Volume 53 · Issue 08 · 2017

This issue focuses on the clinical and basic research of ocular tumor orbital disease. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Fan Xianqun, Department of Ophthalmology, Ninth People's Hospital affiliated to Shanghai Jiaotong University School of Medicine.

Retinoblastoma (RB) is the most common intraocular malignancy in childhood. It may seriously affect vision, and even threaten the life. The early diagnosis rate of RB in China remains low, and the majority of patients are at late phase with high rates of enucleation and mortality. The International Intraocular Retinoblastoma Classification and TNM staging system are guidances for therapeutic choices and bases for prognosis evaluation. Based on the sequential multi-method treatment modality, chemotherapy combined with local therapy is the mainstream in dealing with RB, which may maximize the results of eye saving and even vision retaining. New therapeutic techniques including supra-selective ophthalmic artery interventional chemotherapy and intravitreal chemotherapy can further improve the efficacy of treatment, especially the eye salvage rate. The overall level of RB treatment should be improved by promoting the international staging, new therapeutic techniques, and the sequential multiple modality treatment. (Chin J Ophthalmol, 2017, 53: 561-565)

Intravenous chemotherapy and intra-arterial chemotherapy (IAC) both are the first-line treatment for retinoblastoma (RB) in clinical. There is a controversy on if intra-arterial chemotherapy can substitute the intravenous chemotherapy due to its high eye salvage rate in retinoblastoma therapy. The advantages and disadvantages of these two therapies were retrospectively reviewed here to suggest an individualized and comprehensive regimen for getting the proximal results for retinoblastoma afflicted children. (Chin J Ophthalmol, 2017, 53: 566-569)

To evaluate the efficacy and safety of intravitreal chemotherapy for refractory vitreous seeding from retinoblastoma.

Retrospective series of case studies. Nine patients (13 eyes) with the diagnosis of refractory vitreous seeding were enrolled in Department of Ophthalmology of Eye& ENT Hospital of Fudan University from March 2014 to October 2015.There were 6 males and 3 females. Children aged 8 to 40 months, median age of 18 months. In the 13 eyes, 3 eyes were E period, 9 eyes were D period, and 1 eyes were C period. The fundus was examined by indirect ophthalmoscope and recorded by RetcamIII. Systemic chemotherapy was performed using the VEC protocol, that is vincristine, etoposide, and carboplatin. Local treatment also involves cryotherapy and/or thermotherapy. All patients were treated with intravitreal injection of melphalan. They underwent intravitreal melphalan, once every 4 weeks, with an average of 3 times of injections. The treatment dose of melphalan is 20 to 40 μg per dose. Observe the vitreous seed control and complications of therapy.

Vitreous seeds control was attained in all cases. There was no case of orbital extension or remote metastasis. Complications included retinal pigment epithelial and choroidal atrophy in 7 eyes, pupillary synechia and iris atrophy in 2 eyes,retinal vasculitis and vascular occlusion in 2 eyes, optic atrophy in 2 eyes, vitreous hemorrhage in 1 eye, and temporary hypotony in 3 eyes.

Intravitreal melphalan is an effective treatment for refractory vitreous seeding from retinoblastoma. High dose may lead to local adverse reactions. (Chin J Ophthalmol, 2017, 53: 570-574)

To assess the risk factors associated with decreased quality-of-life in patients with thyroid-associated ophthalmopathy (TAO).

Cross-sectional study. One hundred and twelve patients with TAO and 68 controls were recruited to answer the Graves' ophthalmopathy quality-of-life questionnaire (GO-QOL) from January 2014 to April 2016. The GO-QOL included two subscales: the visual functioning and the psychosocial consequences. The differences in the GO-QOL scores between TAO patients and controls were analyzed. The influences of multiple factors on the GO-QOL scores among TAO patients were explored.

