Table of Content

25 March 2021, Volume 30 Issue 2

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Main problems and countermeasures of ophthalmic artificial intelligence research

Wang Yaxing, Xue Cancan, Li Jianjun

2021, 30(2):  81-84.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.001

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 With the advent of artificial intelligence (AI) and its implication in medical field in recent years, AI in ophthalmology has been a trending topic. In case of major vision-threatening diseases, like diabetic retinopathy, glaucoma, and age-related macular degeneration, AI-related researches have emerged expansively. Despite much promising research currently being undertaken, general issues exist, like being lack of transparency, clear reporting to facilitate replicability, and clear demonstrations of effectiveness. This article described the challenges and unmet needs for AI application in major eye diseases and the common conditions in the field, and additionally introduced guidelines to regulate AI researches in ophthalmology and health care. （Ophthalmol CHN, 2021, 30: 81-84）





Pay attention to the perioperative management of corneal refractive surgery and prevent postoperative corneal ectasia

Zhang Fengju, Sun Mingshen

2021, 30(2):  85-88.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.002

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 In order to prevent the serious complications after corneal refractive surgery, especially the occurrence of corneal ectasia, we should pay attention to the key points of perioperative management and control, and strengthen the links of preoperative screening, surgical design and reasonable postoperative nursing. Combined with corneal biomechanical changes and corneal morphology measurement can assist in screening keratoconus before corneal refractive surgery. The rational selection of corneal refractive surgery indications, personalized design and standardized treatment are keys to effectively prevent the occurrence of complications of corneal ectasia. (Ophthalmol CHN, 2021, 30: 85-88)

Trans-lens pressure difference and ciliary block—A new concept for the mechanism of angle closure glaucoma

Liang Yuanbo, Lin Haishuang, Zhang Shaodan, Liu Chengtan, Xu Shuxia, Le Rongrong, Xie Yanqian, Li Guoxing

2021, 30(2):  89-96.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.003

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 Angle closure glaucoma is (ACG) one of the main causes of blindness in Chinese. Shallow anterior chamber and narrow angle are the anatomical basis and main risk factors of ACG. Based on the current ACG mechanism and the thinking in clinical practice, the author puts forward the hypothesis of “trans-lens pressure difference and ciliary block ”. There is aqueous humor hydrodynamic block between lens and ciliary body, which called ciliary block. Trans-lens pressure difference then formed based on ciliary block. The pressure difference in front and behind the lens can promote the lens to move forward, resulting in shallow central and peripheral anterior chamber. Pupillary block which is secondary to shallow central anterior chamber, causes iris bombe and narrowing/closure of chamber angle. Aqueous humor outflow was obstructed subsequently. In clinic, we can eliminate trans-lens pressure difference by relieving ciliary block and deepening anterior chamber. That may bring new ideas for the prevention and treatment of ACG. （Ophthalmol CHN, 2021, 30: 89-96）

Cross-sectional study of retinal vascular tortuosity in elderly population-Beijing Eye Study

