甲状腺相关眼病(thyroid-associated ophthalmopathy,TAO)，又称Graves眼病，是与甲状腺疾病密切相关的一种器官特异性自身免疫性疾病。眼球突出是TAO的主要临床表现之一，也是临床上多数患者就诊的原因。眼球突出一方面会影响美观，另一方面可因眼睑闭合不全导致暴露性角膜炎或因眼眶压力增大导致压迫性视神经病变。眼眶减压术用于重度TAO已有过百年历史，从最早经外眦皮肤切开的传统外部切口入路进行骨性眼眶减压及脂肪减压到内镜下经鼻入路眼眶减压术，其安全性和有效性均已得到肯定。术后复视是眼眶减压术常见的并发症。近年来，随着眼眶减压术的发展，其越来越多地用于美容目的以矫正眼球突出。然而术后的新发复视仍然是困扰众多相关眼科医疗工作者的难题。近年来，多项研究对术后新发复视的相关因素进行了探讨，并由此对眼眶减压术进行改良，在对术后新发复视的减少方面取得不同程度的进展。该文对眼眶减压术后新发复视的研究进展进行综述，旨在促进专科医生更精准地开展TAO的手术，进而提高手术患者术后的生活质量及手术满意度。
Thyroid-associated ophthalmopathy (TAO), known as Graves’orbitopathy, is an organ specific autoimmune disease closely related to thyroid diseases. Exophthalmos is one of the main clinical manifestations of thyroid related ophthalmopathy and is also the reason for most patients seeking medical atention in clinical practice.Eyeball protrusion can afect aesthetics on the one hand, and on the other hand, it can lead to exposed keratitis due to incomplete closure of the eyelids or compressive optic neuropathy due to increased orbital pressure.Orbital decompression has been used to treat severe TAO that threatens vision for over 100 years, and its safety and efectiveness have been confrmed.However, postoperative new diplopia remains a challenge for many ophthalmic medical workers.In recent years, many studies have explored the relevant factors of postoperative new diplopia, and improved the surgery, achieving varying degrees of progress in reducing postoperative new diplopia.Tis article reviews the research progress of new diplopia afer orbital decompression, aiming to promote more accurate surgery for thyroid related eye diseases by specialized doctors.
本文总结了15例自膨胀水凝胶眶内植入术患儿围手术期的护理要点。术前主要评估患儿是否完善术前检查，给予患儿及其家属个性化的心理护理，进行术前准备以及禁食禁饮的管理。术后主要给予患儿安全管理，饮食、疼痛、眼部用药以及弹力绷带包扎护理，关注有无并发症的发生及给予相应的护理，并对患儿及其家属做好出院指导。15例患儿均顺利完成手术，术后均出现术眼疼痛，2例出现眶压增高，1例出现呕吐，均得到妥善处理。术后随访3~18个月，患儿均获得了较为满意的眼部外观，生活质量得到了提高。
This paper summarized the nursing experience of 15 children with self-expanding hydrogel orbital implantation during perioperative period. Before operation, children were fully evaluated, given with psychological care, preoperative preparation and management of fasting and drinking. After the surgery, the patients were mainly given with safety management, diet, pain, medicine and elastic bandage dressing care. Nurses should pay attention to the occurrence of complications and give corresponding nursing care and offer useful discharge guidance for the children and their parents. All 15 children completed the operation successfully, postoperative eye pain occurred in 15 cases after operation, and the orbital pressure increased in 2 cases, 1 case vomited, and all cases were properly treated. After postoperative follow-up for 3–18 months, 15 children were satisfied with the appearance of the eye,and the life quality was improved.
目前Wetlab眼科手术教学采用猪眼球作为教学模型，与实际手术差别较大，且无法满足外眼手术教学的需求。通过使用带有眼球、眼外肌、眶组织、眶骨及眼睑结构的全眼模型，可高度模拟真实手术场景，覆盖更多眼科手术教学需求。基于全眼模型构建多个眼科手术教学平台，依照培养阶段设计手术课程，创建新的评价体系，改变传统将“内眼”“外眼”分开的教学理念，可使年轻医师从一开始就建立眼科“分科而不分割”的整体思维，从而使眼科手术培训更加规范和完善。
Porcine eyes have been used as animal model in ophthalmic surgery training. However, it differs greatly from real surgery and cannot meet the needs of external eye surgery teaching. Porcine orbit model with eyeball, extraocular muscles, orbital tissue, bones and eyelids can be more realistic simulation of real surgeries and cover more needs for ophthalmic surgery teaching. By setting up ophthalmic surgery teaching platforms, designing staged course and creating new assessment methods based on porcine orbit model, the traditional concept about separation of internal and external eye is changed. This helps young doctors to establish a holistic view from the very beginning,that ophthalmic surgeries should not be split because of subspeciality. In this way, ophthalmic surgery training will become more standardized and perfected.
