Table of Content

25 September 2023, Volume 32 Issue 5

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Surgical strategy of angle closure glaucoma secondary to lens subluxation 

Yu Xiaowei, Fan Zhigang, Shi Yan

2023, 32(5):  363-368.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.001

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 Angle closure glaucoma (ACG) secondary to lens subluxation is a clinical problem with complex etiology. Its essential anatomic change in its pathogenesis is zonulopathies caused by various reasons. Based on the anatomical characteristics and pathophysiological functions of zonule, this article reconceptualizes the adjacent tissue complex of the zonule, and proposes that the change of pressure between the adjacent tissue complex caused by zonulopathies is the key to understand the physiological process of ACG secondary to lens subluxation. Based on the pathogenesis of various types of lens subluxation and the pathophysiological process of complex pressure change, we can understand the ocular phenotype of zonulopathy and predict its possible surgical risks. Further, we propose four modular treatment methods to make apersonalized treatment for ACG secondary to lens subluxation, including the treatment of aqueous humor countercurrent, lens extraction, maintenance of long-term stability of intraocular lens and reconstruction of angle filtration, which provides guidance for the scientific treatment strategy of this kind of refractory glaucoma. (Ophthalmol CHN, 2023, 32: 363-368)


Anomalous posterior vitreous detachment

Huang Houbin

2023, 32(5):  369-375.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.002

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 Other than innocuous posterior vitreous detachment (PVD), anomalous PVD indicates partial adhesion of posterior vitreous cortex to retina inner limiting membrane, or remnants of posterior vitreous cortex on the surface of inner limiting membrane. Anomalous PVD can result in vitreoschisis, retinal breaks, etc. The residual vitreous cortex could be fibrous with few cells or cell-rich, which are highly associated with the pathogeneses of full-thickness macular hole, lamellar macular hole, pseudomacular hole and epimacular membrane. (Ophthalmol CHN, 2023, 32: 369-375)


Focal scleral nodules

Ran Zhenlong, Peng Xiaoyan

2023, 32(5):  376-380.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.003

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Solitary idiopathic choroiditis (SIC) has been renamed as focal scleral nodule (FSN) based on multimodal imaging findings. FSN presents as yellow-white elevated nodules located between the posterior pole and the equator of the fundus. It exhibits hyperautofluorescent and hyperechogeneic characteristics. On optical coherence tomography (OCT), FSN appears as a highly reflective mass protruding inward from the sclera, and OCT angiography confirms the absence of blood flow within the lesion. FSN can remain stable over a long period without requiring treatment. But it can be misdiagnosed as amelanotic choroidal lesions, especially when there is suspicion of choroidal metastasis. Accurate identification of FSN contributes to making correct clinical decisions for ophthalmologists. This article elucidates the nomenclature process, demographic distribution, multimodal imaging features, and differential diagnosis of FSN. (Ophthalmol CHN, 2023, 32: 376-380)

Ocular metastatic carcinoma

Zhu Yu, Li Yanyan

2023, 32(5):  381-386.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.004

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 With the aging of society and the improvement of medical level, the number of people with tumor in society is increasing, and the number of patients with ocular metastatic cancer is also increasing, and 30% to 50% of the patients have the primary tumor site detected after the first symptom of the eye. Therefore, for middle-aged and elderly people, the ocular space-occupying lesion should be analyzed whether it is the primary tumor or metastatic cancer, and the cause should be found as soon as possible for the corresponding treatment. This article introduces the common primary foci, clinical manifestations and imaging features of the choroidal and orbital metastases, the diagnostic procedures, treatment methods and prognosis of ocular metastases. (Ophthalmol CHN, 2023, 32: 381-386) 

Establishment of immortalized human scleral fibroblast cell line

Li Jiaying, Li Peng, Cheng Zhen, Wang Wenbin, Li Shiming, Tian Jiaxin, Qi Yue, Qian Yuyang, Liu Zihan, Wang Ningli

