Volume 52 · Issue 06 · 2016

This issue focuses on the clinical and basic research of glaucoma. The responsible editorial committee responsible for the planning, composition and review of this issue is Editor-in-Chief Wang Ningli.

During the clinical practice of glaucoma, the fine management is needed in patient's eye history taking, clinical material organization, the standardization, normalization, advantage complement of clinical examination and compliance evaluation of anti-glaucoma medication. The fine management of the glaucoma diagnosis and treatment will enable the greatest extent of visual protection.(Chin J Ophthalmol, 2016, 52: 401-403)

The mechanism of acute attack of primary angle closure glaucoma is unclear. Several studies showed that choroidal thickness was thicker in acute attack eyes than in follow eyes and normal eyes. However, these results are not enough to support the point that choroidal thickness increase is the cause for acute attack of primary angle closure glaucoma. Narrow anterior chamber angle, shallow anterior chamber are risk factors for primary angle closure glaucoma. Dynamic changes of iris, cilliary body crystalline lens and choroid all have effect on the angle width. They could contribute to the acute attack of angle closure. Thus, the acute attack of primary angle closure glaucoma should be the results of interaction effect of multiple risk factors. (Chin J Ophthalmol, 2016, 52: 404-406)

Glaucoma drainage valve implantation is an effective surgical method for the treatment of refractory glaucoma with multiple failures^{[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15]}。 The surgical procedure is more complicated than trabeculectomy, and postoperative complications, such as shallow anterior chamber, exposure of the conjunctival surface of the drainage tube, contact of the drainage tube with the cornea or blockage by the iris, and advancement of the position of the drainage disc, are also common. In order to improve the success rate of glaucoma drainage valve implantation and reduce the occurrence of postoperative complications, experts from the Glaucoma Group of Ophthalmology Branch of Chinese Medical Association reached a consensus on the operating specifications of glaucoma drainage valve (single-disc valve) implantation after discussion.

To study the effectiveness of unilateral selective laser trabeculoplasty (SLT) on the both eyes of patients with primary open-angle glaucoma (POAG).

This was a self-controlled clinical study. Thirty-two patients of 32 eyes with OAG who used same anti-glaucoma medications for both eyes were included aat the Department of Ophthalmology Peking University third Hospital from February 2010 to April 2014. SLT was performed for the poorly controlled eye for each patient. Patients were examined before operation and 1 hour, 1 week, 1 month, 3 months and 6 months after operation. The intraocular pressure was examined after 1 hour of SLT. The rest time points were examined by visual acuity, intraocular pressure (IOP), slit lamp microscope, fundus ophthalmoscope and visual field. The paired t test (Bonferroni) was used to compare the IOP at each time point after SLT with the baseline IOP before SLT. Single factor analysis of variance was used to compare the percentage of IOP drop. Linear correlation analysis was used to analyze the amplitude of the decrease of IOP between treated eyes and untreated eyes at 6-month post-operatively and analyze the IOP between preoperative eyes and 6-month post-operative eyes. The magnitude of the decrease of IOP in patients with glaucoma medication and 6 months after surgery was analyzed. We also analyzed the types of antiglaucoma medications and IOP reductions range for 6 month after SLT.

The preoperative mean IOP was (18.9±2.5) mmHg (1 mmHg=0.133 kPa) in the treated eye of patients with OAG. Mean IOP reduction for 1 week, 1, 3, and 6 months after SLT were (1.7±2.9) mmHg, (2.5±2.5) mmHg, (3.5±2.8) mmHg, (3.4±2.5) mmHg and the percentage of IOP reduction were (8±16) %, (13±13) % (18±14) %, (18±12) % respectively (compared with the baseline, P< 0.05) . With the success criteria of IOP reduction ≥3.0 mmHg or ≥20%, the success rate of SLT in the treated eye after 1 week, 1, 3, 6 months was 38%, 52%, 50% and 60% respectively. For the untreated fellow eyes, the preoperative mean IOP was (17.3±2.4) mmHg. Mean IOP reduction for 1 week, 1month, 3 month, and 6 month after SLT were (1.1±2.0) mmHg, (1.0±2.7) mmHg, (2.6±2.2) mmHg and (2.5±2.2) mmHg respectively (compared with the baseline, P<0.05) . There was a positive correlation between preoperative IOP and IOP reduction either in the treated or in the untreated eyes at 6-month post-SLT (R=0.63, P<0.01; R=0.60, P<0.01) . There was a positive correlation in IOP reduction between treated eyes and untreated eyes at 6-month post-operative (R=0.66, P<0.01). All patients didn't need further treatment such as another laser treatment or surgery. Anti-glaucoma medications were remained unchanged after SLT.

