Volume 43 ·  Issue 07 ·  2007

Under the condition of concentrated ophthalmic surgery, any negligence in any link will leave hidden dangers for the occurrence of postoperative cluster infections. Postoperative cluster infections are mainly bacterial infections. Cataract extraction and excimer laser corneal refractive surgery are the most common in these two fields, and domestic ophthalmology should pay great attention to them. Facing the painful lessons of postoperative cluster infections that have already occurred, ophthalmologists need to carefully summarize and be vigilant at any time. As long as all links in the intraoperative and perioperative periods are strictly controlled, postoperative cluster infections can be completely avoided.

Infectious keratitis is one of the common ocular diseases causing blindness in China, and its rapid and definite diagnosis is the key to reasonable treatment and saving vision. For a long time, it is a difficult point for ophthalmologists to first have a definite etiological diagnosis and then give corresponding drug treatment, or apply drug treatment based on experience and then consider etiological diagnosis. The author believes that etiological diagnosis should be paid attention to at the same time as the first anti-infection treatment, so as to improve the diagnosis rate and cure rate of the disease, and also enhance ophthalmologists' awareness of etiological diagnosis of infectious keratitis.

Objective to investigate the different clinical effects of deep lamellar keratoplasty (DLKP) and penetrating keratoplasty (PKP) on keratoconus. Methods A case-control study was designed. The data of 29 patients with keratoconus who underwent DLKP (11 eyes) and PKP (18 eyes) from April 2003 to April 2006 were selected. The preoperative and postoperative uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), graft status, astigmatism status and surgical complications were analyzed. Results BCVA was higher than 0.5 in 9 patients after DLKP and 0.5 in 14 patients after PKP. The mean spherical power (DS) and cylindrical power (DC) were (-1.21 ± 3.36) D in DLKP group and (-4.03 ± 1.87) D in PKP group. The mean DS and DC were (-3.86 ± 2.43) D and (-3.43 ± 2.31) D in PKP group, respectively. There was no statistically significant difference between the two groups (DS: t =2.135, P =0.46; DC: t = -0.643, The morphology of endothelial cells in the affected eyes of DLKP group was basically normal, the mean density of endothelial cells in the affected eyes was (2311.72±439.73) /mm2, and the density of endothelial cells in the opposite eyes was (2477.81±535.92) /mm2, the difference between them was not statistically significant (t =1.06, P =0.78); In PKP group, the area of endothelial cells was larger, the cell size was uneven, and the proportion of non-hexagonal cells was high. The mean density was (1642.17±583.41) cells/mm2, which was significantly lower than that of contralateral eyes (2739.05+401.77) cells/mm2, and the difference between them was statistically significant (Z =7.32, P =0.006). The complications of DLKP group were mainly perforation of posterior elastic layer, suture loosening and interlaminar opacity, etc. The complications of PKP group were mainly suture loosening, intraocular pressure increase, rejection and endothelial failure. Conclusion The refractive status after DLKP is similar to that of PKP. Although the operation is difficult, the probability of postoperative endothelial rejection and endothelial failure is low and the safety is high.

Objective to investigate the characteristics of immune rejection after total keratoplasty with scleral ring and the outcome of anti-rejection therapy. Methods The clinical data of 14 patients who underwent total keratoplasty with scleral ring in our hospital from July 2003 to July 2005 were retrospectively analyzed. The inclusion criteria of patients were: the corneal graft was transparent, the anterior chamber depth was normal, the intraocular pressure and B-ultrasound examination were normal at 1 week after operation, and the clinical symptoms of immune rejection occurred at 1 week after operation. The rejection time, visual acuity changes, symptoms, signs and outcome after treatment of the selected patients were analyzed. Results The first immune rejection occurred at 11~13 days (2 cases), 2 weeks to 1 month (10 cases), 3 months (1 case) and 6 months (1 case) after operation. The patient has symptoms of eye irritation such as photophobia and tearing; Corneoscleral limbus congestion and edema, tortuous and distended blood vessels, even dark red congestion or subconjunctival hemorrhage-like changes; The whole corneal graft was edema, turbid and thickened, the posterior elastic layer was wrinkled, and the anterior chamber became shallow; No epithelial rejection line, endothelial rejection line and retrocorneal deposition (KP) were found. When immune rejection occurred, intraocular pressure decreased significantly in 12 patients,<10 mm Hg. B-ultrasound showed retinochoroidal edema in 5 patients. Within 3 days of onset, 7 patients went to the doctor, and all corneal grafts returned to transparency after anti-rejection therapy. 3~5 days after onset, 3 patients went to the doctor, including 2 corneal grafts returned to transparency, and 1 corneal graft endothelial decompensation. After 7 days of onset, 4 patients went to the doctor, including 1 corneal transparency, 2 corneal graft endothelial decompensation, and 1 ocular atrophy. Conclusion The clinical characteristics of immune rejection after total keratoplasty with scleral ring are: early onset and sudden visual decline; The corneal scleral limbus vessels were tortuous and dilated, and the total corneal graft edema; Prompt treatment and effective anti-rejection therapy will directly affect the prognosis of patients with shallower anterior chamber and lower intraocular pressure.