Among 112 TAO patients, 63 were male and 49 were female, with an average age of (45.4±13.1) years. Among 68 controls, 36 were male and 32 were female, with an average age of (39.5±10.8) years. Independent sample t test showed that TAO patients had significantly lower scores than controls in the visual functioning subscale and the psychosocial consequences subscale (55.63±29.02 vs 97.48±6.96, t=-14.58, P<0.01; 57.61±29.97 vs100±0.00, t=-14.97, P<0.01). Among TAO patients, smokers were associated with significantly lower psychological subscale scores than non-smokers (t=-2.284, P=0.024). Patients with abnormal primary position of eye scored significantly lower than those with normal alignment in functional (t=-3.979, P<0.001) and psychological subscales (t=-2.154, P=0.034) Patients with abnormal eye movement had significantly lower functional scores than those without (t=-2.975, P=0.004). One-way analysis of variance showed that higher CAS scores were significantly related to lower psychological subscale scores (F=3.178, P=0.018). Patients with upper eyelid retraction had significantly lower psychological subscale scores than those without (F=3.562, P=0.032). Pearson correlation analysis showed that age was negatively correlated with functional subscale scores (r=-0.366; P<0.01). TAO course was negatively correlated with functional (r=-0.235, P<0.05) and psychological subscale scores (r=-0.320, P<0.01). The degree of exophthalmos was negatively correlated with psychological subscale scores (r=-0.209, P<0.01). Multivariable linear regression analysis showed that only primary position of eye (P=0.013) and TAO course (P=0.007) were negatively correlated with functional subscale scores and only CAS scores (P=0.022) and TAO course (P=0.024) were negatively correlated with psychological subscale scores.

Risk factors associated with lower quality-of-life among TAO patients included abnormal primary position of eye, higher CAS scores, and longer TAO course.(Chin J Ophthalmol,2017,53: 575-582)

To describe the clinicopathologic characteristics of 422 conjunctival melanocytic nevi and detect the incidence of malignancy in those patients.

Retrospective case series study. A retrospective study was conducted by reviewing 422 conjunctival melanocytic nevi specimens obtained at Beijing Tongren Eye Center from June, 2004 to May, 2016. The data included the information of gender, age, clinical and histopathological diagnosis of all collected conjunctival melanocytic nevi cases. All patients were divided into three groups according to age: juvenile groups (<18 years old), young group (18-40 years old) and the elderly group (>40 years old). The histopathology change and its malignant incidence of conjunctival nevi in different age and sex were analyzed by SPSS 18.0 software package.

Of the 422 cases, 195 were males and 227 were females (male∶female=0.89∶1). The average age at surgery was (27.9±17.9) years old. The pathological types of conjunctival nevi included compound nevus, intraepithelial nevus and junctional nevus. The most common type of conjunctival nevus was compound nevus (256 cases, 60.7%; mean age (22.2±15.4) years old). The second was intraepithelial nevus (130 cases, 30.8%; mean age (37.7±16.6) years old). The least was junctional nevus (36 cases, 8.5%, mean age was (32.7±22.4) years old).The average age of patients with different types of conjunctival nevi was statistically significant (F=3.169, P=0.031). Occurrence of conjunctival compound nevus was most common in juvenile group (44.1%), followed by the young group (40.6%), and the elderly group (only 15.2%). Occurrence of conjunctival intraepithelial nevus was the most common in youth group (45.4%), followed by the elderly group (44.6%), and youth group was relatively rare (only 10%). The junctional nevus appeared mainly in elderly group (44.4%), but the junior group also had 13 cases (36.1%) and younger group had 7 cases (19.4%). Among 422 cases of conjunctival nevi, 37 cases transformed into malignant tumor. The canceration rate was 8.8%. The average age of malignant patients was (48.6±12.1) years old. Comparing with the patients without malignant, the age was age (25.3±4.2) years old and there was a significant difference (t=4.252, P=0.002). Among them, 24 cases (64.9%) came from conjunctival compound nevus and 13 cases (35.1%) came from the junctional nevus. Non malignant cases occurred in patients with conjunctival intradermal nevus. The male and female average age of patients with malignant transformation from compound nevus and junctional nevus were not statistically significant (P=0.730, 0.993). Thirteen cases were occurred malignant change in 36 cases of patients with junctional nevus, accounting for 36.1% of all patients with junctional nevus. It was obviously higher than the average malignant incidence of conjunctival nevi (8.8%). Non malignant junctional nevus were most common in juvenile group, and malignant junctional nevus were most common in the elderly group.

The pathological type distribution of conjunctival melanocytic nevi in different age groups was different, and the onset age of different types of melanocytic nevi was also different. Patients with junctional nevus were prone to malignant change, and most of them were middle-aged and elderly patients. (Chin J Ophthalmol, 2017, 53: 583-587)

To discuss the etiology, clinical features and treatment principles of the orbital and periorbital abscess.

A retrospective case series of 17 cases with orbital and periorbital abscess between July 2010 and November 2015 were conducted. All patients^, clinical data including medical history, etiology, abscess location, paranasal sinus involvement, eye involvement, microbiological test results, imaging features, treatment and prognosis were summarized and analyzed.