2023, 32(5):  387-391.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.005

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 Objective To establish an immortalized human scleral fibroblast cell line and analyze the effect of immortalization using transcriptome sequencing. Design Experimental study. Participants The experimental group was immortalized human scleral fibroblasts, and the control group was primary human scleral fibroblasts. Methods Lentiviral particles were obtained by transfection of HEK293T using calcium phosphate transfection method using plasmid carrying SV40 T gene and lenti-Mix lentivirus packaging plasmid. The obtained lentiviral particles were transfected with primary cells and exposed to puromycin containing 1 μg/ml for 2 days, and the surviving cells were continued to be cultured for 25 generations to obtain immortalized human scleral fibroblast cell lines. Afterward, total RNA of primary human scleral fibroblasts and immortalized human scleral fibroblasts were extracted and sequenced to analyze the transcript characteristics of immortalized cells and primary cells. Differential genes were analyzed using the DESeq package and gene ontology (GO) analysis was performed using Clusterprofiler.  Main Outcome Measures Cell morphology, collagen-related gene expression and transcript correlation. Results Immortalized human scleral fibroblasts maintained the morphology of the primary cells and showed significantly enhanced proliferation ability and were successfully cultured for more than 20 generations. The transcriptomes of the immortalized and primary cells were highly similar, and the correlation between the two was r2=0.995 obtained by RNA sequencing. The transcriptome yielded 22903 genes and 33691 isoforms, and the eifferential gene analysis based on DESeq package revealed that 2063 (3.6%) genes were up-regulated and 2776 (4.9%) genes were down-regulated. GO functional analysis showed that the up-regulated genes were mainly clustered in DNA replication, cell division and other basic cellular metabolic activities and interactions with viruses, while the down-regulated genes were mainly enriched in extracellular matrix regulation and intercellular junction pathways. As for the extracellular matrix-related gene pathways, transcription of genes encoding collagen and fibronectin was slightly downregulated (log2 fold change=-0.4~-3.1), and COL1A1 transcription was downregulated 3.34-fold. Conclusion In this study, an immortalized human scleral fibroblast cell line was constructed by introducing SV40T exogenous gene using lentiviral transfection method, with high similarity to primary cells and good stability, which can provide sufficient research material for sclera-related experiments. (Ophthalmol CHN, 2023, 32: 387-391)

Analysis of the prognosis of visual function in blinding neuromyelitis optica spectrum disorders associated with optic neuritis

Yang Qinglin, Sun Houliang, Meng Chao, Wang Jiawei

2023, 32(5):  392-396.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.006

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 Objective To analyze the clinical and immunological features of blinding neuromyelitis optica spectrum disorders associated optic neuritis, and to explore the predictive factors of visual function prognosis. Design Retrospective case series. Participants Patients with blinding neuromyelitis optica spectrum disorders related optic neuritis admitted to our department from 2018 to 2022 were enrolled. Methods The patients were divided into poor prognosis group (27 cases) and good prognosis group (18 cases). The demographic characteristics, symptoms, laboratory and imaging examinations, treatment methods, and visual acuity improvement at 6 months after treatment were compared between the two groups. Main Outcome Measures Clinical features, visual acuity improvement. Results In the poor prognosis group, the proportion of patients with optic nerve involvement longer than half was higher (P=0.009), the positive rate of serum immune antibody was lower (P=0.028), and the time from onset to methylprednisolone pulse therapy was longer (P=0.032). Logistic regression showed that the length of optic nerve involvement greater than 1/2 (OR=16.247, 95%CI: 10.834-24.363, P<0.01), serological immune antibody negative (OR=13.965, 95%CI: 9.465-20.603, P<0.01), the time from onset of methylprednisolone pulse therapy (OR=1.107, 95%CI: 1.075-1.139, P<0.01) were the risk factors for poor prognosis. ROC curve analysis showed that the area under the ROC curve (AUC) for predicting poor prognosis was 0.794 (P=0.001, 95%CI： 0.659-0.928) when the time from onset was more than 7 days. Conclusions The prognosis of blinding neuromyelitis optica spectrum disorders associated with optic neuritis is poor, and the duration of methylprednisolone pulse therapy is closely related to the prognosis. (Ophthalmol CHN, 2023, 32: 392-396)

Clinical study on the effects of posterior corneal astigmatism (PA) on Toric intraocular lens (IOLs) cylinder calculation 

