Volume 51 ·  Issue 08 ·  2015

To determine the indications, surgical skills, and complications for removal of intraorbital lesions using an endoscopic transethmoidal approach.

A retrospective case series of 12 cases between May 2014 and January 2015 were conducted. Data included visual acuity, exophthalmos, ocular movement, and eyelid function of preoperation and follow-up. The location and size of the lesions were showed and recorded on CT and MRI scans. The cases with imaging diagnosis of cavernous hemangioma, schwannoma or dermoid cyst were included into this study. On the coronal slices the lesions should be located medially to the optic nerve. On the axial slices they should be located in the middle, posterior orbit or apex. The surgical approach began with performance of an endoscopic ethmoidectomy under general anesthesia. A bony window was opened on the lamina papyracea and transethmoidal dissection and removal of an intraorbital lesion was made, with the combination of a mini caruncula incision in 10 cases.

There were 4 male and 8 female patients, with the median age of 44.5 years (ranging from 14.0 to 67.0 years).En bloc tumor resection in 11 cases or piecemeal resection in 1 case was achieved, including 10 cases of hemangioma, and one each schwannoma and dermoid cyst, confirmed by pathologic examination. The tumor size ranged from 11 mm×11 mm×10mm to 24 mm×23 mm×16 mm. Three tumors were located medially to the muscle cone, 7 tumors in the cone. One case was located extra-and intracone simulataneously and 1 in the medial rectus muscle. There are 8 tumors within the apex and 4 in the middle and posterior orbit. After 3-11 months follow-up, the best-corrected visual acuity and visual field improved in 3 cases, decreased in 2 case, and vision loss in 1 case. Transient limited ocular movement in 5 cases was recovered within 3 months after surgery. The irreversible limited ocular lateral or medial movement was recorded in 1 case respectively. All complications were recorded in the cases of tumors in the muscle cone.

The endoscopic transethmoidal approach is a useful approach for cavernous hemangiomas, schwannoma or dermoid cyst located medially to the optic nerve in the middle or posterior orbit. It's safer for the tumor located medially to the muscle cone than in the cone. It's an important surgical skill to reduce the complications that intraorbital dissection and exposure of tumors in the cone are assisted with a mini caruncula incision.(Chin J Ophthalmol, 2015, 51: 569-575)

An evaluation of orbital development in children from birth to 6 years of age was conducted in order to provide normal reference values for clinical use.

Retrospective cohort study. By combining multi- section helical computerized tomography (CT) imaging with a computer- aided design system (BrainLAB, Munich, Germany; iPlan Cranial Software, version 2.5), we measured the orbital volume of 100 emergency children (200 eyes), who underwent computerized tomography (CT) scanning due to mild injury in Beijing Tongren Hospital and had normal CT findings. From birth to 6 years of age, according to the age of <1 years of age for the treatment of 0 year old group, aged 1 years old and <2 years old for 1 year old group, and so on, divided into 7 groups. Among the 50 male and female patients, the ages are 0–6 years. All of these were in order to analyze the relationship between the age and orbital volume with unary linear correlation and regression.The comparison of orbital volume between females and males was performed using two independent t- tests. Comparisons of bilateral orbital volumes were performed using a paired t- test.

The average orbital volume of children was initially (12.57±3.80) cm³ at birth, and then increased to (19.34±1.86) cm³ at 6 years of age, with an average annual growth of 1.13 cm³. There was a positive linear relationship between orbital volume and age in children from birth to 6 years of age, yielding the regression equation: Y (orbital volume)=13.582 + 1.042 ×X(age). There is no statistic difference on the orbital volume between boys and girls (t=1.073, 0.533, 1.808, 1.039, 1.346, 0.983, 1.774, P>0.05). In addition, no statistic difference was found between the left and right orbital volume(t=1.059, P=0.292). The growth curves for all groups almost overlapped with each other.

There is a positive linear relationship between orbital volume and age in children from 0 to 6. The bilateral orbital volumes were almost the same. There is no statistic difference on the orbital volume between boys and girls. (Chin J Ophthalmol, 2015, 51: 576-580)

To summarized the clinical features of thyroid associated ophthalmopathy patients with myasthenia gravis.