Objective to investigate the characteristics of rejection after pig-monkey penetrating keratoplasty and the role of glucocorticoid in xenoplasty rejection. Methods Six 3-month-old Wuzhishan mini-pigs (WZS) were used as donors and 12 rhesus monkeys as recipients. The animal model of pig-monkey xenoplasty was established. The recipient monkeys were divided into corneal transplantation group and hormone intervention group, 6 in each group. Corneal transplantation group was injected with the same amount of normal saline at the same time point after operation. The survival of the graft was observed in the two groups. The corneal graft was taken 1 month after operation for histopathological examination. The concentrations of cytokines IFN, TNF, IL-4, IL-5 and IL-10 in plasma and aqueous humor of monkeys were detected by flow protein analysis system. The changes of immunoglobulin IgG, IgA, IgM and complement C3 and C4 in peripheral blood of monkeys were detected by immunoturbidimetry. The changes of CD4+, CD8+ and CD16+ T lymphocytes in whole blood of recipients before and after operation were analyzed by flow cytometry. Results The mean survival time of graft in pig-monkey penetrating keratoplasty group was (15.5±2.3) d; In the hormone intervention group, the graft was (182.8±66.1) d. In the corneal transplantation group, exudative membrane formed in the anterior chamber after the graft operation, and the corneal graft edema was obvious, and the graft neovascularization grew into the graft. However, in the hormone intervention group, the graft remained transparent during the administration period, with only slight graft edema reaction. In the group of hormone intervention, a small amount of lymphocytes infiltrated the graft, the endothelium was intact and there was no exudative membrane, and the concentrations of various cytokines in the aqueous humor of the recipient monkeys in the group of corneal transplantation increased significantly at the third week after operation, especially IFN; The changes of cytokines in aqueous humor were mainly increased in IL-10 and IL-4 concentrations, but decreased in IFN and TNF concentrations in the hormone intervention group. The systemic humoral immunity and cellular immunity indicators of the two groups showed that the concentrations of immunoglobulin IgG, IgA, IgM and complement C3 and C4 increased in the 2nd to 3rd week after corneal transplantation group, while the concentrations of IgG and complement C4 decreased in the hormone intervention group. Conclusion the main manifestation after pig-monkey xenokeratoplasty is corneal endothelial rejection, systemic humoral immunity may be involved in the rejection, and the local application of glucocorticoid can significantly prolong the survival time of graft.

Objective to investigate the biocompatibility of polyhydroxyethyl methyl acrylate (PHEMA) sponge scaffold material with corneal tissue, and to evaluate the preliminary clinical effect of modified PHEMA-polymethyl methacrylate (PMMA) integrated corneal prosthesis implanted into rabbit and monkey corneas. Methods The modified integrated corneal prosthesis was synthesized by two-stage chemical polymerization combined with lathe mechanical cutting. The experiment was divided into two parts. Part 1 (Group A): PHEMA sponge skirt material was implanted into the corneal lamella of 10 normal rabbits, and histopathological, immunohistochemical and electron microscopic examinations were performed at 2, 4 weeks and 2, 3 and 4 months after operation, respectively, to observe the biological healing of sponge skirt and corneal tissue. Part 2 (Group B): 8 rabbit eyes and 2 monkey eyes were implanted with integrated corneal prosthesis in stage I. The healing of material and tissue was observed clinically after operation; Results (1) Group A: 10 rabbits had no complications during the follow-up period. Histopathology showed that fibroblasts grew in 2 weeks after implantation of PHEMA sponge skirt material, and a large number of fibroblasts grew in 2~3 months after implantation with neovascular growth; Immunohistochemistry showed that the cells grown in the sponge pores and corneal stromal cells were positive for vimentin immunoreaction; Under electron microscope, fibroblasts grow in the spaces of sponge material, and the cells grow well, and secrete collagen and extracellular matrix. (2) Group B: 6 rabbit eyes have integrated artificial cornea in place, and the other 2 rabbit eyes have anterior lamellar corneal matrix melt after stage I surgery, and 2 monkey eyes have no obvious complications after stage I and stage II surgery. Conclusion PHEMA sponge can heal well with corneal tissue; The modified PHEMA-PMMA integrated artificial cornea implantation can obtain a relatively stable therapeutic effect after operation.

