That cotton wool spot is focal retinal ischemia and retinal nerve fiber layer infarct could have been read in most ophthalmic textbooks, monographs and journals. Whereas, although retinal ischemia is the most important cause for cotton wool spot, cotton wool spot is not ischemia per se, but localized accumulations of axoplasmic debris within retinal ganglion cell axons owing to axoplasmic flow interruption insulted by many factors including ischemia, mechanic impression and so on. The first part of this article systematically illustrate the etiology, pathological changes, and pathophysiological processes of cotton wool spots formation, in order to improve and clarify the acquaintance. (Ophthalmol CHN, 2024, 33: 401-411)

 Objective To study the clinical characteristics at initial diagnosis of patients with primary open-angle glaucoma (POAG). Design Retrospective case series. Participants 395 patients ultimately diagnosed with POAG. Methods The records of patients were reviewed, which from the glaucoma specialty clinic who were ultimately diagnosed with POAG and had complete data from 2004 to 2021. The initial diagnostic characteristics, including reasons for consultation, intraocular pressure (IOP) values, and cup-to-disc ratios, were recorded and compared among patients with different consultation pathways. Visual function damage was classified based on the mean deviation (MD) value of the visual field. Main Outcome Measures Reasons for consultation, proportion of ocular symptoms, and differences in visual function damage among patients with different consultation reasons. Results The proportion of patients who visited the specialty clinic due to high IOP or an abnormal cup-to-disc ratio found during physical examinations was 38% of 395 patients, while 62% visited for other reasons. High myopia accounted for 32.2%. Among patients who visited due to physical examination, only 7.3% had symptoms like blurred vision, eye distension, or perceived visual field narrowing, whereas among those not referred due to physical examination, the proportion was 64.5%. At the initial diagnosis, only 16.2% having IOP>21 mmHg. Best corrected visual acuity >0.5 was found in 73.9% of patients, and 77.2% had a cup-to-disc ratio >0.7, of which 85.6% had an initial IOP <21 mmHg. The average MD value of the visual field was (6.69±0.35) dB. The proportions of patients with mild, moderate, severe, and extremely severe visual function damage were 61.8%, 19.5%, 10.1%, and 8.6%, respectively. Among patients who visited due to physical examination, 87.9% had mild to moderate visual function damage, while among those referred for other reasons, 77.2% had mild to moderate damage, with a higher proportion of severe and extremely severe cases (22.8% vs. 12.1%, P=0.014). Conclusion Regular ocular examinations are crucial for early detection of POAG. Most POAG patients in the early stages have relatively good visual acuity and nearly normal IOP values. (Ophthalmol CHN, 2024, 33: 412-416)

Objective To observe the long-term clinical effect of partial vitrectomy on idiopathic epiretinal membrane (IERM), and compared with conventional vitrectomy. Design Retrospective comparative case series. Participants 68 Cases (68 eyes) of IERM surgery at Nanjing Drum Tower Hospital. Methods According to different surgical methods, 34 cases (34 eyes) of partial vitrectomy with preservation of the anterior vitreous body combined with removal of the IERM and inner limiting membrane were selected as the partial resection group (from September 2019 to August 2022), while 34 cases (34 eyes) of conventional vitrectomy combined with removal of the IERM and inner limiting membrane were selected as the conventional resection group (from September 2017 to August 2019). The median follow-up time was 16.0 (12.0, 23.8) months in the partial resection group and 15.5 (13.0, 20.5) months in the conventional resection group, compare the operation time, the best corrected visual acuity (BCVA), intraocular pressure (IOP), and central retinal thickness(CRT) between the two groups before and after operation, and observe the occurrence of intraoperative and postoperative complications. Main Outcome Measures Operation time, BCVA, IOP, CRT and the occurrence of intraoperative and postoperative complications. Results In the partial resection group, LogMAR BCVA at the last follow-up after surgery was 0.3 (0.2, 0.4), which was significantly higher than that before surgery 0.8 (0.68, 1.00) (Z=-5.121, P=0.001). The CRT at the last follow-up was (374.35±128.69) μm, which was significantly lower than that before surgery (513.79±148.49)μm (t=7.221, P=0.001). There was no significant difference in IOP between postoperative follow-up at all time and preoperative (all P＞0.05). 