This is a retrospective case series study. The clinical data of 12 thyroid associated ophthalmopathy patients with myasthenia gravis were collected in the 416 Hospital of Nuclear Industry from Oct. 2012 to Feb. 2014. All patients had a detailed medical history including symptoms of onset, the best corrected visual acuity, anterior and posterior segment examination, the exophthalmos, eyelid position, eye movement, diplopia, strabismus, systemic symptoms, concurrent fatigue test, neostigmine test, thyroid function and orbital CT scan. One patient underwent CT examination of thymus.

In all 12 patients, there were 8 females and 4 males with age from 13.0 to 44.0 years (the median age of 26.5 years), 11 cases had difficulties to open their eyes which was least severe in the morning and worsened in the evening. All of cases did not have general symptoms. Ptosis was observed in 9 cases, 3 cases were bilateral, and 6 cases were unilateral. Abnormal extra ocular muscle function was observed in 8 cases, all of them were bilateral. In these 16 eyes, the limitation of downward gaze were observed in 15 eyes, the limitation of upward, outward and inward gaze were observed in 14 eyes, eye fixation occurred in 4 eyes. Four cases had diplopia, 3 cases had strabismus, and 2 of them were exotropia. Orbital CT demonstrated extraocular muscle thickening in 6 cases. Thickening of inferior rectus were observed in all 12 eyes, superior rectus and medial rectus were found thickened in 6 eyes, and thickening of lateral rectus muscle was found in 3 eyes.

The clinical features of thyroid associated ophthalmopathy patients with myasthenia gravis were complex. When ptosis and eye movement disorders were not consistent with TAO severity, associating with exotropia and systemic muscle paralysis, myasthenia gravis should be considered. (Chin J Ophthalmol, 2015, 51: 581-585)

To analyze the clinical pathologic characteristics of angioleiomyoma of the eyelid and orbit.

Retrospective case series study. The clinical and pathological characteristics of 8 cases of eyelid and orbital angioleiomyoma which were treated in Tianjin Eye Hospital from January 2005 to April 2014 were reviewed and analyzed.

In the 8 cases, 5 were male and 3 were female. The median age was 52.5 years (32.0 to 65.0). Six cases of angioleiomyoma occurred in the orbit. Three of them located in the muscle cone, 2 of them located in superotemporal orbit and 1 of them located in the inferior orbit. The remaining 2 cases of angioleiomyoma occurred in the medial side of the eyelid subcutanously. Five cases were male and three cases were female. Seven cases revealed a solitary eyelid or orbital mass. One case of orbital angioleiomyoma companied with a cavernous hemangioma of ipsilateral lower eyelid. The color Doppler ultrasound of the orbit showed a well- demarcated mass with homogeneous inner- echoes without obviously blood stream signal. The CT showed a circumscribing rounded or irregular shaped soft mass with isotropic density and the CT value were 45 to 50 Hu. Grossly, the tumor appeared as a rounded or irregular oval ranged from 0.7 to 2.8 cm. Six cases had complete fibrous capsule. Microscopically, the tumor was mainly consisted of well- differentiated smooth muscle cells and thick- walled vessels. Five cases were cavernous type, two cases were venous type and one case was solid type according to histological classification. The smooth muscle cells surrounding the vascular walls and the intervascular muscle bundles showed a positive reaction for smooth muscle actin (SMA) and desmin by immunohistochemical staining. Eight patients underwent complete resection of mass. During the surgery, the tumor was observed with clear boundary and capsule surrounded by mild adhesive tissue.

Angioleiomyoma of the eyelids or orbit was a uncommon benign tumor which was usually occured in adults, with well- encapsulated and composed of numerous thick- walled vessels and smooth muscle components. It should be considered in differential diagnosis of a well-circumscribed orbital mass, and distinguished from leiomyoma or cavernous hemangioma in pathological diagnosis. (Chin J Ophthalmol, 2015, 51: 586-591)

To evaluate the morphology of optic nerve and retina in the model of the rat non- arteritic anterior ischemic optic neuropathy (rNAION).

Experimental study. Thirty- six SD rats were randomly divided into four groups: 6 for naïve group, 3 for laser group, 3 for Rose Bengal (RB) group and 24 for rNAION group. After rNAION was induced by RB and laser, the retina and optic nerve were observed by Hematoxylin-Eosin (HE) staining and the optic nerve was investigated by transmission electron microscope and toludidine blue staining at different time points.

