Reprinted from: Department of Ophthalmology, Tongji Hospital, Tongji University
Note: experts rank in no order
From 2006 to 2016, the total number of keratoplasty in Germany has been increasing, and the composition of surgical methods has also changed greatly, Posterior lamellar keratoplasty (dmek / DSAEK) has gradually replaced penetrating keratoplasty (PKP) as the most popular corneal transplantation; at least 850 corneal grafts are performed in the eye center of the University of Cologne in Germany every year, of which dmek or DSAEK accounts for about 70% and anterior lamellar keratoplasty (dalk) accounts for about 8%, penetrating keratoplasty accounts for about 20%, and Boston artificial cornea accounts for about 2%.
In the introduction of high-risk dmek, the experts first successfully performed dmek under the guidance of OCT in a patient with bullous keratopathy caused by chemical burn, and showed beneficial results. Tips: 1 Dmek is at "high risk" of corneal edema and neovascularization (scarless) Effective in eyes; 2. Intraoperative navigation OCT is helpful to the operation; 3. Decreased neovascularization. Then, he conducted a retrospective study on 24 high-risk eyes with high vascularization and stromal edema to further study the effect of dmek on these patients. The results showed that neovascularization decreased significantly, and the immune response was slightly higher than that of normal risk dmek, but significantly lower than that of high-risk penetrating keratoplasty. Dmek is an optional procedure for (selective) high-risk corneal edema eyes, and more prospective studies are needed in the future.
Among the methods to improve the survival rate of grafts, he introduced the effect of fine needle cautery with anti VEGF drug injection and UV crosslinking on corneal neovascularization and the future research direction.
With the advent of dmek and dalk, corneal transplantation is moving towards a relatively more refined "lamellar" era, which also provides several new methods to improve the success rate of high-risk corneal transplantation: first, high-risk dmek; 2、 Pretreatment before corneal transplantation: fine needle method with anti VEGF injection and corneal cross-linking method.
——Interpretation: Dr. Shao Yuting graduate student
Ocular trauma is one of the main causes of low vision in China. A large number of patients with complex corneal ocular trauma need corneal transplantation to reconstruct visual function.
There are many methods of corneal transplantation. Experts mainly introduced the application of dmek and dsek in complex ocular trauma. Dsek is Descemet's stripping endothelial keratoplasty. Expert Feng pointed out that "the thinner the better" That is, ultra-thin corneal graft can accelerate the healing of donor recipient interface and obtain better visual benefits. However, the depth of anterior chamber in Asian population is mostly shallow, which increases the difficulty of operation. Then Professor Feng explained to us the design points and operation steps of this kind of operation through several cases of decompensation of corneal endothelium and extensive adhesion between iris and corneal endothelium after ocular trauma operation: first, determine the adhesion part through UBM before operation, and fully separate the rainbow membrane and cornea. The key point is to remove all fibrous membranes adhered to the cornea as far as possible, Finally, the pupil was reconstructed. After operation, the anterior segment can be observed by Oct. for some cases with uneven posterior corneal surface, ultra-thin dsek can be repaired by phase II. Professor Feng also pointed out that 23g lighting can be used to assist in cases where obvious corneal opacity and edema affect intraocular operation. Next, Professor Feng showed us that her first dmek operation, Descemet's membrane endothelial keratoplasty, also achieved good results.
Even for patients with complex ocular trauma, we should try our best to use dsek / dmek method to treat corneal endothelial lesions. The key point of this kind of operation is to flatten the posterior surface of cornea and reconstruct the anterior chamber structure. Ultra thin donor graft is very necessary in this kind of operation. In addition, 23g auxiliary lighting is very helpful for cases of severe corneal edema!
——Interpretation: Dr. Liu Xin graduate student
Glaucoma valve implantation is essentially a filtering drainage operation. It needs enough anterior chamber and clean anterior chamber when screening patients. The choice of this premise is very important.
