亚洲春季角结膜炎的诊疗规范：2022年亚洲专家共识解读

春季角结膜炎(VKC)是一种反复发作的眼部过敏性疾病,其特征表现为双侧眼表慢性炎症,若不及时干预,可导致眼表不可逆性损伤甚至失明。《亚洲春季角结膜炎的诊断、管理和治疗：亚洲春季角结膜炎管理专家工作组的建议》详细介绍了VKC的最新管理方法。本文就该共识进行全面解读,旨在进一步提高广大医务工作者诊断和治疗VKC的水平,以便更好地服务于广大眼病患者。     

New perspectives in ocular surface disorders. An integrated approach for diagnosis and management

The cornea, conjuctiva and the limbus comprise the tissues at the ocular surface. All of them are covered by stratified, squamous, non-keratinizing epithelium and a stable tear film. The ocular surface health is ensured by intimate relationship between ocular surface epithelia and the preocular team film. There are two types of ocular surface failure. The first one is characterized by squamous metaplasia and loss of goblet cells and mucin expression. This is consistent with unstable tear film which is the hallmark of various dry-eye disorders. The second type of ocular surface failure is characterized by the replacement of the normal corneal epithelium in a process called limbal stem cell deficiency. It is essential to establish accurate diagnosis for appropriate management of complex ocular surface disorders. There has been considerable advancement in the understanding of the pathophysiology of ocular surface disease. Management has improved with introduction of the limbal stem cell concept and use of amniotic membrane transplantation.     

Management of the late ocular sequelae of Stevens-Johnson syndrome

The acute conjunctivitis seen initially in Stevens-Johnson syndrome is followed by a cicatricial phase, which often leads to severe ocular surface disease and visual morbidity. Manifestations include keratinization of the conjunctiva, lid margins, and lacrimal and meibomian ducts, resulting in an unstable tear film and mechanical trauma to the conjunctiva and cornea with blinking. Limbal stem cell deficiency is the most vision-threatening sequela of Stevens-Johnson syndrome, as it causes corneal neovascularization, chronic corneal inflammation, and an irregular corneal epithelium. Management of late sequelae often requires a multipronged approach, including strategies for ocular surface protection, ocular surface support, and ocular surface reconstruction. In this review, established therapies, as well as new experimental therapies, are discussed.     

Anterior scleritis: three case reports and a review of the literature.

BACKGROUND: Scleritis is a rare ocular condition involving vasculitis. It can result in severe ocular morbidity and has a high association with underlying systemic disease and mortality. Management can be challenging and under-diagnosis is a concern. Treatment usually requires systemic medications and co-management with a medical specialist in the appropriate field to manage any underlying systemic etiology. METHODS: Three cases are presented: idiopathic nodular scleritis with complete recovery; bilateral, diffuse anterior scleritis with rheumatoid arthritis; and scleromalacia perforans treated with chemotherapeutic agents and co-managed with a rheumatologist. A search of the English language literature is reported, also. RESULTS: The reported cases exemplify much of our knowledge regarding scleritis. The literature review focuses on the challenges of an accurate diagnosis and management. Management is challenging and, although standards exist, controversy remains. The literature discusses the relationship of scleritis to underlying systemic disease and the significant implication of this association. CONCLUSION: Knowledge of scleritis may aid in determining a timely and accurate diagnosis and treatment of both the ocular and any underlying systemic conditions, thus decreasing morbidity and mortality.     

Ocular involvement in Beh?et's disease

Beh?et's disease is a chronic systemic disorder characterized by recurrent uveitis, aphthous lesions of the mouth, and ulcerations of the genitalia. Vision loss from ocular involvement is frequently the presenting symptom and optometrists should be aware of the various ocular signs of Beh?et's disease. Management of the Beh?et's patient involves systemic therapy and therefore requires comanagement with an internist and/or ophthalmologist. A case report of this infrequent type of uveitis is described along with a discussion of the care and visual prognosis of the Beh?et's patient.     

