Table of Content

25 September 2017, Volume 26 Issue 5

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Progression of diagnosis and treatment of amblyopia

LU Wei, YAN Li

2017, 26(5):  289-293.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 001

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The progression of brain visual science enables a further understanding of the pathogenesis of amblyopia and the characteristics of the neural defect of amblyopia. The study of the neural mechanism of amblyopia has promoted the progression of amblyopia treatment. The visual perception examination and treatment system platform enriches detection methods for amblyopia, and provides a basis for accurate diagnosis and treatment. The combination of visual perception learning and binocular vision therapy will change the current situation of amblyopia treatment; and enable us to treat amblyopia more effectively. (Ophthalmol CHN, 2017, 26: 289-293)

The study of binocular rivalry of the children with amblyopia

LIN Nan1, LU Wei1, SUN A-li1, YAN Li2, CHU Hang2, ZHANG Ling-ge2

2017, 26(5):  295-298.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 002

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Objective To investigate the characteristics of the binocular rivalry of children with amblyopia. Design Prospective case series. Participants 90 mild, moderate, severe amblyopic children with normal eye position, each group included 30 cases. Method The main test method was the computer based visual perceptual test software, each amblyopic child must take the binocular visual balance point of dynamic signal to noise ratio, static signal to noise ratio, dynamic contrast sensitivity, static contrast sensitivity. Main Outcome Measures The measured value of each binocular visual balance point. Results (1) In mild, moderate, severe amblyopic children, the binocular balance point of static signal to noise ratio was 6.17±1.548, 5.51±1.804 and 2.08±0.935 respectively (H=51.526, P<0.001); the binocular balance point of dynamic signal to noise ratio was 6.42±1.334, 5.73±1.840 and 2.34±1.260 respectively (H=58.453, P<0.001); the binocular balance point of static contrast sensitivity was 7.08±2.350, 6.44±2.520 and 3.52±2.365 respectively (H=26.826, P<0.001); the binocular balance point of dynamic contrast sensitivity was 7.40±2.430, 7.13±2.554 and 3.31±2.007 respectively (H=42.200, P<0.001). (2) In mild, moderate, severe amblyopic children, the difference between two eyes of static signal to noise ratio was 1.67±1.561, 2.20±1.584 and 4.71±2.312 respectively (H=20.873, P<0.001); the difference between two eyes of dynamic signal to noise ratio was 1.33±1.241, 1.90±1.739 and 4.52±2.293 respectively (H=26.684, P<0.001); the difference between two eyes of static contrast sensitivity was 2.67±1.709, 2.73±2.651 and 5.48±3.329 respectively (H=11.116, P=0.004); the difference between two eyes of dynamic contrast sensitivity was 2.50±2.080, 2.72±2.534 and 5.00±3.327 respectively (H=10.396, P=0.006). Conclusion The binocular visual balance point of signal to noise ratio and contrast sensitivity was abnormal in amblyopic children with normal eye position. The more severe the degree of amblyopia, the more serious the abnormality was. The difference between two eyes of signal to noise ratio and contrast sensitivity increased with the degree of amblyopia. (Ophthalmol CHN, 2017, 26: 295-298)

