Volume 52 · Issue 08 · 2016

This issue focuses on the clinical and basic research of strabismus and amblyopia and pediatric ophthalmology. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Zhao Kanxing.

In this paper, some typical excessive medical problems in the treatment of common eye diseases in children were listed as follows: unnecessary examinations carried out for children with little or no corresponding complaints; prescription for spectacles for physiological hyperopia or astigmatism in children; over-diagnosis, over-or nonstandard-treatment for amblyopia; strabismus surgeries performed in children with esotropia but without full optical correction of hyperopic refractive error, in children with monocular strabismus and amblyopia but without standard cover therapy, in children with intermittent exotropia but without optical correction of myopic refractive errors and myopic anisometropia, and without evaluation of their fusional control ability; exaggerated the harm of myopia and the curative effect of Orthokeratology contact lenses without considering the patient's compliance; cataract surgery performed in infants with partial opacity of the lens that has little effect on the vision. Every ophthalmologist should work based on evidence-based preferred practice pattern, professional standards and expert consensus to promote the standardization of the diagnosis and treatment of children's common eye diseases in China.(Chin J Ophthalmol, 2016, 52: 561-564)

Either superior oblique weakening or strengthening surgery is the most complicated and most difficult to perform in the field of strabismus surgery. The effect of superior oblique surgery is also unpredictable. In addition, improper superior oblique strengthening surgery may produce limited elevation in adduction (iatrogenic Brown syndrome). In this article, we reviewed the history of superior oblique surgery, especially on when and how to perform the superior oblique strengthening surgery for providing reference to the clinicians in the field of strabismus and pediatric ophthalmology. (Chin J Ophthalmol, 2016, 52: 565-567)

To evaluate the application of anterior segment optical coherence tomography (ASOCT) in surgical design for residual horizontal strabismus patients.

This article was a retrospective case series analysis. Total 20 residual strabismus patients (13 with residual exotropia and 7 with residual esotropia) in Eye Hospital of Wenzhou Medical University from Jan 2009 to Jan 2011 were studied. Routine strabismus examinations were completed preoperatively. The distance between insertion of horizontal rectus muscles and corneal limbus were measured with ASOCT preoperatively and calipers intraoperatively. Reoperational amount and method for residual strabismus patients were designed according to the limbus-insertion distance. The paired t test was used to compare the agreement between two methods of measurement of limbus-insertion distance. The cure rates of reoperation were analyzed.

No statistical significance was observed between the measurements with ASOCT (7.7±1.7) mm and calipers (7.8±1.1)mm (t=-1.37, P=0.19). According to ASOCT image, the second surgical method was re-recession muscle for 4 patients; re-recession of original performed muscle combined with antagonist muscle resection for 10 patients and antagonist muscle resection combined with horizontal rectus muscle recession in fellow eye for 6 patients. All the surgical processes went on successfully, no severe intraoperative and postopereative complications were noted. Sixteen cases were cured (80%) .

Horizontal rectus muscle evaluation with ASOCT preoperatively may benefit the choice of performed muscle, calculation of surgical amount, reduction of unnecessary surgical procedure and optimization second surgical design for residual strabismus patients. (Chin J Ophthalmol, 2016, 52: 568-573)

To study clinical characteristics and surgical treatment of idiopathic congenital nystagmus (ICN).

A retrospective study was conducted in 224 patients with ICN in Tianjin eye hospital from July 2007 to February 2013.

There were 224 patients, 158 (70.54%) males and 66 (29.5%) females, mean age was (11.6±8.4) years and (11.4±6.4) years separately. Horizontal nystgamus happened in 215 cases, 3 cases were vertical type and 6 cases were mixed. 214 cases were with no history of operation and 10 patients had ever underwent surgeries before. Furthermore, 151 patients combined with strabismus and refractive error, anterior segment or retinal disorders, which accounting for 67.4% of all the patients. 48 patients were associated myopia, 30 patients with hyperopia, 43 patients with strabismus. Among them, 153 cases of compensatory head position direction were horizontal with face turn, 43 cases (43/153, 28.1%) showed face turning to the left, 110 cases (110/153, 71.9%) showed face turning to the right. Surgeries were designed according to the compensatory head position and head retroversion angle. For 15 patients with double intermediate zones, the position which was often used with good visual function was chosen for operation design. As for the patients with nystagmus and strabismus, the transfer null zone to primary position for the dominant eye and strabismus surgery for the other eye was chosen. And for complicated patients with compensative head position, the dominant head posture were designed for surgery.

