Volume 54 · Issue 07 · 2018

This issue focuses on the research progress of diagnosis and treatment of orbital diseases. Professor Li Dongmei is the responsible editorial committee responsible for the planning, composition and review of the key contents of this issue.

Eyelid sebaceous carcinoma is a malignant tumor originating from Meibomian glands, Zeis glands, and other glands surrounding hair follicles. It is the second most common eyelid malignancy, following basal cell carcinoma, in China. Considering its diversified clinical manifestations and strong tendency for recurrence and metastasis, standardized cancer staging, surgical excision with frozen section control, and postsurgical follow-up has been internationally adopted with the aim to considerably reduce the risk of recurrence and metastasis. However, the lack of standardized and normalized staging, surgical treatment and follow-up in China inevitably caused high recurrence rate and low predictability of prognosis of eyelid sebaceous carcinoma. Therefore, it is of great significance to standardize the clinical diagnosis and treatment of eyelid sebaceous carcinoma in China. (Chin J Ophthalmol, 2018, 54: 481-483)

External orbital decompression, including medial wall, inferior wall, lateral wall and orbital fat decompression alone or in combination, has long been considered to be the standard treatment for thyroid related eye diseases. Deep lateral wall orbital decompression has better effect in the balance of eye position, correction of serious exophthalmos and severe oppression optic neuropathy. Recently, however, endoscopic orbital decompression is becoming increasingly popular with the development of endoscopic surgery technique in naso-orbit related diseases. Endoscopic orbital decompression has the advantages of avoiding an external incision scar. Nevertheless, the new method also has some disadvantages, for example, application limited to medial and inferior orbital wall orbital decompression, high incidence of esotropia, need for external lateral wall decompression and expensive cost for equipment. Both surgical approaches have advantages and disadvantages respectively for medial wall and inferior wall decompression. The operative result depends on the individualized surgical design and the experience of the surgeon rather than the choice of the surgical approach. As a result, the choice of the surgical approaches should be specifically based on the patient's conditions, patient's acceptance of the operation, experience of the surgeon and available resources.(Chin J Ophthalmol, 2018, 54: 484-487)

Dysthyroid optic neuropathy (DON) is the most common cause of visual loss in thyroid associated ophthalmopathy, for which steroid pulse therapy and orbital decompression are the common treatments currently. While steroid pulse therapy was recommended as the first-choice for DON, orbital decompression remained as an indispensable therapy although controversies on such treatment still exist. The mechanism, approaches and outcomes of orbital decompression, as well as its advantages and disadvantages over steroid pulse therapy were retrospectively reviewed, and it was suggested that the combination therapy of steroid pulse therapy and surgical decompression might be the better choice for the treatment of DON. (Chin J Ophthalmol, 2018, 54: 488-490)

Demodex blepharitis is a chronic inflammatory reactive disease caused by Demodex infection of the eyelid margin. It mainly involves the skin of the eyelid margin, eyelash capsules and glands, and meibomian glands. The typical clinical manifestations are eye itching, eye foreign body sensation, dry eyes, eyelid margin congestion, scales and sleeve-shaped discharge at the root of eyelashes. In severe cases, it can cause conjunctival and corneal complications. The disease may be somewhat contagious.

To evaluate the outcome of autogenic facia lata suspension in the treatment of paralytic ectropion.

It was a retrospective case series study. The clinical records of 21 patients (21 eyes) who were treated for paralytic ectropion with autogenic facia lata suspension between January 2015 and September 2017 at Beijing Tongren Hospital were analyzed. In the 21 patients, 7 were male and 14 were female. The range of age was 20-74 years and the mean age was (61±14) years. All of the participants received facia lata suspension for the correction of ectropion. Some of the patients also received associated wedge resection of the tarsus or lateral tarsal strip procedure. The anterior lamella was reconstructed with local flaps in some patients. The preoperative and postoperative degree of ectropion was measured. Paired sample t test was used to compare the preoperative and postoperative data.

