2018年 · 第54卷第09期

This issue focuses on the research progress in the diagnosis and treatment of ocular tumors. Professor Li Bin is the responsible editorial committee responsible for the planning, composition and review of the key contents of this issue.

The patient was a 56-year-old male. On January 18, 2017, he was admitted to the Affiliated Optometry Hospital of Wenzhou Medical University due to the conjunctival mass of the external superior fornix of his left eye for more than one year. He visited the local hospital many times and was treated with local eye drops, but there was no relief. Past physical health, denying a family history of similar eye diseases. No obvious abnormalities were found on the general examination at admission. Eye examination: Naked eye visual acuity: 0.6 in right eye, 0.15 in left eye. Corrected visual acuity: right eye-0.75 D ×90° =1.0, left eye +3.00 D-2.00 D ×70° =0.3. Intraocular pressure: right eye 11.1 mmHg (1 mmHg =0.133 kPa); Left eye 9.1 mmHg. No obvious abnormalities were found in the anterior segment and fundus examination of the right eye; The eyelid of the left eye is mildly red and swollen, normal in position, incomplete closure, red tongue-like bulge in the upper temporal conjunctiva, prolapse outside the palpebral fissure, unclear posterior boundary, conjunctival congestion on the surface, vasodilatation (Figure 1), no tenderness and spontaneous pain, flaky defect of corneal epithelium, opacity of the stromal layer below the central heminose, normal anterior chamber depth, clear iris texture, round pupil, about 3 mm in diameter, direct and indirect light reflection sensitivity, and invisible structure in the remaining eye. Local orbital CT examination before admission showed soft tissue density mass, homogeneous and irregular shape in the conjunctival area of left upper eyelid. Color ultrasound examination of the eye showed that a hypoechoic bulge could be detected outside the superior temporal bulb of the left eye, and the internal echo was uniform, with clear boundary and compressible. No abnormal blood flow signal was found in color Doppler flow (Figure 2）。 The initial diagnosis of admission was a conjunctival mass in the left eye, which may be a conjunctival cyst. Since he had been treated with various ocular drugs locally and did not improve, he underwent a mass removal operation under local anesthesia on January 19, 2017. Surgical findings: The conjunctiva was cut along the surface of the tumor in an arc shape, and the tumor was red, soft and enveloped when it was separated under the conjunctiva. The surrounding adhesive tissues were separated and cut along the envelope, and then completely removed. The shape was irregular and the size was about 10 mm ×10 mm ×5 mm, and it was sent for pathological examination. After operation, the eyes were treated with 0.5% levofloxacin eye drops, 0.1% fluorometrolone eye drops and 0.3% sodium hyaluronate eye drops; One week later, reexamination and suture removal showed that the left eyelid was completely closed, the temporal conjunctival incision healed well, the conjunctiva was mildly congested, and the cornea was transparent and intact. The pathological report was conjunctival stromal tumor (Figure 3), immunohistochemical staining results: S-100 (-); CD34 (+); CD68 (partial +); vimentin (+); myosin (-); Smooth muscle actin (smooth muscle actin, SMA) (−); B-cell lymphoma-2 (Bcl-2) (+); Ki-67 (-); Schiff staining method of alicinlan periodic acid (alcian blue periodic acid schiff staining, AB-PAS) (+).

The patient was a 57-year-old female. The right eye was found to protrude for 2 months, and he went to Nanchang University Eye Hospital on August 12, 2016. Two months ago, the right eye was found to protrude without obvious trigger, without discomfort, and no diagnosis and treatment were performed. Previous physical health, no family history. Systemic conditions are acceptable, laboratory tests only suggest hyperlipidemia. There were no obvious abnormalities in CT of the head. Chest X-ray showed thickening of the hilar shadow (Figure 1）。 Ophthalmic examination: visual acuity: 0.25 (correction 0.5) in right eye, 0.5 (correction 1.0) in left eye; Right exophthalmos, restricted upward and inward turning of the eye (Figure 2), increased orbital pressure, tenderness at the upper, outer and inner edges of the orbit, swelling of the eyelids, and no obvious abnormalities in the fundus. Orbital CT showed abnormal bone fibrous proliferation in the upper wall, outer wall and medial wall of the right orbit, considering abnormal bone fibrous proliferation and right ethmoid sinusitis (Figure 3）。 Combined with symptoms, signs and CT findings, diagnostic considerations: fibrous dysplasia, right ethmoid sinusitis. During the hospitalization, the patient's visual acuity decreased progressively, considered due to compression of the optic nerve, and he underwent right orbital decompression on 16-Aug-2016 with the patient's consent. During the operation, it was found that the supraorbital wall, external wall and medial wall were thickened, the surface of bone tissue was rough and honeycomb, and the periosteum was destroyed. The thickened bone walls on three sides were excised and sent for pathological examination to confirm the diagnosis. Hemostasis and anti-inflammatory treatment were given after operation. Pathological examination showed abnormal glands between trabecular bones. Combined with immunohistochemical staining, the results were: cytokeratin7 (CK7) +, thyroid transcription factor-1 (TTF-1) +, novel aspartie proteinase A (Napsin A) +, and metastatic lung adenocarcinoma (Figure 4）。 Half a month later, he was transferred to the local oncology department for continued treatment. Bone scans revealed multiple bone metastases throughout the body. Chest CT showed right lung occupying space. MRI of the head showed extensive bone destruction and soft tissue mass at the anterior and middle skull base. Diagnosis of bone metastasis from right lung adenocarcinoma (T2N2M1, stage IV), given chemotherapy: docetaxel 100 mg + carboplatin 400 mg. The patient was lost to follow-up on 10 Sep 2016.