In poorly anti-glaucoma medication controlled Chinese POAG eyes with mean IOP about 18.0 mmHg, unilateral STL can reduce the IOP about 18% at 6-month post-operative for the treated eyes. There was also a continuous IOP reduction effects for the fellow eyes.(Chin J Ophthalmol, 2016, 52: 410-415)

To evaluate the safety and effectiveness of the Suture Canalization, which is a kind of Schlemm canal surgery, on the treatment of patients with primary open angle glaucoma (POAG).

Retrospective cases series study. Fifty-two patients (52 eyes) with POAG were recruited from October 2007 to July 2009 from Hospital of Optometry and Ophthalmology, Wenzhou Medical University. Twenty-six patients (26 eyes) were included in the study group, who were treated with the Suture Canalization surgery with trabeculectomy. Twenty-six patients (26 eyes) were included as the control group, who were treated with trabeculectomy only. Best correct visual acuity (BCVA), intraocular pressure (IOP), bleb morphology, postoperative treatment of medicine of anti-glaucoma and complications of surgery were recorded at 1 d, 1 week, 1, 3, 6, 12, 18, 24, 30 and 36 months after surgery. After testing the normality and homogeneity of variance of the data of the multiple sets of measurement data, the variance analysis was adopted, and the t test was used in the comparison of two groups. Counting data using chi-square test, the level of variables between the groups should be compared with the rank sum test.

No significant difference was found in baseline data, as well as the changes of BCVA between the study group and control group at the last visit (χ²=3.06, P=0.08) . Complete and qualified success was achieved in 18 (69.2%) and 23 (88.5%) cases separately in study group, 16 (61.5%) and 22 (84.6%) cases separately in control group (χ²=0.17, P=0.69) . There was no significant difference between two groups. IOP was decreased post-operatively: from (32.4±9.3) mmHg(1 mmHg=0.133 kPa)to (16.9±3.5) mmHg at the last visit in study group and (31.3±10.0) mmHg to (15.5±4.6) mmHg at the last visit in control group. There were significant difference between last visit and preoperative IOP between two groups (study group: t=8.12, P<0.01; control group: t=7.20, P<0.01). No significant difference was found between two groups in the decreased amplitude of IOP with treatment at the last visit (t=0.23, P=0.63), as well as the postoperative IOP at the different visits (P>0.05). 65.4% of cases in the study group and 61.5% patients in control group formed functional blebs (diffuse type and microcapsule type) at the last visit. No significant difference between the IOP of patients with functional blebs (15.5±3.5) mmHg and those with non-functional blebs (16.0±3.4) mmHg in study group at the last visit (t=-0.49, P=0.64). No serious complications during and after surgery were found in subjects of the both groups. No significant difference was present in medicine amounts at last visit between the two groups (t=2.93, P=0.09).

Suture Canalization is a safe and effective surgical procedure to decrease intraocular pressure in patients with POAG, through Schlemm canal and external filtration. While it maybe not suitable to the patient with high pre-operative IOP.(Chin J OPhthalmol, 2016, 52: 416-421)

To analyze the morphologic changes of the lamina cribrosa (LC) in primary open angle glaucoma (POAG) patients using enhanced depth imaging optical coherence tomography (EDI-OCT).

This was a case-control study. Serial horizontal and vertical B-scans of the optic nerve head were obtained from one eye of 52 POAG patients and 50 age- and sex-matched healthy subjects by EDI-OCT. The number and location of focal LC defects as well as their relationship with retinal nerve fiber layer(RNFL) defects were investigated in glaucomatous eyes and compared with healthy controls. The LC thickness was measured at the center of mid-superior, central, and mid-inferior horizontal B-scans. The intra- and interobserver reproducibility were evaluated by intraclass correlation coefficient (ICC). A repeated measure ANOVA was used to analyze regional differences of the LC thickness. Independent t-test was conducted to compare LC thickness between POAG and healthy controls. A Pearson correlation was calculated for variation in LC thickness relative to global mean RNFL thickness. Spearman rank correlation was calculated to test the strength of the relationship between LC thickness and visual field mean deviation (MD).