眼眶泪腺淋巴上皮癌是一种非常少见的恶性肿瘤。本例为一位46岁女性患者，表现为左眼睑红肿、眼球突出和视力下降，临床和影像学表现类似于泪腺炎型假瘤。手术完整切除后送检病理检查，其特征是未分化的癌巢之间有大量分化成熟的淋巴细胞、浆细胞浸润，确诊为淋巴上皮癌。术后行化学治疗和局部放射治疗，随访6.5年无复发。眼眶泪腺淋巴上皮癌的临床表现容易与泪腺炎型假瘤相混淆，应该进行病理学检查以明确其恶性表型，完整切除后辅助放化学治疗有较好的效果。
Lymphoepithelial carcinoma of the orbital lacrimal gland is a rare carcinoma. A 46-year-old female patient presented with red and swollen left eyelid, proptosis and blurred vision. The clinical and imaging manifestations were similar to inflammatory pseudotumor. Pathological examination was performed after complete resection.Pathological features showed undifferentiated carcinoma nests surrounded by obvious infiltration of non-neoplastic lymphocytes and plasma cells, which was consistent with the diagnosis of lymphoepithelial carcinoma.Chemotherapy and local radiotherapy were performed after the resection. The case did not relapse after 5 years of follow-up. The clinical manifestations of orbital lacrimal lymphoepithelial carcinoma were easily confused with inflammatory pseudotumor. Pathological examination should be performed to clarify its malignant phenotype.Adjuvant radiotherapy and chemotherapy after complete resection had a good effect.
目的：分析发生于眶骨的占位性病变的CT表现及其与组织病理学之间的关系。方法：回顾性收集15例经临床表现、影像学特征、病理证实为发生于眶骨占位病变患者的临床资料，分析其CT检查、组织病理学切片及其他临床表现。结果：在15例患者中，经病理诊断为骨瘤的患者有4例，骨内血管瘤3例，骨样骨瘤和骨化性纤维瘤各2例，嗜酸性肉芽肿3例，尤文肉瘤1例。骨瘤由成熟板层骨构成，对应在CT上呈现为高密度的骨样结节状隆起；骨内血管瘤病理主要表现为骨小梁间的畸形血管，在CT上表现为典型的“栅栏状”“蜂窝状”特征；骨样骨瘤以骨样组织和结缔组织为主，在CT上为类圆形的高密度影，中央为典型的低密度“瘤巢“影，外周为增生的骨密度影；骨化性纤维瘤由增生的纤维组织及骨样组织构成，CT表现为肿瘤表面常有骨壳包绕，病变多呈圆形或椭圆形；嗜酸性肉芽肿主要由大量朗格汉斯细胞组成，对应CT上的软组织肿块影，可伴溶骨性破坏；尤文肉瘤以低分化的小圆细胞为主，CT表现为虫蚀样骨质破坏，破坏的骨组织间有软组织病变。结论：发生于眶骨的各类病变有其特有的病理组成，不同的病理组成在CT上表现出相应的影像特征。
Objective: To analyze computed tomography (CT) manifestations of space-occupying lesions of the orbital bone and their relationship with histopathology. Methods: The clinical data of 15 patients with orbital bone occupying lesions confirmed by clinical manifestations , imaging features and pathological symptoms features were retrospectively collected, and their CT examination, histopathological sections and other clinical manifestations were analyzed. Results: Among the 15 patients, 4 cases were pathologically diagnosed with osteoma, 3 cases of intraosseous hemangioma, 2 cases of osteoid osteoma and 2 cases of ossifying fibroma, 3 cases of eosinophilic granuloma and 1 case of Ewing’s sarcoma. Osteoma was composed of mature lamellar bones, which corresponded to a high-density osteoid nodular protuberance on CT. The pathological features of intraosseous hemangioma were mainly malformed blood vessels between bone trabeculae and typical “fence” and “honeycomb” features on CT. Osteoid osteoma was mainly composed of bone-like tissue and connective tissue, mainly showing round high-density shadow, typical low-density “tumor nest” shadow in the center, and hypertrophic bone density shadow in the periphery. Ossifying fibroma was composed of proliferative fibrous tissue and bone-like tissue. CT showed that the surface of the tumor was often surrounded by bone shell, and the lesions were mostly round or oval. Eosinophilic granuloma was mainly composed of a large number of Langerhans cells, which corresponded to the soft tissue mass on CT and could be accompanied by osteolytic destruction. Ewing’s sarcoma was mainly composed of poorly differentiated small round cells, and CT manifestations were worm-eaten bone destruction with soft tissue lesions between destroyed bone tissues. Conclusion: Various lesions occurring in the orbital bone have their own special pathological composition. Different pathological components show corresponding imaging features on CT.