The patient was a 26-year-old male. Because his right eye was stabbed with bamboo chopsticks for 3 h, he went to the Department of Ophthalmology, Wuqing District People's Hospital, Tianjin on September 19, 2016. After complaining of injury, the patient pulled out the chopsticks, and there was no injury in the whole body except the eye. The patient was in prior health and had no family genetic history. Eye examination: Skin laceration of the right eyelid, the upper eyelid wound is about 1.5 cm long, the lower eyelid oblique wound is about 2.5 cm long, the upper and lower eyelid wounds are discontinuous, and the rest of the examination patients do not cooperate. In the emergency department, Siemens 64-slice dual-energy spiral CT was used to perform orbital CT transverse and coronal examinations. The transverse position was scanned with the auditory inferior orbital line as the baseline, and the coronal position was scanned with the vertical line to the auditory inferior orbital line as the baseline. The slice thickness was 5 mm and the slice distance was 5 mm (Figure 1), Return of results: Consider right orbital soft tissue injury with intraorbital pneumatosis and bilateral ethmoid sinus nasal mucosa thickening. The emergency ophthalmologist performed debridement and suture of the right eyelid under local anesthesia. During the operation, the upper and lower lacrimal ducts were explored with a lacrimal duct irrigation needle, and the lacrimal punctum and lacrimal duct were not damaged. After the operation, levofloxacin eye drops and lomefloxacin eye gel were applied to the eye, and the right eye was partially pressurized and bandaged. At the request of the patient, the ophthalmology department was hospitalized on the same day after the operation. A laceration of the right eyelid was diagnosed.

The patient was a 43-year-old female. On April 11, 2016, he went to the outpatient clinic of Chongqing Aier Eye Hospital because his left eye was injured by a glass door and his visual acuity in both eyes decreased for 3 days. The patient underwent binocular phakic intraocular lens implantation (ICL) in our hospital in July 2012. During the operation, the astigmatic posterior chamber ciliary sulcus fixed intraocular lens (lens model referred to as V4) of STARR Company was implanted. The operation was smooth, and the postoperative uncorrected distance visual acuity (UCDVA) was 1.0. The postoperative uncorrected distance visual acuity (UCDVA) was reviewed on time 3 years after the operation, and the visual acuity was good without decline. Three days ago, the patient accidentally hit the "glass door" with his left eye, and immediately developed binocular vision loss, eye pain, tearing, dizziness, headache, no nausea, vomiting, etc. After bed rest and ice application for about 30 minutes, his vision gradually improved. After 1 h of collision, he felt that his vision was ok, which did not affect normal living activities, and the patient did not care. After going out to play 1 d ago, I consciously felt foreign body sensation, redness and vision decrease in my left eye, so I came to our hospital on the third day after the injury. The outpatient clinic was admitted to the hospital with blunt contusion of my left eye, hyphema of my left eye and intraocular lenses in both eyes. There was no special medical history in the past, and no obvious abnormalities were found in the whole body examination. The patient's mother was a highly myopic patient. Patient admission eye examination: right eye UCDVA 0.8, corrected visual acuity +0.50 D-0.50 D x 10° =1.0; Left eye UCDVA 0.5, corrected visual acuity-1.00 D =1.0, non-contact tonometer (NCT): 15 mmHg (1 mmHg =0.133 kPa) in right eye and 16 mmHg in left eye. There were no obvious scars on the patient's face, no edema, bleeding and scab. Slit lamp microscopy showed: conjunctiva congestion in the right eye, transparent cornea, retrocorneal deposit (-), anterior chamber flash (-), V4 lens in front of the anterior chamber iris, periiris incision at 10 points, round pupil, about 3 mm in diameter, sensitive to light reflection, and no obvious abnormalities were found. Conjunctival congestion and edema of the left eyeball (+), corneal edema (+), posterior elastic layer folds (-), posterior corneal deposits (-), 1 mm ×4 mm blood clot below the anterior chamber, anterior chamber flashes (-), peripheral incision holes at 2 and 10 o'clock of the iris are visible, the pupil is round, about 3 mm in diameter, sensitive to light reflection, and a V4 lens is visible in the posterior chamber with an arch height of about 0.5 mm, but no obvious abnormalities are observed (Figure 1）。 The results of UBM showed: (1) There was strong intraocular lens echo in the anterior chamber of the right eye, and the upper and lower angle of the chamber were slightly narrowed. The iris root swelled forward near the corneoscleral limbus, the nasal and temporal angle was open, and the echo of the iris root was interrupted at about 10 o'clock (periiris incision). No obvious abnormality was found in the ciliary body, and the lens echo was visible; (2) There are scattered punctate weak echoes in the anterior chamber of the left eye, the arch height of the ICL lens is 0.86 mm, the angles of each quadrant are open, the echoes at the root of the iris are interrupted at about 2 o'clock and 10 o'clock (periiris incision), and there is no obvious abnormality in the ciliary body, and the lens echoes are visible. Fundus OCT showed high refractive error in both eyes and fundus changes. Corneal endothelial cell count: right eye (2 152.0 ± 123.1) /mm²Left eye (1 976.5±80.9) /mm²。