In all 17 patients, there were 10 males and 7 females with age from 3.0 to 71.0 years (the average age was 33.9 years).Eight patients^, bacterial cultures of the pus and secretion were positive in all 17 patients. Orbital and periorbital abscess patients could manifest decreased vision, redness and swelling of eyelid, conjunctival congestion and edema, ocular motility disorders, displacement of eyeball, increased orbital pressure, abscess rupture etc. CT showed us the soft tissue mass, accompanied with sinusitis or paranasal sinus mass. MR performed with the long T₁ and T₂ signals. The signals of the abscess cavity were not uniform. For the etiology,11 cases were secondary to sinusitis, including 1 case of diabetes; 2 cases with orbital fractures.One case was secondary to orbital fracture repairment surgery. One case was secondary to the remnant of sequestrum and foreign bodys in the wound after repairment surgery. One case was injured by the hard object. One case was secondary to paranasal sinuses large B-cell lymphoma. One case had diabetic history and the blood sugar was controlled unstablly. For the treatment, 7 cases were treated by the drainage surgery which was performed via the sinus with endoscopic and abscess resection performed via the skin.Two cases were treatment by the abscess resection only.One case was treated by the drainage surgery performed via the sinus with endoscopic only. Six cases were treated by the drainage surgery performed via the skin. One case was only administered intravenous antibiotic. Sixteen cases acquired well prognosis without serious complications except 1 case which occurred central retinal artery and vein occlusion.

The orbital and periorbital abscess is mainly a complication of paranasal sinus infection, or secondary to trauma, surgery, tumor, etc; Orbital and periorbital abscess always manifest inflammatory neoplastic clinical features, the key of the diagnosis is to make sure the etiology; Incision and drainage of the abscess is the main treatment method when necessary. We can do the surgery with other departments to avoid the occurrence of serious complications.(Chin J Ophthalmol, 2017, 53: 588-593)

To investigate the risk factors, clinical manifestations, and treatment of visual loss caused by cosmetic fillers injection.

It was a retrospetive case series study. Collect the clinical data of 18 cases (18 eyes) which were diagnosed as visual loss caused by facial cosmetic fillers injection in the Second Hospital of Dalian Medical University during December, 2014 to June, 2016. Summarize the general condition, medical history, clinical examination results (including visual acuity, intraocular pressure, fundus condition, etc.) and the patient's facial appearance at the time of admission. Take the examinations such as VEP, FFA, OCT, etc. Confirm the composition of the fillers according to the medical history and the product packaging. After the diagnosis, all patients were treated generally combined with intraocular pressure reduction treatment and other treatment measures.

All the patients were female, 24—45 years old, with average age of 33.4. The fillers were mainly consisted of hyaluronic acid or autologous fat. For 6 patients the fillers were injected in the forehead, 8 patients were in the nose, the other 4 patients were in both sites. The mean time was 31.7 hours since the onset to the acceptance of medical treatment. All the patients manifested as no light perception, injection site ischemia, different degree of ptosis and fundus examination showed artery occlusion signs. Seventeen patients were central retinal artery occlusion, one was posterior ciliary artery occlusion. After active treatment, 2 patients' visual acuity improved to light perception, one improved to hand movements, while the others had no significant improvement.

Most patients who suffered visual loss after cosmetic injections are young or middle-aged women, with most common injection sites at nose or forehead. The visual loss is mainly caused by central retinal artery occlusion which leads to an ineffective clinical treatment. The main factors that may induce artery occlusion are: injection done by informal medical organization, use of non-standard drugs, inadequate understanding of facial anatomy of the operator, and improper injection methods.(Chin J Ophthalmol, 2017, 53: 594-598)

To observe the clinical effect of long term visual quality after the implantation of the aspheric diffractive multifocal intraocular lens.

This was a retrospective cohort study.One hundred and thirty cases of age-related cataract (170 eyes) after phacoemulsification cataract extraction combined with IOL implantation were collected from September of 2009 to January of 2011 in the First Affiliated Hospital of Zhengzhou University.There were 42 patients (57 eyes) with aspheric multifocal group, 43 patients (57 eyes) in the aspheric group and 45 patients (56 eyes) in the spherical group according to the different types of IOL implanted.At 1 year, 3 years and 5 years after operation, the following parameters were assessed: uncorrected and best corrected distance, medium and near vision acuity, contrast sensitivity, wavefront aberrations, modulation transfer functions (MTF), stereopsis, visual function and quality of life (VF/QOL) questionnaire survey.