The binocular visual perception function after cure of amblyopia in children

CHENG Juan-juan１, FU Jing１, LU Wei１, CHU Hang２, YAN Li２

2017, 26(5):  299-302.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 003

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 Objective To evaluate the binocular visual perception function after cure of amblyopia in children. Design Retrospective case series. Paticipants 75 children with cured amblyopia due to ametropia and anisometropia. Methods The patients were divided into mild, moderate and severe amblyopia group according to the corrected visual acuity. Mild amblyopia was defined as corrected visual acuity varied from 0.6 to 0.8, moderate amblyopia with 0.2 to 0.5, severe amblyopia with less than 0.1. The quantitative assessment of binocular visual perception function in the three groups was compared. Main Outcome Measures Binocular perception eye position difference, binocular fixation difference, signal-to-noise ratio balance point difference, contrast balance difference, and the passing rate of random point 0-order, 1-order, 2-order stereopsis tests. Results After the participants with mild, medium and severe amblyopia were cured, we found that 3 °optotype horizontal eye level averaged at 22.63±18.94, 31.96±32.70, 46.86 ±31.70 pixels, respectively. The vertical eye level averaged at 3.59±4.36, 4.66±4.29, 9.93±10.27 pixels. 1 °optotype horizontal eye level averaged at 28.00±22.68, 36.06±26.90, 31.33±22.42 pixels, and the vertical eye level averaged at 4.74±5.15, 5.69±5.04, 7.80±12.03 pixels respectively. Binocular fixation stability averaged at 4.11±1.99, 4.79±2.37, 2.36±3.24 pixels for the three groups respectively. The static signal-to-noise ratio balance point averaged at 6.52±1.31, 6.12±1.72, 5.83±2.68 level. The balance point of static contrast averaged at 7.70±1.78 7.12±2.29 and 6.53±3.05 level. The static signal-to-noise ratio balance point difference was 1.48±1.48, 1.63±1.45 and 2.20±1.89 level and the balance point of static contrast difference was 1.92±1.66, 2.24±1.95 and 3.60±2.89 level respectively. In the random point 0-order stereoscopic test, 53 cases (71%) achieved 100 ", with 68 cases (90%) in 1-order stereoscopic test and 73 cases (97%) in 2-order stereopsis test. Conclusion After cure of amblyopia, the binocular perception, eye position, binocular inhibition and the stereopsis of different channels have not reached normal level. This new method of examination and analysis of the results of the visual recovery offers a new way to recognize the defects of visual system after cure of amblyopia. (Ophthalmol CHN, 2017, 26: 299-302)

Long-term clinical effects of rigid gas permeable contact lens on adolescents with myopia and myopic astigmatism

LV Yan-yun1, WU Jing-jing1, LIU Li-zhou1, PENG Li1, WANG Yan-xia1, JIAO Yong-hong2

2017, 26(5):  303-306.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 004

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Objective To investigate the clinical effects of rigid gas permeable contact lens (RGPCL) on adolescents with myopia and myopic astigmatism. Design Retrospective case series. Participants 101 adolescents (202 eyes) with myopia and myopic astigmatism. Methods 51 adolescents (102 eyes) with myopia and myopic astigmatism were fitted with RGPCL and followed up for 8 years. The changes of the corneal curvature, spherical and cylindrical refractive error and corneal astigmatism were measured every year. The control group consisted of 50 cases (100 eyes) with continuous spectacles wearing for more than 6 years, with the changes of spherical and cylindrical refractive error measured every year. Main Outcome Measures Corneal curvature, spherical refractive error, cylindrical refractive error, corneal astigmatism. Results The mean radius of corneal curvature increased (0.10±0.17) mm with RGPCL for 8 years. The spherical refractive error increased by (-1.88±0.32) D. The ocular cylindrical refractive error decreased by (-0.28±0.21) D, and corneal stigmatism decreased by (-0.40±0.20) D. All the differences were statistically significant (t=-3.285, -29.536, 12.803, 10.025; all P<0.001 respectively). During the 6-year follow up, the ocular spherical and cylindrical refractive error increased by (-2.73±0.37) D and (-0.32±0.34) D respectively, and the differences were statistically significant compared to the baseline data (t=-35.063, -5.457; both P<0.001). The growth of spherical and cylindrical error in RGPCL wearers was lower than spectacle wearers (t=-14.036, -14.955; both P<0.001). Conclusion Myopia progression can be controlled by long-term RGPCL wearing. RGPCL has a mild effect on corneal shape. (Ophthalmol CHN, 2017, 26: 303-306)

Axial length and corneal curvature and their associations in 4 to 16-year-old children