3 eyes (8.82%) had mild retinal hemorrhage. The epiretinal membrane recurred in 1 eye (2.94%) 18 months after surgery. The mean operation time in the partial resection group (36.12±2.49) minutes, it was significantly shorter than that in the conventional resection group (42.08±2.36) minutes (t=-10.124, P=0.001). The IOP (12.21±3.12)mmHg in the conventional resection group was lower than that in the partial resection group (14.79±2.17)mmHg one day after surgery (t=3.969, P=0.001). There was no significant difference in BCVA and CRT between the two groups before and after operation (all P>0.05). In the conventional resection group, mild retinal hemorrhage occurred in 2 eyes (5.88%) and iatrogenic retinal hole occurred in 1 eye (2.94%). Fourteen months after surgery, the epiretinal membrane recurred in 1 eye (2.94%), and the retinal atrophy under the upper vascular arch in 1 eye (2.94%). Conclusion Partial vitrectomy is a safe and effective method for IERM, with the same effect as conventional vitrectomy, but shorter surgical time, less postoperative intraocular pressure fluctuations, and fewer complications. (Ophthalmol CHN, 2024, 33: 419-423)

Objective  To explore the distribution of etiology and clinical characteristics of patients with ptosis. Design Retrospective case series. Participants 537 patients presenting with ptosis from January to December 2023 in the Department of Neurology, Beijing Tongren Hospital. Methods Clinical data were collected for etiological classification and statistical analysis. Main Outcome Measures The average age of onset, disease duration, gender, bilateral involvement, and the presence of major clinical symptoms such as pain, diplopia, and pupillary involvement in different etiological subgroups. Results Among the 537 patients, 251 were male with an average age of (58.1±19.4) years. Bilateral ptosis was observed in 375 cases, and unilateral ptosis in 162 cases. The etiology distribution was as follows: myogenic ptosis in 177 cases (33.0%), of which 165 cases (30.7%) were due to myasthenia gravis; neurogenic ptosis in 90 cases (16.8%), mainly due to oculomotor nerve paralysis in 86 cases (16.0%); pseudoptosis in 233 cases (43.4%), with eyelid spasm in 197 cases (36.7%); and undetermined causes in 37 cases (6.9%). Among patients with myasthenia gravis, 82.4% had bilateral eye involvement, 95.8% exhibited fluctuating symptoms of worsening in the evening, 78.8% had diplopia or eye movement disorders, 89.1% showed varying degrees of compensatory frontalis muscle activation, 64.8% had disappearance of the burying eyelashes sign after forceful eyelid closure, and 57.8% had symptoms of systemic skeletal muscle involvement. Patients with eyelid spasm did not have eye movement disorders and typically had a longer disease course. 38.9% of patients with unilateral facial spasm experienced paroxysmal vertigo and/or tinnitus. Patients with oculomotor nerve paralysis typically had eye movement disorders and pain, with some cases involving pupil impairment and generally a shorter disease duration. Conclusion Myasthenia gravis is the most common cause of myogenic ptosis, while eyelid spasm predominates in pseudoptosis, and oculomotor nerve paralysis is an important cause of neurogenic ptosis. Clinical features differ significantly among different etiologies of ptosis, necessitating comprehensive judgment to optimize individualized diagnostic and treatment processes. (Ophthalmol CHN, 2024, 33: 424-428)