Twenty-six focal LC defects were found in 20 eyes (38.5%) with glaucoma versus none in the healthy controls. There were 13 (50.0%) focal LC defects in the inferotemporal sector, 6 (23.1%) defects in the inferior sector, 4 (15.4%) in the superotemporal sector, and 3 (11.5%) in the superior sector. Twenty-five of 26 focal LC defects (96.2%) corresponded to the RNFL defects. The intra- and interobserver ICCs of LC thickness measurement ranged from 0.90 to 0.95 and 0.84 to 0.90, respectively. The thicknesses of the superior midperipheral, central, and inferior midperipheral LC in POAG eyes were 180.7±26.3, 196.7±24.0, and 184.1±23.5 μm, respectively. In healthy controls, the laminar thicknesses were 203.2±21.0, 225.2±22.7, and 202.6±16.5 μm, respectively. In both groups, the midperipheral LC was significantly thinner than the central LC ( P<0.01). The mean LC thickness was (187.2±19.4) μm in POAG eyes. It was significantly thinner than that in healthy controls (210.3±17.4 μm) ( t=5.06, P<0.01). The superior midperipheral, central, and inferior midperipheral regions of the LC were also significantly thinner in POAG than in controls (t=3.52 to 4.96, P<0.01). In POAG patients, mean LC thickness was found to significantly correlate with both global mean RNFL thickness (r=0.45, P<0.01) and visual field MD (r_s=-0.58, P<0.01).

The LC thickness was thinner in POAG than in healthy eyes, and correlated with the severity of POAG. Focal LC defects occurred frequently in POAG eyes, and might be associated with RNFL defect. EDI-OCT is a useful tool for the evaluation of LC deformation in glaucoma.(Chin J Ophthalmol, 2016, 52: 422-428)

To evaluate vision-and health-related quality of life in patients with uveitis, and to evaluate the relationship between quality of life and visual acuity.

Cross-sectional study. One hundred and eleven patients with uveitis were enrolled in the study from January 1, 2013 to April 1, 2014 in Peking University First Hospital. Clinical data collected included medical history, complete ophthalmologic examination and best corrected visual acuity (LogMAR). Basic clinical data (gender, diagnosis, etc.) was also collected. The National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) and the 36-Item Short Form Health Survey (SF-36) were administered. The patients were divided into two groups, anterior uveitis group (ATU), and other types of uveitis in this study (OTU). T-test was used for analysis of the data which obey standard normal distribution, otherwise rank sum test was used for data analysis. Correlation and Linear regression were constructed between bilateral visual acuity and the scores of NEI VFQ-25 and SF-36 questionnaires.

For all the 111 cases included in this study, 87 (78.4%) of them were anterior uveitis (ATU), 5 of them were intermediate uveitis, 7 of them were posterior uveitis and 12 of them were pan uveitis. Mean visual acuity of better and worse eye were 0.0 and 0.2 in ATU patients, respectively. Mean visual acuity of better and worse eye were 0.1 and 0.4 in OTU patients, respectively. Patients rated the general health subscale score of NEI VFQ-25 and SF-36 lower than other subscales, respectively (score of general health was 25.0 (25.0-50.0) in NEI VFQ-25 and 46.8 (19.8) in SF-36). ATU group scored higher that OTU group (Mean score of SF-36 was 77.5 (10.7) and 68.8 (16.9) in ATU and OTU group respectively, P value of SF-36< 0.01,t=9.54. Mean score of NEI VFQ-25 was 77.3 (12.8) and 59.1 (16.5) in ATU and OTU group respectively, P value of NEI VFQ-25<0.01,t=33.16). Mean score of NEI VFQ-25 of all patients was 73.4 (15.5). Mean visual acuity of better eye and worse eye of all patients were 0.0 (-0.2-1.0) and 0.3 (0.5), respectively. The correlation coefficient was -0.497 (P<0.01, t=-5.98) between NEI VFQ -25 score and visual acuity in better eye, and -0.32 (t=-3.48, P<0.01) between NEI VFQ-25 score and visual acuity in worse eye. The coefficient was -3.9 in linear regression of visual acuity in better eye against NEI VFQ-25 score (t=-5.98, P<0.01), and -1.1 of visual acuity in worse eye against NEI VFQ-25 score (t=-3.48,P<0.01).

