2018年 · 第54卷第12期

This issue focuses on ocular surface diseases. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Zhang Mingchang.

In recent years, the shift from inpatient treatment to non-inpatient treatment has become a major change in the medical service model, and day surgery is the concentrated embodiment of this change. With the continuous development of medical technology, the transformation of medical payment methods, and the increase of medical demand caused by the aging of the population, day surgery has been popularized in many countries^[1]In the past 20 years, it has also been developed vigorously in China.

Pterygium is a common ocular surface disease in clinic, which mostly manifests as degeneration, hypertrophy and hyperplasia of subconjunctival tissue, and slowly invades the center of the cornea in a triangular shape. The prevalence of pterygium is reported to be geographically related, and the overall prevalence of pterygium in China is approximately 9.84%^[1], which is similar to the global overall prevalence (10.2%). Based on this calculation, as the world's most populous country, it is estimated that the total number of pterygium patients in China exceeds 100 million.

Thanks to the Chinese Journal of Ophthalmology for opening the academic controversy column, so that some hot issues in clinical work can be widely discussed through academic controversy articles.

A 23-year-old male patient with blurred vision for 4 d 1 month after keratoconus surgery in his left eye was seen in Henan Provincial Eye Hospital on March 24, 2015. The patient was given tobramycin dexamethasone eye drops, gatifloxacin gel, sodium hyaluronate eye drops and bovine alkaline recombinant fibrous growth factor gel for 1 month after keratoconus surgery. The patient felt eye astringency and discomfort to see a doctor. In addition to the above drugs, vitamin A sodium palmitate eye drops were added for 1 week. Under the slit lamp microscope, the patient's left eye was wearing contact lenses, the conjunctiva was moderately mixed congested, the corneal graft and the implant bed were well aligned, the sutures were in place and clear, and 5 mm ×3mm irregular gray-white infiltration focuses were seen above the graft, epithelial defects, and the underlying matrix was turbid. The ulcer and turbid area was about 6 mm ×8 mm (Figure 1）。 Confocal microscopy of the cornea revealed a large number of fungal hyphae, vertically branched (Figure 2）； Following local anesthesia with 0.5% tetracaine, Giemsa staining microscopy of the corneal scraper revealed a large number of blue fungal hyphae with long, right or acute branches, and rod-shaped conidia (Figure 3）； No typical bacteria were seen. The corneal scraper and contact lens were inoculated in Sabourand medium, blood plate medium and enriched broth medium, respectively, and placed at 26℃ ~28℃ and 35℃ for fungal and bacterial culture. Patients were given alternating eye points with 0.5% natamycin eye drops, 0.5% voriconazole eye drops and 0.5% terbinafine eye drops once/h.

Case 1 was a 46-year-old female. On July 5, 2016, he went to the Department of Ophthalmology of Enshi Central Hospital because he was found to have no vision in his left eye for 2 months. Two months ago, the patient accidentally occluded his right eye and found that his left eye was not visible, without symptoms such as eye pain and eye swelling, without headache, convulsions, and without movement and sensory impairment. There was no diagnosis and treatment, and there was no obvious change in visual acuity after 2 months of self-observation. Past physical fitness. Ocular examination: visual acuity of right eye 0.8, anterior segment (-), unclear boundary of fundus optic disc, pale color, atrophic focus visible above temporal optic disc, unclear reflection of fovea, intraocular pressure 9.1mmHg (1 mmHg =0.133 kPa); The visual acuity of the left eye was 40 cm, without correction, anterior segment (-), fundus optic disc congestion, edema, unclear boundary, macular hemorrhage with yellow exudation, no foveal reflection, intraocular pressure 10.8 mmHg (Figure 1）。 Diagnosis: optic disc edema in both eyes. Routine systemic examination after admission excluded systemic diseases and infectious diseases. Specialist examination: OCT examination results showed thickening of nerve fiber layers on the nasal side and lower side of the optic disc of the right eye, and thickening of nerve fiber layers on the nasal side, temporal side and lower side of the left eye; Macular edema in the right eye was not obvious; The macular retina of the left eye was thickened and bulged, with multiple liquid dark areas between the layers (Figure 2，Figure 3）。 The results of FFA examination showed late fluorescein leakage and blurred boundary in the optic disk of both eyes; The temporal side of the optic disc of the right eye showed flaky hyperfluorescence with clear boundaries and no obvious enlargement in the late stage. Irregular flaky hyperfluorescence in the macular area of the left eye mixed with masked fluorescence, late leakage (Figure 4，Figure 5）。 CT examination showed that the left frontal lobe density was not uniform, and further MRI examination was recommended. MRI results showed abnormal signals in the left frontal lobe. Considering the possibility of vascular malformation, CT angiography is recommended (Figure 6）。 He was transferred to the neurosurgery department on July 10, 2016, and underwent digital subtraction angiography of the head on July 15, 2016. The results showed that the M2 segment of the left middle cerebral artery showed local vascular thickening and tortuous deformity, forming a vascular mass, arteriovenous communication, drainage vein flowing back into the superior sagittal sinus, left anterior cerebral artery atrophy and thinning, and left ophthalmic artery showed poor display; The right internal carotid artery supplies bilateral anterior cerebral arteries and some branches of the left middle cerebral artery, and a thickened and tortuous vascular mass similar to the M2 segment of the middle cerebral artery can be seen, with arteriovenous communication. No significant abnormalities were observed in the right ophthalmic artery (Figure 7）。 Resection of left frontal vascular malformation under general anesthesia on 16 Jul 2016. The visual acuity of the left eye recovered to 0.1 3 months after surgery.