Objective To summarize the subtypes, clinical features, and treatment outcomes of optic neuritis (ON) patients presenting with altitudinal visual field defects. Design Retrospective case series. Participants Twenty-two ON patients with altitudinal visual field defects admitted to the Neurology Department of Beijing Tongren Hospital from January 2022 to June 2024. Method Clinical data, laboratory findings, imaging results, treatment and outcomes were collected and analyzed. Main Outcome Measures The degree of optic disc edema and presence of hemorrhage, Humphrey visual field index (VFI), optic nerve enhancement on MRI, best-corrected visual acuity (BCVA), serum demyelinating antibodies and rheumatological markers, cerebrospinal fluid oligoclonal bands (OCBs), presence of ocular or periocular pain, and treatment strategies. Results The study included 22 ON patients with a male-to-female ratio of 1:1 and a mean onset age of (45.6±12.6) years. Among them, 10 cases (45.5%) were diagnosed with single isolated optic neuritis (SION), 3 cases (13.6%) with MOG-IgG associated ON, 2 cases (9.1%) with AQP4-IgG associated ON, and 7 cases (31.8%) with autoimmune-related ON. Thirteen patients (59.1%) experienced ocular pain, and optic disc edema was observed in 19 eyes (86.4%), with 54.5% classified as mild. Seventeen patients (77.3%) demonstrated abnormal optic nerve signals on MRI, with involvement of the intraorbital segment in 16 cases (72.7%), canalicular segment in 6 cases (27.3%), and intracranial segment in 3 cases (13.6%). All patients received corticosteroid therapy during the acute phase, and 10 patients underwent immunosuppressive therapy during the remission phase. After three months, there was a significant improvement in VFI, with an average increase from (53.0±8.0)% at the onset of the disease to (79.8±13.5)% (P＜0.001), 7 eyes (31.8%) achieved complete visual recovery, 3 eyes (13.6%) experienced significant improvement in vision, and 6 eyes (27.3%) showed partial improvement，and 6 eyes(27.3%) showed no significant betterment or betterment that had not yet reached the level of  improvement. Conclusion Altitudinal visual field defects are associated with multiple ON subtypes, primarily involving the optic disc and anterior optic nerve. Treatment with corticosteroids and immunosuppressants contributes to a better recovery of visual function. (Ophthalmol CHN, 2024, 33: 429-434)

Objective To assess the characteristics of intraretinal cysts (IRC) in patients with inherited retinal degenerations (IRD) using spectral domain optical coherence tomography (SD-OCT) images. Design Retrospective case series. Participants 92 eyes of 56 patients diagnosed with IRD at Beijing Tongren Hospital between 2020 and 2024, including 34 patients (54 eyes) with retinitis pigmentosa (RP), 15 patients (24 eyes) with Bietti crystalline dystrophy (BCD) and 7 patients (14 eyes) with autosomal recessive bestrophinopathy (ARB). Methods 92 eyes of 56 cases in the IRD database, all displaying IRC, were further examined to analyze the macular structures on SD-OCT and vascular changes on fundus fluorescein angiography (FFA). On SD-OCT iamges, the characteristics and locations of IRC, as well as structural alterations in the outer layers of the retina such as the outer limiting membrane (OLM), ellipsoid zone (EZ), outer segments of photoreceptors layer (PRL-OS), interdigitation zone (IZ), and retinal pigment epithelium (RPE) were assessed. Main Outcome Measures The morphology and locations of IRC, structural alterations in the outer layers of the retina on SD-OCT images. Results IRC appeared in different forms including "the central type", "the microcystic macular edema (MME) type", and "the mixed type" on SD-OCT images. In RP patients, IRC demonstrated as the central type or the mixed type in 24 eyes (44.5%), and as MME type in 30 eyes (55.5%). IRC were observed in the inner nuclear layer (INL) (54 eyes, 100%), outer nuclear layer (ONL) (25 eyes, 46.3%), and Ganglion cell layer (GCL) (5 eyes, 9.3%). Structural changes such as partial or complete loss of OLM, EZ, IZ, and RPE layers at parafovea were noted, and fovea affected in 23 eyes (42.6%). IRC located in preserved sections of these layers in 46 eyes(77.8%). Conversely, BCD patients all displayed IRC as the MME type (24 eyes, 100%) with MME of dispersed distribution located in the INL (24 eyes, 100%) and GCL (10 eyes, 41.7%). Severe loss of the OLM, EZ, IZ, and RPE layers was noted throughout the macula, and usually presented as multifocal and typically presented as interval distributed with preserved and lost sections, while IRC located at the lost sections. The IRC in ARB patients presented as the mixed type (10 eyes, 71.4%) or the MME type (4 eyes, 28.6%), with multiple continuous distributed MME located in the INL (14 eyes, 100%) and enlarged or coalesced cavities in ONL (10 eyes, 71.4%), and accompanied by neurosensory retinal detachment, thickening of PRL-OS and hyperreflective dots (HRD). Additionally, findings from FFA showed retinal vascular leakages(14 eyes, 87.5%), fishing net shaped telangiectasia and aneurysmal dilation(2 eyes, 12.5%) and petaloid hyperfluorescence at the macula(12 eyes, 75%)   in RP patients(n=10, 16 eyes), while BCD (n=7, 14 eyes) and ARB (n=3, 6 eyes) exhibited none of these alterations. Conclusions IRC secondary to different types of IRD has distinct features on SD-OCT. RP can manifest as either of three types, while BCD as MME type and ARB mainly as the mixed type, with diversed degenerative structural alterations in the outer layers of the retina. (Ophthalmol CHN, 2024, 33: 435-440)