目的：探讨眼眶黏膜相关淋巴组织(mucosa-associated lymphoid tissue，MALT)结外边缘区B细胞淋巴瘤的临床表现、影像学特征及病理学特点，以期减少眼眶淋巴瘤的误诊，提高生存率。方法：对2020年1月至2020年12月中山大学中山眼科中心诊治的71例眼眶MALT结外边缘区B细胞淋巴瘤的临床、影像及病理学资料进行回顾性分析。结果：71例患者中，男38例，女33例；左侧眼眶31例，右侧眼眶34例，双侧眼眶6例；原发病例67例，复发病例4例；年龄23~84岁，病程为3个月~15年。最常见的临床表现是眼部肿块和不同程度的眼球活动受限；磁共振成像(magnetic resonance imaging，MRI)检查见密度均匀的软组织影，呈“铸造样”，眼球内未见侵犯；组织病理检查可见肿瘤由小至中等大小淋巴样细胞组成，瘤细胞呈弥漫或片状生长，核小到中等、不规则，核仁不明显，部分细胞呈单核样淋巴瘤细胞改变，其中9例可见浆细胞样分化，伴浆细胞分化的病例kappa与lambda的表达不对称。结论：眼眶MALT结外边缘区B细胞淋巴瘤有多种临床表现，影像学检查具有一定的特征，可辅助术前诊断。病理学检查可用于术后的准确诊断及分型，据此制定合适的治疗方案，提高疗效。
Objective: To investigate the clinical, imaging and pathological features of orbital extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT), so as to reduce misdiagnosis and improve survival rate.Methods: The clinical, imaging and histopathological data of 71 patients with orbital extranodal marginal zone B cell lymphoma of MALT who were treated in Zhongshan Ophthalmic Center, Sun Yat-sen University from Jan.2020 to Dec. 2020 were retrospectively analyzed. Results: There were 38 males and 33 females in the 71 patients.There were 31 cases located on the left orbit, 34 cases on the right orbit, and 6 cases were bilateral; there were 67 primary cases and 4 relapsed cases. The age ranged from 23 to 84 years old. The disease course ranged from 3 months to 15 years. The main clinical manifestations included ocular masses and limited eyeball movement.Magnetic resonance imaging showed a “cast-like” soft tissue shadow of uniform density, and no intraocular invasion is observed. Histopathological examination showed that the tumor was composed of small to medium sized lymphocyte-like cells. Tumor cells exhibited diffuse or lamellar growth, with small to medium-sized irregular nuclei, and the nucleoli were inconspicuous. Some of the lymphocyte-like cells showed mononuclear lymphoma cells changes, and plasmacytoid differentiation was observed in 9 cases, in which kappa and lambda expressions were asymmetric.Conclusion: The clinical manifestations of orbital extranodal marginal zone B cell lymphoma of MALT are various, and imaging examination has certain characteristics, which can assist preoperative diagnosis.Pathological examination can be used for accurate diagnosis and classification after operation, based on which appropriate treatment plan can be made and curative effect can be improved.