Wei Chuanchuan, Liu Xue, Wang Shuang, Peng Xiaoyan, Xu Liang

2021, 30(2):  97-101.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.004

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Objective To quantitatively describe the population distribution characteristics of retinal vascular tortuosity in elderly population. Design Cross-sectional study. Participants Baseline population of Beijing Eye Study. Methods Quantitative measurement software (Singapore I Vessel Assessment, SIVA 3.0) was used to measure the parameters of retinal vascular tortuosity in color fundus photographs selected from 3901 subjects. One eye of each participant was randomly selected. The study population was divided into 6 groups: 40-44, 45-49, 50-54, 55-59, 60-64 and age of 60+ years. The region from 0.5 to 1 PD away from the disc margin was zone B, 0.5-2 PD away from the disc margin was zone C. Parameters include simple tortuosity arteriole (sTORTa), curvaturetor tuosity arteriole (cTORTa), simple tortuosity venue(sTORTv), curvature tortuosity venule (cTORTv). The distribution of population, age and gender of these indicators was described and the relationship between retinal vascular tortuosity and related factors such as age, gender, BMI and hypertension, diabetes, coronary heart disease, stroke, smoking and drinking from the questionnaire were analyzed with multivariate analysis. Main Outcome Measures sTORTa, cTORTa, sTORTv, cTORTv.  Results The sTORTa and cTORTa of 3901 subjects was 1.087±0.021 and 0.0000291±0.0000071, respectively. The sTORTv and cTORTv was 1.098±0.019 and 0.0000356±0.0000079, respectively. The TORTa in different age groups was significantly different (P=0.000), the indicator gradually decreased with age. Men's cTORTa was smaller than women's (all P=0.034). There was no significant difference in sTORTv between different age groups (P=0.169), but cTORTv was gradually increased with age (P=0.022). There was no difference in sTORTv between different genders (P=0.141). Multivariate analysis showed that sTORTa was associated with age (r=-0.001, P=0.013). cTORTa was associated with age (r=-4.21E-8, P＜0.0001), BMI (r=-5.64E-8, P＜0.0001) and hypertension (r=-8.16E-8, P＜0.0001). sTORTv was associated with BMI (r=0.001, P=0.008). cTORTv was associated with age (r=4.36E-8, P＜0.0001), BMI (r=1.16E-7, P＜0.0001), hypertension (r=1.36E-9, P＜0.0001) and hyperlipemia(r=-8.85E-8, P＜0.0001). Conclusion In population with 40 years or older, retinal arteries tend to straighten with age, while cTORTv was slightly increased with age. Men's cTORTa was smaller than women's. The retinal artery with a straight shape was associated with older age, higher blood pressure and BMI; the curved retinal vein was associated with higher BMI, higher blood pressure and lower levels of blood lipids. (Ophthalmol CHN, 2021, 30: 97-101)





Longitudinal detection of radiation-induced macular retinal and choroidal capillary density changes with OCT angiography in choroidal melanoma

Wang Qian, Yang Jingyan, Liu Yueming, Chen Mengxi, Wei Wenbin

2021, 30(2):  102-107.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.005

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 Objective To study longitudinal changes in retinal and choroidal capillary circulation in eyes treated with iodine 125 (¹²⁵I) plaque brachytherapy for uveal melanoma with OCT angiography (OCTA), and to explore changes in ocular blood flow before radiation retinopathy (RR). Design Prospective cohort study. Participants 30 patients diagnosed with choroidal melanoma from May 2017 to July 2018 and underwent 125I scleral radiotherapy. Methods Patients underwent OCTA examinations before 125I plaque brachytherapy, 1 day, 1 month, 3 months, 6 months and 12 months after the surgery. Retinal vascular density and choroidal capillary density were measured respectively and the correlation between visual acuity and OCTA parameters were analyzed. Main Outcome Measures Best corrected visual acuity(BCVA), retinal thickness, vacular density of the superficial and deep retinal in parafovea area, foveal avascular zone (FAZ) area, FD-300 area density, FD-300 length density and choroidal capillary vascular density. Results Before plaque brachytherapy, compared with the contralateral uninvolved eye, the choroidal melanoma eyes had thicker central macular thickness (P=0.004), lower parafoveal vascular density in superficial (P=0.05) and deep (P<0.001) retinal layer, smaller FAZ area (P=0.002), lower FD-300 area density (P<0.001), lower FD-300 length density (P=0.042), and lower choroidal capillary density (P=0.001). Patients were followed up for up to 12 months and found that FD-300 area density (P<0.001) and length density (P=0.007) gradually decreased. Although without statistically significant (all P>0.05), the superficial retinal vascular density gradually decreased with time, while the choroidal capillary vascular density increase at first and then decreased. Prior to scleral radiation application, the visual acuity of the affected eye was significantly correlated with the distance of the tumor from the optic disc (P=0.006) and macula (P=0.021). Multivariate linear regression analysis showed that 1 month after scleral radiation application, after adjusting the age and the distance of the tumor from the optic disc, the BCVA of the affected eye was significantly negatively correlated with central macular thickness. Conclusion Patients with choroidal melanoma had undergone changes in retinal and choroidal blood flow before receiving scleral radiotherapy, and the superficial retinal blood flow density gradually decreased as time passed after the plaque brachytherapy. It suggests that there may have been retinal vascular changes before the occurrence of radiation retinopathy. The retinal vascular changes existed before the occurrence of RR, which provides a new basis for the diagnosis and treatment timing of RR. (Ophthalmol CHN,  2021, 30: 102-107)