General health was more affected than other function subscales in uveitis. The quality of life in anterior uveitis was higher than other types of uveitis in this study. Vision-related quality of life correlated with both eyes.(Chin J Ophthalmol, 2016, 52: 429-436)

To study the protective effect of Salubrinal on human lens epithelial cells and its mechanism in endoplasmic reticulum stress (ERS).

Hydrogen peroxide (H₂O₂ 200 μmol/L) was used to intervene in the cultured human lens epithelial cells B ₃ (HLE-B₃) so as to create an oxidative stress model and induce ERS in the model. Different concentration of Salubrinal (10, 15, 20, 25, 30 and 35 μmol/L) were added to the cultured HLE-B ₃ with or without H₂O₂ intervention. Then the cells were cultured for 24 hours. The cell counting kit (CCK-8) assay was used to test the viability of HLE-B₃. The HLE-B₃ cells were divided into three groups: Group A (normal control group), Group B (H₂O₂ 200 μmol/L group), and Group C (H ₂O₂ 200 μmol/L+ Salubrinal 25 μmol/L group). After 48 h, TUNEL and flow cytometry assay (FCM) were used to examine the effect of Salubrinal on HLE-B ₃ apoptosis. The expression of glucose-regulated protein 78(GRP78), C/EBP homologous protein (CHOP), cysteinyl aspartate specific proteinase 12 (Caspase-12) and phosphorylation eukaryotic translation initiation factor 2α (p-elF2α) were tested by western blot at different points in time. Data from different groups was analyzed by one-way analysis of variance (ANOVA) while Dunnettt test was used under an equal condition, Dunnett's T3 for the unequal variances.

CCK-8 results showed that without the intervention of H₂O₂, different concentrations of Salubrinal had no inhibitive effect on HLE-B₃ viability, and that survival rates were (98.6±3.3) %, (98.7±2.6) %, (99.4±3.2) %, (98.6±1.9) %, (98.8±2.5) %, (99.3±3.2) % and (99.5±2.4) %. There was no statistically significant difference between them (F=0.09, P=0.10). With the increasing of Salubrinal concentration, the survival rates of HLE-B₃ in the presence of H₂O₂ intervention were (52.9±4.7) %, (65.0±3.6) %, (72.9±3.8) %, (84.5±3.6) %, (91.6±2.1) %, (93.1±2.9) %, (92.0±3.3) %. There was statistically significant difference from the control group (all P<0.01). However, the survival rates no longer increased (P=0.56, 0.88) if the Salubrinal concentration was greater than 25 μmol/L. FCM results indicated that apoptosis rates of Group A, B and C were (1.9±0.7) %, (8.8±0.5) %, (4.3±0.3) %, respectively and the differences were statistically significant ( F=396.26, P<0.01, comparing with Group A, all P<0.01). TUNEL results showed that apoptosis indexes of Group A, B, and C were (7.7±1.0) %, (36.9±1.0) %, (16.7±2.2) %, respectively and the differences were statistically significant. (F=618.39, P<0.01, comparing with Group A, all P<0.01). Results of western blotting in group B at different points in time (0, 12, 24, 36, 48 h) showed that p-elF2α had increased by (2.16±0.38) times at 6 h; GRP78 had increased by (2.56±0.15) times at 12 h; CHOP started to rise after 12 h until it dropped after 24 h, and its amount had increased by (2.49±0.23) times at 48 h; Caspase-12 had increased significantly by (3.53±0.30) times at 48 h. The expression of GRP78, CHOP and p-elF2α in group C was greater than that in Group B, but the expression of Caspase-12 in Group C was lower than that in Group B (GRP78:F=37.85, P<0.01; CHOP: F=61.09, P<0.01; Caspse-12: F=22.27, P<0.01; p-eIF2α:F=15.11, P<0.01).

Salubrinal might protect HLE-B₃ against H₂O₂-induced apoptosis by inhibiting ERS related apoptosis pathways.(Chin J Ophthalmol, 2016, 52: 437-443)

To investigate the protection of Verapamil against advanced glycation end products (AGE) induced human lens epithelial cells (HLEC) apoptosis.