With these methods, significant changes were only found in the RB-laser induced eyes. The damage only occurred in the retinal ganglion cell (RGC) layer without any loss of the other layers of retina in the rNAION. Toludine blue-stained optic nerve showed that there was a loss of axons centrally and largely intact axons were spared in the peripheral nerve. More and more degenerative axons were observed with the transmission electron microscope as time went on.

The morphological changes of HE staining, toludine blue staining and transmission electron microscopic finding were consistent with each other. The results made a contribution to further study. (Chin J Ophthalmol, 2015, 51: 592-596)

To explore the effects of Gremlin on transdifferentiation and extracellular matrix synthesis in cultured human lens epithelium cells (HLEC).

This is an experimental research. HLEC were incubated with different concentrations of Gremlin (0, 100, 200 and 400 μg/L) for 24 h. The morphological changes of HLEC were observed by inverted microscope. Real-time PCR and Western-Blot were used to evaluate the expression of α-smooth muscle actin (α-SMA) (as a landmark protein of epithelial mesenchymal transition), fibronectin (Fn) and collagen type 1 (COL-1) (as major components of extracellular matrix) after stimulation with different time (0, 12, 24, 48, 72 h) by 200 μg/L Gremlin. The same parameters were observed in Gremlin.siRNA transfected HLEC which treated with 1.0 μg/L TGF-β2. α-SMA, Fn and COL-1 protein and mRNA expressions comparison with control group were analyzed using one-way and twoway ANOVA, while the difference between groups were compared using Turkey HSD and LSD- t test.

The normal morphology of HLEC showed polygonal and anchorage-dependent. After the incubation of different concentrations of Gremlin for 24 h, morphological feature of HLEC were changed from monolayer and polygonal to multilayer and spindle fibroblast-like cells, and the intercellular space widened. The expression of α-SMA, Fn and COL- 1 were increased with prolonging of Gremlin treatment time (α- SMA gene induction: 1.00±0.00,1.62±0.57,3.40±0.83,5.90±0.49,7.97±0.91; F=61.64, P<0.05,q=6.43, 13.13, 18.66, P<0.05; Fn gene induction: 1.00±0.00,3.26±0.23,5.86±0.90,10.17±2.16,12.89±1.63;F=42.03, P<0.05,q=6.45, 12.18, 15.79, P<0.05; COL-1 gene induction: 1.00±0.00, 1.78±0.88,6.80±0.44,12.76±2.46,21.12±3.66;F=51.79, P< 0.05,q=4.97, 10.08, 17.26, P<0.05) (α-SMA protein expression: 0.13±0.02, 0.26±0.02,0.29±0.09,0.47±0.06, 0.68±0.05;F=45.14, q=5.11, 10.67, 17.40, P<0.05; Fn protein expression: 0.16±0.04,0.26±0.07, 0.65±0.03, 0.82±0.04,0.73±0.02;F=144.4, q=20.09, 26.78, 23.12, P<0.05; COL-1 protein expression: 0.11±0.02, 0.23± 0.09,0.41±0.05,0.61±0.03,0.74±0.03;F=75.47, q=9.99, 16.60, 21.07, P<0.05). Gremlin.siRNA transfection effectively suppressed TGF-β2- induced expression of α-SMA, Fn, and COL- I (α-SMA gene induction:F= 81.89, P<0.05,t=3.234, 4.346, 10.35; t=2.252, 7.272, 19.11, P<0.05; Fn gene induction:F=83.61, P<0.05,t= 2.538, 8.202, 11.99; t=6.316, 7.304, 14.80, P<0.05; COL-1 gene induction:F=73.64, P<0.05,t=3.385, 7.942, 11.64; t=4.794, 9.006, 13.75, P<0.05; Gremlin gene induction:F=46.11, P<0.05,t=5.08, 7.24, 8.27; t=6.27, 8.27, 12.14, P<0.05)(α-SMA protein expression:F=129.6, P<0.05,t=4.34, 4.85; 3.83, 4.34; 13.03,14.82, P< 0.05; Fn protein expression:F=26.18, P<0.05,t=5.68, 5.95; 3.10, 4.06; 4.19, 4.73, P<0.05; COL- 1 protein expression:F=41.37, P<0.05,t=6.93, 5.51; 7.82, 6.93; 8.71, 7.64, P<0.05; Gremlin protein expression:F= 59.52, P<0.05,t=2.24, 3.49; 5.74, 6.23; 6.98, 9.98, P<0.05).