ICN is dominated by male with variable clinical manifestations. Surgical choice for ICN depends on the direction of head position and if there is strabismus accompanying it.The aim of ocular muscle surgery is to transfer null zone to primary position. (Chin J Ophthalmol, 2016, 52: 574-578)

To investigate the effect and safety of the graduated "hang-back" recession of superior oblique (SO) in treatment of A-pattern strabismus with superior oblique overaction (SOOA).

Retrospective study. The clinical data of 15 cases (28 eyes), who underwent graduated "hang-back" recession of SO depending on the scales of SOOA, were collected and analyzed. The principle we carried on was hang-back recession 8-10mm for SOOA+4, 6 to 8 mm for SOOA+3, 5 to 6 mm for SOOA+2 and 4 mm for SOOA+1. The pre-operative and post-operative outcomes, including the ocular alignment, ocular motility, A-pattern and objective torsion demonstrated by fundus photographs were evaluated and compared.

In 15 cases (28 eyes), 2 cases had unilateral hang-back recession of SO for unilateral SOOA. Thirteen cases had bilaterally symmetric or asymmetric hang-back procedure. All the patients had no A pattern after surgery. The average difference of pre- and post-operative A-patterns were (24.5±11.9) PD and (3.2±4.2) PD in 13 cases with bilateral SOOA (t=8.01, P=0.00). The bilateral SO hang-back procedure could correct A-pattern in an amount of 21.3±10.3 PD in average. The average amount of pre- and post-operative SOOA were +3.0±2.0 and +0.5±1.0 in 28 eyes (Z=-4.70, P=0.00). Only 1 case remained residual SOOA+2.0. Fundus photos were measured by SigmascanPro5.0 program and the average pre- and post-operative torsion were +5.4°±3.9°and +0.3°±5.6° (The baseline was the line across the center of optic disc. The torsional angle was measured between the line across the fovea and and the line across the center of optic.) in 28 eyes (t=5.76, P=0.00). The average corrected torsion was 5.2°±4.8°. The pre-operative SOOA was related with the pre-operative torsion (Spearman correlation coefficient=0.47, P=0.01). The surgical amounts in 28 eyes were various from 4 to 10 mm (8±12 mm in average), which were not related with the corrected torsion (Spearman correlation coefficient=0.17, P=0.39), but related with pre-operative torsion (Spearman correlation coefficient=0.44, P=0.02). The total amounts on both eyes in patients operated by bilateral SO hang-back procedure were also not related with the corrected A-pattern (Spearman correlation coefficient=0.55, P=0.05). No case had secondary SO palsy and V-pattern after surgery.

The graduated "hang-back" recession of SO is optional for treatment of mild to moderate SOOA and A-pattern. It corrected objectively in-torsion without risks of secondary SO palsy and V-pattern. It is a safe and effective SO weakening procedure. ( Chin J Ophthalmol, 2016, 52: 579-583)

To discuss the application of disparity discriminating accuracy test in evaluating the stereopsis of postoperative intermittent exotropia.

Patients with intermittent exotropia who underwent surgery during July 2011 to June 2013 were followed up. The stereoacuity was examined by Titmus Stereotest, Randot Stereotest and Frisby Stereotest. Twenty adult cases whose stereoacuity reached normal were chosen as experimental group. Twenty healthy adults were selected as normal control group. Both groups were examined with disparity discriminating accuracy test. Discriminating accuracy of the two groups were analyzed with Two-Way ANOVA method. Test-retest reliability was analyzed with Intraclass Correlation Coefficient analysis.

The test-retest reliability of disparity discriminating accuracy test is excellent (ICC=0.99, P<0.01) . Discriminating accuracy under different disparities in experimental group were 0.56±0.09, 0.67±0.14, 0.77±0.15, 0.82±0.14, 0.85±0.11, 0.85±0.14, 0.87±0.10, 0.84±0.16, while those in control group were 0.77±0.09, 0.88±0.09, 0.93±0.08, 0.91±0.09, 0.95±0.08, 0.96±0.05, 0.97±0.06, 0.96±0.04. There were statistically significant differences between them (F=38.06, P<0.01) . The discriminating ability of group grating in both groups was affected by the size of disparity. Under situation of small disparity, a large difference was found between the experimental group (0.67±0.12)and control group(0.86±0.07) (F=4.84, P<0.05).