Mycobacterium chelonae conjunctivitis and scleritis following vitrectomy

The atypical, or nontuberculous, mycobacteria are opportunistic pathogens that usually cause infection following accidental trauma or surgery. These organisms are ubiquitous in nature but have been found with increasing frequency in other environments that include medical offices and surgical suites. Management of atypical mycobacterial ocular infections can be difficult because in vitro antibiotic activity does not always correlate with in vivo efficacy and because normal immune defenses against mycobacteria may work too slowly to prevent irreversible damage to infected ocular tissues. This report describes a patient who developed a severe ocular infection due to Mycobacterium chelonae after vitrectomy. Despite eradication of the infection, the eye became blind and painful. Arch Ophthalmol. 2000;118:1125-1128     

Rhegmatogenous retinal detachments with cytomegalovirus retinitis

The most important ocular opportunistic infection in patients with AIDS is cytomegalovirus (CMV) retinitis. Management of CMV retinitis has become complex, as the life expectancy of many patients has increased exponentially. Most retinal detachments in CMV retinitis are rhegmatogenous in nature. Because of atrophic changes in the retina and alterations in the vitreous, surgical management of these detachments leads to a stepladder approach. Options include laser demarcation, scleral buckle, and vitrectomy with silicone oil. In some patients, a combination of all three procedures may be necessary. Management in all cases should be individualized, with the realization that failure of retinal reattachment may occur.     

Stroke: The Optometrist's Role

ABSTRACT: The mechanisms of cerebrovascular insufficiency leading to stroke and transient ischemic attack (TIA) are outlined. Signs and symptoms of TIA are explained in terms of the cerebral and ocular territory supplied by the various cerebral arteries. The internal carotid artery in its cervical course is particularly liable to atherosclerotic lesions; these lesions cause TIA having ocular and general deficits with characteristic patterns of expression. It is suggested that carotid auscultation should form part of the optometric clinical routine provided for hypertensive and diabetic patients and all those 50 years of age and over. Management guidelines for patients at risk of stroke are outlined and a schematic diagram is provided to facilitate recognition of these subjects.     

MEK inhibitors: a new class of chemotherapeutic agents with ocular toxicity

A new class of chemotherapeutic agents, MEK inhibitors, has recently been developed and is proving to be an effective treatment for a number of cancers. A pattern of ocular adverse events has followed these drugs through clinical trials and their association with retinopathy is only just beginning to be recognized. We present two cases of MEK inhibitor-associated retinopathy followed by a review of the current literature on ocular toxicity associated with MEK inhibitors. Patients undergoing treatment with MEK inhibitors appear to have high rates of multifocal serous retinal detachments as well as retinal vein occlusions. We present the first report of cystoid macular edema associated with MEK inhibitor use. The mechanism of these adverse events is still unclear though they seem to be related to oxidative stress and blood retinal barrier breakdown. Management of the ocular toxicity can range from observation to topical treatments or intravitreal injections. Fortunately most ocular adverse events appear to be self-limited and do not require discontinuing the MEK inhibitor. Discontinuation or decreased dosing of MEK inhibitors may be reserved for cases of severe sight-threatening ocular toxicity.     

Options for management of intra ocular tumors

The management of intra ocular tumors has undergone a sea change from the era of enucleation or external beam radiation. With the advent of new chemotherapy protocols, globe and vision salvage have become possible in a majority of cases of retinoblastoma. This article is an overview of the various modalities available for the management of intra ocular tumors and their indications. Chemotherapy has been covered elsewhere in this series of articles on ocular oncology. Photocoagulation and cryopexy are easily administered modalities of treatment for small tumors and totally within the ophthalmologist''s domain. Slightly larger tumors are treatable with brachytherapy. The susceptibility of the tumors to chemotherapy and radiation decide the choice of treatment and the dosage. Management of intra ocular tumors very often needs a multidisciplinary approach including ophthalmologist, oncologist, radiation physicist, and radiotherapist.     

Lateral fixation of sclera to the periosteum with medial rectus disinsertion for severe myopic strabismus fixus

Myopic strabismus fixus is characterized by severe ocular motility restriction with the development of progressive esotropia and hypotropia. Management of severe cases with strongly positive forced duction test can be challenging. We describe a longstanding case of myopic strabismus fixus, which was managed by bilateral medial rectus disinsertion and scleral fixation laterally to the periosteum.     