目的：探讨眼眶原发性滑膜肉瘤(synovial sarcoma，SS)的临床病理学及分子遗传学特点。方法：收集1例复旦大学附属眼耳鼻喉科医院眼科2020年10月收治并经病理学检查证实为眼眶原发性SS的病例，同时回顾性分析文献中已报道的10例眼眶原发性SS的临床及病理检查资料，包括临床表现、影像学检查、组织学特点、免疫表型及分子病理学检查结果。结果：患者女，53岁，因“复发性右眼眶内肿物13余年”收治入院。SS组织病理学：肿瘤由弥漫分布的单一短梭形细胞组成，肿瘤细胞异型性明显，胞质少，核分裂多见；肿瘤侵犯结膜下、巩膜表面、视神经鞘膜、眶内肌肉及纤维脂肪组织。免疫组织化学检查提示波形蛋白(Vimentin)、Calpolnin、CD99、Bcl-2均阳，SMARCB1(INI-1)部分阳/弱阳。荧光原位杂交(fluorescence in situ hybridization，FISH)法检测到SS18基因易位。回顾性总结文献中已报道的10例和本例(总共11例)眼眶SS患者，其中男性2例，女性9例，左眼6例，右眼5例；患者发病年龄为1~53岁，平均年龄22岁，中位年龄24岁。患者术前病程范围较广，为1周~13年。11例中，5例症状至少出现3年以上，多表现为进行性眼球突出伴眼球移位及运动受限，疼痛及视力下降。CT和MRI上多表现为分叶状或者卵圆形软组织肿块，部分因出血坏死出现囊性外观，增强扫描显示病灶呈不均匀强化。组织学上，本组11例眼眶SS中单相纤维型7例，双相型4例，单相纤维型中有2例存在分化差的成分。免疫组织化学染色显示：上皮样成分表达上皮标记(CKpan、CK7、CK19)和Vimentin；梭形细胞表达Vimentin、CD99、Bcl-2、Calpolnin、TLE1及灶性表达上皮标记。结论：眼眶原发性滑膜肉瘤罕见，形态上需要和眼眶其他软组织来源恶性肿瘤相鉴别，其具有特征性t(x:18)(p11;q11)染色体易位，产生SY T-SSX融合基因，分子病理学的检测有助于最后确诊。
Objective: To investigate the clinicopathological and molecular genetics features of synovial sarcoma (SS) of the orbit. Methods: We retrospectively reviewed 10 published cases of primary SS of the orbit, along with 1 case of primary SS of the orbit confirmed by pathology who was admitted to the ophthalmology department of Eye & ENT Hospital of Fudan University in October 2020. The clinical data, radiological findings,morphology, immunophenotype and genetic characteristics of the cases were analyzed. Results: Our case was a 53-year-old woman with an SS in the right orbit, which had recurred multiple times. Histopathologic examination showed a primitive tumor composed of spindled and ovoid cells. Focal infiltration was observed in adjacent structures, such as the sub-conjunctiva, scleral surface, optic nerve sheath, muscle, and fibro-fatty tissue. Immunohistochemistry showed positivity for vimentin, calponin, CD99, and Bcl-2 and loss of INI-1expression, which is typical of SS. Fluorescence in situ hybridization (FISH) showed the (X;18)translocation in the tumor cells. The analysis included 2 males and 9 females aged between 1 and 53 years old (mean: 22 years; median: 24 years). Among the SS cases, 6 left eyes and 5 right eyes (all monocular cases)were affected. Symptoms had been present from 1 week to 13 years in the case from our hospital, while in 5 cases, symptoms had been present for at least 3 years. Common clinical features of the patients included proptosis or globe displacement, decreased vision, and pain. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed an ovoid mass with heterogenous enhancement and a cystic appearance,which was probably attributable to hemorrhage or necrosis. Of these 11 cases, 7 cases were biphasic SS,4 were monophasic fibrous SS, and 2 were poorly differentiated in monophasic SS. Immunohistochemistry revealed positivity for pan-cytokeratin (CKpan), CK7, CK19, vimentin, cluster of differentiation 99 (CD99),B-cell lymphoma 2 (Bcl-2), calponin and transducin-like enhancer protein 1 (TLE1). Conclusion: Primary SS of the orbit is extremely rare and needs to be distinguished from other spindle cell tumors of orbital soft tissue. The SS diagnosis is based on the presence of the t(X;18) (p11; q11) translocation, which results in an SYT-SSX fusion gene.
目的：中重度甲状腺相关眼病内下壁骨性减压联合脂肪减压术的临床疗效观察。方法：回顾性分析25例(31眼)在浙江大学医学院附属第二医院眼科行内下壁骨性减压联合脂肪减压术治疗的甲状腺相关眼病患者，观察时间为2020年1月至2022年1月。术前所有患者均进行了眼眶CT检查，并对双眼视力、眼球突出、复视及双眼外观形态进行了测量。手术效果评价指标为：术后眼球突出度、视力和复视程度，并对相关数据进行统计和分析。结果：术后眼球突出度回退2~6 mm，平均回退(3.45±0.93)mm，切除眶内脂肪1.4~3.6 mL，平均切除(2.33±0.66)mL，外观恢复满意。4例患者术前存在复视，2例患者术后新发复视，术前已存在复视的患者，术后复视程度并未加重，新发的2例复视患者均为轻度复视。术后CT检查显示眼眶减压效果良好。结论：内下壁骨性减压与脂肪减压术联合，可以有效扩大眼眶容积，对眼球进行回纳，减少眼球突出程度，改善容貌外观，且手术切口隐蔽美观，具有较好的临床疗效果。
Objective: To observe the clinical efficacy of medial-inferior wall orbital decompression combined with fat decompression in the treatment of moderate-to-severe thyroid associated ophthalmopathy (TAO). Methods: A retrospective analysis was performed on 25 patients (31 eyes) with moderate-to-severe TAO from January 2020 to January 2022 in Eye Hospital of Zhejiang University, who were treated with medial-inferior wall orbital decompression combined with fat decompression. All of patients were given orbital computed tomography to measure visual acuity, exophthalmos, diplopia and ocular appearance before operation. The preoperative and postoperative exophthalmos, visual acuity and diplopia before and after operation were taken as efficacy evaluating indicators. The related data was counted and analyzed statistically. Results: After operation, the reduction of exophthalmos was 2-6 mm, with an average of (3.45±0.93) mm, the volume of intrazonal fat-removal was 1.4-3.6 mL, with an average of (2.33±0.66) mL, with a satisfactory appearance. There were 4 cases of preoperative diplopia and 2 cases of new diplopia after operation, all of which were mild diplopia. Diplopia did not exacerbate after operation in the patients who had diplopia before operation. Conclusion: Medial-inferior wall orbital decompression combined with fat decompression in the treatment of moderate-to-severe TAO can effectively expand orbital volume, reduce exophthalmos, improve appearance with a concealed beautiful surgical incision, showing its good clinical efficacy.