Postoperative follow up for patient was conducted for 6-38 months. Residual lagophthalmos of 3 mm or more were present in 3 cases. Mild lower eyelid ectropion recurred in 1 patient one year after surgery. The rest cases achieved satisfactory aesthetic outcomes. No complication in the donor site was observed. The preoperative scleral show was (3.02±1.31) mm, and the postoperative data was (-0.05±0.72) mm. The preoperative margin reflex distance 2(MRD2) was (8.83±1.77) mm, and the postoperative MRD2 was (5.43±0.78) mm. The preoperative lagophthalmos was (6.17±1.91) mm, and the postoperative data was (1.98±1.09) mm. The differences between the preoperative and postoperative data were significant (t=13.530, P=0.000;t=11.913, P=0.000; t=11.882, P=0.000).

Autogenic facia lata suspension is an effective method for the correction of paralytic ectropion, with good aesthetic outcome, low recurrence rate and few complications. (Chin J Ophthalmol, 2018, 54: 496-501)

To summarize the treatment outcomes of embolizing orbital vascular malformation with intracavitary injection of medical glue during surgery.

A retrospective case series study was performed on 25 patients with orbital vascular malformation who were treated at Tianjin Medical University Eye Hospital during March 2008 and March 2016. In the 25 patients(25 eyes), 7 were male and 18 were female. The range of age was 2-64 years and the median age was 29 years. The clinical features, operation records, pathological reports and follow-up data were analyzed.

The location of vascular malformation involved intraorbital in 11 cases and superficial area of eyelid and(or) face in 5 cases, as for the rest 9 cases, both intraorbital and superficial area were involved. Conjunctiva was involved in 4 patients. Clinical manifestation included intermittent protopsis or mass volumn changed (7 cases), pulsating exophthalmos and vascular murmur (1 case). Imaging examination showed solitary mass with regular shape in 5 cases and space occupying lesion with irregular shape and ill-defined margins in 20 cases. Optic nerve was involved in 7 cases. Surgical debulkling were performed via skin incision on the mass surface (in 3 cases), lateral orbitotomy (in 2 cases), and anterior orbitotomy (in 20 cases). The anterior orbitotomy approaches include skin incision under eyebrow (9 cases), skin incision under lower eyelid eyelash (3 cases), transconjunctiva joint lateral canthus incision (6 cases) and transconjunctiva incision only(2 cases). The intra-orbital part of vascular malformation involved intraconal compartment (10 cases) and extraconal compartment (10 cases). During the operation, vascular malformations were exposed and injected with medical aural and encephalic glue. The amount of injected glue ranged from 0.25 ml to 2.50 ml in divided doses. When the soft venous malformations turned hard, the lesions and remnant glue were fully removed. The whole procedure cause less bleeding and shorter time of operation. Histopathologic diagnosis were intraosseous hemangioma (1 case), arteriovenous malformation (2 cases), venous malformation (22 cases), including varix (4 case) and venous hemangioma (18 cases). One patient suffered from sudden central retinal artery embolism on the third day postoperatively, in which case, visual acuity recovered to 0.6 by timely rescue and appropriate procedure. Topical skin aseptic inflammation took place at the same side of medical glue injection in 3 cases which might be caused by medical glue. These 3 cases had superficial eyelid lesions. Postoperative follow up for patient was conducted from 6 months to 5 years. One young patient underwent recurrent orbital hematoma and many times surgery.

Embolization of orbital vascular malformation with medical glue injection intraoperatively can be utilized as an easy approach to control hemorrhage. The surgeon should be careful with the application methods, for instance not to push too quickly, not to pass through the vascular malformation, and to remove the lesions and remnant glue completely, in order to avoid complications. (Chin J Ophthalmol, 2018, 54: 502-508)

To explore and summarize the clinical manifestation, iconographic characterizations, principles of diagnosis and treatment of orbital neurilemomas.

Retrospective case series study. A total of 112 patients diagnosed with orbital neurilemomas and received surgery at Tianjin Eye Hospital from January 2002 to December 2016 were included. The clinical symptoms, eye signs, imageological examination, diagnosis treatment and prognosis of the patients were analyzed. SPSS 21.0 software was used to describe age and follow-up time.