Clinic feature of eyelid granulomatous mass following forehead and face augmentation surgery

Yang Mingming, Yang Bentao, Jiang Libin

2021, 30(2):  108-111.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.006

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 Objective To summary the clinic feature and treatment of eyelid granulomatous mass following forehead and face augmentation surgery. Design Retrospective case series. Participants 16 patients (22 eyes) with periorbital lumps following forehead and face augmentation surgery from 2019 to 2020 in Beijing Tongren Hospital. Methods Clinical manifestation, physical signs, ophthalmic imaging and treatment were reviewed. Main Outcome Measures Manifestation, neuroimaging features and outcome. Results All patients were female. Age ranged from 26 to 46 years with an average of 36.43 ±5.65 years old. 3 patients(18.7%) merely received facial creotoxin or hyaluronic acid injection. 13(81.2%) patients received facial fat injection with 1 patient among them received forehead creotoxin injection, and 4 of them received double eyelid surgery after facial fat injection. The average duration between last surgery and onset of symptom was 19.50±19.70 months, with a median of 12 months. 6(37.5%) of them had bilateral lumps and 10 (62.5%) had unilateral lumps. 2 (12.5%) of them had eyelid swelling. Lumps located in upper eyelid in 13 cases (81.2%), and located in lower eyelid in 2 patients(12.5%). Lumps located both upper and lower eyelid in1 patient(6.3%). All the patients were found the lumps unintentionally. MRI demonstrated a mass with hypointense or hyperintense signal (12 patients with 14 eyes) in T1WI and hyperintense signal (12 patients with 17 eyes) in T2WI. Contrast-enhanced MRI showed heterogeneous enhancement. All 16 following patients rejected to receive any treatment and their lumps showed no change during 6 mouths follow up. Conclusion As a rare complication, the clinic manifestation of eyelid granulomatous mass following forehead and face plastic surgery remain quite stable and have a high chance to be misdiagnosed. Radiologic feature combined with the history of facial augmentation surgery would be helpful for diagnosis.  (Ophthalmol CHN, 2021, 30: 108-111)





Clinical characteristics and etiological analysis of adult non-traumatic Horner syndrome in first visting of ophthalmology

Jiang Hanqiu, Peng Jingting, Cui Shilei, Ma Zhonghua, Yue Changli, Liu Xuefei, Zhao Juan, Li Wenwen, Wang Jiawei