Gremlin could induce HLEC to express α-SMA, Fn and COL-1 in a time-dependent manner and promote transdifferentiation and extracellular matrix synthesis. Specifically silencing the expression of Gremlin could effectively block the TGF-β2-induced EMT and ECM synthesis in HLEC. (Chin J Ophthalmol, 2015, 51: 597-603)

Ten researches that may represent the progress in Chinese ocular trauma related studies were selected through voting by specialists from Chinese Ocular Trauma Society. These researches focused on the following fields: new strategies for the treatment of ocular trauma, study of vitreoretinal surgery and new technique application for severe ocular trauma, establishment of animal modal for basic research of ocular trauma, prevention of infectious endophthalmitis, clinical and basic study of ocular chemical burn, establishment of the public service and research platform of ocular trauma. These studies represented the level and influence of Chinese ocular trauma specialists in the international academic community and they were the landmark studies of our areas of expertise. (Chin J Ophthalmol, 2015, 51: 604-607)

Ten researches that may represent the progress in Chinese oculoplastic surgery and orbital disease were selected through voting by specialists from Chinese Society of Ophthalmic Plastics and Orbital Disease. These researches focused on the following fields: the endoscopic navigation system of orbital surgery, orbital bone regeneration and materials, comprehensive sequence treatment of retinoblastoma, the mechanism of thyroid related ophthalmopathy, the intervention strategy and evaluation of orbital development with congenital microphthalmia and anophthalmia, blepharophimosis genotypephenotype relationship and intervention strategies and clinical study of new materials for frontal muscle suspension. These studies represented the level and influence of Chinese oculoplastics and orbital disease in the international academic community and they were the landmark studies in our areas of expertise. (Chin J Ophthalmol, 2015, 51: 608-610)

The child was a 10-year-old male. Due to the intermittent attack of right exophthalmos with eyelid redness and swelling for 1 year, he went to the Department of Ophthalmology of Guizhou Provincial People's Hospital for treatment. One year ago, the child developed right eye protrusion without obvious trigger, accompanied by redness and swelling of the upper eyelid, without eye pain, vision loss and other discomfort. The child had no general discomfort, no abnormal crying, and the ocular symptoms gradually worsened. The local hospital once gave intravenous infusion of cefazolin sodium to the whole body, and the exophthalmos and eyelid redness and swelling were significantly improved, and the attacks recurred after stopping the drug. Being in good health. He denied eating raw meat, frogs and snakes, denied the history of parasite contact, and did not keep chickens, dogs and other animals at home. Physical examination after admission: binocular visual acuity 1.0, axial protrusion of the eyeball, right exophthalmos of 12 mm and left exophthalmos of 10 mm. The upper and lower eyelids were mildly red and swollen, the movement of eyeballs in all directions was not obviously restricted, the eyelids opened and closed freely, and the conjunctiva was mildly congested. No obvious abnormalities were found in the rest of the examinations. Orbital CT examination showed that the right orbit occupied space, located on the lateral side of the lateral rectus muscle and below the outside of the muscle cone. The lateral rectus muscle was slightly thickened and slightly displaced upward, and the lesion boundary was unclear and the shape was irregular (Figure 1)。 Orbital MRI examination showed that the lesions were uneven and enhanced, and the lesions were closely related to the lateral rectus muscle (Figure 2)。 Blood examination: white blood cells, red blood cells, neutrophils and eosinophils were all normal. Routine stool examination was normal. Preoperative diagnosis: space-occupying lesion of right orbit, considering that inflammatory lesion may be large. The right lateral orbital mass was explored under general anesthesia. During the operation, a ductile mass was detected on the lateral side of the lateral rectus muscle, which could be separated from the lateral rectus muscle. The surface was wrapped with degenerated fat, and the boundary with the surrounding normal fat was not clear. The mass was separated and incised. A living parasite, white and linear, about 30.0 mm ×0.6 mm, was removed from the mass. The parasite peristalsis was obvious when placed in normal saline, and the head and tail could be clearly distinguished. The adipose tissue wrapped in the parasite was sent for pathological examination. Pathological report: Acute and chronic inflammatory cell infiltration in fibroadipose tissue (right orbit), more eosinophil infiltration, focal eosinophil abscess formation with granulation tissue hyperplasia, consistent with parasitic infection (Figure 3)。 The parasite was identified as Sparganus mansoni (Figure 4)。 Final diagnosis: right orbital parasitosis. Anti-inflammatory and hemostatic therapy was routinely given after operation, but systemic anti-insect therapy was not performed. Reexamination after 1 month: visual acuity was the same as before surgery, no exophthalmos or eyelid redness and swelling, eyelids opened and closed freely, and eyeball movement in all directions was unlimited. The whole body examination showed no obvious abnormalities. There was no abnormality in the routine of the child's reexamination, and the blood image was normal.