In the 112 cases, 48 cases were male, 64 cases were female. At the time of diagnosis, the age of patients ranged from 13 to 73 years. The mean age at diagnosis was (40±4) years. B ultrasound scan was applied in all 112 cases, results revealed round, elliptical, beaded, and irregular shaped lesion in orbit with clear boundary, which was characterized with poor echo, strong sonolucency, and mild compressibility. CT scan was also applied in all 112 cases. The lesions were elliptical, lobulated, S-shaped, or peanut shaped, primarily characterized with evenly high density and a few with the low density fluidized region. MRI was applied in 54 cases. T₁ weighted image (T₁WI) showed medium signal in all lesions. T₂ weighted image (T₂WI) showed high, mixed and medium signal. Surgical approaches included lateral orbitotomy in 75 cases, and anterior orbitotmy in 37 cases. Average follow-up time was (64.3±4.1) months. Surgical complications included vison loss (in 3 cases), postoperation ptosis (in 16 cases), and disturbance of eyeballs movement (in 9 cases), while 6 cases involved with recurrence.

Orbital schwannoma is mostly characterized with benign solid orbital lesions. Orbital CT examination results of orbital schwannoma are mainly characterized with ellipsoid or beaded mass along the anterior posterior axis of orbit, while a few of tumors showed low density liquefaction areas. T₁WI shows medium signal in most lesions, and T₂WI shows mixed signal in most lessions. Histopathologic examination is the basis for confirmation of diagnosis. The recurrence rate is lower after the complete resection of the tumor. Postoperative radiotherapy could be used for controlling the recurrence. (Chin J Ophthalmol, 2018, 54: 509-514)

To discuss the clinical features, imaging features, pathological patterns, treatment principles and prognosis of the orbital nonspecific inflammatory response diseases patients whose CT or MR images show enlargement of the infraorbital nerves.

A retrospective case series study. Seven orbital disease patients who were treated at Tianjin Medical University Eye Hospital between March 2013 and May 2017 were included. All patients, imaging pictures showed enlargement of the infraorbital nerve. The medical histories, clinical featuers, imaging features, pathologies, serological examinations, therapeutic processes and prognosis were collected and analyzed.

The 7 patients included 4 males and 3 females aged from 55 to 68 years (the average age was 60). Bilateral involvement was present in 5 of 7 patients. The main clinical manifestations include proptosis, increasing of orbital pressure, impairment of visual functions, reduction in ocular motility, facial sensation, periocular ache, involvement of lymph node and salivary gland, etc. CT results showed enlargement of infraorbital nerve, accompanied with or without the destruction of bone. The inflammatory response may involve with extraocular muscles and lacrimal glands, or were shown as lesions with irregular shape and blurred borders. The MR images generally showed equal T₁ and equal T₂ signal, accompanied with evident enlargement of the infraorbital nerve. Of all the 7 patients, 6 underwent operation, and the pathology confirmed that 2 of the 6 were involved with inflammatory pseudotumors and the rest 4 were involved with IgG4-related ophthalmic disease (IgG4-ROD). The level of IgG4 in the serum were detected for 4 patients, the results of 3 were high and the other was normal. Of all the 7 patients,1 patient underwent conservative treatment, but disease recurred for several times, and the serum IgG4 level for the patient was higher than normal;1 inflammatory pseudotumor patient was cured completely only by surgery, and has a favourable prognosis; 1 IgG4-ROD patient accepted glucocorticoid, surgery, radiotherapy and chemotherapy, but disease recurred several times; The rest of the patients accepted glucocorticoid and operation, 2 were sensitive to glucocorticoid, 2 were not sensitive, and 1 involved with recurrence.

If orbital nonspecific inflammation response was accompanied with enlargement of infraorbital nerve, it is suggested that patient is more likely to be involved with IgG4-ROD;Pathology and serological tests can be used for the diagnosis of IgG4-ROD, however treatment effect appears to be poor for most patients, and patients prone to relapse. (Chin J Ophthalmol, 2018, 54: 515-519)

To investigate the changing trends of topical anti-glaucoma medications in the outpatient of the Eye Hospital of Wenzhou Medical University over the decade 2005-2014.

Retrospective case series study. The medications data of glaucoma outpatients in the Eye Hospital of Wenzhou Medical University were collected for the period of January 1^st 2005 to December 31^st 2014. SPSS 20.0 statistical software was used, mainly for statistical description of the data. The main outcome measures were the proportions of the prescriptions of different medications, and the proportions of the monotherapy and combination therapies.

