2018年 · 第54卷第07期

This issue focuses on the research progress of diagnosis and treatment of orbital diseases. Professor Li Dongmei is the responsible editorial committee responsible for the planning, composition and review of the key contents of this issue.

Demodex blepharitis is a chronic inflammatory reactive disease caused by Demodex infection of the eyelid margin. It mainly involves the skin of the eyelid margin, eyelash capsules and glands, and meibomian glands. The typical clinical manifestations are eye itching, eye foreign body sensation, dry eyes, eyelid margin congestion, scales and sleeve-shaped discharge at the root of eyelashes. In severe cases, it can cause conjunctival and corneal complications. The disease may be somewhat contagious.

The patient was a 26-year-old female. Due to painless swelling of the upper eyelids of both eyes for 1 month, he went to the Eye, Ear, Nose and Throat Hospital affiliated to Fudan University on February 22, 2016. The patient underwent facial microplastic surgery abroad 6 months ago, and underwent autologous lipofilling on the forehead twice within 3 months; The lower eyelid of both eyes was injected with "hyaluronic acid" twice within 10 days, and the left lower eyelid appeared transient redness, swelling and pain after operation. Two months after the completion of all treatment, the patient found that the bilateral eyelids were slightly thickened, with slight redness and swelling, no pain, and several nodular masses could be palpable on both sides, which were enlarged and connected into pieces within one month. During the illness, the patient used antibiotic eye drops, eye ointment, etc. irregularly, without hormonal drugs, and had no obvious curative effect after medication, so he went to our hospital for treatment. After asking about the medical history, the patient also underwent 2 forehead autologous fat filling, 3 rhinoplasty, and 5 full face "water light needling" within 3 years. Physical examination showed no special blood routine, liver and kidney function, electrolytes and autoantibodies, and urine routine showed urinary tract infection. Ophthalmic examination revealed painless masses in bilateral upper eyelids, medium quality, and unclear demarcation with surrounding tissues. The right upper eyelid mass was located on the temporal side, approximately 2.5 cm ×1.5 cm in size, and continued with the lacrimal gland (Figure 1）； The left upper eyelid mass was located on the nasal side and was approximately 1.0 cm ×0.5 cm in size. Binocular vision, color vision and visual field were normal. The patient refused to undergo magnetic resonance examination, so he changed to orbital enhanced CT. The image showed diffuse swelling and thickening of the right upper lid and slightly thickening of the left upper lid (Figure 2）。 The proposed diagnosis is: (1) orbital granulomatous inflammation; (2) Orbital lymphoid tissue proliferative lesions. He was admitted to the hospital for a right eyelid mass biopsy.

The patient was a 54-year-old female. Due to the sharp decline of visual acuity in his left eye for 10 days, he went to the Ophthalmology Center of the Second Affiliated Hospital of Zhejiang University School of Medicine on January 5, 2015. The patient was diagnosed with "left eye optic neuritis" in the local hospital, and was treated with oral hormones and neurotrophic drugs, but there was no improvement. He had a history of hypertension for 2 years, and was treated with oral amlodipine besylate tablets, and his blood pressure was controlled smoothly. Five months ago, the patient visited the Second Affiliated Hospital of Zhejiang University School of Medicine for 1 week because he didn't see the lower half of his left eye. At that time, the eye examination showed that the visual acuity of the right eye was 1.0 and the left eye was 0.6. The color and boundary of the optic disc of the right eye were normal, the optic cup was not obvious, and the upper part of the optic disc of the left eye was mildly edema with blurred boundary (FIG. 1A、FIG. 1B）。 FFA showed slow choroidal filling in the posterior pole of the left eye, low fluorescence in the upper part of the optic disc, dilation of capillaries and leakage of fluorescein in the middle part of the optic disc in the early stage of angiography; In the late stage of angiography, the optic disc showed diffuse strong fluorescence, but the fluorescence in the upper part of the optic disc was slightly weaker (Figure 1C，Figure 1D，Figure 1E）。 Visual field examination revealed a defect in the lower half of the left eye, and the central fixation point was not affected (Figure 1F）。 At that time, he was diagnosed as anterior ischemic optic neuropathy (AION) in the left eye, and drug treatment had no obvious effect.