LI Jia, WANG Jun

2017, 26(5):  307-312.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 005

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Objective To investigate the distribution of the axial length and corneal curvature and its associated factors in 4-16 year old children. Design Cross-sectional study. Participants Two thousand eight hundred and twenty six 4-16 year old children in Changping Distric in Beijing. Methods Using a random cluster sampling method, the study included children from ten schools in Changping Distric in Beijing. The children underwent questionnaire, autorefraction and ocular biometry measurements. The questionnaire consisted of questions on the children’s basic information, family history and time spent outdoors and the activities performed outdoors, time spent indoor and the activities carried out indoors. We performed univariate and multivariate analyses of the associations between axial Length and corneal curvature and other parameters.  Main Outcome Measures Axial length, corneal curvature. Results The mean age of participants was 8.98±3.54 years. The mean axial length was 23.22±1.20 mm and the mean corneal curvature was 43.33±1.40 diopters (D). The axial length of males (23.45±1.15 mm) was significantly longer than that of females (23.00±1.21 mm) (P<0.001). The corneal curvature (D) of males (43.01±1.35 D) was significantly smaller than that of females (43.64±1.37 D) (P<0.001). In multivariate linear regression analysis, longer axial length was significantly associated with older age (P<0.001), male gender (P<0.001), smaller corneal curvature (P<0.001), deeper anterior chamber depth(P<0.001), smaller spherical equivalents(P<0.001). Steeper cornea was significantly associated with female (P<0.001), shorter axial length (P<0.001), deeper anterior chamber depth (P<0.001), smaller horizontal corneal diameter (P<0.001), smaller spherical equivalents (P<0.001), non-paternal myopia (P=0.029), less time spent watching TV (P<0.001). Conclusion Longer axial length was significantly associated with older age, male gender, smaller corneal curvature, deeper anterior chamber depth, smaller spherical equivalents. Steeper cornea was significantly associated with female, shorter axial length, deeper anterior chamber depth, smaller horizontal corneal diameter, smaller spherical equivalents, non paternal myopia, less time spent watching TV.  (Ophthalmol CHN, 2017, 26: 307-312)

The application and value of nine external photograph in clinical diagnosis of strabismus

MA Ying-nan, AI Li-kun, ZHAO Bo-wen, WANG Xin

2017, 26(5):  314-316.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 006

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Objective  To comparare nine external photographs and clinical face to face examinations in diagnosis of strabismus. Design Prospective comparative case series. Participants One hundred and one cases of strabismus patients over 5-year old in Department of Ophthalmology of Beijing Tongren Hospital were selected. Methods Nine external photographs and wryneck photographs were performed. Grading of strabismus was carried out by an experienced ophthalmologist. Main Outcome Measures Kappa value, sensitivity, specificity. Results The results of the Kappa values was 0.91. The sensitivity of the presence of photographs for strabismus was 98.6%, and the specificity was 100%. The Receiver Operating Characteristic analysis was 0.993. Conclusions Nine external photographs have good prospect both in clinic and in screening. It is worth popularizing in tele-ophthalmology. (Ophthalmol CHN, 2017, 26: 314-316)

Analysis of the glaucoma diagnostic parameters measured by FD-OCT and HRT-III in myopia