At 1 year, 3 years and 5 years after operation, the uncorrected medium visual acuity in aspheric diffractive multifocal IOL group(0.30(0.10, 0.50), 0.30(0.10, 1.00), 0.30(0.10, 0.50)) was better than that of eyes in aspheric IOL group(0.40 (0.10, 0.0), 0.40 (0.20, 1.00), 0.40 (0.20, 0.50)) (Z₁=-3.32,-1.73,-3.01, P₁=0.00, 0.01, 0.00) and spherical IOL group (0.40(0.30, 1.00), 0.40(0.20, 1.00), 0.40(0.20, 1.00)) (Z₂=-5.77,-3.19,-4.49, P₂=0.00, 0.00, 0.00).And the near vision in aspheric diffractive multifocal IOL group(0.25(0.00, 1.00), 0.30(0.00, 1.00), 0.30(0.00, 1.00)) was also obviously better than that of eyes in aspheric IOL group (0.50(0.18, 1.00), 0.50(0.18, 1.00), 0.50(0.18, 1.00)) (Z₁=-5.57,-5.37,-4.93, P₁=0.00, 0.00, 0.00) and spherical IOL group(0.60(0.18, 1.00), 0.60(0.18, 1.00), 0.60(0.18, 1.00)) (Z₂=-7.00,-6.91,-6.53, P₂=0.00, 0.00, 0.00). At 5 years after operation, the mean higher-order aberration for 3.0mm and 5.0mm optical zone in aspheric diffractive multifocal IOL group (0.21(0.03, 0.46), 0.37(0.12, 2.01)) were significantly lower than that in spherical IOL group (0.43(0.10, 1.91), 0.46 (0.10, 1.91) ) (Z₂=-4.81,-1.97, P₂=0.00, 0.01).But there was no statistical difference between the aspheric diffractive multifocal and aspheric IOL group (0.21(0.03, 1.17), 0.34(0.06, 1.74)) (Z₁=-0.10,-1.81, P₁=0.92, 0.07).The mean spherical aberration for 3.0mm and 5.0mm optical zone in aspheric diffractive multifocal IOL group (0.01(-0.01, 0.20), 0.03(-0.10, 0.20)) were significantly lower than that in spherical IOL group (0.29(0.10, 0.99), 0.32(0.10, 0.99)) (Z₂=-8.48,-8.54, P₂=0.00, 0.01).But there was no statistical differences between the aspheric diffractive multifocal and aspheric IOL group (0.02(-0.09, 0.37), 0.04(-0.09, 0.37)) (Z₁=-0.60,-0.73, P₁=0.55, 0.46).About 86% of patients in aspheric diffractive multifocal IOL group do not need to wear glasses, it was better than the other two groups (χ²=17.83, 24.45, P=0.00, 0.00).The incidence of night glare and halo in aspheric diffractive multifocal IOL group 16/50(32%) was higher than that of aspherical IOL group 5/50(10%) and spherical IOL group 3/50(6%), and the difference was statistically significant (χ²=7.29, 10.98, P=0.00, 0.00).The overall satisfaction in aspheric diffractive multifocal IOL group was 45/50 (90%), better than that of aspherical IOL group 29/50(58%) and spherical IOL group 20/50(40%), and the difference was statistically significant (χ²=13.31, 27.47, P=0.00, 0.00).

The aspheric diffractive multifocal IOL can provide patients with good and stable far, medium and near vision, to meet the needs of patients without glasses.At the same time, it can effectively reduce the high order aberrations and spherical aberration, improve visual quality.But due to night glare and glow, it does not apply to professional drivers and nighttime drivers. (Chin J Ophthalmol, 2017, 53: 599-609)

To analysis of the change of the constitution of the admitted patients with glaucoma in Capital Medical University affiliated Beijing Tongren Hospital between 2003—2005(group 2003) and 2013—2015(group 2013).

The medical charts information of inpatient with glaucoma were collected by ICD-10 of the disease diagnosis. Statistical analysis was conducted for the change of the proportion of types, gender and age. The age difference between two groups was analyzed by rank sum test and the difference of different types of glaucoma was analyzed by chi square test.

Totally, 8 160 inpatients cases were included. There were 2 878 cases in the group of 2003 and 5 282 cases in the group of 2013. Between two groups, there was no statistical difference in age. The ratio of male patients decreased from 55.8% (1 607/2 878) to 51.7%(2 732/5 282) (χ²=23.73, P<0.05).Primary angle-closure glaucoma(PACG) was the main type (2 987/8 160, 36.6%) followed by secondary glaucoma (SG, 2 172/8 160, 26.6%). PACG reduced from 40.0% (1 151/2 878) to 34.8%(1 836/5 282) (χ²=21.99, P<0.01). Congenital glaucoma(CG) increased from 4.6%(132/2 878) to 8.3%(437/5 282)(χ²=39.04, P<0.01). Glaucoma related with trauma reduced from 27.2%(208/764) to 18.2%(256/1 408)(χ²=24.11, P<0.01). Glaucoma with syndrome increased from 3.8%(29/764) to 7.2%(102/1 408)(χ²=10.39, P<0.01).