During operation, 1. Select the upper temporal quadrant as far as possible, avoid the lower nasal quadrant and avoid the nasolacrimal duct area as far as possible. 2. 2. Fixation of eyeball Professor Sun improved the previous rectus suture traction and changed it to 8 / 0 absorbable suture for corneal traction. 3. Production of conjunctival flap: the former 90 ° - 120 ° fornix is improved as the base, and it is improved to be cut about 5-6mm away from the edge of angular conjunctiva to facilitate the implantation of drainage disc. The separation of conjunctiva and fascia is as blunt and deep as possible to avoid other complications caused by the ejection of drainage disc. 4. The operation needs to be combined with the use of drugs. The operation effect: the mitomycin is improved into MMC solution, and the cotton swab is used instead of the cotton piece, so as to avoid the cotton piece remaining and difficult to take out. 5. When the drainage valve is implanted, the key point is to sew firmly to avoid prolapse or deep damage to cornea and other tissues. 6. During anterior chamber puncture, Professor Sun proposed tunnel puncture to prevent the catheter from eroding through the bulbar conjunctiva. 7. For the suture of catheter, it is recommended that 8-0 absorbable suture be fixed on the surface without sliding. Pay attention to the damage of cornea and iris, and observe whether the catheter orifice is accompanied by tissue obstruction. 8. Do not press bandage after operation, try to avoid sneezing and constipation, and use force to avoid excessive drainage. 9. Management of postoperative complications: low intraocular pressure, shallow anterior chamber and anterior chamber hemorrhage are common complications. The causes of complications can be prevented during operation and treated with drugs after operation. Do not press bandage in the early stage is very important for the prevention of choroidal leakage. If the orifice is blocked, laser incision and reoperation if necessary. Finally, Professor Sun stressed that skilled surgical skills and rich experience are the most critical factors for surgical results.
In addition to learning the skills and precautions of surgical procedures, we should also pay attention to the learning ideas of surgery. Understand the key points and difficulties of the operation steps, the details that need to be paid attention to in each step and the accidents that are easy to occur, and put forward improvement strategies on the principle after understanding the operation principle. Only with the blessing of internal medicine and shell operation skills can the operation effect be doubled.
——Interpretation: Lin Mingyue postgraduate
Since 2018, the general secretary has made the latest instructions on the prevention and control of children's myopia, and the screening and prevention and control of children's myopia in Shanghai have been carried out earlier. At present, myopia in children and adolescents presents a blowout phenomenon, especially in Shanghai, where the myopia rate reaches the top three in China. It is estimated that in 2050, the global population of patients with high myopia will reach 10%, and 925 million patients are expected (Holden El at Ophthalmol 2016).
The long-term and short-term factors leading to myopia include genetic factors, accounting for 10-45%. The environmental factors that can be changed include education, outdoor time and close eye use. At present, there are still controversies about how to quantify close eye use. The scale method is prone to memory bias and has low reliability; The advantage of diary method is that the recall bias is reduced, but the compliance of young recorders is poor, and there is a great difference between diary method and scale method; Empirical sampling method is difficult to evaluate the eye distance at a specific time. In addition, close eye use is not just a matter of distance, But the distance and time of using eyes (diopter hours), but there is no unity. At present, wearable sensors have been used for research, which can actually measure users' close-up eyes. The most widely used is "cloud clip", which can analyze data through app with good accuracy. In addition, "cloud clip" "It can also remind users to improve the way of eye use. The inevitable problem is that users will have different changes when wearing. Although there are differences in the conclusions of several classic studies on close eye use, they all suggest that the increase of close eye use is related to the decrease of outdoor activities and the prevalence of myopia. Electronic video screens also contribute to the occurrence and development of myopia, but we still need to further understand Confirm the settings of the electronic video screen and find the correlation. The mechanisms of myopia mainly include adjustment lag, peripheral defocus, reading material polarity and so on. Although the mechanisms are different, reducing close eye use may be beneficial to control myopia, at least harmless.
——Interpretation: Wang Zhiyue postgraduate
The concept of conventional surgery for incomplete dislocation of lens is to preserve and reshape the suspensory ligament septum of lens capsule to the greatest extent. Vitrectomy is not recommended as soon as the lens is dislocated. How to keep the bag fixed permanently? Previously used MCtr (not available in China in recent years), 9-0 polypropylene suture is used to fix the milk knot on the small hook and sew it on the sclera 1.5-2mm behind the corneoscleral margin. The suture runs through the sclera. Compared with traditional crystal cutting and vitrectomy, it has the advantage of reducing vitreoretinal complications, and the incidence of postoperative net detachment is higher than that of vitreoretinal complications after simultaneous vitrectomy Greatly reduced, but the incision is usually 2.6mm. If it is a child, general anesthesia is also required for suture removal, so it is best to try minimally invasive surgery.