患儿因“左眼红肿12 d”就诊。左上睑红肿(++++)，眼眶鼻侧可触及约黄豆大小硬结，界不清，质地中等，压痛(?)，伴上睑下垂，遮盖角膜下缘。双眼眼位正，左眼眼球外转轻度受限。眼眶及视神经MRI显示左眼上睑软组织肿胀，考虑炎性改变。入院诊断为左眼特发性眼眶炎性假瘤(Idiopathic orbital inflammatory pseudotumor，IOIP)。予以激素治疗后症状好转且随访期间无复发。本例患儿为拒绝外院活检而就诊于暨南大学附属第一医院的小儿IOIP病例，提示早期规范治疗是降低此病复发率的关键，尤其是儿童患者。
The pediatric patient was referred to our hospital with a 12-day history of left eye redness and swelling. On the orbital and nasal side of the eye, there was a firm, nontender mass about the size of soybeans, with unclear boundary, medium texture. Orbital examination showed left ptosis, covering limbus. Motility examination revealed both eyes were in normal position, and the left eye was slightly limited in extraocular rotation. Magnetic resonance imaging (MRI) revealed evidence of diffuse inflammation of left eyelid, and orbital inflammatory was considered. Excluding other etiologies, the child was diagnosed initially with idiopathic orbital inflammatory. The symptoms improved after hormone therapy and there was no recurrence during follow-up. This case was a case of IOIP in a child who was admitted to the First Affiliated Hospital of Jinan University for refusing biopsy from another hospital. The paper suggests that early standardized treatment is the key to reduce the recurrence rate of this disease, especially in children.
目的：探讨基于微信的图像存储和传输系统(picture archiving and communication system，PACS)教学在眼眶科规培医生中的教学效果及质量评价。方法：将中山眼科中心眼眶科轮训的66名规培医生分为A组(PACS组)与B组(微信+PACS组)。通过出科考核和问卷分析比较两组学生的教学效果及满意度。结果：B组学生的基础知识测试和阅片技能测试得分均显著高于A组(P<0.001，P=0.037)。教学效果自我评估量表显示B组学生对解剖结构位置的熟悉程度、影像学诊断、鉴别诊断能力、工作中解读CT或MRI图像的能力预判，以及对CT或MRI影像学的兴趣，明显优于A组(均P<0.001)。所有学生(100.00%)对这种教学模式感到非常满意。结论：在眼眶科住院医师规划化培训中应用基于微信的PACS教学模式能显著提高教学效果和满意度，提高教学质量。
Objective: To evaluate the application quality of picture archiving and communication system (PACS) based on WeChat in standardized resident training in orbital department. Methods: A total of 66 doctors trained in the Orbital Department of Zhongshan Ophthalmic Center were divided into group A (PACS group) and Group B (WeChat +PACS group). The quality and feedback of teaching of the two groups of students were compared through examination and questionnaire. Results: The scores of basic knowledges and reading skills of group B were significantly higher than those of group A (P<0.001, P=0.037). The self-assessment scale for teaching quality showed that the students in group B were superior to group A in understanding the position of anatomical structure, imaging diagnosis and differential diagnosis according to CT or MRI, interpreting CT or MRI images in the future, and interest in CT or MRI imaging (all P<0.001). All the students (100.00%) were very satisfied with this mode of teaching. Conclusion: The application of PACS based on WeChat in standardized resident training in orbital department can significantly improve the quality and satisfaction of ophthalmology teaching.