During the 10 years, the number of glaucoma outpatients increased year by year, from 994 in 2005 to 3 266 in 2014, the gender ration was close to 1∶1, and the age were (57±18) years. The proportion of β-blockers decreased from 56.7% (750/1 323) in 2005 to 33.1% (2 120/6 407) in 2014. The proportion of cholinergic agents decreased from 17.2% (227/1 323) in 2005 to 10.3% (663/6 407) in 2014. While the proportion of prostaglandins increased from 13.3% (176/1 323) in 2005 to 36.8% (1 916/5 209) in 2011, which was close to the 37.9% (1 972/5 209) of β-blockers in 2011. In 2012, the prostaglandins proportion increased to 41.9% (2 435/5 810) exceeding the 37.2% (2 161/5 810) of β-blockers, and became the most prescribed medication. The proportion of prostaglandins continued to increase to 46.9% (3 008/6 407) in 2014. The proportion of α ₂-agonists increased from 17.0% (225/1 323) in 2005 to 22.8% (1 460/6 407) in 2014. The proportion of carbonic anhydrase inhibitors increased from 9.6% (127/1 323) in 2005 to 24.1% (1 546/6 407) in 2014.The proportion of monotherapy decreased from 78.0% (1 032/1 323) in 2005 to 58.6% (3 757/6 407) in 2014. The proportion of two drugs combination increased from 20.0% (264/1 323) in 2005 to 26.7% (1 709/6 407) in 2014. The proportion of three drugs combination increased from 2.0% (26/1 323) in 2005 to 12.3% (788/6 407) in 2014. The proportion of four drugs combination increased from 0.1% (1/1 323) in 2005 to 2.3% (150/6 407) in 2014.

The changes of the proportions of topical anti-glaucoma medications were remarkable from 2005 to 2014 in the outpatient of the Eye Hospital of Wenzhou Medical University. The β-blockers and cholinergic agents were declining, while the prostaglandins, α ₂-agonists and carbonic anhydrase inhibitors were increasing, and the prostaglandins became the most prescribed medication since 2012. The proportion of combination therapy was increasing. (Chin J Ophthalmol, 2018, 54: 520-525)

To study clinical and genetic characteristics of a Leber hereditary optic neuropathy (LHON) family with the heteroplasmic m.14484T>C mutation.

A cross-sectional study. The objects of the study included a 31-year-old male LHON patient with the heteroplasmic m.14484T>C mutation (the proband) who visited Department of Ophthalmology in the Affiliated Central Hospital of Qingdao University in March 2015 and other 36 matrilineal relatives in a four-generation family (12 males and 24 females aged 2-81 years, median 27 years). The visual acuity, intraocular pressure, fundus, color vision, visual field, visual evoked potential and optical coherence tomography were evaluated in maternal members. The mitochondrial DNA (mtDNA) sequence of fragments including m.14484 loci was detected by Sanger sequencing in 33 members. The sequencing peaks were analyzed by QSVanalyzer software to get the heteroplasmy levels of m.14484T>C mutation. The mtDNA of the proband was amplified by PCR and sequenced. Assembled sequence of mtDNA was compared with the updated consensus Cambridge sequence. The differences in visual evoked potential, optical coherence tomography and heteroplasmy levels were compared between two groups by thet-test, and among multiple groups by the single factor variance analysis.

Among the 33 maternal members of the family, 4 patients, 28 carriers and 1 person without a mutation were confirmed. The penetrance was 12.5% (4/32) . In addition to 4 patients with obvious abnormality on the ophthalmic examination, 5 carriers also appeared anomaly on the electrophysiological and visual function examinations. Compared to carriers, the amplitude of P100 was obviously decreased in the LHON patients[ (5.6±2.6) μV vs. (15.6±9.6) μV, t=2.880, P=0.006]. Significantly reduced values were seen in the average retinal nerve fiber layer thickness[ (71±17) μm vs. (99±11) μm, t=5.969, P< 0.001], in each side of the sub-area macular thickness, and in the nasal side of the lateral sub-area macular thickness [ (260±16) μm vs. (291±12) μm, t=5.593, P<0.001] between the LHON patients and carriers. The heteroplasmic levels were 80%±3% in the LHON patients, and 27%±18% in the unaffected members;the difference was significant (t=-8.395, P<0.001). The average degree of heteroplasmy had no difference between male and female members (48%±34% vs. 35%±28%, t=-1.147, P=0.258). The average mutation load was 29%±14% in the second generation members, 36%±29% in the third generation members, and 51%±36% in the fourth generation members;the differences were not statistically significant (F=1.152, P=0.330). The difference in the heteroplasmic levels was not statistically significant between mothers and their offspring (31%±25% vs. 42%±32%, t=1.165, P=0.251). Compared to Cambridge consensus sequence, 41 mutations was found in mtDNA of the proband, of which, 10 were missense mutations, including mutations m.4216T>C and m.3394T>C. According to the phylogenetic tree, the haplotype of the proband was M9a (M9a1a1c1a).