Complicated lens dislocation is difficult to operate. For example, in patients with traumatic large-scale lens dislocation, there are a large number of vitreous bodies in the anterior chamber and secondary glaucoma. The problem of vitreous cavity pressure should be solved first during the operation. The anterior vitrectomy can be carried out first, then the vitreous body in the anterior chamber can be removed, and the capsulorhexis of appropriate size can be carried out, In situ quartering method for nucleus splitting (less impact on the suspensory ligament) and super emulsion. Because there is no posterior suspensory ligament, negative pressure suction increases the risk of posterior capsule rupture. Be careful. You can put the tension ring first, but the equatorial cortex is not fully absorbed. How can the tension ring be permanently fixed? 5-0 polypropylene suture retractor can be used for pupil traction and lens release, and the incision is not sutured (incision 2.2mm, main fluid flow control).
For large dislocation, press the dislocated crystal with the strabismus hook, carefully puncture and tear the anterior capsule, and then tear the capsule after fixing the capsule, otherwise the nucleus will be removed and vitrectomy will be required, which will cause great disturbance in the eye. Try to solve the problem from the front and reduce the disturbance to the rear.
Lens dislocation with ciliary body separation (atrial angular fistula), mark the cornea in the middle of the separation, make a 2.2mm main incision, separate the adhesion first, suck out the lens cortex and nucleus, pay attention to inject viscoelastic agent before pulling out the IA handle, bind 9-0 polypropylene suture with CTR, press the ciliary body separation in the ciliary sulcus, fix the suture with tension ring tail shifting method, thread the suture out of the ciliary body separation, sneak between scleral layers for 3-4 times, and close the ciliary body separation Close.
Clinically, children with loose suture have the risk of intraocular infection, and the suture needs to be removed under general anesthesia. Professor Jiang also explored the operation of incomplete dislocation of lens without corneal suture. He suggested that patients over 5 years old should cooperate with 1 The corneoscleral incision should be as far back as possible, about 2mm behind the limbus; 2. Make a 2.2mm corneal incision with good configuration (the tunnel is longer), be careful of CCC, absorb cortex, lead out the bag hook made of 5-0 polypropylene thread at 1.5mm behind the limbus, and take out the needle 1.5mm behind the limbus without suture. However, this is not recommended for congenital cataract, which has the risk of iris prolapse and anterior synechia.
IOL capsular complex dislocation: when there is no vitreous detachment, the capsular retractor of the complex is fixed (the most minimally invasive and feasible). The retractor first fixes the complex and uses the capsular retractor to fix it. If the complex is removed through a large incision, vitreoretinal complications may increase. Therefore, if the conditions are appropriate, it shall be solved through minimally invasive surgery as far as possible.
Conclusion: we should try to solve the problem with small incision and minimally invasive, and reduce surgical trauma, suture Incision and disturbance to vitreous body (high-speed vitrectomy), comprehensive application of bag retractor, 2.2mm incision, main control handle and high-speed vitrectomy make the operation safe and efficient with less complications. It is recommended to start with the conventional incision at the beginning of minimally invasive surgery, and then make a small incision after proficiency. Operation concept: as soon as possible, as well and efficiently as possible.
The next challenge is lens dislocation with intraocular tumor, dislocation of white nucleus, etc. He said that at any time, we should ensure that 10% of the operations have not been done or feel difficult, so as not to "lie flat" and make progress all the time.
——Interpretation: Dr. Niu Guozhen
Pathological myopia (PM) is one of the main causes of blindness in the world, especially in East Asia. At present, the prevalence of PM in young people has been significantly higher than that in middle-aged and elderly people. There is still a lack of grading standards with high guiding significance for the clinical diagnosis and treatment of PM. Today, with the rapid development of computer image pattern recognition technology, we should focus on exploring artificial intelligence (ibid., AI) application in the field of PM fundus lesion recognition.
In high myopia and PM, myopic maculopathy (MMD) is one of the main causes of visual impairment, including paraoptic atrophy (ibid., PPA), lacquer crack, leopard shaped fundus and pathological myopia choroidal neovascularization (mcnv).