Stereoscopic function can be evaluated comprehensively with disparity discriminating accuracy test. Use this test, a certain degree of dysfunction in stereopsis can still be found in postoperative intermittent exotropic patients who reached normal stereoacuity examined with traditional stereotests. (Chin J Ophthalmol, 2016, 52: 584-588)

To investigate the effect of superior oblique tucking on the Bielschowsky head tilt test.

A retrospective analysis of 22 patients with congenital unilateral superior oblique palsy, who underwent tucking of the superior oblique tendon in Tianjin Eye Hospital, depending on vertical deviation in the primary position, ocular motility, objective cyclotorsion and abnormal head posture. Bielschowsky head tilt test was evaluated quantitatively by the prism cover test. Α positive Bielschowsky head tilt test was defined as one in which the vertical deviation when the head tilt to the side of the paresis was at least 5. 0 ^△ greater than that on tilt to the uninvolved side. The follow-up period ranged from 3 to 12 months (mean 4.6 months). Kolmogorov-Smirnov (K-S), Rank sum test and Spearman correlation analysis statistical methods were used in this study.

All patients had vertical deviation and significant abnormal head posture before operation. After the procedure of superior oblique tucking,vertical deviation and symptom of unacceptable abnormal head posture were ameliorated or disappeared. Objective torsion was 15.62°±7.36° before the surgery, 9.91°±10.09°1d after the surgery and 11.25°±9.17°at the last follow-up visit, respectively (P<0.05). We found that there were positive correlations between the objective cyclotorsion and the vertical deviation difference value between the paralyzed side and uninvolved side at 1 d after the surgery and last follow-up visit(P<0.05). The vertical deviation of the paresised eye when the head tilted to the side of paresis side and uninvolved side difference were 5.00^△-17.00^△, average 8.68^△±3.23^△, 1.00^△-8.00^△,average 3.36^△±2.01^△ and 0.00^△-14.00^△,average 3.77^△±3.01^△, preoperatively, 1d after the surgery and at the last follow-up visit respectively. Using Rank sum test, the pre-and postoperative difference was statistically significant (Z=-4.64, P<0.01). A positive Bielschowsky head tilt test was found in all cases preoperatively. The results of Bielschowsky tilt test was still positive in 5 cases and negative in 17 cases (77.3%).

In most cases with unilateral superior oblique paresis, the results of Bielschowsky tilt test became negative after superior oblique tucking. The long-standing results is worthy of observation. (Chin J Ophthalmol, 2016, 52: 589-595)

To evaluate the reliability and validity of Chinese version of Quality-of-life assessment Questionnaires for Intermittent Exotropia (CIXTQ).

Cross-sectional study. The original English version of the IXTQ was translated into Chinese. The final Chinese version of the IXTQ (CIXTQ) consists of 3 parts: the 12-item child CIXTQ (for children ≥5 and<8 years old and ≥8 and<18 years old, respectively, to assess their health quality of life (HRQoL)), the 12-item proxy CIXTQ (for parents to assess children's HRQoL), and the 17-item parent CIXTQ (containing functional, psychosocial, and surgery subscales; for parents to assess their HRQoL). 175 IXT children and 151 control children along with one of their parents were recruited to answer the CIXTQ. Cronbach's α coefficient and split-half reliability were used to test the internal consistency reliability of the CIXTQ. Kappa coefficient was used to assess the test-retest reliability. Scale-level content validity index/average (S-CVI/Ave) was used to evaluate the content validity of the CIXTQ. Principal component analysis (PCA) was used to verify the construct validity of the parent CIXTQ. Comparison of different CIXTQ scores in IXT patients with controls was conducted by independent-samplest test to evaluate the discriminate validity of the CIXTQ.

For all scales and subscales of the CIXTQ in different age groups, the Cronbach's α ranged from 0.804 to 0.963; the split-half reliability ranged from 0.658 to 0.963 and was higher than 0.7 except for the proxy CIXTQ for children aged ≥5 and<8 years old; the test-retest reliability ranged from 0.569 to 0.944. The S-CVI/Ave of the child, proxy and parent CIXTQ was 0.988, 0.988 and 0.966, respectively. Principal factors identified by PCA for the parent CIXTQ could be regrouped into the originally described 3 subscales which was functional, social psychology and surgery in different age groups. The mean scores of all the scales and subscales among IXT children and their parents (8.0±12.5-81.6 ±15.1) were significantly lower than these among control children and their parents (83.1±11.3-99.6±1.2) (t values range from -50.36 to -6.93, P<0.001).