  Objective To compare the difference, correlation and agreement of anterior chamber biological parameters measured by Scheimpflug tomography Pentacam AXL and swept-source anterior segment optical coherence tomography CASIA 2 in myopic eyes. Design Diagnostic technique evaluation. Participants 50 myopic patients (50 eyes) of Beijing Tongren Hospital from December 2021 to December 2022, with an average age of (29.62±6.79) years. The data of the right eye was included for analysis. Method Pentacam AXL and CASIA 2 were used to measure anterior chamber depth (ACD), including ACD (Epi), which means the distance from the corneal epithelium to the anterior surface of the lens, and ACD (Endo), which means the distance from the corneal endothelium to the anterior surface of the lens, anterior chamber volume (ACV) and anterior chamber angle (ACA). Paired t-test, Pearson correlation analysis and Bland-Altman analysis were used to evaluate the differences, correlation and agreement between the two measurements. Main Outcome Measures The value of ACD (Epi), ACD (Endo), ACV, ACA, 95% limits of agreement (LoA) and the probability of points inside the boundary line of 95%LoA in Bland-Altman analysis. Results ACD (Epi), ACD (Endo), ACV and ACA measured by Pentacam AXL were (3.60±0.22)mm, (3.09±0.22)mm, (175.48±23.53)mm3 and (40.27±5.30)°, respectively. ACD (Epi), ACD (Endo), ACV and ACA measured by CASIA 2 were (3.66±0.21)mm, (3.15±0.21)mm, (175.97±21.58)mm3 and(47.04±8.66)°, respectively. Compared with the values in Pentacam AXL, the ACD (Epi), ACD (Endo) and ACA were larger in CASIA 2 with significant differences (t=8.04, 7.67, 5.25, all P<0.001). There was no significant difference in ACV (t=0.53, P=0.60). The correlation of ACD (Epi) (r=0.969, P<0.001), ACD (Endo) (r=0.964, P<0.001) and ACV (r=0.961, P<0.001) were significant. There was no significant correlation of ACA (r=0.216, P=0.132) between Pentacam AXL and CASIA 2. The Bland Atman analysis showed that the 95% LoA of ACD (Epi), ACD (Endo), ACV and ACA were (-0.04~0.17)mm, (-0.05~0.18)mm, (-12.49~13.47)mm3 and(-11.11~24.65)°. The probability of points inside the boundary line of 95% LoA were 48 (96%), 48 (96%), 50 (100%) and 45 (90%). Conclusion Pentacam AXL and CASIA 2 had slight difference as well as good correlation and agreement in the measurement of ACD, which can be clinically interchangeable. There was no significant difference as well as good correlation and agreement in ACV, which can be clinically interchangeable. Since there was significant difference, no significant correlation and poor agreement between Pentacam AXL and CASIA 2 in ACA measurement, they were not clinically interchangeable. (Ophthalmol CHN, 2024, 33: 441-445)

  Objective To solve the problems of poor patient experience and comfort during ophthalmic conjunctival sac irrigation and cumbersome processes when using traditional water receivers, and to improve the efficiency of healthcare professionals. Design Randomized controlled clinical trial. Participants 106 patients who underwent laser keratoconus refractive surgery from April to July 2019 at the Refractive Surgery Clinical Center. Methods The 106 patients were divided into 53 cases each in the experimental group and the control group using the randomized numerical table method. The experimental group used the self-designed disposable eyewash bag for conjunctival sac irrigation, and the control group used the traditional stainless-steel funnel-type aqueous humor. The time required for conjunctival sac irrigation was recorded for both groups, and a self-designed questionnaire was used to investigate the satisfaction of the patients of the two groups as well as the preparation of the objects, the restraint of the head position, the pouring of liquid, and the adjustment of instruments by the medical staff during the operation. Main Outcome Measures Conjunctival sac irrigation operation time, patient satisfaction, ease of operation. Results The operation time of conjunctival sac rinsing in the experimental group was 120 (117.5, 139.5) seconds, which was significantly shorter than that of (177.58±25.38) seconds in the control group (U=106.50, P<0.001). In the patient satisfaction survey, the number of patients in the experimental group with no limb mobility limitation accounted for 75.47%, which was significantly more than the 43.37% in the control group (?