Objective to investigate the effect of small molecule compound J2 on inhibiting rejection of corneal transplantation in mice. Methods 23 C57BL/6 mice were used as donors and 76 BALB/C mice were used as recipients to establish a corneal transplantation model. The experimental model was divided into groups A, B, C and D by random number method. Group A received autologous orthotopic keratopic transplantation of BALB/C mice, and group B, C and D received interallogeneic keratopic transplantation of C57BL/6-BALB/C mice. The survival time and survival rate of corneal grafts were compared by intragastric administration for 12 days, and the peripheral blood mononuclear cells were examined by flow cytology and histological examination of corneal grafts were performed on 21 days after operation. Results the corneal grafts in group A did not reject during the observation period. The mean survival time of corneal grafts in group B was (17.8±2.1) d, and that in group C was (38.1±9.9) d Compared with group C, there was no significant difference (P =0.99). Flow cytology examination showed that CD4+ cells and CD8+ cells in peripheral blood of mice treated with J2 did not proliferate, and histological examination confirmed that there was no obvious lymphocyte infiltration in corneal grafts in group D on 21 days after operation. Conclusion Small molecule compound J2 can inhibit the occurrence of rejection and prolong the survival time of corneal grafts in mice.

Objective to investigate the clinical manifestations and pathological changes of non-tuberculous mycobacterial (NTM) keratitis in rabbits at different stages. Methods 48 rabbits (48 eyes) were randomly divided into 3 groups: subcorneal NTM infection group (UFI group), subcorneal NTM infection group (UFIC group) and corneal surface NTM infection group (SI group). The corneal stromal infiltration was observed, and the corneal lesion bacteria quantitative culture, histopathology and immunohistochemical examination were performed at 5, 7, 14 and 21 days after operation. Results the corneal tissue reactive edema was observed at 5 days after infection in rabbits with NTM keratitis; From 7 to 14 days, the superficial stromal layer of the cornea showed multifocal spots, flaky gray and dense infiltration; There were significant differences in corneal stromal infiltration area between the three groups at 5, 7, 14 and 21 days after operation (F =19.224, P<0.05). The corneal infiltration area in UFIC group was greater than that in UFI group and SI group, and the differences were statistically significant (F =9.362, 8.341; all P<0.05). The quantitative culture of corneal bacteria showed that the number of bacteria in UFIC group was higher than that in UFI group and SI group, and the differences between the three groups were statistically significant (F =411.272, P<0.05). Pathological observation showed that a large number of neutrophils infiltrated the corneal stromal layer at 5 days after infection, focal infiltration of corneal lymphocytes at 7-14 days, and obvious proliferation of corneal fibroblasts and neovascularization at 21 days after infection. The difference of CD4+ cell counts in the corneal tissues of the three groups was statistically significant (F =21.907, 196.521, 12.552, 11.100; all P<0.01), and the difference of CD8+ cell counts was statistically significant at 7 and 14 days after infection (F =171.115, 77.017; all P<0.01). Conclusion Multifocal corneal stromal infiltration and patchy gray dense infiltration were the clinical features of NTM keratitis.