The CIXTQ are useful tools to evaluate the influence of IXT on HRQoL among Chinese children and their parents. (Chin J Ophthalmol, 2016, 52: 596-603)

To evaluate the effect of long-term contact lens (CL) wear on the morphology of meibomian glands (MGs) using meiboscore and digital analysis.

Retrospective study. Sixty right eyes of sixty patients were involved in this study, and the data were analyzed retrospectively. According to the duration of CL wear, all patients were divided into three groups, nonwear group (n=21), short-term group (duration of CL wear ≤3 years, n=19) and long-term group (duration of CL wear>3 years, n=20). Digital images of MGs obtained by meibography were analyzed using Image J software, providing the area percentage of MGs loss. The meiboscores were also examined, and the data were analyzed using one-way ANOVA and Kruskal-Wallis test.

Ten out of 21 nonwearers were scored 0 point, and 11 were scored 1 point in the upper lid meiboscores, while 7 were scored 0 point, 9 were scored 1 point, and 5 were scored 2 points in the total meiboscores. Seven out of 19 short-term wearers were scored 0 point, 10 were scored 1 point, and 2 were scored 2 points in the upper lid meiboscores, while 5 were scored 0 point, 6 were scored 1 point, 6 were scored 2 points, and 2 were scored 3 points in the total meiboscores. Four out of 20 long-term wearers were scored 0 point, 7 were scored 1 point, and 9 were scored 2 points in the upper lid meiboscores, while 3 were scored 0 point, 4 were scored 1 point, 4 were scored 2 points, 4 were scored 3 points, 4 were scored 4 points, and 1 was scored 5 points in the total meiboscores. The meiboscores of the upper eyelid and total meiboscores among the three groups were significantly different (Hc=9.967, P=0.007; Hc=9.725, P=0.008). The meiboscores of the upper eyelid and total meiboscores were significantly higher in the long-term group compared to the nonwear group (Z=102.500, P=0.003, Z=100.500, P=0.003) and the short-term group (Z=120.500, P=0.050, Z=117.500, P=0.041). No significant difference was found between the short-term group and the nonwear group. The median of the MGs loss area percentage in the upper eyelid of the nonwear, short-term and long-term groups was 9.2%, 13.3% and 16.7%, respectively. The median of the total MGs loss area percentage in the nonwear, short-term and long-term groups were 6.6%, 8.8% and 13.0%, respectively. The above medians were significantly different among the three groups (Hc=6.390, P=0.041; Hc=7.019, P=0.030). They were significantly larger in the long-term wearers than the nonwearers (Z=120.500, P=0.019, Z=120.500, P=0.009). No significant difference was found between the short-term group and the nonwear group, or between the short-term group and the long-term group. No significant differences in the meiboscores or MGs loss area percentage in the lower eyelid were noticed among the three groups. The area under the curve of total area percentage of MGs loss in receiver operating characteristic analysis was 0.981 (P<0.001).

Long-term (more than 3 years) CL wear can cause MGs loss. Digital analysis is helpful in the morphologic evaluation of MGs. (Chin J Ophthalmol, 2016, 52: 604-609)