In the family with the heteroplasmic m.14484T>C mutation, clinical manifestations of LHON appear in the individuals whose heteroplasmic level is more than 75%, and all of patients show typical chronic optic atrophy on the ophthalmic examination. The carriers with the m.14484T>C mutation also appear anomaly on the electrophysiological and visual function examinations. The heteroplasmic level of m.14484T>C mutation has a tendency to increase during the transmission in the family. The primary mutation m.14484T>C coordinate mutations m.4216T>C and m.3394T>C to increase the penetrance and incidence of abnormal visual function in carriers.(Chin J Ophthalmol, 2018, 54: 526-534)

患儿男性，1岁7个月。木筷刺伤右眼睑红肿15 d、发热3 d，于2015年12月8日收入四川大学华西医院。入院前15 d患儿手拿吃饭用过的木筷玩跑时摔倒，不慎将木筷插入右侧眼部，木筷自行完全脱落。当地医院就诊，右眼局部应用妥布霉素滴眼液。入院前10 d（伤后5 d），患儿出现右眼睑红肿，当地医院行CT检查后给予头孢唑林静脉滴注（50 mg/kg，每8小时1次）全身抗感染治疗。入院前3 d（伤后12 d），出现高热39.3 ℃。全身体检：患儿生命体征平稳，血常规白细胞17.13×10⁹/L，中性粒细胞0.788；尿常规、大便常规、胸部X线片未见明显异常。眼部检查：右上睑红肿、下垂，皮下包块质软，有波动感（图1）。入院前5 d当地医院眼眶CT提示右眼上睑皮下及眶内软组织密度影，中央有低密度区（图2），右眶上壁局部骨折（图3）。入院诊断：右眼上睑皮下及眶内脓肿，右眼眶顶骨折。儿科急会诊后建议行心电监护，全身应用万古霉素（10 mg/kg，每6小时1次）抗感染。2015年12月9日全身麻醉下行右眼上睑及眶内脓肿切开引流术，术中引流出黄色脓液1.5 ml（图4），万古霉素冲洗脓腔后放置引流条。术中麻醉下发现右眼上睑穹隆结膜瘢痕，右眼角膜透明，眼前节未见异常。术后第1天患儿右眼眼睑红肿明显消退（图5），但体温仍高（38.5℃），复查血常规：白细胞35.43×10⁹/L，中性粒细胞0.818，立即再次请儿科会诊，检查患儿生命体征平稳，情绪较差，无明显嗜睡，脑膜刺激征阴性，建议继续万古霉素全身抗感染治疗。术后第3天，患儿体温仍未控制（37.3~39.5℃），生命体征平稳，逐渐出现嗜睡，复查血常规提示白细胞23.03×10⁹/L，中性粒细胞0.845，C反应蛋白87.6 mg/L，血培养结果阴性，术中取脓液培养结果提示米勒链球菌生长（对氯霉素、万古霉素、头孢噻肟、左旋氧氟沙星、利福平敏感；对阿奇霉素、红霉素、克林霉素耐药）。儿科医师会诊，检查患儿脑膜刺激征不明显，术后第5天儿科医生行腰椎穿刺，穿刺脑脊液呈米汤样混浊，脑脊液常规白细胞升高（7 500/ml）、中性粒细胞88%、单核细胞12%，糖含量0.02 mmol/L（正常参考值2.5~4.4 mmol/L），微量蛋白3.48 g/L（正常参考值0.15~0.45 g/L），建议转科，当日予以头孢曲松全身抗感染治疗，同时行CT提示颅内脓肿形成（图6），脑脊液涂片及培养未查见厌氧菌、细菌和真菌。术后第6天，患儿转至儿科治疗。后来电话随访患儿仍然发热，全身情况恶化，神经外科建议手术治疗，患儿家属拒绝手术，眼部切开引流术后13 d患儿因呼吸循环衰竭死亡。