2021, 30(2):  112-117.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.007

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 Objective To analyze the clinical features and etiology of non-traumatic and non-iatrogenic Horner syndrome (HS) in adults. Design Retrospective case series. Participants From January 2018 to June 2020, hospitalized 7 patients with HS were collected in Beijing Tongren Hospital. Methods Their clinical and imaging data of characteristics, location and etiology of the disease were reviewed and analyzed. Main Outcome Measures The patient's onset form, HS three main signs, other clinical manifestations, imaging and other examination results. Results There were 6 males and 1 female with pituitary apoplexy. The age of onset ranged from 41 to 60 years. All patients had obvious neuro-ophthalmic signs, including exophthalmos in 2 cases, oculomotor nerve involvement in 2 cases, abducent nerve involvement in 2 cases, and the first branch of trigeminal nerve involvement in 2 cases. There were 6 cases of acute or subacute onset, 1 case of chronic course. The difference in the size of the difference of fissure size was 2-4 mm, and the difference of the pupil was 1-1.5 mm. The lesions of the third-order neurons of the cervical sympathetic nerve involved the internal carotid artery and cavernous sinus was in 3 cases, including malignant tumor, apoplexy and arteriovenous fistula. The all 3 cases were no abnormal secretion of facial sweat glands, and 2 cases had obvious local pain. There were 2 cases of secondary neuron involvement, all of which were malignant tumors, 1 case of pulmonary apex lesion and 1 case of thyroid lesion involving common carotid artery. There were abnormal secretion of facial sweat glands, but there were no pain and other signs of neuro ophthalmology and nervous system. There were 2 cases of pathological changes in the first level neurons of sympathetic pathway, which was from thalamus to cervical 8 or thoracic 2 (spinal ciliary center). 1 case was medulla oblongata infarction and 1 case was demyelinating disease of nervous system. All patients had abnormal secretion of facial sweat glands and other positive signs of nervous system. Conclusion The onset form, symptoms and other manifestations of nervous system damage of non-traumatic HS play very important roles in the localization and qualitative diagnosis of the disease. Detailed neuro-ophthalmic examination and early confirmation of physical signs are particularly important for the diagnosis of malignant tumor disease, invasive artery and cavernous sinus with HS. (Ophthalmol CHN, 2021, 30: 112-117)





Consistency analysis of the results of fitting orthokeratology lens based on sagittal height simulation software and standard trial lens

Zhen Yi, Shen Jing, Wang Wenhua, Gao Jie, Li Qian, Wang Ningli,

2021, 30(2):  118-123.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.008

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 Objective To compare the consistency of the results of fitting orthokeratology lens based on sagittal height simulation software and standard trial lens. Design Diagnostic tests. Participants 60 subjects (117 eyes, age 9.9±2.2 years) with myopic who needed orthokeratology fitting in Beijing Tongren Hospital. Methods Standard trial lenses were used for orthokeratology fitting in all subjects. The optometrist first experientially selected the first trial lens based on the patient's topographic map data, and then determined the parameters of lens to be produced according to the slit lamp fluorescent staining and the change of the topographic map after the try-on. The AC values of the first trial lens and the lens to be produced were recorded separately. The TR-SAG Sagittal height simulation software was developed by Beijing Institute of Ophthalmology. The software automatically calculates the corneal sagittal height based on the input patient corneal flat K value, e value, and corneal diameter, and further searches for the lens closest to the corneal sagittal height in the lens database. The AC value of the lens was taken as the output of the simulation software. One-way analysis of variance and Bland-Altman scatter plot was used to evaluate the difference between the two methods, and the intra-group correlation coefficient was used to evaluate the consistency of the results of the two methods. Main Outcome Measures AC value of the lens. Results The AC value of the first trial lens determined by the optometrist was 42.15±1.30 D. The AC value of the lens to be produced determined after the try-on was 42.10±1.28 D. And the AC value of the lens calculated by simulation software was 42.12±1.28 D. There was no significant difference among the three groups (F=0.050, P=0.951). The correlation coefficient between the AC value of the lens calculated by simulation software and the AC value of the first trial lens was 0.970 (P=0.000), and the correlation coefficient with the AC value of the lens needs to be produced was 0.968 (P=0.000), which were in good consistency. Conclusions The parameters of the orthokeratology lens calculated by the TR-SAG software are in good agreement with the parameters obtained by the optometrist using the standard trial lens. (Ophthalmol CHN, 2021, 30: 118-123)





Effect of Toric orthokeratology on corneal higher order aberrations in myopia and high astigmatism