The patient was a 26-year-old male. He was injured by a beer bottle in his right eye for 6 days, and was admitted to the emergency department of ophthalmology of Wenling Hospital of Wenzhou Medical College on December 6, 2014. To diagnose contusion of the right eye, debridement and suture of the upper lid of the right eye, intramuscular injection of tetanus antitoxin and oral antibiotics were given. First follow-up visit on December 10. Eye examination: the visual acuity of the right eye is 0.1, the correction is not improved, and the visual acuity of the left eye is 1.0. The upper and lower eyelids of the right eye are blue and purple, the upper eyelid wound has been sutured, and the bulbar conjunctiva has thick bleeding; The cornea is transparent, there is no obvious exudation in the anterior chamber, there are a small amount of iris pigment epithelium granules on the temporal iris surface, and the lower iris surface can be seen to curl into a braid-shaped, dark brown iris pigment epithelium, which is adhered to the iris surface, the upper end is attached to the pupil margin, the lower end is free, and the edge is torn (FIG. 1A）； The pupil is round, dilated about 5 mm in diameter, and the direct and indirect light response is slow; No iris light leakage, negative iris light transmission, normal iris color and clear texture; The lens was transparent, the vitreous body was not obviously opaque, the optic nerve head was not edema, the posterior pole retina was edema, and the macular light reflex disappeared. Anterior segment of left eye normal (FIG. 1B）。 IOP: 12 mmHg (1 mmHg =0.133 kPa) in right eye and 13 mmHg in left eye. On the second follow-up visit on the 12th of the same month, the exfoliated iris pigment epithelium layer was curled into a mass and settled deep in the lower anterior chamber angle. UBM showed a central anterior chamber depth of 2.4 mm and normal lens position. The angle of the anterior chamber was wide at 12 o'clock, but slightly narrower at 3 o'clock and 9 o'clock. There was no angular recession and ciliary body detachment. At 12, 3 and 9 o'clock, the iris was thick and shortened, and the ciliary process was loose. At 6 o'clock, the iris was obviously thinner and uneven in thickness, and the pigment epithelium fell into the lower anterior chamber angle. Orbital CT examination revealed fracture of the medial wall of the right orbit. Clinical diagnosis: Iris pigment epithelium injury with partial exfoliation, traumatic mydriasis and retinal contusion in the right eye.

The child was a 5-year-old female. Mainly due to repeated redness, swelling and bulging of the upper lid of the left eye for more than one month, he was admitted to the Institute of Orbital Diseases of Armed Police General Hospital for treatment on December 30, 2013 with "left orbital tumor". In November 2013, the child developed redness, swelling and bulge of the left upper lid. He was treated with antibiotics, and the symptoms were slightly relieved, but they appeared again after stopping the drug. Multiple soft masses paraspinal were identified in December 2013 (Figure 1) and multiple hard nodules in the front of the neck, the local hospital diagnosed "acne tumor", without special treatment, the skin on the surface of the posterior anterior neck nodule spontaneously ruptured (Figure 2）。 In December 2013, the left upper lid was red, swollen and bulged again, and gradually aggravated. Orbital CT examination showed that irregular soft tissue density shadows were seen under the periosteum above the left external orbit, with unclear boundaries, and bone erosion was seen in the roof of the orbit and the lateral wall of the orbit (Figure 3）。 Orbital MRI showed that irregular soft tissue density shadows were visible above the left external orbit, with poor boundary, T₁Medium signal, T₂Moderate to high confounding signal, envelope enhancement, no significant enhancement in content (Figure 4）。 The children had no systemic symptoms such as low afternoon fever, night sweats, fatigue and weight loss. His father and uncle suffered from tuberculosis. Ophthalmological examination showed that the upper lid of the left eye was red and swollen, slightly drooping, and a swelling was raised on the outside and upper side, with unclear boundaries, soft texture, no tenderness, and poor mobility, about 0.3 cm ×0.8 cm in size; The eye position is correct, and the eyeball can move in all directions; Exophthalmos: right eye 14 mm, left eye 18 mm, orbital distance 90 mm; The conjunctiva was slightly edema, but no abnormalities were observed. Chest radiograph showed no obvious abnormalities in heart and lung. Blood Mycobacterium tuberculosis gamma interferon release test showed: IFN-gamma (interferon assay)>200 S/mLYM; A antigen (lymphocyte culture): positive; IFN-γ (interferon assay)>200 S/mLYM; B antigen (lymphocyte culture): positive. On January 2, 2014, a left orbital mass resection was performed under general anesthesia. A yellow-white rare mass was visible under the periosteum of the upper external orbit, which was soft and tender in texture. The bone wall above the external orbit was involved and eroded, and it was insect erosion and uneven (Figure 5）。 Postoperative pathological findings: granulomatous lesions with large necrosis, consistent with tuberculosis characteristics (Figure 6）。 Combined with the systemic manifestations, family history, test results and orbital pathology of the children, the diagnosis: (1) tuberculosis; (2) Tuberculous abscess of left orbit; (3) Paraspinal mass (tuberculosis to be drained); (4) Anterior neck mass (lymphatic tuberculosis to be drained). After 3 months of telephone follow-up, the child was given oral anti-tuberculosis drugs regularly. The redness and swelling of the eyelids subsided, the skin at the front of the neck healed, and the paraspinal mass shrank.