The patient was a 48-year-old female. He went to the ophthalmology clinic of Xuanwu Hospital of Capital Medical University on June 24, 2016 due to headache accompanied by painless progressive visual acuity loss in both eyes for 40 days and aggravated visual acuity loss in both eyes for 20 days. 40 days ago, the patient went to the neurosurgery department of our hospital due to headache accompanied by nausea and vomiting, and performed magnetic resonance cerebral venous sinus angiography. It was found that the patient had congenital cerebral vascular stenosis, resulting in an increase in intracranial pressure, and the intracranial pressure was 300 mmHg (1 mmHg =0.133 kPa). 20 days ago, the visual acuity of both eyes decreased, without red eyes and swelling, without visual deformation and dark vision. Past physical health, denying systemic disease and family genetic history. Eye examination after admission: visual acuity: no light sensation in both eyes; IOP: 12 mmHg in right eye and 14 mmHg in left eye; The conjunctiva of both eyes is slightly congested, the cornea is transparent, the anterior chamber is deep, the pupil is medium large, the diameter is 4 mm, the direct and indirect light reflection disappears, and the lens of both eyes is opaque. Fundus: optic disc edema in both eyes, up to 5 D, unclear boundary, tortuous dilatation of optic disc veins, dense flame-like bleeding around the optic disc in both eyes, retinal edema around the optic disc, and macular stellate exudation (Figure 1）。 B-ultrasound of the eye showed widening of the optic nerve in both eyes, and fluid was visible in the sheath (Figure 2）。 The admission diagnosis was binocular papilledema and congenital cerebral vascular stenosis. After admission, all preoperative preparations were completed. On June 27, 2016, the right eye optic nerve sheath decompression was performed under local anesthesia. During the operation, the retrobulbar optic nerve was fully exposed, and it was found that the optic nerve was thickened, and fluid was visible in the optic nerve sheath. The thickened optic nerve sheath was cut open, and cerebrospinal fluid was seen flowing out of the optic nerve sheath. The operation was successful. After operation, levofloxacin eye drops were given for anti-inflammatory treatment and neurotrophic drugs were given. Ocular review 1 week after surgery: visual acuity: right eye light sensation, left eye no light sensation, intraocular pressure: right eye 11 mmHg, left eye 14 mmHg, right eye conjunctiva congestion, suture in place, transparent cornea in both eyes, deep anterior chamber, round pupil, direct and indirect light reflection slow, lens opacity, fundus: retina in both eyes is rosy, right optic disc edema is significantly reduced compared with before, the boundary is ill, the arteries are thin, retinal edema around the optic disc can be seen, a small amount of flame-like radial bleeding and exudation, macula can be seen exudation, left eye optic disc edema is obvious, the boundary is unclear, the optic disc veins are tortuous, and the periphery can be seen flame-like bleeding.

The patient was a 10-year-old female. Because of poor vision in both eyes since childhood, he went to Changchun Aier Eye Hospital. Physical examination: The skin and hair color of the whole body of the child were normal. Eye examination: Right eye naked visual acuity 0.5, corrected visual acuity 0.6 (+1.00 DS-1.25 DC x 175°); The left eye visual acuity was 0.1 in the naked eye and 0.15 in the corrected eye (-4.00 DS-3.00 DC x 10°); IOP was 14 mmHg (1 mmHg =0.133 kPa) in the right eye and 16 mmHg in the left eye; The iris in both eyes is of normal color, clear texture, transparent lens, transparent vitreous body, extensive pigmentation loss in the fundus of both eyes, large choroidal vessels visible, optic disc tilted with clear boundaries, normal color, flattened fovea, and thick vortex veins visible below the temporal (Quintessence Picture 1）。 Clinical diagnosis: refractive error in both eyes; The cause of fundus pigmentation loss in both eyes remains to be investigated.