PPA is a common complication, which is caused by the poor blood supply of capillaries in this area due to the collapse of the inner cavity of choroidal capillaries near the optic nerve. AI automatic and accurate identification and extraction of PPA lesions can help doctors deal with a large number of case data efficiently and also contribute to the quantitative analysis of subsequent case data. Lacquer crack pattern damage mostly occurs in the macula and between the optic disc and the macula. At present, it is mostly considered to be caused by the atrophy of pigment epithelium at the chapped Bruch membrane. The automatic segmentation and quantitative analysis of paint crack by AI can effectively reflect the severity of MMD. The research shows that the improved cgan network has high accuracy and good effect in identifying paint crack lesions.
Leopard shaped fundus is a characteristic lesion. The ocular axis of patients with high myopia is longer, the retina becomes thinner, and the thickness and structure of each layer of fundus have also changed. AI can recognize and calculate the thickness of each layer of retina by using machine learning method, and it is faster, more accurate and more stable than manual recognition. Automatic quantitative analysis can not only identify subtle differences that are not easy to find by the naked eye, but also supplement simple manual film reading, which greatly improves the work efficiency.
Mcnv is the most serious complication of PM, Retinal pigment epithelium detachment (ibid., PED) is its clinical feature. The quantitative analysis results of PED can guide the prognosis and treatment plan of the disease. Artificial intelligence can identify and analyze serous ped and vascular ped by using deep neural network method. Moreover, it has high consistency with manual measurement results, high accuracy and fast analysis speed, making AI have a very broad application in the field of PM fundus lesion identification Prospects.
In addition to lesion recognition, artificial intelligence also has its own advantages in PM typing, and also helps doctors solve some doubts about typing. Grade C2 in MMD refers to diffuse atrophy, According to its location, it is divided into PDCA (paraoptic atrophy) and MDCA (macular atrophy), PDCA has little impact on visual function, but MDCA has a great impact on visual function. Therefore, we classify PDCA in C0, C1 and C2 as mild lesions and the rest as severe lesions. Artificial intelligence can automatically and accurately distinguish the classification of myopic macular lesions, and determine whether the lesions are serious, which greatly improves the work efficiency.
Imaging features are superior to clinical features in AI recognition of severe myopic maculopathy. In the future, we should strive to build a standard database of multimode imaging data of pathological myopia, apply artificial intelligence algorithm to identify and locate mcnv and related lesions, conduct joint analysis in combination with patient gene, protein and metabolomics, and mine morphological characteristic parameters closely related to the occurrence and development of PM disease, Look for indicators that can predict the occurrence and development of PM disease.
——Interpretation: Ma Xiaoyu postgraduate
IIT (investigator initiated clinical trial) is the abbreviation of clinical research initiated by researchers, and the administrative measures for clinical research initiated by researchers in medical and health institutions (Trial) issued by the National Health Commission It was officially implemented on October 1 this year and was first piloted in Beijing, Shanghai, Guangdong Province and Hainan Province. IIT has become more and more in recent years, and its concept was first put forward by foreign researchers, Taking individuals or groups (including medical and health information) as the research object and not for the purpose of product registration, it is an activity to study the diagnosis, treatment, rehabilitation, prognosis, etiology, prevention and health maintenance of diseases, which is divided into intervention research and observational research. The administrative measures define and implement IIT.
Details of the regulations on the two types of research in the administrative measures, such as: attention should be paid to carrying out intervention research: 1 To be carried out in Level 3 medical institutions, 2 To be reviewed by the academic committee and ethics committee, 3 It is not allowed to charge any research related fees to the subjects, and it is best to give some compensation; It also explains the precautions for carrying out observational research. In addition, the administrative measures mentioned that if the intervention research has been fully verified, meaningless repetitive clinical research shall not be carried out.
The common misunderstandings in the design of ophthalmic IIT are as follows: 1 Whether the scheme design is selected correctly; 2. Whether the main end point of the study is clear; 3. Whether the sample size is calculated correctly. As for the scheme design, if you want to evaluate the efficacy, you can choose RCT. If you want to conduct etiological research, you can choose case-control study or cohort study. At the same time, for the same research problem, you can choose different design methods to get conclusions with different levels of evidence, and give examples to explain. As for the research endpoint, Professor Zhang pointed out that the setting of the main research endpoint is very important, and shared how to reasonably set the main research endpoint. Professor Zhang also mentioned that the calculation of minimum sample size can help experimenters get research results, and shared several methods of sample size calculation.