The patient was a 66-year-old female. He was admitted to hospital on December 17, 2014 due to blurred vision in both eyes since childhood, which was aggravated for 1 year. The patient has not been diagnosed and treated with blurred vision since childhood, and has no history of wearing glasses. There was no surgery for ocular trauma and family history, and the parents were not close relatives. Systemic history: A history of hypertension for more than 20 years. The whole body examination showed no abnormalities. Ophthalmic examination: Visual acuity: 0.02 in right eye, anterior index in left eye. Correction does not improve. Transparent cornea in both eyes, moderate anterior chamber depth, atrial flash (-), clear iris texture, iris tremor, obvious subtemporal, round pupil, response to light (+). After mydriasis, the inferior temporal defect of the lens can be seen, the range is left>right, the suspensory ligament is intact and obviously increased, the lens cortex is gray-white and opaque, and the opaque at the defect is more obvious (Figure 1), no obvious opacity in the vitreous body, blurred fundus with leopard-shaped fundus changes, and atrophy of the choroid around the left eye papilla. Non-contact IOP: 18 mmHg (1 mmHg =0.133 kPa) in the right eye and 15 mmHg in the left eye. Auxiliary examination: right eye axis 25.5 mm, left eye axis 27.6 mm. UBM showed that the inferior temporal suspensory ligament was longer than the contralateral, and the lens edge in the defect area was rounded and blunt (Figure 2）。 OCT showed a lamellar macular hole in the left eye. Admission diagnosis: congenital lens defects in both eyes, complicated cataract in both eyes, and lamellar macular hole in the left eye.

The child was a 5-year-old male. On August 28, 2015, he went to the Department of Ophthalmology of Peking Union Medical College Hospital due to decreased visual acuity in his right eye and white deposits behind the cornea. Six months ago, the parents found the above symptoms and went to an external hospital. At that time, the eye examination showed that the visual acuity of the right eye was 0.08, the intraocular pressure was 22.5 mmHg (1 mmHg =0.133 kPa), corneal edema, retrocorneal precipitates (KP) (+ + +), aqueous humor flashes (+), planktonic bodies (+ +), and fundus blurred. Ocular B-ultrasound examination revealed vitreous opacity in the right eye. Aqueous humor cytology in the right eye revealed a large number of thawed tissue cells with unclear structure, a small number of inflammatory exudate cells and 100% neutrophils. Diagnosis: right eye viral uveitis, right eye corneal endotheliitis? Glucocorticoids and antiviral drugs were applied topically and systemically, but the efficacy was poor. Three months ago, he was referred to a superior hospital. On physical examination, the intraocular pressure of the right eye was 50.0 mmHg, and gray-white material deposition appeared in the anterior chamber. He was diagnosed as endophthalmitis of the right eye. Antifungal, antiviral and intraocular pressure lowering treatments were given, but no effect was seen, and visual acuity continued to decline. Retinal detachment of the right eye was found by ocular B-ultrasound 2 months ago. Right eye vitrectomy combined with silicone oil filling was performed in an external hospital, and the pathogenic test of intraocular specimens was negative. Subsequently, the patient went to the Department of Ophthalmology of Peking Union Medical College Hospital. Ocular examination: right eye visual acuity light perception, intraocular pressure T +2, mild protrusion of eyeball, mixed conjunctiva congestion, diffuse corneal edema, KP (+ +), aqueous humor flash (+), obscure plankton, posterior adhesion of part of the iris, anterior adhesion of part of the peripheral iris, and more white nodules on the surface of the iris (Figure 1), the lens is transparent, and the vitreous body and fundus of the eye are not clear. No obvious abnormalities were observed in the anterior segment and fundus of the left eye.