Wang Xiaotao, Chen Haiying, Liu Gang, Zhang Chuan

2021, 30(2):  125-129.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.009

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Objective To observe the changes of corneal higher-order aberrations (HOAs) by Toric orthokeratology (ortho-k) in correcting myopic teenagers with high astigmatism. Design Retrospective case series. Participants 35 patients (67 eyes) with myopia of -1.00~4.00 D and astigmatism of -1.50~-3.00 D. Method The patients were examined for uncorrected visual acuity (UCVA), refractive error, corneal topography, root mean square(RMS) values of total the HOAs before and at 1, 3, 6, 12 months after wearing ortho-k. All indexes were analyzed with repeated measurement analysis of variance. Main Outcome Measures UCVA, refractive error, corneal topography, decentration distance, RMS values of total the HOAs. Results All 67 eyes were in good and stable condition after wearing Toric orthokeratology. All the decentrations were less than 0.5 mm. There were no statistically significant differences in the decentration measurements at different time points after wearing Toric orthokeratology (all P>0.05)． UCVA were changed significantly (P=0.002) compared with the baseline, the myopia and astigmatism, FK and SK were changed significantly (P<0.001) compared with the baseline. 12 months after wearing Toric orthokeratology, RMS values of total the HOAs 6 mm pupil diameter of Coma (0.958±0.611) Eq.D, spherical aberration (0.486±0.24) Eq.D, residual aberration (0.797±0.663) Eq.D and total HOAs (1.191±0.794) Eq.D were increased than before wearing Toric orthokeratology, the difference was statistically significant (F=11.02, 10.31, 6.76, 10.74, P=0.002, 0.002, 0.015, 0.004). Conclusion Toric orthokeratology is an effective correction option for myopia with high astigmatism. However, Toric orthokeratology can increase the corneal HOAs and affected visual quality. (Ophthalmol CHN,  2021, 30: 125-129)





Bacterial distribution and antibiotic susceptibility of conjunctival sac before keratoplasty

Li Chendi, Feng Yun, Hong Jing

2021, 30(2):  131-135.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.010

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Objective To investigate the distribution of conjunctival bacteria before different type of  keratoplasty (include limbal stem cell transplantation) and the factors that affecting the positive rate as well as the antibiotic susceptibility. Design Retrospective case series. Participants 572 patients underwent keratoplasty in Peking University 3rd Hospital were included and patients with current infection were excluded. Method Bacterial culture of conjunctival sac, results of antibiotic susceptibility and clinic data were reviewed. Clinic data of acute infection after surgery was also collected. All cases were divided into case group (positive culture) and control group (negative culture) depending on the result of conjunctival culture. Main Outcome Measures Clinical information, conjunctival culture results and antibiotic susceptibilities. Results The positive rate of bacterial culture was 4% (23/572). The main detected bacteria were Staphylococcus epidermidis (78.2%). There was no significant difference in gender, age, left/right eyes, type of keratoplasty, history of eye surgery, diabetes mellitus (all P>0.05). The positive rate of local antibiotic time (1 day, 2 days, 3 days and more) before keratoplasty was statistically significant (χ2=5.807, P=0.046). The positive rate was significantly different in different protopathy（P=0.001）and immune diseases was the highest (38.5%). Antibiotic susceptibility test suggest that gram positive bacteria was sensitive to rifampicin (100%) and vancomycin (88.9%). One patient with Stevens-Johnson syndrome had acute infection after keratoplasty, and his result of conjunctival culture was Escherichia coli. Conclusion The positive rate of conjunctival bacteria culture before keratoplasty would reduce by extend time of antibiotic. The patients with immune diseases should be concerned due to the high positive rate of bacteria culture. The positive result of preoperative conjunctival bacteria culture might have relation with acute infection after surgery. (Ophthalmol CHN, 2021, 30: 131-135)





Study of corneal thickness measurements with Pentacam HR and Optovue iVue OCT in keratoconus and myopic patients