During the implementation of IIT, 6 aspects need to be paid attention to 1 The problem of project application, the system of project application, eight cases of not approving the project, six cases of suspending or terminating the research, etc; 2. Clinical research registration; 3. Declaration of human genetic resources: the scope and requirements of declaration, and pointed out that the collection, preservation and utilization of biological samples should be declared as required, otherwise a fine of 500000-5 million yuan will be imposed, and the preservation of biological samples also needs national approval; 4. Ethical approval; 5. Quality control: researchers need to conduct regular self-examination, and medical institutions should also carry out multi-stage secondary quality control; 6. Data management: the archives shall be kept for at least 10 years from the end of the study. It is mentioned that CTMS system can also be used for archives archiving. Our institute also has CTMS system to support the researchers' research process.
——Interpretation: Dr. Niu Guozhen
Adolescent keratoconus is a progressive corneal cone-shaped change secondary to stromal thinning and lordosis, which can lead to myopia and irregular astigmatism, which is common in adolescents aged 10-20 years.
Traditional corneal collagen crosslinking can inhibit the progress of keratoconus, improve the best corrected visual acuity and improve the results of corneal topography. It has good safety and effectiveness. On this basis, Professor Zhou proposed a new surgical treatment method of "cross epithelial rapid corneal collagen crosslinking".
The results showed that the corrected far visual acuity was improved in 18 eyes, accounting for 36% of all eyes; 26 eyes were stable, accounting for 52% of all eyes; Decreased in 6 eyes, accounting for 12% of all operative eyes. There was no significant difference in K1, K2, kmax, CCT, TCT and apex between before and after operation. At the same time, it was found that there was no significant difference in the three-year follow-up points and regions compared with that before operation.
Finally, the experts concluded that compared with the traditional corneal crosslinking method, the advantages of cross epithelial rapid corneal crosslinking lie in better preservation of epithelium, short ultraviolet irradiation time, better patient comfort and light postoperative reaction, which is more suitable for patients with thin cornea.
——Interpretation: Master Chen Kaichuan
At present, in addition to functional indications such as relief of optic nerve pressure, refractory exposed keratitis and choroidal folds caused by increased extraocular muscle compression, there are more rehabilitative indications requiring orbital decompression, such as disfigured exophthalmos, orbital discomfort and compression.
Any surgical method to reduce high orbital pressure belongs to orbital decompression, mainly including expansion of bony orbital cavity and orbital fat resection. This time, Professor Wei mainly introduced orbital fat resection and decompression. This paper introduces the characteristics of orbital fat, guides the scope of fat resection, emphasizes the common postoperative complication diplopia, and how to avoid the occurrence of complications.
Experts pointed out that fat decompression is not suitable for every patient. When selecting the operation object, we should carefully evaluate in many aspects. The indications mainly include: facial disfigurement caused by lipomatous moderate exophthalmos, fat prolapse and venous congestion, and some optic neuropathy dominated by lipomatosis. The operation method often selects the concealed incision through conjunctiva or lacrimal caruncle. The total amount of fat removal can reach 5.5-6.5ml. For each 1ml of fat removed, the protrusion can be reduced by 0.7mm.
Finally, experts summarized some valuable surgical experience: 1 The amount of orbital fat was evaluated according to orbital CT before operation, and the reasonable amount of fat resection was designed; 2. Removing infratemporal fat can reduce eye protrusion by 0.5-1mm; 3. Removing the fat above the nose can reduce the exophthalmos by 0.5-1mm; 4. Cut the diaphragm between the fat, and the fat will come out by itself. Try to avoid pulling; 4. Press the eyeball moderately to herniate some fat in the muscle cone; 5. Electrocoagulation of blood vessels in fat before cutting can avoid bleeding; 6. The effect of removing fat in muscle cone is good, but safety should be the first; 7. Moderately use tumor tweezers or planer to suck and cut fat; 8. Try to preserve peribulbar circular fat, tenon's capsule and pully ligament near extraocular muscle.