The constitution of the admitted patients with glaucoma in our hospital changed during the ten years. PACG was still the major type of inpatient glaucoma.(Chin J Ophthalmol, 2017, 53: 610-615)

The patient was an 82-year-old female. On November 3, 2014, I went to the Department of Ophthalmology of Shaoxing People's Hospital because the painless mass in the upper lid of my left eye increased rapidly for more than 3 months. Ocular examination: A strip-shaped mass, about 25 mm ×8 mm ×5 mm, was seen near the upper eyelid margin of the left eye, pink, with clear borders, soft texture and smooth surface, with telangiectasia, no tenderness and ulceration (Figure 1), the palpebral conjunctiva has no bulge; The visual acuity is 0.6 in the right eye and 0.5 in the left eye; When looking up, the upper eyelid edge of the left eye is located at the upper edge of the pupil; The lenses of both eyes were opaque, and there were no obvious ocular abnormalities. Systemic examination: No obvious preauricular, head and neck lymph nodes were palpable, blood pressure 138/82 mmHg (1 mmHg =0.133 kPa), and electrocardiogram showed premature ventricular contractions. Past: history of hypertension for many years, oral medication to control blood pressure is basically normal, denying diabetes, leukemia, organ transplantation and the use of immunosuppressants; No obvious abnormalities were found in laboratory and radiological auxiliary examinations; The patient is a farmer and has been engaged in agricultural labor for a long time; There is no history of similar disease in the family. On November 5, 2014, the left upper eyelid mass was resected under local anesthesia. Pathological examination showed that the tumor cell nest was located in the dermis and spread to the subcutaneous tissue under low magnification, and there was no connection with the epidermis. The tumor cells were round or oval, evenly distributed (Figure 2）； High power microscope shows that the tumor cytoplasm is very little, and there are many mitotic phenomena (Figure 3）； Immunohistochemical examination revealed cytokeratin 20 (CK20) (FIG. 4A), neuron specific enolase (NSE) (FIG. 4B), chromaffin A and CD56 were all positive, and carcinoembryonic antigen, human leukocyte common antigen, and anti-melanoma specific monoclonal antibody (HMB45) were all negative. Diagnosis: Merkel cell carcinoma of left upper eyelid (stage II/T₂N₀M₀), left eye ptosis (mechanical), cataract in both eyes, hypertension, premature ventricular contractions. Because of the patient's personal reasons, radiotherapy (referred to as radiotherapy for short) and other treatments are abandoned after surgery. At 3 months follow-up, no local recurrence and distant metastasis were observed.

The patient was a 27-year-old female. He was admitted to the Department of Ophthalmology of the First Affiliated Hospital of Zhengzhou University on August 29, 2014 due to recurrence for 15 days 1 month after resection of inner and inferior conjunctival mass in his left eye. One month ago, the patient underwent resection of the inner and inferior conjunctival mass in the left eye in the local hospital, and the postoperative pathological diagnosis was spindle cell tumor. 15 d ago, the lesion recurred and gradually increased to a cord-like mass. Admission examination: the visual acuity of the right eye was 1.0, and no abnormalities were found in the examination of eyeball and orbit; The visual acuity of the left eye was 1.0, and the medial conjunctiva showed a longitudinal cord-like mass, enlarged lacrimal mons, and it was hard to touch (Figure 1), the medial angle of the upper eyelid was swollen and hypertrophic, the lateral movement of the eyeball was slightly limited, the lacrimal duct was irrigated smoothly, the area of the lacrimal sac was compressed without pus, and no abnormalities were found in the eye examination. Bilateral submandibular lymph nodes were not swollen. CT examination: Long soft tissue density shadow on the medial side of the anterior part of the left orbit, the lesion involved the eyeball wall and medial rectus muscle, and the adjacent bone was not damaged (Figure 2）。 Admission diagnosis: recurrent space-occupying lesions of left medial canthus and anterior orbit.