ZHANG Han-qiao1, QIAO Rong-hua2, ZHU Sai-nan3, WU Hai-long

2017, 26(5):  317-322.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 007

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Objective To investigate if there are any differences and consistency of the glaucoma diagnostic parameters measured by FD-OCT and HRT-III in myopia. Design Prospective comparative case series. Participants 131 myopia patients and 82 emmetropia subjects recruited in Beijing from Oct 2012 to Mar 2013 were included. Methods All the subjects underwent FD-OCT(ONH module) and HRT-III(glaucoma module) in addition to routine ocular examination, refraction and axial length measurement. One eye of each subject was selected for this study by randomization. Myopia subjects were assigned into three groups according to their refractive power: low (≤-3.00 D), moderate (-3.00D to-6.00 D) and high(>-6.00 D). The difference between myopia groups and emmetropia control group regarding glaucoma diagnostic parameters of FD-OCT and HRT-III were analyzed with one-way ANOVA, LSD, and rank sum test respectively. Pearson correlation analysis was performed to investigate the association between those diagnostic parameters and refractive powers as well as axial length. Main Outcome Measures RNFL thickness parameters and optic disc parameters. Results (1)RNFL thickness analyses：The difference in mean RNFL(mRNFL) thickness between myopia and emmetropia group was significant (P＜0.05 with FD-OCT measurement (in moderate and high groups) and HRT-III measurements (in low and moderate groups). However, the mRNFL thickness measured by FD-OCT was thinner than that measured with HRT-III. For quadrants parameters, most of the 16 sectors values of FD-OCT were thinner in myopia group (P＜0.01 or P<0.05 ), especially in the moderate and high groups. On the contrary, for the 6 sectors of HRT-III, the RNFL was thicker in moderate myopia group than that of control group(P＜0.01 or P<0.05 ), while the high and low myopia groups showed no difference compared with emmetropia group. (2) Optic disc parameters: the disc area and rim area of myopia group obtained from both FD-OCT and HRT-III were found to be statistically less than those of the emmetropia group（P<0.01）whereas no significant difference of other disc parameters  (P＞0.05) was found. (3) Negative correlations were found in OCT between mRNFL thickness, RNFL thickness in some quadrants, rim area, rim volume and refractive power, axial length（P<0.01）, whereas no significant correlation was found in regard to HRT RNFL thickness with refractive power and axial length（P>0.05）. Conclusions The glaucoma diagnostic parameters of myopia patients showed difference and consistency between FD-OCT and HRT-III. RNFL related parameters  were thinner in myopia group comparared to that of emmetropia group measured by FD-OCT, but vise versa by HRT-III. With regard to parameters of optic disc measured by FD-OCT and HRT-III in myopia group, the disc area and rim area were both smaller comparared to emmetripia group. This would make early diagnosis of primary open-angle glaucoma with myopia more challenging. (Ophthalmol CHN, 2017, 26: 317-322)

The level of neuroglobin in eye and serum of patients with proliferative diabetic retinopathy

LI Kang, GAO Xiao-hong, LI Gai-yun, LI Jing, LIU Zhao-hui

2017, 26(5):  323-327.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 008

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Objective To evaluate the expression of neuroglobin (NGB) in aqueous, vitreous, fibrous proliferation membrane and serum of patients with proliferative diabetic retinopathy (PDR). Design Clinical case control study. Participants Thirty patients who were diagnosed as PDR were divided into 3 groups equally according severity of the disease: IV, V, and VI. The control group consisted of 10 patients with idiopathic macular hole. Methods We collected aqueous, vitreous, fibrous proliferation membrane or internal limiting membrane during vitrectomy. Serum was collected before operation. The level of NGB in the aqueous, vitreous and serum was determined quantitatively using ELISA method. The expression level of NGB in the fibrous proliferation membrane or internal limiting membrane was determined using immunohistochemistry method. Main Outcome Measures The level of NGB in serum aqueous, vitreous, fibrous proliferation membrane and internal limiting membrane of patients. Results In PDR groups, the level of NGB in serum, aqueous and vitreous was significantly higher than in the idiopathic macular hole group (F=494.433, 143.923, 2568.291; all P<0.001). The  NGB level in serum and vitreous was lower in PDR4 group than in PDR5 group (t=-9.766, -27.578; both P<0.001), lower in PDR4 group than in PDR6 group(t=-29.678, -26.419; both P<0.001), lower in PDR5 group than in PDR6 group (t=-15.117, -3.231; P<0.001, P=0.003 respectively). The level of NGB in aqueous in PDR4, PDR5 and PDR6 groups was not significantly different (all P>0.05). The positive rates of NGB expression in fibrous proliferation membrane in the IMH group, PDR4 group, PDR5 group, PDR6 group were 0, (6.12±2.12)％, (13.43±2.05)％, (16.39±2.46)％ respectively. The differences between any two PDR groups were statistically significant. It was lower in PDR4 group than in PDR5 group (t=-21.552, P<0.001), lower in PDR4 group than in PDR6 group(t=-25.059, P<0.001),lower in PDR5 group than in PDR6 group (t=-7.238, P<0.001). Conclusions The level of NGB in serum, aqueous, vitreous and fibrous proliferation membrane of PDR patients significantly increased compared to the control group, and increased with the severity of the disease. (Ophthalmol CHN, 2017, 26: 323-327)

Effect of serum in constructing pellet three-dimensional model for keratocytes culture in vitro