——Interpretation: Dr. Zhang Yushan
The general process of medical research includes: scientific research topic selection, topic design, scientific research implementation, result analysis and thesis writing. The starting point of scientific research is to find the core problem, and then quickly adopt effective methods to solve it. Among them, cultivating the ability to find and solve problems is very important. We should closely link clinical scientific research with our own development disciplines, and start from clinical practical problems in order to better serve the clinic.
Scientific research ideas should be clear, but also pay attention to the following basic principles: first, innovation, innovation is the lifeline of scientific research. Lack of innovation will lose the premise of scientific research. Professor Zhao has applied the new treatment technology of macular degeneration to the "pulp" of the new field, and opened a new world of "Chinese herbal medicine" treatment. Secondly, scientific research needs to be scientific. The subject design is to truly reflect the objective results, and all subjective and accidental factors that may affect the results need to be eliminated. Finally, the reasoning should be logical and the conclusion should be rigorous. Professor Zhao found that the retinal atrophy in the lesion area was obvious when he used full measurement visodal in the treatment of plasma middling. Then he made scientific improvement, grouped the measurement from high to low, and finally found a safe and effective drug treatment concentration. Third, practical, clinical scientific research should be combined with the reality of medical work and strive to solve clinical problems. The training of problem finding ability needs long-term induction, summary and thinking. In the short term, case data can be collected, disease status can be reviewed and scientific problems can be found.
To carry out clinical scientific research is ultimately to serve the clinic. We should "do" with problems, live "do" and use it flexibly, combine "do" with use, and "do" first in urgent need. We should make great efforts in the word "use" immediately. We hope everyone can wear other people's shoes and go their own way!
——Interpretation: Dr. Han Wenting graduate student
Eye surgery related dry eye is an inevitable event in the perioperative period. Clinical perioperative intervention should be carried out in time to reduce the chance of its occurrence.
Eye surgery related dry eye refers to the dry eye characterized by tear film homeostasis imbalance after eye surgery, including preoperative dry eye, postoperative aggravation and postoperative dry eye, which will occur in all kinds of ophthalmic surgery. Therefore, early perioperative intervention is particularly important. The risk factors include ocular local factors, perioperative medication factors, systemic factors, environmental factors and emotional disorders. Preoperative ocular surface diseases, such as dry eye, meibomian gland dysfunction, contact lens misuse, striped eyeliner, etc., are more likely to have eye related dry eyes after surgery. At the same time, advanced age, diabetes, women and immune diseases are also systemic risk factors for dry eye. Therefore, we should pay attention to basic diseases and high-risk groups before surgery. During the operation, we should also pay attention to the standardization of operation and try to avoid the factors leading to dry eye, such as too long corneal exposure time, high-intensity or long-term microscope irradiation, excessive liquid and high-intensity flushing of the ocular surface, which will cause ocular surface cell damage; The ocular nerve injury will lead to the decrease of tear secretion and blink, the mechanical injury of ocular tissue structure will lead to the change of tear film stability, and the change of corneal morphology after refractive surgery and glaucoma surgery will lead to the change of tear dynamics. At the same time, we should also pay attention to the standardization and careful use of relevant drugs during the perioperative period. Antibiotics, hormones, NSAIDs, mydriasis drugs, disinfectants and other drugs are not standardized. Excessive and prolonged use may cause damage to eye surface cells. The preservatives contained in most eye drugs, especially benzalkonium chloride, can cause dry eyes through cytotoxicity, pro-inflammatory reaction and increasing tear osmotic pressure.
Surgery related dry eyes often occur in 1 week after operation, and the symptoms of dry eyes are the most obvious in 2-4 weeks, and then gradually reduce, Its clinical diagnosis can refer to the consensus of Chinese dry eye experts: examination and diagnosis (2020) 。 Therefore, dry eyes should be found and treated early after operation. Dry eyes after cataract surgery are mostly relieved in 3-6 months and recovered in 6-12 months after refractive surgery. The relevant treatment methods are similar to general dry eye treatment, but it should be noted that massage and strong pulsed light should be avoided in the early postoperative period to avoid infection.
Eye surgery related dry eye involves all aspects of Ophthalmology. It is necessary to strengthen the control of all links in the perioperative period, and carry out early detection, early prevention and early treatment, so as to improve the prognosis quality and satisfaction of patients.
——Interpretation: Dr. Zhang Xiruo is a graduate student