Experiment study. SRA01/04 (HLEC line) was cultivated and passaged to the third generation and then divided into four groups. A group was named as control group, and B group was named as AGE group (LEC was treated by 20 μmol/L AGE). C group was AGE+SB202190 group (LEC was treated 2 hours by SB2012190 and then treated by 15 μmol/L AGE). D group was AGE+ Verapamil group (LEC was treated 2 hours by 50 μmol/L Verapamil and then treated by AGE). MTT was used to evaluate the cell viability. Flow cytometry with Annexin V-FITC apoptosis detection was used to assess cell apoptosis.The expression of p-p38 and caspase3 was detected by Western blot between groups. One way Chi-square analysis was used for data analysis. LSD- t test was used as comparison between every two groups.

After 24 hours, LEC viability (A570) was (0.28±0.08) in B group, which was significantly lower than A group (0.97±0.05) (LSD-t test, P=0.008). LEC viability in C and D group was (0.79±0.06) and (0.62±0.07) separately, which can partly higher than it was in B group (F=34.52, P=0.001). The apoptosis cells were (19.9±1.1)% in B group, which were significantly higher than they were in A group (2.5±0.6)% (P=0.003). The apoptosis cells in C and D group were (4.23±1.20) and (5.79±1.75) separately, which were significant lower than they were in B group (F=371.61, P<0.01). In additional, expressions of p-p38, Caspase3 proteins in the cells of group B were (223.35±20.15) and (256.77±19.88) separately, which were higher than it were in A group,which were (106.44±10.74) and (100.26±18.65) separately. However, they were (139.17±19.10) and (142.75±23.36) in group C and (154.79±21.87) and (139.79±25.73) in group D (F=248.01, F=76.68; P<0.01), which were lower than they were in A group.

p38 pathway is involved in the apoptotic procedure of LEC induced by AGE. Verapamil can interdict the p38 signal pathway and protect LEC apoptosis. (Chin J Ophthalmol, 2016, 52: 444-448)

Glaucoma is the first irreversible blinding eye disease in China. The prevalence rate of people over 40 years old exceeds 2.6%. At present, there are about 15 million patients, of which 2.25 million to 4.5 million will be blinded by it^[1]。 Glaucoma has become one of the major public health problems that seriously endanger the visual health of our people.

The patient was a 53-year-old male. On January 8, 2005, he came to Shenzhen Eye Hospital for treatment due to sudden decline of vision in his right eye and exophthalmos for 1 week. The patient was previously in good health. General physical examination showed no abnormalities, and thyroid function was normal. Eye examination: the visual acuity of the right eye is manual in front of the eye, which cannot be corrected, and the visual acuity of the left eye is 1.5. Goldman tonometer measured intraocular pressure: 18 mmHg (1 mmHg =0.133 kPa) in the right eye and 17 mm Hg in the left eye. Height of palpebral fissure in heads up: 8 mm in right eye and 8 mm in left eye. There is no delay in both upper eyelids. There was no redness and swelling in both eyelids, and no conjunctiva congestion. The refractive interstitium of the right eye is transparent, the pupil is round, about 4 mm in diameter, the direct response to light is slow, the indirect response to light is normal, and there are no abnormalities in the fundus. No abnormalities were observed in the left eye. The right eyeball is slightly protruding forward, and the exophthalmos is 17.5 mm in the right eye, 15.5 mm in the left eye, and the orbital distance is 100 mm. Both eyes are in straight position and movement is coordinated. F-VEP and P-VEP in the left eye were normal, while F-VEP P in the right eye was normal₁₀₀The incubation period of the wave was moderately delayed and the amplitude was moderately decreased compared to the left eye. Orbital CT examination showed that the lateral rectus muscle, medial rectus muscle and inferior rectus muscle of the right eye were obviously spindle-shaped hypertrophy in the abdomen, the lower rectus muscle was the most serious, and the muscle stop was normal. Orbital MRI revealed obvious fusiform hypertrophy in the abdomen of the lateral rectus, medial rectus and inferior rectus of the right eye (FIG. 1A), the inferior rectus is the most severe (FIG. 1B), T₁WI showed medium-high signal, T₂WI showed medium signal, obvious enhancement, and the muscle stop end was normal. Preliminary diagnosis: External muscle hypertrophy of the right eye. Cause to be investigated: thyroid-related ophthalmopathy of the right eye (grade VI)?