The patient was a 50-year-old male. Due to blurred vision in his right eye for 2 months, he came to Tianjin Eye Hospital in November 2011. Both eyes of the patient underwent phacoemulsification and cataract aspiration with IOL implantation 4 years ago. The operation went smoothly and there were no postoperative complications. High myopia in both eyes, no family genetic history, hypertension, arthritis, and no other systemic or ophthalmic history. Ocular examination: right eye, best corrected visual acuity (BCVA) 0.3, cornea and anterior chamber normal, IOL position normal, uniform milky white liquid opacity between IOL and posterior capsule, no obvious opacity in posterior capsule (FIG. 1A), and no obvious abnormalities were observed in the fundus. A non-contact tonometer (NCT) measured intraocular pressure of 20 mmHg (1 mmHg =0.133 kPa). Left eye, BCVA 1.0, IOL position positive, remaining no abnormalities, intraocular pressure 19 mmHg. B-ultrasound and fundus fluorescence angiography in both eyes showed no abnormalities. The axial length was 28.2 mm in the right eye and 28.1 mm in the left eye. Diagnosis: Liquid posterior cataract in right eye, IOL eyes in both eyes, and high myopia in both eyes. The right eye was given 0.1% flumerone eye drops and diclofenac sodium eye drops 4 times/day for 1 week. After 1 week, there was no remission. After Nd-YAG laser, the capsule was incised in a circular way, and milky white liquid was released into the vitreous body. The above two eye drops were continued for 2 weeks after laser surgery. There were no postoperative complications. One week after the operation, the BCVA of the right eye was 0.9. The white opacity disappeared under the slit lamp microscope, and the anterior capsule lacrimal fibrosis (FIG. 1B), no significant uveal inflammation, NCT 19 mmHg. The refractive status did not change significantly before and after laser treatment.

A 49-year-old female was admitted to the Institute of Orbital Diseases of the General Hospital of the Armed Police on March 18, 2014 due to the discovery of a mass above the right orbit for 2 years. In September 2010, the patient felt that his right eye was red and swollen with eye pain. He went to the local hospital and was given symptomatic treatment with infusion (the specific medication was unknown). After treatment, the patient felt that his right eye pain was relieved. In September 2011, the patient felt that a flat bulge could be palpable above the right orbit and at the root of the medial nose. He went to the local hospital for a CT examination, which was considered to be "internal carotid aneurysm". In October 2011, he underwent embolization of internal carotid aneurysm under general anesthesia, but the postoperative symptoms did not improve. In January 2014, the patient suddenly developed headache without obvious trigger, accompanied by nausea and vomiting, the mass above the right orbit and the medial nasal root was significantly larger than before, and the right eyeball was obviously prominent with external and inferior displacement. He went to the Institute of Orbital Diseases of Armed Police General Hospital. Ophthalmological examination: the naked eye visual acuity of the right eye was 0.3, and the correction did not improve. The right eyelid is swollen and ptotic, covering about 1/2 of the pupil. A tortuous tubular mass can be palpable above the right orbit and at the root of the medial nose, which is soft and pulsatile, and a blowing-like murmur can be smelled, consistent with the pulse. The eyeball is obviously prominent, externally displaced, and externally oblique about 45°. The eyeball can not turn internally past the midline, and the movement in the remaining direction is almost fixed. Exophthalmos: right eye 17 mm, left eye 10 mm, orbital distance 95 mm. The bulbar conjunctival vessels in the upper part of the right eye were tortuous and dilated, the pupil was round and dilated, about 5 mm in diameter, and the direct and indirect light reflection disappeared. No abnormalities were found in the anterior and posterior segments of the remaining eye (Figure 1）。 Fundus examination: The vein was slightly dilated, but no abnormalities were found. Orbital pressure (+ +). Syphilis (+). Color Doppler ultrasound showed tortuous and thickened superior vein of the right eye, with a maximum internal diameter of about 12.8 mm, and CDFI showed venous blood flow spectrum. Orbital CT showed thickening of the right superior vein, thinning of the ipsilateral sphenoid greater wing bone, enlargement of the ipsilateral supraorbital fissure, and widening of the cavernous sinus (Figure 2）。 Orbital MRI showed thickening of the superior vein in the right eye, T₁Medium signal, T₂Moderate and low signal, obvious enhancement, ipsilateral cavernous sinus obvious enhancement, optic nerve obvious compression, medial displacement (Figure 3）。 Admission diagnosis: thickening of the superior vein of the right eye; Right internal carotid cavernous fistula; right supraorbital fissure syndrome; Post-cavernous fistula embolization of the right internal carotid artery.