The child was a 5-year-old male. Due to the inward deviation of his right eye for 4 1/2 months, he went to Beijing Tongren Eye Center of Beijing Tongren Hospital affiliated to Capital Medical University on December 16, 2015. At the beginning of August 2015, the child showed slight inward deviation of his right eye without obvious trigger, accompanied by looking up. By the end of August, his right eye could not turn up, showing progressive inward deviation. During the disease, there were no obvious symptoms such as red eyes and eye pain, occasionally nausea with head and eye discomfort, and poor spirit. At the beginning of the disease, it was diagnosed as tonsillitis due to fever, which improved after symptomatic treatment. The diagnosis of "right eye internal hypostrabismus" in the outside hospital failed to find the cause. Triamcinolone acetonide was injected retrobulbar twice, and retrobulbar hemorrhage occurred the second time, and the eye position did not improve. On November 19, 2015, he underwent exploration of the right inferior rectus muscle in a local hospital. The pathology of the anterior inferior rectus muscle showed extraocular muscle fibrosis. One week after surgery, he developed low fever, head discomfort, nausea after eating, and his right eye was further deviated inward and fixed inward and posteriorly. The child was born by cesarean section at 36 weeks; Hand, foot and mouth disease at 1 year old; 4-year-old suffered from herpetic pharyngitis, and at the same time, mesenteric lymph nodes were found to be swollen, which improved after antiviral treatment. The history of trauma, family history and infectious diseases were denied, the history of vaccination was normal, and there was no history of drug allergy. No history of pandemic exposure. There were no abnormalities in brain magnetic resonance enhancement and magnetic resonance angiography, and there were no abnormalities in chest CT and thymus CT. Blood routine, urine routine, blood biochemistry, coagulation function, serum immunoglobulin, serum thyroid hormone, C-reactive protein, erythrocyte sedimentation rate, anti-streptolysin O, rheumatoid factor, protease 3 and myeloperoxidase were not abnormal. No abnormalities were found in the consultations of otolaryngology, neurology, endocrinology, rheumatology and immunology and respiratory medicine. Eye examination: visual acuity cannot be detected in the right eye, 0.8 in the left eye; Intraocular pressure was normal in right eye, left eye 16 mmHg (1 mmHg =0.133 kPa). The eyelid of the right eye was swollen, the bulbar conjunctiva was congested and edema, the right eyeball was extremely transposed internally, and the movement in all directions was limited. No abnormalities were observed in the anterior and posterior segments of the left eye. No abnormalities were seen in the fundus of both eyes. Orbital MRI (Beijing Tongren Eye Center, December 16, 2015) showed deformation of the right eyeball and abnormal changes in the superior and inferior rectus muscles, considering the possibility of inflammatory lesions (Figure 1）。 On January 6, 2016, MRI examination was performed again. MRI showed that the right eyeball was invaginated and deformed, showing extreme internal transposition. There was no abnormal change in the morphology and signal of the bulb content, and the bulb fascia sac was blurred and strengthened. The levator palpebral muscle, the superior rectus muscle, the whole course of the inferior rectus muscle, the abdomen of the temporal muscle of the inferior oblique muscle and the abdomen of the medial rectus muscle were thickened,₁Slightly longer T₂Signal, which showed obvious enhancement after enhancement; The morphology and signal of lateral rectus muscle and superior oblique muscle were not abnormal, and no abnormal strengthening was observed; There were no abnormal changes in the morphology and signal of optic nerve; No abnormalities were seen on the left side. Imaging opinion: right eyeball deformation with blurred bulbar fascia sac, thickening and strengthening of multiple extraocular muscles, inflammatory lesion? Review after treatment is recommended. Outpatient diagnosis: Acquired progressive restrictive esotropia in the right eye, subacute nonspecific extraocular myositis in the right eye?

The patient was a 66-year-old male. Due to sudden blurred vision in his right eye for 3 weeks, he went to the Department of Ophthalmology, the Second Affiliated Hospital of Wenzhou Medical University. Prior history of ophthalmic disease is denied, and systemic history is denied. Eye examination: naked eye visual acuity of right eye 0.1, correction 0.4; intraocular pressure 14 mmHg (1 mmHg =0.133 kPa); The conjunctiva of the right eye is not congested, the cornea is transparent, the central anterior chamber is deep, and the lens is mildly opaque; The right fundus optic disc has a clear boundary, reddish color, slightly thinner arteries, a disc-shaped bulge in the macular area, a little hard exudation near the vascular arch above, a dark red lesion faintly visible under the macular fovea, and scattered punctate deep hemorrhage in the peripheral retina. The results of OCT examination are presented inQuintessence Picture 1。 Clinical diagnosis: detachment of retinal pigment epithelium in the right eye.