The patient was a 58-year-old male. He was admitted to hospital on January 18, 2011 due to the discovery of a mass in the left orbit for 2 years. When the patient washed his face 2 years ago, he accidentally found a small nodular mass on his left lower eyelid, about 1 cm in diameter. He did not have any other discomfort and had not been treated. The mass gradually grew, and now he felt obviously grown. He was admitted to hospital for treatment. The left face of the patient was blue-gray since childhood, and the area did not change significantly. Admission examination: the superficial lymph nodes of the whole body were not palpable and swollen, and the skin on the left face appeared blue-gray (Figure 1), the visual acuity of both eyes was 1.0, no abnormalities were found in the right eye examination, the skin of the lower eyelid of the left eye was raised, and a medium mass with a diameter of about 2 cm could be palpable subcutaneously, which could be pushed into the orbit, the conjunctiva was blue-gray, and no abnormalities were found in the anterior segment of the eyeball and fundus examination. Auxiliary examination: Orbital CT examination showed a nodular soft tissue density shadow in the soft tissue of the left lower eyelid, with a clear boundary and uneven density, about 1.0 cm ×1.5 cm in size, no abnormalities in the bone quality of the eyeball and orbital wall, and no abnormalities in the right orbit (Figure 2）。 Orbital B-ultrasound examination showed that a solid lesion of approximately 13.0 mm ×14.8 mm could be detected at the left inferior orbital margin, with clear boundaries, a small number of punctate weak echoes could be seen in it, and no obvious blood flow signal could be seen by color Doppler. Preliminary diagnosis: left orbital tumor. After admission, all examinations were completed. After no surgical contraindications, left lateral canthotomy and conjunctival approach orbital tumor resection was performed under local anesthesia. During the operation, it was found that the tumor was located in the fat below the orbit, and a large number of pigment cells were seen in the surrounding fat. The border of the tumor was clear, black, and there was no obvious envelope. It was completely removed, and the inside was black when dissected (Figure 3）。 Return of postoperative pathological findings: left orbital malignant melanoma (Figure 4）。 The patient was advised to undergo enucleation of the contents of the orbit of the left eye, but the patient refused to undergo enucleation of the contents of the orbit due to good vision in the left eye and was discharged. After 3 years of follow-up, the patient was in good health, and there was no recurrence after reexamination of orbital CT.

A 51-year-old female was seen in our hospital on September 27, 2013 due to an increase in secretion for 1 week 8 months after recanalization of the left lacrimal duct. She had a history of persistent epiphora in both eyes for 5 years and pus in her right eye for 1 year. She had undergone 3 lacrimal duct probing operations in another hospital. After treatment, the above symptoms did not improve and she was admitted to our hospital. endoscopic endonasal dacryocystorhinostomy (EE-DCR) was performed by a skilled surgeon in our hospital, and the symptoms of bilateral epiphora and right epiphora disappeared after operation. Eight months later, the patient appeared yellow-white discharge in his left eye after exertion, which was the heaviest in the morning, and the eyelid could be closed when the discharge was high. Orbital CT showed an open bone window at the left ostomy and no significant inflammation in the paranasal sinuses (Figure 1）。 Endoscopic examination showed that the anastomosis was open, without obvious granulation tissue around it, and a large amount of yellow-white purulent secretion was seen inside and outside the anastomosis (Figure 2）。 There was no obvious resistance to lacrimal duct irrigation. Considering the left EE-DCR postoperative infection, systemic cefazolin sodium intravenous drip, local levofloxacin, tobramycin, 0.1% flumetrolone and other eye drops combined with tobramycin and dexamethasone to irrigate the lacrimal duct treatment, no obvious improvement. The patient's ocular and nasal secretions were taken for bacterial and fungal smears and cultures, as well as drug sensitivity tests. It was found that Klebsiella pneumoniae and Streptococcus pneumoniae were growing, and they were sensitive to levofloxacin lactate. Levofloxacin lactate was given 0.3 g intravenous drip twice a day. After 5 days of anti-infective treatment, the eyelid secretions were significantly reduced. Endoscopic nasal examination was performed again, and secretion was still visible at the anastomosis. The lacrimal duct probe was used to explore the anastomosis, and the hyperplastic nasal mucosa tissue closed the anastomosis below, resulting in the formation of residual lacrimal sac below (Figure 3), combined with the above anatomical characteristic changes, the diagnosis of lacrimal pool syndrome was revised. The hyperplastic nasal mucosal tissue was resected under endoscopic local anesthesia, the pouch was opened, and Merogel (hyaluronic acid, Xomed, USA) was placed on the surgical wound (Figure 4）。 The eyelid and anastomotic discharge disappeared 3 days after surgery, and the phenomenon of tearing and pus did not appear again after 9 months of follow-up (Figure 5）。