A practical treatment algorithm for managing ocular surface and tear disorders

Management of ocular surface irritation and morbidity associated with dry eye has been plagued by the complex interplay of different pathogenic elements and substantial variability of ocular surface deficits in patients. A practical algorithm is proposed to achieve effective management of dry eye. When the eye is open, ocular surface health is governed by a stable tear film that is maintained by neuroanatomic integration via 2 reflexes. Any dysfunctional element in this neuroanatomic integration is potentially pathogenic and creates ocular surface deficits leading to dry eye. In general practice, 5 major dysfunctional elements have been identified: decreased ocular surface sensitivity, aqueous tear deficiency, lipid tear deficiency, delayed tear clearance, and ineffective tear spread. Clinical workup should be individualized to identify all such dysfunctional elements in each patient through history taking, external and slit-lamp examination, and special tests. However, practical management lies in the detection of delayed tear clearance. The following strategies are advised: (1) eliminate all intrinsic inflammatory, infectious, allergic, and toxic insults, especially those associated with delayed tear clearance; (2) correct diseases that impede and interfere with tear spread and capacity; (3) create delayed tear clearance for aqueous tear-deficient dry eye by punctual occlusion; and (4) treat lipid-deficient dry eye after sufficient aqueous tears have been conserved. The aforementioned algorithm ameliorates ocular surface irritation and curtails morbidity in most patients. This algorithm can also be adopted for complex cicatricial ocular surface diseases before managing the remaining deficits resulting from hydrodynamic deficiency.     

Diabetic retinopathy – An update

Management of diabetes should involve both systemic and ocular aspects. Control of hyperglycemia, hypertension and dyslipidemia are of major role in the management of diabetic retinopathy. In the ocular part; laser treatment remains the cornerstone of treatment of diabetic macular edema (focal/grid), severe non-proliferative and proliferative diabetic retinopathy (panretinal photocoagulation). There is a strong support to combination therapy. Using one or two intravitreal injections such as anti-VEGF and or steroid to reduce central macular thickness followed by focal or grid laser to give a sustained response may offer an alternative to treatment in diabetic macular edema. Anti-VEGF were found to be effective as an adjunct therapy in proliferative diabetic retinopathy patient who is going to have vitrectomy for vitreous hemorrhage with neovascularization, panretinal photocoagulation, and other ocular surgery such as cases with neovascular glaucoma and cataract with refractory macular edema.     

Neovascular glaucoma diagnosed following carotid endarterectomy

We report a case of bilateral asymptomatic rebeosis iridis related to a bilateral obstruction of the carotid arteries. The iridocorneal angles were closed by a neovascular membrane and intraocular pressures were normal within both eyes (normotensive neovascular glaucoma). After left carotid endarterectomy, the increased perfusion of the ciliary body and the increased secretion of aqueous humor resulted in a sudden bilateral ocular hypertension. Management of ocular neovascularization related to carotid artery obstruction may involve the destruction of areas of retinal ishchemia (laser panretinal photocoagulation or cryotherapy) before carotid surgery.     

The treatment of animal bite injuries of the eye and ocular adnexa

Animal bites to the eye and ocular adnexa may result in significant morbidity. Management includes wound care and surgical repair of traumatized tissue, treatment of infection (most commonly Pasteurella multocida), appropriate tetanus and rabies prophylaxis, and notification of state public health officials.     

Ocular adnexal lymphomas: five case presentations and a review of the literature

The ocular adnexal lymphomas represent the malignant end of the spectrum of lymphoproliferative lesions that occur in these locations. The Revised European and American Lymphoma (REAL) Classification and the new World Health Organization Classification of Tumors of Hemopoietic and Lymphoid Tissues are the most suitable for subdividing the ocular adnexal lymphomas, whereby the extranodal marginal zone B-cell lymphoma represents the most common lymphoma subtype. This review is based on five cases subtyped according to the above classifications-three "typical" lymphomas (an extranodal marginal zone B-cell lymphoma, a diffuse large cell B-cell lymphoma arising from an extranodal marginal zone B-cell lymphoma, and a follicular lymphoma) and two "atypical" lymphomas (a non-endemic Burkitt lymphoma in an immune competent elderly patient, and a primary Hodgkin lymphoma of the eyelid) of the ocular adnexa. Management of patients with ocular adnexal lymphomas includes a thorough systemic medical examination to establish the clinical stage of the disease. The majority of patients with ocular adnexal lymphoma have stage IE disease. Current recommended therapy in stage IE tumors is radiotherapy, while disseminated disease is treated with chemotherapy. Despite usually demonstrating an indolent course, extranodal marginal zone B-cell lymphomas are renowned for recurrence in extranodal sites, including other ocular adnexal sites. Long-term follow-up with 6-month examinations are therefore recommended. Major prognostic criteria for the ocular adnexal lymphomas include anatomic location of the tumor; stage of disease at first presentation; lymphoma subtype as determined using the REAL classification; immunohistochemical markers determining factors such as tumor growth rate; and the serum lactate dehydrogenase level.     