The patient was a 23-year-old female. On February 1, 2015, he went to the strabismus and pediatric ophthalmology clinic of Suzhou Ideal Eye Hospital due to the discovery of intermittent outward deviation of his left eye for half a year. The patient complained of outward deviation of the left eye intermittently in the past six months, no diplopia, and no restriction of eye movement. He denied a history of head trauma, metabolic disease and vascular disease, and his previous binocular vision was roughly normal. Initial diagnosis: Distant vision: 1.0 in right eye, 0.8 in left eye, subjective optometry: flat light in right eye, -0.50 DC ×145° =1.0 in left eye. Slit lamp microscopy showed clear refractive interstitium and normal fundus in the right eye. There was no obvious congestion in the bulbar conjunctiva of the left eyelid, a small cloud was seen in the center of the cornea (a corneal foreign body had occurred, and the patient complained that the visual acuity of the left eye did not decrease after the injury), and the rest of the anterior segment and fundus were normal. Eye position: 33 cm reflecting light, orthogonal or right eye fixation, left eye-15°L/R slight; Degree of strabismus by prism covering method (naked eye): 33 cm: right eye fixation-40^△, L/R8^△； Left eye fixation-40^△, L/R8^△。 6 m: Right eye gaze-40^△, L/R5^△； Left eye fixation-25^△。 The compensatory head position is not obvious. A-V strabismus: none. Eye movement: No obvious abnormalities were found. The outpatient was admitted with intermittent exotropia, and it was planned to undergo strabismus correction surgery. The patient was admitted to our hospital 3 d later. The slit lamp microscopy and fundus examination at the time of hospitalization were the same as those in the outpatient clinic. The degree of strabismus was re-examined by prism covering before operation (naked eye examination). 33 cm: Right eye gaze-40^△, L/R8^△； Left eye fixation-40^△, L/R5^△。 6 m: Right eye gaze-25^△, L/R5^△； Left eye fixation-25^△, L/R5^△。 And found compensatory head position: head slightly tilted to right shoulder. No strabismus type A-V. Eye Movement: Slight hyperactivity of the oblique muscle under the left eye. Considering that the patient has exotropia combined with small degree vertical strabismus and has caused compensatory head position, the examination found that the patient's left inferior oblique muscle is hyperactive, and the left inferior oblique muscle can be severed while correcting horizontal strabismus, which is conducive to solving vertical strabismus and abnormal head position. Preoperative preparation was sufficient, and the left inferior oblique muscle was dissected, the left lateral rectus muscle was retrogressed by 4 mm, and the medial rectus muscle was shortened by 4 mm on February 4 after excluding the contraindications for surgery.

The patient was a 55-year-old male. Due to progressive blurred vision in his right eye for 2 years, he went to Tianjin Medical University Eye Hospital on July 10, 2014. Two years ago, there was no obvious trigger for progressive blurred vision in the right eye, no fear of light, eye pain, rainbow vision, shadow occlusion in front of the eye, etc. Without treatment, sight was lost for several months, and the outpatient clinic was age-related cataract, and the mature stage was admitted to the hospital. Past history: self-complained of myopia in both eyes, and underwent phacoemulsification combined with IOL implantation in the left eye in an external hospital 1 year ago. Denial of other systemic diseases. Ocular examination: Right eye visual acuity manual/30 cm, intraocular pressure 8.2 mmHg (1 mmHg =0.133 kPa), corrected intraocular pressure (Pentacam corrected by corneal thickness) 15.1 mmHg, normal external eye, large corneal diameter, total cornea transparent and thin, about 2/3 of the normal thickness, spherical expansion, normal scleral color. The anterior chamber is deep, the iris is not depigmented, there is no atrophy and tremor, the pupil is round, 3 mm in diameter, and the pupil has light reflection. White opacity of the lens (Figure 1), the fundus of the eyes cannot be seen. Left eye visual acuity 0.25, corrected 0.4 (+2.5 DS () -4.5 DC ×178°), IOP 8.4 mmHg, corrected IOP 12.2 mmHg. The condition of corneoscleral and iris was the same as that of the right eye, IOL haptic clamping (Figure 2), the pupil is underround, there is light reflection, the border of the optic disc of the fundus is clear and normal, and the macular area is mild edema. Lenstar-900 white values were 14.31 mm in the right eye and 14.17 mm in the left eye. Intraoperatively, the horizontal corneal diameter of both eyes was 14.20 mm and the vertical diameter was 12.75 mm. Pentacam (Oculus, Germany) examination in both eyes showed total corneal thinning in both eyes, with central thickness of 408 μ m on the right and 456 μ m on the left (Figure 3）； The anterior chamber is deep, 4.84 mm on the right and 5.08 mm on the left; Corneal astigmatism right eye-3.7×102 (K1=41.11 D, K2=44.84 D), left eye-3.6×74 (K1=40.9 D, K2=44.5 D). The mean values of central corneal thickness, anterior chamber depth and corneal astigmatism measured by Pentacam and Lenstar-900 were similar. Right eye phacoemulsification cataract aspiration combined with IOL implantation anterior segment OCT is as followsFigure 4As shown. The diagnosis was: age-related cataract in right eye, mature stage; globular cornea in both eyes; Enlargement of the anterior segment of both eyes; Left eye IOL eye, left eye IOL pupil clamping; Refractive error in both eyes. Right eye phacoemulsification combined with IOL implantation was performed, and +19.00 D corrected astigmatism IOLSN6T7 (Alcon, USA) was implanted. On the first day after surgery, the right eye had visual acuity of 0.5, intraocular pressure of 11.0 mmHg, correction of 16.9 mmHg, transparent cornea, deep anterior chamber, correct IOL position and no significant axial deviation. The best corrected visual acuity of the right eye was 0.8 (-1.00 DS () -0.50 DC ×101°), the intraocular pressure was 8.3 mmHg, the correction was 15.4 mmHg, the cornea was transparent, the anterior chamber was deep, the IOL was correct, and the axial position was still not significantly deviated.