FAN Zi-xi1, LUO Shi-nan2, JIN He1, LI Jie1, LI Xia1

2017, 26(5):  328-332.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 009

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Objective To investigate the influence of serum in establishing a corneal stroma Pellet three-dimensional model by detecting cell growth and collagen fibers production, in order to offer a new culture pattern for extracellular matrix(ECM) fibrosis study in vitro. Design Experimental study. Participants Bovine keratocytes. Methods The primary bovine keratocytes were isolated and cultured, and the first generation  cells were used for building Pellet model. The constructions in Pellet systems were cultured in the DMEM/F12 without serum (control group) or with 10% fetal bovine serum (FBS) (group serum), respectively.  After 3 weeks cultured, the Pellets were observed. The state of cell growth and cell activity was assayed by HE and Calcein AM/PI staining. And then, MASSON staining and transmission electron microscopy(TEM) were used to detect the formation of collagen arrangement. Main Outcome Measures Cell growth, cell activity, collagen arrangement. Results Cultured for 3 weeks in Pellet model, cells in the control group didn’t assemble and could be broken up easily. It was difficult to do sequential experiment. Inversely, in group serum Pellet huddled growing and was in grain appearance, combining firmly. The majority of living cells in Group serum growed closely and remained structural integrity through the HE and Calcein AM/PI staining. MASSON staining showed many collagen fibers. TEM showed that extracellular collagen deposited and densely distributed. Conclusions Serum could assist in-vitro three-dimensional culture of keratocytes, and generate the ECM rich of collagen fibers. (Ophthalmol CHN, 2017, 26: 328-332)

Observation of complications of corneal crosslinking in the treatment of progressive keratoconus

LU Li-xin, LU Hong-shuang, JIN Tao, JIE Ying

2017, 26(5):  333-336.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 010

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Objective To report the main complications of progressive keratoconus treated by epithelial removal(ER) corneal collagen crosslinking(CXL). Design Retrospective case series. Participants 40 patients with progressive keratoconus admitted to Tongren Hospital from January to December 2015.  Methods Retrospective analysis was performed on the pre and post-operative data of the patients, whose thinnest cornea thickness was 375-450 μm prior to surgery, and treated by epithelial removal corneal collagen crosslinking (CXL). The ocular pain and foreign body sensation were assessed by questionaire and the anterior segment at 1 day, 3 days, 1 week, 1 month after operation. Main Outcome Measures The pre and post-operative visual acuity (VA), intraocular pressure, ocular pain and recovery of corneal epithelia of each patient. Results On the first day after operation, patients complained obvious ocular pain and foreign body sensation. The scores was 3.19±0.37 and 3.15±0.23 respectively. Examination showed epithelial defects on the corneas of patients. There was still moderate foreign body sensation  (2.23±0.43) and painfulness (2.23±0.32) 3 days after surgery, and the epithelial defects were fairly recovered. There was only slight foreign body sensation (0.23±0.07) and painfulness (0.22±0.11) 7 days after surgery, and the epithelial defects were mostly recovered. There was no foreign body sensation and painfulness two weeks later. At 6-month follow up visit, we found that keratoconus was well controlled with no advancement in all 40 patients, among whom 30 cases found their uncorrected visual acuity improved and 35 cases had their corrected visual acuity improved. No such complications as corneal infection, scaring, ulceration or epithelial defect occurred. Conclusion Corneal collagen crosslinking is an effective treatment for progressive keratoconus. It is crucial for clinical management that we deal with patients’ pain at early stage and corneal epithelial defect. (Ophthalmol CHN, 2017, 26: 333-336)

The clinical and imaging features of patients with hematologic system tumors who initially presented to neuro-ophthalmology department