Objective to investigate the changes of extracellular matrix of medial rectus muscle fibers in patients with common exotropia and its relationship with intermittent exotropia and constant exotropia in common exotropia.Methods 31 patients with common exotropia (17 intermittent exotropia, 14 constant exotropia, 7 with positive family history) were treated with medial rectus muscle shortening, and the anterior medial rectus muscle was resected during operation as the patient group; The contents of proteoglycan and fibronectin in medial rectus muscle were measured by quantitative enzyme-linked immunosorbent assay (QELISA) in 21 normal subjects respectively. The differences between patients and control groups, patients with intermittent exotropia and constant exotropia, patients of different genders and patients with different family history were compared. The changes of proteoglycan and fibronectin contents among patients of different ages were analyzed. Results The contents of fibronectin in medial rectus muscle in patients group (23.56 μ g/g) were significantly lower than those in control group (444.59 μ g/g), the difference was statistically significant (P<0.01), but the contents of proteoglycan were not statistically significant (P>0.05). The contents of fibronectin in intermittent exotropia patients (103.88 μ g/g) were significantly higher than those in constant exotropia patients (11.2 μ g/g), the difference was statistically significant (P<0.01), but the contents of proteoglycan were not statistically significant (P>0.05). The contents of proteoglycan in medial rectus muscle increased with age The contents of proteoglycan and fibronectin were not related to the gender and family history of patients (P>0.05). Conclusion the changes of fibronectin content of medial rectus muscle in patients with common exotropia may be related to the development of common exotropia and intermittent exotropia to constant exotropia.

Objective to investigate the effect of anterior retinal condensation on the content of vascular endothelial growth factor (VEGF) in the aqueous humor of patients with neovascular glaucoma and the relationship between the changes of VEGF content and iris neovascularization. Methods 28 patients with neovascular glaucoma were treated with iris angiography to determine the extent and number of neovascularization, and then anterior retinal condensation was performed. After 7~14 days, it was determined that most of the iris neovascularization was resolved by iris angiography, and then trabeculectomy was performed. Aqueous humor samples were collected before anterior retinal condensation and before trabeculectomy, and the aqueous humor samples of 30 senile cataract patients were taken respectively. The content of VEGF in all aqueous humor samples was determined by enzyme-linked immunosorbent assay, respectively. Results The content of VEGF in the aqueous humor before trabeculectomy was significantly lower [(2.096±0.512) ng/ml] than that before anterior retinal condensation [(0.478 ±0.312) ng/ml], and the difference between them was statistically significant (P<0.01). Conclusion VEGF may play a certain role in the formation of iris neovascularization; Blocking the source of VEGF, which promotes neovascularization in the iris, can inhibit the occurrence of neovascular glaucoma.

Objective to investigate the prevalence of macular edema in patients with diabetic retinopathy in the community.Methods 100 patients (151 eyes) with type 2 diabetes mellitus over 15 years old were examined by direct ophthalmoscopy, fundus photography, ultrasound and coherence optical tomography (OCT), and the results of the examination were statistically analyzed.Results Among 795 participants, 215 patients with diabetic retinopathy were found, and 100 diabetic patients were randomly selected. 151 eyes had diabetic retinopathy, and the mean thickness of macular fovea was 195.7 μ m; There were 46 eyes with macular thickening, including 35 eyes (76.1%) with macular cavernous swelling, 8 eyes (17.4%) with macular cystoid edema, and 3 eyes (6.5%) with neuroepithelial detachment. There was a correlation between the foveal thickness and the negative logarithm of the best corrected visual acuity (r =0.2869, P =0.0004). The prevalence of macular edema in patients with different degrees of diabetic retinopathy was different (P =0.0003). The correlation between the occurrence of diabetic macular edema and retrovitreous detachment was not statistically significant (P =0.472). Conclusion The prevalence of macular edema in patients with diabetic retinopathy in the community was 37.1%. The OCT images of the affected eyes were classified into three types: retinal cavernous swelling, macular cystoid edema and neuroepithelial detachment. The more serious the diabetic retinopathy, the more likely the occurrence of macular edema.

