40^△, L/R8^△； Left eye fixation-40^△, L/R8^△。 6 m: Right eye gaze-40^△, L/R5^△； Left eye fixation-25^△。 The compensatory head position is not obvious. A-V strabismus: none. Eye movement: No obvious abnormalities were found. The outpatient was admitted with intermittent exotropia, and it was planned to undergo strabismus correction surgery. The patient was admitted to our hospital 3 d later. The slit lamp microscopy and fundus examination at the time of hospitalization were the same as those in the outpatient clinic. The degree of strabismus was re-examined by prism covering before operation (naked eye examination). 33 cm: Right eye gaze-40^△, L/R8^△； Left eye fixation-40^△, L/R5^△。 6 m: Right eye gaze-25^△, L/R5^△； Left eye fixation-25^△, L/R5^△。 And found compensatory head position: head slightly tilted to right shoulder. No strabismus type A-V. Eye Movement: Slight hyperactivity of the oblique muscle under the left eye. Considering that the patient has exotropia combined with small degree vertical strabismus and has caused compensatory head position, the examination found that the patient's left inferior oblique muscle is hyperactive, and the left inferior oblique muscle can be severed while correcting horizontal strabismus, which is conducive to solving vertical strabismus and abnormal head position. Preoperative preparation was sufficient, and the left inferior oblique muscle was dissected, the left lateral rectus muscle was retrogressed by 4 mm, and the medial rectus muscle was shortened by 4 mm on February 4 after excluding the contraindications for surgery.

The patient was a 55-year-old male. Due to progressive blurred vision in his right eye for 2 years, he went to Tianjin Medical University Eye Hospital on July 10, 2014. Two years ago, there was no obvious trigger for progressive blurred vision in the right eye, no fear of light, eye pain, rainbow vision, shadow occlusion in front of the eye, etc. Without treatment, sight was lost for several months, and the outpatient clinic was age-related cataract, and the mature stage was admitted to the hospital. Past history: self-complained of myopia in both eyes, and underwent phacoemulsification combined with IOL implantation in the left eye in an external hospital 1 year ago. Denial of other systemic diseases. Ocular examination: Right eye visual acuity manual/30 cm, intraocular pressure 8.2 mmHg (1 mmHg =0.133 kPa), corrected intraocular pressure (Pentacam corrected by corneal thickness) 15.1 mmHg, normal external eye, large corneal diameter, total cornea transparent and thin, about 2/3 of the normal thickness, spherical expansion, normal scleral color. The anterior chamber is deep, the iris is not depigmented, there is no atrophy and tremor, the pupil is round, 3 mm in diameter, and the pupil has light reflection. White opacity of the lens (Figure 1), the fundus of the eyes cannot be seen. Left eye visual acuity 0.25, corrected 0.4 (+2.5 DS () -4.5 DC ×178°), IOP 8.4 mmHg, corrected IOP 12.2 mmHg. The condition of corneoscleral and iris was the same as that of the right eye, IOL haptic clamping (Figure 2), the pupil is underround, there is light reflection, the border of the optic disc of the fundus is clear and normal, and the macular area is mild edema. Lenstar-900 white values were 14.31 mm in the right eye and 14.17 mm in the left eye. Intraoperatively, the horizontal corneal diameter of both eyes was 14.20 mm and the vertical diameter was 12.75 mm. Pentacam (Oculus, Germany) examination in both eyes showed total corneal thinning in both eyes, with central thickness of 408 μ m on the right and 456 μ m on the left (Figure 3）； The anterior chamber is deep, 4.84 mm on the right and 5.08 mm on the left; Corneal astigmatism right eye-3.7×102 (K1=41.11 D, K2=44.84 D), left eye-3.6×74 (K1=40.9 D, K2=44.5 D). The mean values of central corneal thickness, anterior chamber depth and corneal astigmatism measured by Pentacam and Lenstar-900 were similar. Right eye phacoemulsification cataract aspiration combined with IOL implantation anterior segment OCT is as followsFigure 4As shown. The diagnosis was: age-related cataract in right eye, mature stage; globular cornea in both eyes; Enlargement of the anterior segment of both eyes; Left eye IOL eye, left eye IOL pupil clamping; Refractive error in both eyes. Right eye phacoemulsification combined with IOL implantation was performed, and +19.00 D corrected astigmatism IOLSN6T7 (Alcon, USA) was implanted. On the first day after surgery, the right eye had visual acuity of 0.5, intraocular pressure of 11.0 mmHg, correction of 16.9 mmHg, transparent cornea, deep anterior chamber, correct IOL position and no significant axial deviation. The best corrected visual acuity of the right eye was 0.8 (-1.00 DS () -0.50 DC ×101°), the intraocular pressure was 8.3 mmHg, the correction was 15.4 mmHg, the cornea was transparent, the anterior chamber was deep, the IOL was correct, and the axial position was still not significantly deviated.