Li Dan, Zhang Yang, Guo Lili, Wang Zhiqun, Chen Kexin, Li Na

2021, 30(2):  136-141.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.011

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 Objective To analyze the consistency of Pentacam HR and Optovue iVue OCT in the measurement of corneal thickness in patients with keratoconus and myopia, and to provide guides for the measurement of corneal thickness in keratoconus and myopic patients. Design Diagnostic technique evaluation. Participants 181 cases (359 eyes) of keratoconus and myopia patients scheduled for refractive surgery from October 2018 to October 2020 in Beijing Tongren Hospital. 166 eyes were in the myopia group, and 193 eyes were in the keratoconus group. Methods Pentacam HR and Optovue iVue OCT were used to measure the thickness and related parameters of different cornea areas. A one-way analysis of variance or Kruskal-Wallis H test was used to analyze the differences. the Bland-Altman consistency test was used to analyze the consistency. The Spearman correlation coefficient was used to analyze the correlation between the differences and corneal surface morphological parameters. Main Outcome Measures Corneal thickness in central corneal thickness, the thinnest corneal thickness, maximum keratommetry (Kmax), index of surface variance (ISV), index of vertical asymmetry (IVA), index of height asymmetry(IHA), index of height decentration(IHD). Results In the myopia group and keratoconus group, the thinnest point and central thickness of the cornea measured by Optovue iVue OCT was about 20 μm lower than Pentacam HR on average, and the difference was statistically significant (all P<0.05). For the central and thinnest thickness in myopia group and keratoconus group, the consistency of the measurement results of the two measuring instruments are quite different. The difference both the central area and the thinnest part in myopia group was about 35 μm. The measured difference spans of the central area and the thinnest part in keratoconus group were 60 μm and 84.56 μm, respectively. Both myopia group and keratoconus group, the corneal thickness difference in the central area and the thinnest point had no obvious linear correlation with KMax, ISV, IVA, IHA, IHD. The central corneal thickness in myopia group: r=0.025, -0.15, -0.165, -0.104, -0.15; PIVA=0.034. However, the scatter plot showed no linear correlation, and the other P values all were >0.05. Conclusions The corneal thickness measured with Optovue iVue OCT is about 20 μm lower than with Pentacam HR. It is recommended to refer to the corneal thickness measured with Optovue iVue OCT for patients before refractive surgery and keratoconus cross-linking surgery. (Ophthalmol CHN, 2021, 30: 136-141)





Treatment efficacy of endoscopic cyclophotocoagulation on post-traumatic refractory glaucoma

Li Qiyan, Chen Xiaoli, Zheng Pengfei, Tang Xin

2021, 30(2):  142-146.  doi:10.13281/j.cnki.issn.1004-4469.2021.02.012

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Objective To explore the safety and effectiveness of endoscopic cyclophotocoagulation (ECP) in the treatment of post-traumatic refractory glaucoma. Design Retrospective case series. Participants 24 eyes of 24 post-traumatic refractory glaucoma patients who previously had undergone anti-glaucoma surgeries at least 1 time at Beijing Tongren Hospital from May 2013 to May 2020. Methods ECP was used to treat all patients. Patients were followed up for at least 6 months and average 3.6±2.3 years (range 6 months to 7 years). Changes in intraocular pressure (IOP), visual acuity, the number of IOP-lowering drugs and complications were reviewed. The data were analyzed by ANOVA and paired t test. Main Outcome Measures IOP, visual acuity and the number of IOP-lowering drugs. Results The average pre-operation IOP was 37.8±8.7 mmHg. The IOP at last visit (21.9±6.9 mmHg) was significantly lower than that before the ECP (P<0.001), and the IOP was successfully controlled in 83.3%. The number of IOP-lowering drugs used before operation was 2.75±0.79, and it was 0.88±1.12 at the last follow-up after ECP. The difference was statistically significant (P＜0.001). The postoperative visual acuity remained unchanged or improved in 87.5% of the patients. There was no severe complication observed during or after ECP. The average follow-up of 3.6 years showed that ECP was effective in the treatment of traumatic refractory glaucoma. (Ophthalmol CHN, 2021, 30: 142-146)