Case 1 was a 51-year-old male. He was admitted to the Department of Ophthalmology of Cangzhou Central Hospital on June 19, 2014 due to ptosis of his left eye for 8 days. He had a history of hypertension for more than 20 years. In May 2010, the patient was hospitalized in another hospital due to "left eye oculomotor nerve paralysis", and was discharged after symptomatic treatment (details unknown). On February 22, 2014, the patient was hospitalized in our hospital due to double vision of both eyes and ptosis of right eye for 10 days. Physical examination: visual acuity of right eye 0.8 and left eye 0.6. The upper eyelid margin of the right eye occludes 1/3 of the pupil, the pupil is round, 3 mm in diameter, and the light response is sensitive. The eye position: 33 cm corneal reflection-15°, which alternately occludes both eyes from the outside to the orthogonal position. Eye movement^[1]: Insufficient movement of upward, downward and internal rotation of the right eye, respectively, upward rotation-3, downward rotation-3 and internal rotation-2. No obvious abnormalities were found on head CT. Diagnosis: Oculomotor nerve paralysis in the right eye, given glucocorticoids, improving circulation, dilating blood vessels, and nourishing nerves for more than 1 month, the symptoms of ptosis in the right eye disappeared, and the insufficient eye movement improved significantly, respectively, upward turning-1, downward turning-1, and internal turning-1. On June 19, 2014, the patient was re-hospitalized in our hospital for 8 days of blepharoptosis in his left eye. Before hospitalization, the patient was given circulation improvement, blood vessel dilation and oral glucocorticoid administration for 1 week in the outpatient clinic, but no significant improvement was seen, so he was admitted to the hospital. Physical examination after admission: visual acuity 0.8 in the right eye and 0.6 in the left eye. The upper eyelid margin of the left eye covered all the cornea, and the eye position was 33 cm. The cornea reflected the correct position, and there was no obvious abnormality in the movement of both eyes. The pupils of both eyes are round, about 3 mm in diameter, and they are sensitive to light reflection directly and indirectly. The lenses of both eyes are mildly opaque, the boundary of the optic disk of the fundus is clear and colorful, the blood vessels can travel, the arteries are thin, the reflection is strong, the phenomenon of arteriovenous cross compression can be seen, and the foveal light reflection exists. MRI of the head showed that there was no obvious abnormality in the head, and inflammation of the left maxillary sinus and the right sphenoid sinus. Chest CT revealed thickening of both lungs, and the white blood cell count was 12.96×10 in blood test⁹/L, the % neutrophils was 93.8%. The muscle strength of the limbs was normal, and there were no general myasthenia gravis manifestations. Ice test (-), fatigue test (+) and neostigmine methylsulfate test (+) were performed. During hospitalization, the patient's left eye ptosis was found to be mild in the morning and heavy in the evening, and the ptosis was slightly reduced after rest. Following the family history, the patient's two uncles (who died) had a history of myasthenia gravis. Diagnosis: myasthenia gravis of ocular muscle type, left maxillary sinusitis, and right sphenoid sinusitis. The patient's ptosis was improved after 3 days, and the symptoms of ptosis basically disappeared after 6 days. Occasionally, the patient's ptosis was mild after fatigue. After discharge, the patient was instructed to adhere to oral bromobistigmine and gradually reduce the dose of glucocorticoids. Up to the follow-up date of August 20, 2015, the patient had no recurrence of ocular myasthenia gravis, and there were no systemic myasthenia gravis manifestations.