The patient was a 27-year-old male. She suffered from intermittent blurred vision in her right eye for 3 years with headache, and went to Baoding Yinghua Eye Hospital on December 11, 2014. History of hypertension and epilepsy denied. General physical examination: A large number of densely distributed reddish papules were seen on bilateral cheeks and mandibles (Figure 1), 3 depigmented spots were seen on the skin of both lower limbs (Figure 2）。 Eye examination: naked visual acuity of both eyes 0.8, corrected visual acuity 1.0; No abnormalities were seen in the anterior segment of the eye; Yellow-white nodular lesions were seen in the right fundus immediately above the optic papilla and in the nasal retina, with clear boundaries, slight bulge, and uneven surface, covering part of the retinal blood vessels (FIG. 3A）； The left fundus was roughly normal. Autofluorescence: the right eye lesion showed nodular hyperfluorescence (FIG. 3B）。 OCT examination: the lesion was located between the retinal layers, the nerve fiber layer was thickened, and the retinal tissue in the inner layer of the lesion surface was smooth and undulating; The lesion was a cystic hyporeflex, with a large number of punctate hyperemission around the hyporeflex, which was erosion-like (Figure 4）。 Skull MRI examination was performed in February 2014: patchy long T was seen in the cortex of bilateral frontal lobe, right parietal lobe, right occipital lobe and left temporal lobe₁Long T₂Signal shadow, fluidattenuated inversion recovery (FLAIR) showed high signal; Patchy long T was seen under bilateral frontal cortex₁Long T₂Signal, FLAIR showed high signal; There were no abnormalities in the morphology, size and signal of sulcus, fissure, cistern and ventricle; No obvious enhancement was observed in the lesions of enhanced scan. Cranial magnetic resonance angiography showed no obvious abnormalities. Clinical diagnosis: tuberous sclerosis complex (TSC); retinal astrocytic hamartoma (RAH) of the right eye.

The patient was a 64-year-old female. Due to blurred vision for 3 to 4 months, he went to Tianjin Eye Hospital. History of trauma and systemic medical history are denied. Eye examination: visual acuity was 0.8 for the right eye and 0.03 for the left eye; There was no obvious abnormality in the anterior segment examination of both eyes; For left fundus examination, seeQuintessence Picture 1In A, the ICGA inspection is shown inQuintessence Picture 1Medium B, OCT examination is shown inQuintessence Picture 1Medium C. Clinical diagnosis: Age-related maculopathy type II neovascularization in the left eye.

Craniosynostosis(CS), the premature fusion of cranial sutures leading to an abnormal shape and precocious maturity of skull, is classified into Non-syndromic Craniosynostosis (NSC) and Syndromic Craniosynostoses(SC).NCS only has different abnormality of skull according to which cranial suture is involved while extra malformation of midface and limbs present in SCS. Common SCS contains Crouzon Syndrome, Apert Syndrome, Pfeiffer Sydrome, and etc. The clinical manifestation of CS includes malformation of skull, intracranial hypertension, brain hernia, developmental disorder of cerebral function, strabismus, and etc, while SCS has more complex manifestation. Along with the improvement of multidisciplinary cooperation, the ophthalmic complication of CS, like strabismus, is recognised by oculists gradually. This review is summarizing the clinical manifestation, complicated strabismus, pathogenesis and multidisciplinary cure of CS. (Chin J Ophthalmol, 2016, 52: 626-630)

Corneal epithelium, the outermost layer of eyeball, is the main route for foreign materials to enter the eye. Under physiological conditions, the corneal epithelial superficial cells form a functionally selective permeability barrier. Integral corneal epithelial barrier function not only ensures the enrolling of nutrients which is required for regular metabolism, but also prevents foreign bodies, or disease-causing microorganism invasion. Recently, a large number of clinical and experimental studies have shown that abnormal corneal epithelial barrier function is the pathological basis for many ocular diseases. In addition, some study found that corneal epithelial barrier constitutes a variety of proteins involved in cell proliferation, differentiation, apoptosis, and a series of physiological and pathological processes. This paper reviewed recent studies specifically on the corneal epithelial barrier, highlights of its structure, function and influence factors. (Chin J Ophthalmol, 2016, 52: 631-635)

Behcet's disease (BD) is a systemic vasculitis of unknown etiology. Uveitis, which is common and therapeutically challenging, is the major ocular manifestation of BD. Researches have shown that, in addition to the genetic components (e.g. HLA-B51), environmental factors such as infection also play important roles in the pathogenesis of BD. In recent years, with the advances in bio-detecting technologies, accumulating evidence has shown an association between microbial infections and previously believed non-infectious immune disorders. Specifically, there has been increasing research interest in roles of infection in pathogenesis of BD. A variety of microbes, including streptococcus sanguis, staphylococcus aureus, intestinal flora, herpes simplex virus and etc., have been suggested to be involved. The objective of this article is to review current research progress concerning BD and infection, as well as to provide some recommendations for future investigations into this subject.(Chin J Ophthalmol, 2016, 52: 636-640)