患者女性，75岁。因发现右眼红伴溢泪及分泌物增多2年，于2013年4月1日来河南省眼科研究所河南省立眼科医院眼科门诊就诊。既往史、个人史无特殊、无家族史、父母无近亲婚姻史。眼科检查：双眼最佳矫正视力均0.8（右眼为-1.25 DC×165°，左眼为-1.00 DC×170°），右眼上下睑缘红肿，内眦部上下睑缘可见呈肉芽肿样增生隆起，表面不规则（图1），上下泪小点周边明显，尤其上泪小点周边增生显著，包绕上泪小点口（图2），上泪小管区膨隆，压迫可见白色分泌物及多个颗粒状结石自上泪小点溢出（图3）；取泪小管分泌物和结石进行细菌、真菌培养及药物敏感试验。右眼结膜充血（+），角膜透明，前房中深，瞳孔缘，直径约3 mm大小，对光反射灵敏，眼底无明显异常。眼压正常。冲洗右眼泪道：右眼上泪小管后端狭窄，冲洗针头可达骨壁，冲洗通畅，无反流。下泪小管通畅可达骨壁，冲洗无反流。冲洗液可达咽腔。泪小管分泌物细菌及真菌培养及药物敏感试验报告提示：缓症链球菌G+杆菌感染。药物敏感试验：敏感药物：氯霉素、万古霉素、头孢吡肟；中介药物：氨苄西林、青霉素、头孢曲松、头孢噻肟；耐受药物：左氧氟沙星、氧氟沙星、红霉素、四环素、克林霉素、阿莫西林、复方新诺明。经术前常规检查，在手术显微镜下行活检快速切片报告示鳞状细胞乳头状瘤后，再行上下睑缘完整瘤体切除送病理组织学检查，同时行泪道内镜下泪道探查，发现上泪小管中后段管壁见多个结石样嵌附，管腔明显狭窄。应用泪道内镜直视下联合微型钻粉粹泪道结石，采用敏感药物与生理盐水混合液进行冲洗及排石（图4），观察上泪小管中后段管壁未见结石残留，术后给予敏感抗生素滴眼液局部治疗。术后病理组织学报告（图5，图6）示：少量组织，鳞状上皮细胞增生，毛细血管充血，基质纤维内见一些炎症细胞浸润，另见极少量嗜碱性组织，结构辨认不清，部分区域见少量淋巴细胞浸润，GMS染色、PAS染色均未见真菌，Gram染色见可疑革兰氏阳性杆菌。病理诊断：上下睑缘并泪小点周鳞状细胞乳头状瘤；上泪小管结石伴慢性炎症，倾向于细菌性。术后患者1年后复查无复发（图7），冲洗检查右眼泪道通畅无分泌物。诊断：上下泪小点周鳞状细胞乳头状瘤伴上泪小管炎及结石。

The patient was a 45-year-old male. He was admitted to our hospital on June 27, 2014 due to repeated redness, swelling and pain in his right eye, accompanied by visual loss for 1 month. One month before admission, the patient showed redness, swelling and pain in the right eye, blurred vision, conscious right eyelid skin fever, slightly limited eyeball rotation, tearing, dizziness, general fatigue and discomfort, nasal congestion, purulent discharge. After treatment with glucocorticoid eye drops and intraocular pressure lowering eye drops in other hospitals, it improved slightly, but the symptoms of the right eye recurred and gradually worsened. Irregular fever began to occur 10 days ago, with a body temperature of 38.5~40.0 ℃, and systemic anti-inflammatory treatment was ineffective. 20 days ago, due to nasal congestion, purulent discharge and sneezing for 1 month, he was diagnosed with nasal septum deviation in another hospital and underwent nasal septum correction. Since then, he has complained that bilateral nasal congestion has not improved and continues to worsen, with intermittent and repeated epistaxis, which can stop itself. Since the onset of the disease, the spirit, appetite and sleep are poor, the urine and defecation are normal, and the physical strength has decreased. Prior health, family members have no history of tumors.