The patient was an 18-year-old female. In August 2013, the patient found a pale red mass the size of a "soybean grain" in the conjunctiva above the left eyeball growing for 14 days, accompanied by an obvious foreign body sensation. Then he went to Tianjin Eye Hospital on August 13, 2013. After admission, ophthalmic examination revealed that the bulbar conjunctiva above the left eyeball was congested, and a mass with a size of about 8.0 mm ×7.0 mm ×2.0 mm was visible about 2 mm above the limbus. The boundary was unclear, the texture was tough, no tenderness, and it could not be pushed. The bulbar conjunctiva around the mass showed radial and obviously tortuous blood vessels (Figure 1）。 The remaining eye examinations showed no abnormalities. The clinical diagnosis was conjunctival mass of the left eye. Conjunctival mass resection was performed on 15 Aug 2013. The pathological diagnosis was: left eye subconjunctival inflammatory myofibroblastic tumor (IMT). Immunohistochemical staining: acidic calcium binding protein S-100 (-), Vimentin Vimentin (+), smooth muscle actin SMA (+).

The patient was a 68-year-old male. After accidentally falling, the conjunctiva of the left eye was found to protrude immediately outside the eye with a foreign body sensation, and he could not close his eyes, so he went to the Department of Ophthalmology of Shengli Oilfield Central Hospital. Eye examination: the visual acuity of both eyes was 0.6, which could not be corrected; IOP was 14 mmHg (1 mmHg =0.133 kPa) in the right eye and normal in the left eye; The skin of the left eyelid is red and swollen, the eyelid cannot be completely closed, the conjunctiva protrudes outside the palpebral fissure, the protruding conjunctiva surrounds the cornea in a cylindrical well shape, and the conjunctiva is slightly pale (essence picture 1). When the eyelid is touched, the conjunctiva is airbag-shaped, and the movement of the eyeball in all directions is limited; The cornea is transparent, the depth of the anterior chamber is normal, the pupil is round, there is a light response, the lens is mildly opaque, and no obvious abnormality is seen in the fundus; No obvious abnormalities were found in the anterior and posterior segments of the right eye. Orbital X-ray examination: interruption of the medial wall of the left orbit and intraorbital gas accumulation. Clinical diagnosis: fracture of medial orbital wall of left eye; Subconjunctival pneumatosis in the left eyeball. After oral administration of Yunnan Baiyao for 3 days, the gas accumulation under the bulbar conjunctiva was completely absorbed, the bulbar conjunctiva was repositioned, and the eyelid closed well.

Lymphoma is one of the most common malignant tumor of the orbit in adults. Orbital lymphoma mainly consists of extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue, follicular lymphoma, diffuse large B-cell lymphoma, mantle cell lymphoma, infrequent NK/T cell lymphoma and Burkitt lymphoma. Diagnosis on orbital lymphoma remains challenging in that it is difficult to distinguish it from benign lesions, especially for low degree lymphomas. Combined examinations of histological, cytological and molecular features are required to make final differentiation. There are many treatment options for diagnosis of orbital lymphoma, such as surgical resection, radiotherapy, chemotherapy, monoclonal antibody targeted therapy, immunotherapy. The appropriate scenario of treatment on orbital lymphoma should be made based on the Ann Arbor or TNM staging system to determine the stage of orbital lymphoma at the moment for maximizing the results. The latest concepts on diagnosis and management of orbital lymphoma are reviewed in this paper. (Chin J Ophthalmol, 2017, 53: 632-636)

Glaucoma is one of the leading causes of blindness in the world, second to cataract. The treatment of glaucoma mainly includes drugs, laser and operation, which can slow down the progress of the disease. Prostaglandin is the first-line medication at present. With the constant promotion of clinical application, the local side effects have been found, such as conjunctival congestion, lash lengthening, periorbital and iris pigment deepening, blepharitis and macular edema. As people pay more attention to appearance, periorbitopathy caused by prostaglandin has been reported in recent years, including upper eyelid ptosis and dermatochalasis, deepening of the upper eyelid sulcus, periorbital fat loss, enophthalmos and inferior scleral exposure. The mechanism, performance and treatment methods of these prostaglandin-associated periorbitopathies are reviewed. (Chin J Ophthalmol, 2017, 53: 637-640)