The patient was a 26-year-old female. Due to painless swelling of the upper eyelids of both eyes for 1 month, he went to the Eye, Ear, Nose and Throat Hospital affiliated to Fudan University on February 22, 2016. The patient underwent facial microplastic surgery abroad 6 months ago, and underwent autologous lipofilling on the forehead twice within 3 months; The lower eyelid of both eyes was injected with "hyaluronic acid" twice within 10 days, and the left lower eyelid appeared transient redness, swelling and pain after operation. Two months after the completion of all treatment, the patient found that the bilateral eyelids were slightly thickened, with slight redness and swelling, no pain, and several nodular masses could be palpable on both sides, which were enlarged and connected into pieces within one month. During the illness, the patient used antibiotic eye drops, eye ointment, etc. irregularly, without hormonal drugs, and had no obvious curative effect after medication, so he went to our hospital for treatment. After asking about the medical history, the patient also underwent 2 forehead autologous fat filling, 3 rhinoplasty, and 5 full face "water light needling" within 3 years. Physical examination showed no special blood routine, liver and kidney function, electrolytes and autoantibodies, and urine routine showed urinary tract infection. Ophthalmic examination revealed painless masses in bilateral upper eyelids, medium quality, and unclear demarcation with surrounding tissues. The right upper eyelid mass was located on the temporal side, approximately 2.5 cm ×1.5 cm in size, and continued with the lacrimal gland (Figure 1）； The left upper eyelid mass was located on the nasal side and was approximately 1.0 cm ×0.5 cm in size. Binocular vision, color vision and visual field were normal. The patient refused to undergo magnetic resonance examination, so he changed to orbital enhanced CT. The image showed diffuse swelling and thickening of the right upper lid and slightly thickening of the left upper lid (Figure 2）。 The proposed diagnosis is: (1) orbital granulomatous inflammation; (2) Orbital lymphoid tissue proliferative lesions. He was admitted to the hospital for a right eyelid mass biopsy.

The patient was a 54-year-old female. Due to the sharp decline of visual acuity in his left eye for 10 days, he went to the Ophthalmology Center of the Second Affiliated Hospital of Zhejiang University School of Medicine on January 5, 2015. The patient was diagnosed with "left eye optic neuritis" in the local hospital, and was treated with oral hormones and neurotrophic drugs, but there was no improvement. He had a history of hypertension for 2 years, and was treated with oral amlodipine besylate tablets, and his blood pressure was controlled smoothly. Five months ago, the patient visited the Second Affiliated Hospital of Zhejiang University School of Medicine for 1 week because he didn't see the lower half of his left eye. At that time, the eye examination showed that the visual acuity of the right eye was 1.0 and the left eye was 0.6. The color and boundary of the optic disc of the right eye were normal, the optic cup was not obvious, and the upper part of the optic disc of the left eye was mildly edema with blurred boundary (FIG. 1A、FIG. 1B）。 FFA showed slow choroidal filling in the posterior pole of the left eye, low fluorescence in the upper part of the optic disc, dilation of capillaries and leakage of fluorescein in the middle part of the optic disc in the early stage of angiography; In the late stage of angiography, the optic disc showed diffuse strong fluorescence, but the fluorescence in the upper part of the optic disc was slightly weaker (Figure 1C，Figure 1D，Figure 1E）。 Visual field examination revealed a defect in the lower half of the left eye, and the central fixation point was not affected (Figure 1F）。 At that time, he was diagnosed as anterior ischemic optic neuropathy (AION) in the left eye, and drug treatment had no obvious effect.