The patient was a 61-year-old female. Because of visual loss and pain in his left eye for more than 1 year, he went to the Department of Ophthalmology, Affiliated Hospital of Guizhou Medical University. Suffering from rheumatoid arthritis for more than 9 years without systemic treatment; 3 years of steroid glaucoma in both eyes, 3 years after anti-glaucoma surgery in the right eye and 1 year after anti-glaucoma surgery in the left eye. Both father and sister suffer from rheumatoid arthritis. Eye examination: left eye naked visual acuity was 0.12, corrected visual acuity was 0.3; Intraocular pressure is 8.0 mmHg (1 mmHg =0.133 kPa); conjunctival hyperemia and edema; Scleral fusion was observed at 3 mm from the limbus in the supranasal quadrant (Quintessence Picture 1In a), about 8 mm ×8 mm, the pigment membrane is exposed, only a thin layer of epithelium is seen on it, fluorescein staining (-), the filter vesicles next to it are pale, the scleral melt foci spread to the scleral flap, and the scleral flap is partially melted; A strip-like white infiltration was observed in the stromal layer of the supranasal limbus, stained with fluorescein (-) (Quintessence Picture 1in B); The center of the cornea is transparent, the retrocorneal sediment (+ +), the aqueous humor flashes (+ +), the upper periiris incision is patent, the iris texture is poor, the pupil is dilated, the diameter is about 6 mm, and the lens is moderately opaque; The vitreous body is flocculate and turbid, the fundus is blurred and the color of the optic papilla is light, the cup-to-disc ratio is 0.3, the ratio of arteriovenous diameters is 1:2, and the foveal reflection is dark. Clinical diagnosis: scleral uveoma secondary to necrotizing scleritis in the left eye; Secondary uberitis of left eye; Postoperative anti-glaucoma in both eyes.

The patient was a 21-year-old male. He went to Tianjin Eye Hospital because his left eye was blurred for more than 4 months after being injured by a fist. Eye examination: naked eye visual acuity was 0.1 for the right eye and 0.02 for the left eye; The corrected visual acuity was 1.0 in the right eye, but no improvement in the left eye; IOP in both eyes normal; Anterior segment examination in both eyes was roughly normal; No obvious abnormalities were found in the right fundus, and the left fundus was foundQuintessence Picture 1。 For the OCT examination, seeQuintessence Picture 2。 Clinical diagnosis: blunt contusion of left eye; Choroidal laceration of left eye; Macular hole in left eye; Macular hemorrhage in the left eye.

Glaucoma is a leading cause of irreversible blindness world widely. The pathogenesis of glaucoma is still not fully understood. It is proposed that the microcirculation of optic nerve head (ONH) may play an important role in glaucomatous optic neuropathy, but the hypothesis is still lack of direct evidence. In this review, we summarized the technical developments in ONH blood flow examination and findings on relationship between decreased ONH microcirculation and glaucoma. These evidences implicate that damaged ONH microcirculation involves in pathogenesis of glaucoma. (Chin J Ophthalmol, 2016, 52: 466-470)

Glaucoma is a major cause of blindness in China and the world. Currently, all therapeutic means in treating open-angle glaucoma are limited to control the progression of optic neuropathy by lowering intraocular pressure (IOP). Clinically available medicines lower IOP by either enhancing the uveoscleral pathway or inhibiting aqueous humor production. Since the primary cause of IOP elevation in POAG is elevated outflow resistance in the trabecular outflow pathway, current medicines are not able to correct the underlying pathogenesis and pathophysiology of the disease. In this review article, we discuss a series of new therapeutic targets and therapeutic approaches that are designed to directly modify the pathological changes related to the reduction in trabecular outflow in glaucoma patients. Some of these targets and approaches may produce a significant breakthrough in the treatment of this devastating disease. (Chin J Ophthalmol, 2016, 52: 471-475)

The pathogenesis of primary open-angle glaucoma (POAG) is still unclear. The trabecular meshwork (TM) plays an important role for regulation of aqueous humor outflow. The alteration of morphology, structure of TM cells and expression of extracellular matrix (ECM) components contribute to the abnormal increase of outflow resistance leading to elevated intraocular pressure (IOP). Recently, it has been confirmed that a variety of microRNA (miRNA) such as miRNA-29, 24, 200c and so on were expressed in TM tissue and different miRNA can affect the TM function and the synthesis of ECM in different ways. In this paper, we will review the role of miRNA in POAG pathogenesis, in order to provide the basis for probing into pathogenesis of glaucoma. (Chin J Ophthalmol, 2016, 52: 476-480)