字2=15.42, P<0.001); the number of patients in the test group who needed their own or other people's help in fixing the recipient apparatus was 0, which was significantly less than the 100% in the control group (?字2=102.04, P<0.001); the number of people in the experimental group whose instruments fit the skin without discomfort was 75.47%, which was significantly higher than that of the control group, which was 39.62% (?字2=28.31, P<0.001); the number of people in the experimental group who had no leakage during operation was 84.91%, which was significantly higher than that of the control group, which was 37.74% (?字2=26.00, P<0.001). The number of people in the experimental group who needed preparation of supplies, head position restraint, repeated pouring of fluid, and adjustment of instruments during operation was 0, which was significantly less than 100% in the control group (?字2=36.1, P<0.001). Conclusion The self-designed disposable eyewash bag can improve the comfort of patients and the efficiency of healthcare personnel when applied to ophthalmic conjunctival sac irrigation, and it has certain value for clinical promotion and application. (Ophthalmol CHN, 2024, 33: 446-450)

Objective To construct the information management system of ophthalmic outpatient specialist examination, and establish an information management platform that connects three terminals for examination, physician, and data management, and  explore the application and efficiency of picture archiving and communication systems (PACS) during ophthalmology outpatient specialized examination. Design One-group pretest-posttest design. Participants The PACS and a total of 500 patients applied the system from the ophthalmic outpatient clinic in Jiangsu Provincial People's Hospital. Method A project team consisting of ophthalmology, hospital information center and R&D company, developed a PACS ophthalmic image management and analysis system, which will be integrated with the existing Haitai electronic medical record system. This system was applied to ophthalmic clinics. The total patients' visit time from check-in to the end of the visit, as well as the duration of the patient communicating with the doctor in the consulting room were recorded. Patients and doctors were surveyed on their satisfaction using self-made questionnaire. Main Outcome Measures Average waiting time, average consulting time, satisfaction of the patients and doctors. Results After application of PACS system, the average waiting time was decreased from (0.92±0.46) h to (0.72±0.42) h (t=7.096, P<0.001), the average consulting time was decreased from (0.54±0.35) h to (0.43±0.19) h (t=6.283, P<0.001), and the patient satisfaction increased from 80.6% to 95.2% (?字2=50.104, P<0.001), the doctors' satisfaction increased from 83.33% to 95.83% (?字2=4.019, P=0.045). Conclusions PACS system improved the real-time and dynamic feedback of the ophthalmic specialist examination results, improved the work efficiency of doctor, shortened the patients’ visiting time, and improved the satisfaction rates of both doctors and patients significantly. (Ophthalmol CHN, 2024, 33: 452-456)

 Objective To investigate the effectiveness of an intelligent queue calling system in ophthalmology examination rooms at hospitals. Design One-group pretest-posttest. Participants At the Ophthalmology Department of Beijing Tiantan Hospital, 20 patients undergoing examinations were selected both before and after the implementation of the queue calling system. Methods Before and after the implementation of the intelligent queue calling system, the average waiting time from registration at the nursing station to entering the examination room, as well as the total duration of the entire examination process, were recorded for patients who underwent laser scanning ophthalmoscopy, OCT, and UBM examinations. During peak consultation hours (Monday morning, 8:00 to 9:30), the number of patients completing laser