Case 1 was a 51-year-old male. He was admitted to the Department of Ophthalmology of Cangzhou Central Hospital on June 19, 2014 due to ptosis of his left eye for 8 days. He had a history of hypertension for more than 20 years. In May 2010, the patient was hospitalized in another hospital due to "left eye oculomotor nerve paralysis", and was discharged after symptomatic treatment (details unknown). On February 22, 2014, the patient was hospitalized in our hospital due to double vision of both eyes and ptosis of right eye for 10 days. Physical examination: visual acuity of right eye 0.8 and left eye 0.6. The upper eyelid margin of the right eye occludes 1/3 of the pupil, the pupil is round, 3 mm in diameter, and the light response is sensitive. The eye position: 33 cm corneal reflection-15°, which alternately occludes both eyes from the outside to the orthogonal position. Eye movement^[1]: Insufficient movement of upward, downward and internal rotation of the right eye, respectively, upward rotation-3, downward rotation-3 and internal rotation-2. No obvious abnormalities were found on head CT. Diagnosis: Oculomotor nerve paralysis in the right eye, given glucocorticoids, improving circulation, dilating blood vessels, and nourishing nerves for more than 1 month, the symptoms of ptosis in the right eye disappeared, and the insufficient eye movement improved significantly, respectively, upward turning-1, downward turning-1, and internal turning-1. On June 19, 2014, the patient was re-hospitalized in our hospital for 8 days of blepharoptosis in his left eye. Before hospitalization, the patient was given circulation improvement, blood vessel dilation and oral glucocorticoid administration for 1 week in the outpatient clinic, but no significant improvement was seen, so he was admitted to the hospital. Physical examination after admission: visual acuity 0.8 in the right eye and 0.6 in the left eye. The upper eyelid margin of the left eye covered all the cornea, and the eye position was 33 cm. The cornea reflected the correct position, and there was no obvious abnormality in the movement of both eyes. The pupils of both eyes are round, about 3 mm in diameter, and they are sensitive to light reflection directly and indirectly. The lenses of both eyes are mildly opaque, the boundary of the optic disk of the fundus is clear and colorful, the blood vessels can travel, the arteries are thin, the reflection is strong, the phenomenon of arteriovenous cross compression can be seen, and the foveal light reflection exists. MRI of the head showed that there was no obvious abnormality in the head, and inflammation of the left maxillary sinus and the right sphenoid sinus. Chest CT revealed thickening of both lungs, and the white blood cell count was 12.96×10 in blood test⁹/L, the % neutrophils was 93.8%. The muscle strength of the limbs was normal, and there were no general myasthenia gravis manifestations. Ice test (-), fatigue test (+) and neostigmine methylsulfate test (+) were performed. During hospitalization, the patient's left eye ptosis was found to be mild in the morning and heavy in the evening, and the ptosis was slightly reduced after rest. Following the family history, the patient's two uncles (who died) had a history of myasthenia gravis. Diagnosis: myasthenia gravis of ocular muscle type, left maxillary sinusitis, and right sphenoid sinusitis. The patient's ptosis was improved after 3 days, and the symptoms of ptosis basically disappeared after 6 days. Occasionally, the patient's ptosis was mild after fatigue. After discharge, the patient was instructed to adhere to oral bromobistigmine and gradually reduce the dose of glucocorticoids. Up to the follow-up date of August 20, 2015, the patient had no recurrence of ocular myasthenia gravis, and there were no systemic myasthenia gravis manifestations.

The patient was an 18-year-old female. In August 2013, the patient found a pale red mass the size of a "soybean grain" in the conjunctiva above the left eyeball growing for 14 days, accompanied by an obvious foreign body sensation. Then he went to Tianjin Eye Hospital on August 13, 2013. After admission, ophthalmic examination revealed that the bulbar conjunctiva above the left eyeball was congested, and a mass with a size of about 8.0 mm ×7.0 mm ×2.0 mm was visible about 2 mm above the limbus. The boundary was unclear, the texture was tough, no tenderness, and it could not be pushed. The bulbar conjunctiva around the mass showed radial and obviously tortuous blood vessels (Figure 1）。 The remaining eye examinations showed no abnormalities. The clinical diagnosis was conjunctival mass of the left eye. Conjunctival mass resection was performed on 15 Aug 2013. The pathological diagnosis was: left eye subconjunctival inflammatory myofibroblastic tumor (IMT). Immunohistochemical staining: acidic calcium binding protein S-100 (-), Vimentin Vimentin (+), smooth muscle actin SMA (+).

The patient was a 68-year-old male. After accidentally falling, the conjunctiva of the left eye was found to protrude immediately outside the eye with a foreign body sensation, and he could not close his eyes, so he went to the Department of Ophthalmology of Shengli Oilfield Central Hospital. Eye examination: the visual acuity of both eyes was 0.6, which could not be corrected; IOP was 14 mmHg (1 mmHg =0.133 kPa) in the right eye and normal in the left eye; The skin of the left eyelid is red and swollen, the eyelid cannot be completely closed, the conjunctiva protrudes outside the palpebral fissure, the protruding conjunctiva surrounds the cornea in a cylindrical well shape, and the conjunctiva is slightly pale (essence picture 1). When the eyelid is touched, the conjunctiva is airbag-shaped, and the movement of the eyeball in all directions is limited; The cornea is transparent, the depth of the anterior chamber is normal, the pupil is round, there is a light response, the lens is mildly opaque, and no obvious abnormality is seen in the fundus; No obvious abnormalities were found in the anterior and posterior segments of the right eye. Orbital X-ray examination: interruption of the medial wall of the left orbit and intraorbital gas accumulation. Clinical diagnosis: fracture of medial orbital wall of left eye; Subconjunctival pneumatosis in the left eyeball. After oral administration of Yunnan Baiyao for 3 days, the gas accumulation under the bulbar conjunctiva was completely absorbed, the bulbar conjunctiva was repositioned, and the eyelid closed well.