The patient was a 25-year-old female. Due to the discovery of a subconjunctival mass in his left eye for 22 months and the enlargement of the mass for 3 months, he went to Beijing Tongren Hospital affiliated to Capital Medical University on December 8, 2016. The patient had no ocular and systemic symptoms and was previously in good health. Physical examination: There were no obvious positive signs on general physical examination. Ophthalmic examination: visual acuity 0.9 in the right eye and 1.0 in the left eye; IOP was 12 mmHg (1 mmHg =0.133 kPa) in the right eye and 19 mmHg in the left eye. No obvious abnormalities were observed in the anterior segment of the right eye; Left eye: There is no conjunctiva congestion, and a subconjunctival hemispherical black mass can be seen at 11:00 above the nose, with a clear boundary, about 8 mm ×8 mm, about 3 mm away from the limbus, and nourishing blood vessels can be seen (Figure 1）。 Cornea transparent, sclera porcelain white, anterior chamber medium deep, subcorneal deposits (-), aqueous humor flash (-), iris texture clear, no abnormal pigmentation, pupil round, 3 mm in diameter, sensitive to light reflection, crystalline lens transparent. The dilated pupil examination of the fundus showed that the vitreous body of both eyes was transparent, and no obvious abnormality was found in the fundus. Auxiliary examination: Ocular ultrasound showed hemispherical solid lesions (8.6 mm ×2.8 mm ×8.1 mm) detectable in the peripheral bulbar wall of the left eye and nose, with clear boundaries and uneven internal echoes (Figure 2), color Doppler flow imaging can detect blood flow signals; Ultrasound biomicroscopy showed a solid subconjunctival mass above the nose of the left eye, about 7.3 mm ×7.01 mm ×2.24 mm in size, involving the sclera and choroid, with unclear boundaries and uneven internal echoes (Figure 3）； OCT, wide-angle fundus phase, orbital MRI, plain chest radiograph and abdominal B-ultrasound showed no obvious abnormalities.

The patient was a 4-year-old female. He was seen in Tianjin Eye Hospital because he found that the painless black mass in the medial canthus of his right eye was increasing for 1 year. The child had a full-term cesarean section, and no abnormalities were found in the whole body examination. Eye examination: visual acuity was 0.8 for the right eye and 0.6 for the left eye; IOP was 13.5 mmHg (1 mmHg =0.133 kPa) in the right eye and 12.0 mmHg in the left eye; The eyeballs of both eyes can move freely in all directions; The appearance of the right eye was normal, with no redness and swelling of the eyelid, no conjunctiva congestion, and a circular black mass with a diameter of about 5 mm was visible in the mons lacrimal, protruding about 4 mm from the surface of the conjunctiva. It was soft in texture, clearly defined, without tenderness, and had a certain degree of mobility. The surface of the mass was smooth but uneven (Quintessence Picture 1）； Anterior segment and fundus examination of other eyes showed no abnormalities. The left eye examination showed no abnormalities. After admission, the right eye caruncle tumor was resected, and histopathological examination was performed after operation (Quintessence Picture 2）。 Diagnosis: Pigmented nevus of the conjunctiva in the mons lacrimal of the right eye (compound nevus).