Surgical management of recurrent localized eyelid amyloidosis

Amyloidosis is a disease of unknown origin characterized by the widespread or localized deposition of amorphous hyaline material, amyloid, in various body tissues, including the ocular and orbital structures. Primary advanced localized amyloidosis involving the eyelid and conjunctiva is a rare cause of diffuse eyelid thickening. Management of these cases is often unsatisfactory because of the diffuse deposition of amyloid tissue and the increased risk of intraoperative hemorrhage, due to the fragile vessels encountered in amyloidosis. The possibility of recurrence also presents challenging treatment dilemmas. Therapeutic options include en bloc removal of the involved eyelid tissue, radiation therapy or, in advanced cases, no treatment. We describe an effective surgical approach that offers a safe, effective, and, most notably, repeatable procedure for the treatment of advanced ocular adnexal amyloidosis.     

Lymphoproliferative Läsionen der okulären Adnexe

The ocular adnexal lymphomas represent the malignant end of the spectrum of lymphoproliferative lesions which occur in the conjunctiva, eyelids, lacrimal gland and orbit. The new “W.H.O. Classification of Tumours of Haemopoietic and Lymphoid Tissues” is the most suitable for subdividing the ocular adnexal lymphomas, whereby the extranodal marginal zone B-cell lymphoma (EMZL) represents the most common lymphoma subtype. Management of patients with ocular adnexal lymphomas includes a systemic medical examination to establish the clinical stage of the disease. Most patients have stage IE disease and current recommended therapy for this is radiotherapy, while disseminated disease is treated with chemotherapy. Despite usually demonstrating an indolent course, EMZLs are renowned for recurrence in extranodal sites, including other ocular adnexal sites. Furthermore, blastic transformation of EMZL with a corresponding aggressive clinical course has been described. Long-term follow-up with half-yearly examinations are therefore recommended. Major prognostic criteria for the ocular adnexal lymphomas include the age of the patient, anatomical location of the tumour, stage of disease at first presentation, serum lactate dehydrogenase level at the time of diagnosis, lymphoma subtype as determined using the W.H.O. lymphoma classification and the tumour cell growth rate. The clinical symptoms and the histopathological findings of the differential diagnoses of lymphoproliferative lesions of the ocular adnexa are discussed.     

Lymphoproliferative lesions of the ocular adnexa. Differential diagnostic guidelines

The ocular adnexal lymphomas represent the malignant end of the spectrum of lymphoproliferative lesions which occur in the conjunctiva, eyelids, lacrimal gland and orbit. The new "W.H.O. Classification of Tumours of Haemopoietic and Lymphoid Tissues" is the most suitable for subdividing the ocular adnexal lymphomas, whereby the extranodal marginal zone B-cell lymphoma (EMZL) represents the most common lymphoma subtype. Management of patients with ocular adnexal lymphomas includes a systemic medical examination to establish the clinical stage of the disease. Most patients have stage IE disease and current recommended therapy for this is radiotherapy, while disseminated disease is treated with chemotherapy. Despite usually demonstrating an indolent course, EMZLs are renowned for recurrence in extranodal sites, including other ocular adnexal sites. Furthermore, Blastic transformation of EMZL with a corresponding aggressive clinical course has been described. Long-term follow-up with half-yearly examinations are therefore recommended. Major prognostic criteria for the ocular adnexal lymphomas include the age of the patient, anatomical location of the tumour, stage of the disease at first presentation, serum lactate dehydrogenase level at the time of diagnosis, lymphoma subtype as determined using W.H.O. lymphoma classification and the tumour cell growth rate. The clinical symptoms and histopathological findings of the differential diagnosis of lymphoproliferative lesions of the ocular adnexa are discussed.