The child was a 5-year-old male. Due to the inward deviation of his right eye for 4 1/2 months, he went to Beijing Tongren Eye Center of Beijing Tongren Hospital affiliated to Capital Medical University on December 16, 2015. At the beginning of August 2015, the child showed slight inward deviation of his right eye without obvious trigger, accompanied by looking up. By the end of August, his right eye could not turn up, showing progressive inward deviation. During the disease, there were no obvious symptoms such as red eyes and eye pain, occasionally nausea with head and eye discomfort, and poor spirit. At the beginning of the disease, it was diagnosed as tonsillitis due to fever, which improved after symptomatic treatment. The diagnosis of "right eye internal hypostrabismus" in the outside hospital failed to find the cause. Triamcinolone acetonide was injected retrobulbar twice, and retrobulbar hemorrhage occurred the second time, and the eye position did not improve. On November 19, 2015, he underwent exploration of the right inferior rectus muscle in a local hospital. The pathology of the anterior inferior rectus muscle showed extraocular muscle fibrosis. One week after surgery, he developed low fever, head discomfort, nausea after eating, and his right eye was further deviated inward and fixed inward and posteriorly. The child was born by cesarean section at 36 weeks; Hand, foot and mouth disease at 1 year old; 4-year-old suffered from herpetic pharyngitis, and at the same time, mesenteric lymph nodes were found to be swollen, which improved after antiviral treatment. The history of trauma, family history and infectious diseases were denied, the history of vaccination was normal, and there was no history of drug allergy. No history of pandemic exposure. There were no abnormalities in brain magnetic resonance enhancement and magnetic resonance angiography, and there were no abnormalities in chest CT and thymus CT. Blood routine, urine routine, blood biochemistry, coagulation function, serum immunoglobulin, serum thyroid hormone, C-reactive protein, erythrocyte sedimentation rate, anti-streptolysin O, rheumatoid factor, protease 3 and myeloperoxidase were not abnormal. No abnormalities were found in the consultations of otolaryngology, neurology, endocrinology, rheumatology and immunology and respiratory medicine. Eye examination: visual acuity cannot be detected in the right eye, 0.8 in the left eye; Intraocular pressure was normal in right eye, left eye 16 mmHg (1 mmHg =0.133 kPa). The eyelid of the right eye was swollen, the bulbar conjunctiva was congested and edema, the right eyeball was extremely transposed internally, and the movement in all directions was limited. No abnormalities were observed in the anterior and posterior segments of the left eye. No abnormalities were seen in the fundus of both eyes. Orbital MRI (Beijing Tongren Eye Center, December 16, 2015) showed deformation of the right eyeball and abnormal changes in the superior and inferior rectus muscles, considering the possibility of inflammatory lesions (Figure 1）。 On January 6, 2016, MRI examination was performed again. MRI showed that the right eyeball was invaginated and deformed, showing extreme internal transposition. There was no abnormal change in the morphology and signal of the bulb content, and the bulb fascia sac was blurred and strengthened. The levator palpebral muscle, the superior rectus muscle, the whole course of the inferior rectus muscle, the abdomen of the temporal muscle of the inferior oblique muscle and the abdomen of the medial rectus muscle were thickened,₁Slightly longer T₂Signal, which showed obvious enhancement after enhancement; The morphology and signal of lateral rectus muscle and superior oblique muscle were not abnormal, and no abnormal strengthening was observed; There were no abnormal changes in the morphology and signal of optic nerve; No abnormalities were seen on the left side. Imaging opinion: right eyeball deformation with blurred bulbar fascia sac, thickening and strengthening of multiple extraocular muscles, inflammatory lesion? Review after treatment is recommended. Outpatient diagnosis: Acquired progressive restrictive esotropia in the right eye, subacute nonspecific extraocular myositis in the right eye?

