2015年 · 第51卷第03期

Non-infectious inflammatory reaction after cataract extraction is a complication caused by perioperative antigen stimulation, surgical stress, changes of physical and chemical factors, etc. Excessive operation, stimulation of the iris and prolonged operation time during operation may aggravate the inflammatory reaction. In mild cases, it can cause pain and congestion in the operated eye, and in severe cases, it can lead to vision loss and even blindness. The mechanism of inflammatory response is that the intraoperative release of prostaglandins and leukotrienes destroys the blood-aqueous humor and blood-retinal barriers, resulting in increased vascular permeability and aqueous humor protein content. Therefore, blocking the production of prostaglandins and leukotrienes is the main target for controlling inflammatory response. At present, the drugs mainly used to control and treat inflammatory response in clinic include glucocorticoids and non-steroidal anti-inflammatory drugs.

The pathogenesis of primary angle closure glaucoma (PACG) is complex, its prevalence increases with age and is higher in women than in men. The main risk factors for the onset of PACG are pupil block caused by anterior lens position and shallow anterior chamber. In addition, peripheral iris hypertrophy and ciliary body advancement are also common risk factors for PACG. The darkroom challenge test is a challenge test designed for the diagnosis of PACG to screen high-risk patients at risk of angle closure from suspected shallow anterior chamber, narrow chamber angle patients. However, the accuracy of traditional darkroom excitation test is not high, so it needs to be further improved in order to improve the sensitivity and specificity of diagnosis^[1,2,3,4,5]。

Recent findings show that the difference between the intraocular pressure before the sieve plate of the optic papilla and the cerebrospinal fluid pressure behind the sieve plate (the pressure gradient across the sieve plate), rather than intraocular pressure, is a major risk factor for optic nerve injury in glaucoma^[1,2]； And structural changes similar to optic nerve injury in glaucoma have been found in animal models of reduced intracranial CSF pressure alone^[3]It is suggested that there is a causal relationship between the increased pressure gradient across the sieve plate caused by decreased CSF pressure and optic nerve injury.

The 69-year-old female was seen in Eye, Ear, Nose and Throat Hospital affiliated to Fudan University in April 2013 due to the gradual decline of vision in both eyes for more than 20 years and aggravation for 3 years. Eye examination: visual acuity: 30 cm manual in both eyes, no improvement in correction. Intraocular pressure measured by non-contact tonometer was 18.5 mmHg (1 mmHg =0.133 kPa) in the right eye and 17 mmHg in the left eye. Irregular yellow-white lesions were seen in the central visual axis of the cornea in both eyes, and the lesions were slightly higher than the corneal surface and were mulberry-like. A translucent grid-like lesion is visible within the corneal stroma surrounding the central lesion, which does not involve the limbus (Figure 1，Figure 2)。 There were no obvious abnormalities in the anterior chamber, iris and pupil of both eyes. The lens density was slightly increased, and the intraocular structure was unclear. B-ultrasound showed vitreous opacity in both eyes, posterior detachment, and possible posterior scleral staphyloma. Cardiopulmonary examination and other systemic examinations showed no abnormalities. Family history: The patient's mother had poor visual acuity in both eyes, and she was treated conservatively in a local hospital (the specific diagnosis and treatment are unknown); Father is normal. The patient had a total of 3 children, of which the eldest son, the youngest daughter and the son of the youngest daughter had similar diseases (Figure 3、Figure 4、Figure 5、Figure 6)。 Diagnosis: lattice corneal dystrophy in both eyes. The patient underwent deep lamellar keratoplasty in the right eye under general anesthesia on 10 Apr 2013. Tobramycin and dexamethasone eye drops were administered 4 times/d after surgery. In January 2014, the visual acuity of the patient's surgical eye was 0.05. Due to the complicated cataract and vitreous opacity, the corrected visual acuity did not improve significantly.

corneal ring infiltration (CRI) is characterized by white ring or semicircular stromal infiltration in the paracorneal center, with transparent corneal stroma in the annular center^[1]。 Many infectious and non-infectious keratitis have the manifestation of annular infiltration. This article mainly introduces the annular infiltration of amoeba, virus, fungus, bacteria and drug-induced keratitis with two cases as a guide, so as to provide help for clinical diagnosis and differential diagnosis.