Objective to investigate the surgical indications, timing and efficacy of ganciclovir intravitreal injection in the treatment of acute retinal necrosis (ARN). Methods Fourteen patients (14 eyes) with ARN met the diagnostic criteria of ARN of the American Uveitis Society.The initial visual acuity of the patients was light perception, anterior manual movement and numeration of fingers in 1 eye, 0.08-0.1 in 4 eyes, 0.2-0.4 in 5 eyes, 0.5 and 0.8 in 1 eye.Retrocorneal deposition and aqueous humor flash were all positive, and the fundus showed focal and/or flaky retinal necrosis in the periphery, retinal artery white line, retinal hemorrhage, etc. Acyclovir or ganciclovir were administered intravenously, respectively, and the patients' condition continued to progress and deteriorate, but retinal detachment did not appear.Furthermore, ganciclovir intravitreal injection was performed in 14 eyes.After injection, the disease could not be controlled in 2 eyes, and proliferative vitreoretinopathy (PVR) and retinal detachment appeared, and vitrectomy was performed. The patients were followed up for 4 to 74 months. Results After vitreous injection of ganciclovir, the visual acuity of 12 eyes was significantly improved, which increased to 1.0~1.5 in 5 eyes, 0.5~0.9 in 5 eyes, and 0.3 in 2 eyes. The visual acuity of 2 eyes after vitrectomy was also improved compared with that before the operation, from anterior fingers to 0.4, and the photosensitivity to anterior fingers respectively. The inflammatory reaction of anterior segment and vitreous opacity disappeared or significantly reduced in 14 eyes, the yellow-white retinal lesion disappeared, the hemorrhage was absorbed, and the retina was in place. Conclusion For patients with ARN whose disease cannot be controlled by systemic antiviral therapy, when PVR or retinal detachment has not occurred, early injection of ganciclovir into vitreous body can obtain satisfactory curative effect and significantly improve the visual acuity of patients.

A 36-year-old female complained that she accidentally splashed 502 glue (α-ethyl cyanoacrylate) into her right eye, and felt tingling, photophobia and tearing in her right eye.

According to the latest edition of Xinhua Dictionary and Modern Chinese Dictionary, the use specifications of the words "sticky" and "sticky" are as follows: when pronouncing "nian", the word "sticky" is always used, such as mucosa, mucus, slime mold, adhesive, etc.; When pronouncing "zhan", use the word "sticky", such as intestinal adhesion, paste, etc. Regarding the use of the words "Wei" and "Wei", both words mean only and only, but when used in words such as only, only, only, fear, obedience to orders and profit-seeking, the word "Wei" is always used; When used in words such as materialism, idealism, rationalism, nominalism, etc., use the word "only".

With the extensive development of excimer laser refractive corneal surgery in clinical practice, ophthalmologists should not only further master how to evaluate its clinical effect, but also pay more attention to studying its basic theory; We should not only understand the innovative surgical methods, but also pay more attention to improving the safety of surgery and avoiding surgical risks. Therefore, the Ministry of Continuing Education of Chinese Medical Association will hold the 5th Academic Symposium on Excimer Laser Refractive Keratoplasty of Chinese Medical Association and the Excimer Laser Refractive Keratoplasty Certificate Renewal and Assessment Class in Chengdu, Sichuan Province in late October 2007 (the specific notice on renewal and assessment shall be subject to the notice of local medical associations).

During lacrimal canaliculus anastomosis, finding the medial broken end of the lacrimal canaliculus is the key to successful operation [1-3]. Injecting sodium hyaluronate into the lacrimal duct during operation to make it overflow from the medial broken end of the lacrimal canaliculus can shorten the finding time, reduce tissue damage, and improve the efficiency and success rate of operation.

The patient was a 40-year-old male who came to our hospital on August 11, 2006 due to photophobia, tearing, pain in his left eye and visual acuity decrease for more than 1 month. 40 days ago, his left eye had been stabbed by a steel wire, and was treated in a local hospital. The specific situation was unknown, but his condition did not improve significantly. No abnormalities were found in the whole body examination.

The patient was an 80-year-old male who came to our hospital on February 13, 2007 due to the gradual decline of visual acuity in his left eye accompanied by pain and foreign body sensation for half a year.The patient underwent binocular phacoemulsification and cataract aspiration and intraocular lens implantation in another hospital two years ago. Intraocular pressure normal; The corneal endothelial cell count was 1874/mm2 in the right eye and less than 400/mm2 in the left eye. The cornea of the left eye was opaque (extract picture 1); The anterior chamber of both eyes is clear, the pupil is round, and the intraocular lens is in the right position.

When modern imaging technology has gradually become an important means of diagnosis and follow-up of glaucoma, the specificity of visual function detection in glaucoma patients has been significantly improved by using short wavelength perimetry and frequency doubling perimetry.

X-type questions belong to multiple choice questions. Each question consists of a stem and 5 alternative answers A, B, C, D and E. There are 2~4 correct answers, and only all correct answers can be scored. Therefore, this question type has certain difficulty for candidates, and is widely used in basic and clinical examinations.