患者女性，44岁。双眼视物模糊2年，在吉林大学第二医院眼科诊断为双眼中心性浆液性脉络膜视网膜病变（central serou chorioretinopathy，CSC），先后两次对双眼眼底渗漏点行激光治疗，每次激光治疗后病情好转后复发。2016年11月22日再次复发，因双眼视力下降加重1周于我院复查。既往有丙型肝炎病史，现已治愈。患者已婚，孕2产2。高血压2年，口服替米沙坦，血压105~150 mmHg（1 mmHg=0.133 kPa）。全身查体：向心性肥胖，满月脸（图1），多血质，颊部及锁骨上窝可见脂肪垫，腹部未见紫纹。眼部检查：患者右眼视力0.5，左眼视力0.6，双眼前节正常，眼底可见黄斑区盘状神经上皮脱离。FFA检查结果显示双眼黄斑区及血管弓可见多处点状渗漏荧光，双眼后极部可见多片轻度透见荧光。吲哚青绿荧光素血管造影结果显示双眼早期病变部位的脉络膜血管扩张及晚期病变部位可见点状低荧光及低荧光周围的高荧光（图2）。视野检查结果可见左眼鼻侧相对性暗点，右眼颞上象限部分视野缺损。实验室检查：7~9点钟皮质醇661 nmol/L（参考值182~740 nmol/L），促肾上腺皮质激素31.7 pmol/L（参考值0.0~10.1 pmol/L）；15~17点皮质醇431 nmol/L（参考值60~425 nmol/L），促肾上腺皮质激素31.3 pmol/L（参考值0.0~10.0 pmol/L）；葡萄糖4.86 mmol/L。头部核磁提示垂体占位；垂体核磁及增强提示：垂体左侧局部膨隆，上下径为7 mm，T1WI呈等信号，T2WI显示信号不均，可见条形稍长T2信号影，增强扫描呈弱强化。垂体柄向左侧偏移，鞍底未见明显异常（图3）。临床诊断：双眼CSC，Cushing综合征，垂体瘤。考虑患者眼底病变与全身疾病导致的激素水平紊乱有关，故请神经外科会诊，于2017年1月4日行单鼻孔经蝶垂体瘤切除术。术后HE染色显示肿瘤细胞核圆，片块、条索状排列，高倍镜下每视野分裂象约1/10（图4）。免疫组织化学染色结果：细胞角蛋白（cytokeratin，CK）（弱+）、嗜铬粒蛋白A（chranogranin A，CgA）（+）、突触素（synaptophysin，Syn）（+）、CD56（-）、Ki67蛋白（阳性率2%）、P53蛋白（-）。结合免疫组化染色结果及形态学特征支持：垂体腺瘤。术后实验室检查：7~9点钟皮质醇556 nmol/L，促肾上腺皮质激素10.0 pmol/L；15~17点钟皮质醇506 nmol/L；葡萄糖6.02 mmol/L。患者术后1个月复查可见面部多血质体征消失；右眼视力0.8，左眼视力0.6；眼底双眼黄斑中心凹反光欠清；OCT检查较术前网膜下积液明显减少，色素上皮脱离程度减轻（图5，图6，图7，图8，图9，图10）；视野检查双眼暗点较术前均有好转。术后3个月，双眼网膜下积液完全消失，右眼视力0.8，左眼视力0.6。

Orbital venous malformation (OVM) ranks as the most common form of vascular lesions in the orbit. OVM may cause functional impairment as well as disfigured appearance in orbital and periorbital regions. A variety of treatment methods has been used to deal with OVM, including sclerotherapy, laser therapy, embolization, surgical resection. The treatment scenario should be made based on hemodynamics, location and extent of lesions in order to achieve encouraging results. With increased understanding on hemodynamics of OVM and application of newly proposed techniques, a combined modality of multiple approaches with defined order has been advocated to be applied in the treatment of OVM. In this paper, the latest advancement in treatment of OVM is reviewed. (Chin J Ophthalmol, 2018, 54: 548-550)

Including viral retinitis, endophthalmitis and ocular toxoplasmosis etc, Infectious ocular diseases, which include viral retinitis, endophthalmitis and ocular toxoplasmosis etc, are the common causes leading to blindness. Traditional examinations of serum are of limited help in diagnosing these diseases and are sometimes misleading. Examinations of pathogen DNA, antibodies and cytokines in the intraocular fluids including aqueous humor and vitreous humor can help clinicians get in situ information and hereby confirm diagnosis rapidly.(Chin J Ophthalmol, 2018, 54: 551-556)

The patient was a 66-year-old male. Due to sudden blurred vision in his right eye for 3 weeks, he went to the Department of Ophthalmology, the Second Affiliated Hospital of Wenzhou Medical University. Prior history of ophthalmic disease is denied, and systemic history is denied. Eye examination: naked eye visual acuity of right eye 0.1, correction 0.4; intraocular pressure 14 mmHg (1 mmHg =0.133 kPa); The conjunctiva of the right eye is not congested, the cornea is transparent, the central anterior chamber is deep, and the lens is mildly opaque; The right fundus optic disc has a clear boundary, reddish color, slightly thinner arteries, a disc-shaped bulge in the macular area, a little hard exudation near the vascular arch above, a dark red lesion faintly visible under the macular fovea, and scattered punctate deep hemorrhage in the peripheral retina. The results of OCT examination are presented inQuintessence Picture 1。 Clinical diagnosis: detachment of retinal pigment epithelium in the right eye.