The patient was a 48-year-old male. In May 2013, I came to the Department of Ophthalmology of Peking Union Medical College Hospital due to repeated redness and swelling of my left eye for 2 years. The patient had been diagnosed with glaucoma cyclitis syndrome in an external hospital, and the symptoms were relieved at local points prednisolone acetate 1%. In the past 4 months, the intraocular pressure in the left eye was more than 50 mmHg (1 mmHg =0.133 kPa). After intravenous drip of 375 ml of 20% mannitol, the intraocular pressure dropped to about 30 mmHg. After using 1% prednisolone acetate, ganciclovir ophthalmic gel and 3 kinds of intraocular pressure lowering drugs, the intraocular pressure was still about 30 mmHg. Eye examination: naked eye visual acuity is 1.0 in the right eye and 0.6 in the left eye, which cannot be corrected. Non-contact IOP: 17.2 mmHg in the right eye and 29.3 mmHg in the left eye. Anterior segment examination of both eyes: there was no inflammation in the anterior segment of the right eye; The conjunctiva of the left eye is congested, the posterior wall of the cornea is deposited (+), distributed in clusters, relatively old, the aqueous humor flashes (–), the planktonic body is occasionally seen, the iris is loose in texture, there is no posterior adhesion, and the lens is transparent. The papilla boundary of both eyes was clear, the right color was red, C/D was 0.4, and the left color was light, C/D was 0.8, and there was no abnormality in the macular area. Visual field: Right eye normal, left eye 30° tube. Laboratory tests: blood routine, liver and kidney function, erythrocyte sedimentation rate, C-reactive protein, syphilis rapid serum response test, and anterolateral chest radiographs were no abnormalities. Diagnosis: viral anterior uveitis of the left eye? Secondary glaucoma. Treatment: Local medication in the left eye: 1% prednisolone acetate 4 times daily, 2% carteolol hydrochloride 2 times daily, brinzolamide 3 times daily, brimonidine tartrate 3 times daily, and ganciclovir ophthalmic gel 4 times daily. Aqueous humor virus test results: strong positive cytomegalovirus DNA 1.12×10⁴/ml, negative for Epstein-Barr virus and herpes simplex virus, given a vitreous injection of ganciclovir 6 mg to the left eye, intraocular pressure the next day: 14 mmHg in the right eye and 16 mmHg in the left eye. After 3 days, the intraocular pressure was reexamined: 15 mmHg in the right eye and 49 mmHg in the left eye. The conjunctiva of the left eye was mixed and congested, there was no obvious corneal edema, the keratic precipitate (KP) was moderately large and gray-white, the aqueous humor flashed (+), the planktonic body (+), the iris texture was loose, there was no posterior adhesion, and the lens was clear. Treatment: Oral ganciclovir 1g 3 times daily, 1% prednisolone acetate 8 times daily, 2% cartenolol hydrochloride 2 times daily, brinzolamide 3 times daily, brimonidine tartrate 3 times daily. One week after treatment, there was no inflammation in the anterior segment of the left eye, and the intraocular pressure was 14 mmHg in the right eye and 23 mmHg in the left eye. The dose of 1% prednisolone acetate was gradually reduced, and the remaining drug was unchanged. Thereafter, the intraocular pressure in the left eye remained below 20 mmHg. Aqueous humor cytomegalovirus DNA was tested negative 2 weeks after antiviral therapy. Oral ganciclovir 1 g 3 times daily, reduced to 500 mg 3 times daily after 1 month, 0.1% flumetrolone 6 times daily at the local point in the left eye, 2% carteolol hydrochloride 2 times daily, and brinzolamide 2 times daily, the intraocular pressure in the left eye was maintained below 20 mmHg, and there was no inflammatory reaction in the anterior segment of the eye. Oral ganciclovir and topical 0.1% flumetrolone were stopped 2 months later. Check corneal endothelial count: 2 732/mm in right eye²692/mm in left eye²。 Thereafter, the left eye was spotted with ganciclovir ophthalmic gel 4 times daily, 2% cartenolol hydrochloride 2 times daily, and brinzolamide 2 times daily.

The patient was a 48-year-old male. Because the right eye was splashed with high concentration of peracetic acid, eye pain and visual acuity decreased for 1 h, and he went to the ophthalmology department of Shengli Oilfield Central Hospital. Ocular examination: the visual acuity of the right eye was 30 cm manual, the intraocular pressure was normal by finger measurement, the bulbar conjunctiva was pale and edematous, a large number of bubbles of different sizes could be seen under the bulbar conjunctiva, the cornea was gray-white edema, the aqueous humor was mildly turbid, a large number of bubbles could be seen in the anterior chamber, the pupil was round, the lens was gray-white and turbid, and the fundus was unclear (Quintessence Picture 1in a and B); No obvious abnormalities were observed in the left eye. Clinical diagnosis: acid burn of cornea and conjunctiva of right eye; Traumatic cataract of the right eye. Right anterior chamber irrigation was performed in the emergency department. Multiple small bulbar conjunctival incisions were made during the operation, subconjunctival fluid and air bubbles were released, and 2 ml of autologous blood was injected under the bulbar conjunctiva (Quintessence Picture 1C) in.

The usual method to measure the tear river height is to observe the tear level height at the junction of the light band on the surface of keratoconjunctiva and the light band on the lower eyelid margin by slit lamp examination. This height can reflect the amount of tear secretion to a certain extent. Generally, the height ≤0.35 mm is diagnosed as dry eye syndrome. Noninvasive tear river height measurement is currently possible using the Oculus Keratograph ocular surface comprehensive analyzer to evaluate the continuous state of the tear river and the amount of tear secretion (cut-off value is 0.2 mm), with more objective, direct and accurate results (Quintessence Picture 1)。