scanning ophthalmoscopy was recorded. Before the system was implemented, data were manually recorded using stopwatches and counters; after implementation, the system automatically recorded the data. Patient satisfaction was surveyed using a self-designed questionnaire before and after the system's implementation. Main Outcome Measures Average patient waiting time, total examination process duration, number of patients examined during peak consultation hours, and patient satisfaction. Results Compared to before the system was implemented, the average waiting time for patients decreased from (65.9±14.7) minutes to (50.1±11.8) minutes after the new calling system was implemented, a reduction of 23.9% (t=-5.62, P<0.001); the total examination process duration decreased from (73.2±14.4) minutes to (57.2±11.5) minutes, a reduction of 22.9% (t=-6.44, P<0.001); the number of patients examined during peak consultation hours increased from an average of 31.1 to 37.1, a growth of 19.2% (U=9, P=0.03); and the patient satisfaction scores increased from (68.5±7.5) points to (86.7±6.0) points, a growth rate of 26.5% (t=-11.58, P<0.001). Conclusion The application of the intelligent queue calling system significantly reduced patient waiting times and the overall duration of the examination process, effectively improved the efficiency of examinations during peak hours, and greatly enhanced patient satisfaction. (Ophthalmol CHN, 2024, 33: 457-460)

 Objective To explore the feasibility and application value of case-based learning (CBL) combined with multimodal imaging in the clinical teaching of ocular fundus diseases. Design Teaching research. Participants 25 postgraduate students in ophthalmology during the standardized training of residents in Beijing Tongren Hospital. 11 students in the traditional teaching group and 14 students in the CBL multimodal imaging teaching group. Methods  After the basic knowledge training and examination of color fundus photogragh (CFP), fundus fluorescence angiography(FFA), and ocular coherence tomography(OCT), the traditional teaching group took lessons of the characteristics of various common ocular fundus diseases in each imaging mode; the CBL multimodal imaging teaching group were taught multimodal imaging characteristics based on each disease of common ocular fundus diseases. After 4 weeks of clinical practice, the two groups of students finally took theoretical examination and clinical case analysis examination. Main Outcome Measures Score results of theory examination, imaging analysis and case analysis examination at each stage. Results In CBL multimodal imaging teachinggroup, the scores of multimodal imaging analysis 92.14±3.23, final theoretical examination 93.79±2.72, and case analysis 93.71±3.29, were all higher than those in the traditional teaching group of 88.36±3.41, 90.82±4.19, 89.64±4.46 (all P<0.05). In the traditional teaching group, the scores of image basic knowledge examination and single mode image analysis were 92.71±2.43 and 94.71±1.89 in the second year students，whereas 93.00±1.41 and 94.00±2.45 in the third year students (all P>0.05). The scores of the second year students were 86.86±3.18 in multimodal imaging analysis, 88.343±3.60 in final theory examination, and 87.57±3.95 in case analysis, all lower than those of the third year students 91.00±2.00, 94.00±2.83 and 93.25±2.75， with statistical significance (all P<0.05). In CBL multimodal imaging teaching group, the scores of image basic knowledge and single mode image analysis examination were 93.46±2.07 and 93.46±2.38 in the second year students, whereas 92.67±2.52, 94.66±2.30 respectively in the third year students, the difference was no statistically significant between the two academic years (all P>0.05); the scores of final theory examination was 92.91±2.63 in second year students, lower than that (96.67±1.15) in the third year students (P=0.04); but there was no statistically significant difference between the scores of multimodal imaging analysis 91.91±3.35, case analysis 93.45±3.64 in the second year students， and that 93.00±2.64, 94.67±1.53 in the third year students (all P>0.05). Conclusion CBL combined with multimodal imaging teaching can improve students' ability of comprehensive image analysis and clinical case analysis, andis more efficient to promote students to apply the knowledge to ocular fundus disease clinical application. (Ophthalmol CHN, 2024, 33: 461-466)