ZHAO Jie1, WANG Zhao-yan2, YANG Mo2, XIONG Shuai3, XU Quan-gang2, WEI Shi-hui2

2017, 26(5):  338-342.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 011

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 Objective  To investigate the clinical and imaging features of patients with hematologic system tumors who initially presented to neuro-ophthalmology departmnt. Design  Retrospective case series. Participants Three cases initially presented as optic neuropathy, which was confirmed as hematological malignancy finally. Method  The data including clinical manifestations, imaging examinations, laboratory tests and pathological findings of the patients were retrospectively analyzed. Main Outcome Measures  Clinical manifestations, magnetic resonance imaging (MRI) of brain or orbit, blood and cerebral spinal fluid (CSF) tests and pathological findings. Results  The three patients were over 50 years of age. Two patients complained with vision loss, one patient complained with amaurosis fugax bilateral. Orbital MRI showed the optic nerve thickening and different degree of enhancement in two cases of lymphoma, and involvement of optic nerve and optic chiasm without obvious enhancement in multiple myeloma. All the patients underwent biopsy and the outcomes were confirmed by pathology. One case was diagnosed as diffuse large B cell lymphoma, one as small B cell lymphoma and the other case as multiple myeloma. Conclusion  This study documented three extremely rare cases of hematologic tumors initially presented as optic neuropathy. Blood tests and imaging examinations are helpful to making the diagnosis. Pathological examination is the gold standard for diagnosis. (Ophthalmol CHN, 2017, 26: 338-342)

Clinical features of Leber hereditary optic neuropathy

CHENG Xian-hua1,2, YANG Mo1, WEI Shi-hui1, XU Quan-gang1

2017, 26(5):  343-346.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 012

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 Objective To study the characteristics of Leber hereditary optic neuropathy (LHON) for early diagnosing and avoiding unnecessary treatment. Design Retrospective case series. Participants 79 cases (156 eyes) who were diagnosed as LHON (detection of optic nerve damage and mtDNA gene positive). Methods Retrospective analysis the basic data, disease characteristics, visual acuity, pupil and relative afferent pupillary defect (RAPD), visual field of 79 cases (156 eyes) with LHON, collecting its course, clinical characteristic clinical manifestation. Main Outcome Measures Gender, age, visual acuity, visual field, pupil and RAPD and the results of mtDNA test. Results The mean age of scheduled patients was 20.94±11.9 years (median 17 years), with 67 males（133 eyes，84.81%）. 66 cases were misdiagnosed as optic neuritis. 16 cases (20.25%) had family histories. Both eyes suffered from vision loss at the same time in 43 cases (53.43%)， and 34 patients (43.04%) secondary attack of both eyes. MtDNA mutations of 11778G>A, 14484T>C, 3460G>A accounted for 87.34% of the total. The pupil was sensitive to light  in 53 cases (67.09%). 67.90% of cases showed central or paracentral scotoma. Within 3 months of onset,  fundus examination showed optic disc edema.  Optic disc pale as more obvious 6 months after onset. In 71.80% of patients, the vision was less than 0.1. The longer duration, the higher the proportion of low vision was found. Conclusion LHON mainly happened among middle-aged male, mostly under 25 years. The patients suffered from serious vision loss, but the pupil was  sensitive of light. Visual field test usually showed large center or near the center scotoma. (Ophthalmol CHN, 2017, 26: 343-346)

Training of clinical and scientific thinking in cultivate ophthalmic professional graduate students

ZHANG Feng-ju, LI Yu

2017, 26(5):  349-351.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 016

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With the deepening reform of medical education, both supervisors and clinical teachers should change their traditional concept and adjust their cultivating strategy. Cultivating graduate students’ clinical and scientific thinking should be emphasized, and students’ clinical skills and scientific research ability should be improved simultaneously. Based on ophthalmology professional degree graduate cultivation model, it is important to emphasize cultivating specialized clinical skills and improvement of the scientific thinking, in order to train higher-level innovative talents for the development of modern ophthalmology. (Ophthalmol CHN, 2017, 26:  349-351)

Foreign stones may serve to polish domestic jade-hints from the American ophthalmology residency training system

YOU Qi-sheng, WAN Xiu-hua

2017, 26(5):  352-354.  doi:10. 13281/j. cnki. issn.1004-4469. 2017. 05. 017

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 Programmed residency training is critical to standardize medical practice and ensure medical service quality. However, the ophthalmology residency training in China is still in its initial stage. The training quality needs improving, particularly the surgical training. On the contrary, in the United States, the ophthalmology residency training has been operating for many years. Many aspects of the training system in the United States are worth being used for reference in China, such as the basic and clinical sciences course, the required surgical volume, the grand rounds and the examination and assessment system. (Ophthalmol CHN, 2017, 26: 352-354)