A 43-year-old male was admitted to the Department of Ophthalmology of Qingdao University Affiliated Hospital on October 29, 2013 due to prolapse of eyeball after left eye trauma and disappearance of vision for 2 h. When the patient was fighting with someone 2 hours ago, his left eye was stabbed by the other party with a wooden brush handle, and then he lost sight and his eyeball prolapsed out of the orbit. The patient reported no history of ocular trauma. Ophthalmological examination: visual acuity of left eye without light perception, intraocular pressure Tn, orbital pressure T +2. Full-thickness skin laceration in the middle of the upper eyelid, medial canthus and temporal side of the lower eyelid, eyeball prolapse outside the palpebral fissure, ruptured medial rectus muscle, lateral rectus muscle and inferior rectus muscle stumps can be seen on the sclera surface, and partial rupture of the inferior oblique muscle can be seen vaguely (Figure 1)。 The conjunctiva was totally lacerated 1 mm from the corneoscleral margin, with a large defect of corneal epithelium, and the pupil diameter was about 5.0 mm. The direct and indirect response to light disappeared. Fundus: Papilla edema, bleeding, pale and edema of the posterior pole retina. No abnormalities were observed in the right eye. Orbital CT revealed left eyeball prolapse, unclear optic nerve display, except optic nerve rupture, fracture of orbital inner wall and inferior wall (Figure 2)。 Admission diagnosis: (1) dislocation of eyeball (left); (2) extraocular muscle rupture (left); (3) Optic nerve contusion (left); (4) Eyelid laceration (left); (5) Orbital fracture (left); (6) Corneal epithelial abrasion (left).

In recent years, the incidents of killing doctors have occurred frequently, and the tension between doctors and patients has reached its peak since the founding of New China. Although there are still many aspects that need to be reformed in the medical system, the lack or even blank of communication skills education between doctors and patients in traditional medical education makes medical students lack of favorable communication methods before stepping into clinical practice. The busy clinical work and the lack of strong technical training make our doctors often exchange their honesty for harsh words and even killing patients. Therefore, it is urgent to introduce psychological treatment methods education in medical students' education and provide effective communication skills tools.

Generally, peripheral visual function damage was the major sign of early glaucoma, while the central visual function damage happened until the late stage of glaucoma. In recent years, with the development of optical coherence tomography and microperimetry, it has been proven that macular structure and function were affected in early stage of glaucoma. Macular structural and functional changes helped monitoring the development of the disease. Research advances of macular structural and functional damage in glaucoma were reviewed in this article. (Chin J Ophthalmol, 2015, 51: 624-628)

Optical coherence tomography (OCT) has become one of indispensable imaging techniques in ophthalmology. OCT makes far- reaching influence on correct diagnosis, disease assessment, and prognosis evaluation after surgery in various ocular diseases. At present, the application scope of OCT is further expended and gradually being applied to a variety of ocular surgeries. This application is named as intraoperative OCT (iOCT). iOCT not only helps us to come to a better understanding and recognition of ocular diseases from a new perspective, but also influences our decision making of the surgical plan, thus improving safety and success rate of ocular surgery to a great extent. We reviewed the history of iOCT and its application in ocular surgery in this paper. (Chin J Ophthalmol, 2015, 51: 629-635)

Idiopathic intracranial hypertension (IIH) is a common neuro- ophthalmologic disorder which leads to significant visual impairment. Clinically, visual manifestation secondary to increased intracranial hypertension generally shows papilledema and the progressive visual impairment subsequently. IIH is a diagnosis of exclusion. The methods include lumber puncture (LP), laboratory tests and imaging examination. However, those methods do limit in evaluation and follow-up in IIH. Currently, with the development of diagnostic technology in ophthalmology, Optical Coherence Tomography and B-scan ultrasound have been employed to estimate intracranial hypertension not only in early diagnosis, but also in long-term follow-up examination. The goal of this review is to sumarize the value of various ophthalmologic methods in evaluation and management of IIH.(Chin J Ophthalmol, 2015, 51: 636-640)