Jin Tianru, Li Jingjing, Yu Lan, Zhou Yanwen

2023, 32(5):  397-402.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.007

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 Objective To assess the effects of selecting keratometer astigmatism (KA) or total corneal astigmatism (TCA) as a reference on toric IOL calculation among subjects with age-related cataract and high posterior corneal astigmatism (PA). Design A retrospective comparative case series. Participants The present study included 77 eyes with against the role astigmatism (ATR) from age-related cataract patients and measured PA of more than 0.5 D in Aier Eye Hospital (Shenyang) from June 2017 to December 2021. Method The subjects were randomly divided into the KA and TCA groups and each group selected KA and TCA for toric IOL cylinder power calculations with Alcon Acrysoft Toric online calculator (https://www.acrysoftoriccalculator.com/). Holladay formula was choose to calculate the IOL cylinder power by using TCA and Barrett formula was choose to calculate the IOL cylinder power by using KA. Main Outcome Measures The uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), subjective refraction, magnitude of error (ME) and correction index (CI) and the centroid error in predicted residual astigmatism in two groups. Results The postoperative UCVA in the KA and TCA groups were 0.14±0.80 logMAR and 0.15±0.72 logMAR, respectively, whereas the difference between the two groups was not statistically significant（t=0.79, P=0.718）. The subjective refraction stigmatism value in the KA group was similar to that noted in the TCA group (KA group: -0.27±0.92 D, TCA group: -0.40±0.64 D, t=-0.55, P=0.582). The ME value was 0.33±0.33 D in the KA group and -0.22±0.52 D in the TCA group, suggesting postoperative undercorrection in KA group and overcorrection in TCA group. The absolute ME values of the two groups were not statistically significant (t=-0.46, P=0.542). According to the double-angle plot, the postoperative refractive prediction errors were 0.49±0.56 at 175° and 0.13±0.71 at 10°. The postoperative refractive astigmatism prediction error in KA group (48%) was similar with TCA group (43%) in ＜0.5 D. Conclusions In the eyes of high PA, the choice of TCA for Toric IOL lens calculation will lead to mild overcorrection and postoperative with the role astigmatism, which is an ideal refractive state. (Ophthalmol CHN, 2023, 32: 397-402)

Efficacy of improved pars plana vitreous drainage in the combined surgery of glaucoma and cataract for angle closure #br# glaucoma with abnormal lens suspensory ligament#br#

Yin Ruimei, Chen Lin, Wang Tao

2023, 32(5):  403-408.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.008

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Objective To analyze the therapeutic effect of improved pars plana vitreous drainage in the combined surgery of glaucoma and cataract for angle closure glaucoma with abnormal lens suspensory ligament. Design Retrospective case series. Participants 18 patients (18 eyes) with angle closure glaucoma with abnormal lens suspension ligament were reviewed from January 2021 to February 2023 in Beijing Tongren Hospital. Methods All patients were treated with improved pars plana vitreous drainage, phacoemulsification and cataract extraction. All patients were implanted with intraocular lens (IOL) in the bag at the first stage. All patients were treated with wide base peripheral iridectomy. 11 patients were implanted with capsular tension ring, 5 patients with trabeculectomy, and 3 patients with ciliary body photocoagulation under endoscope. The average postoperative follow-up was (8.3±3.6) months. Main Outcome Measures Anterior chamber depth (ACD), visual acuity (VA), intraocular pressure (IOP), number of anti glaucoma drugs used, and surgical complications. Result At the last follow-up, all patients' VA improved compared to before surgery, with an average improvement of (3.7±2.2) lines on the standard VA chart. 16/18 eyes maintained 7~21 mmHg without the use of IOP lowering drugs and 2/18 eyes maintained normal IOP 6 months after surgery with the addition of a local IOP lowering drug. After the improved pars plana vitreous drainage, all patients had a decrease in IOP during surgery, and the ACD deepened compared to before drainage. No serious complications occurred during or after the surgery in all patients. Conclusion The improved pars plana vitreous drainage is a safe and effective method for the combined surgery of glaucoma and cataract in the treatment of angle closure glaucoma with abnormal lens suspensory ligament. (Ophthalmol CHN, 2023, 32: 403-408)

Association study of serumcarotenoids with retinal vessel caliber in type 2 diabetic patients

She Chongyang, Shen Zhijun, Li Yunyun, Cui Min, Liu Ningpu

2023, 32(5):  409-415.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.009

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 Objective To observe the association between serum carotenoid level and retinal vessel caliber in type 2 diabetic patients. Design Cross-sectional study.  Participants A total of 462 subjects with type 2 diabetes mellitus (T2DM) from the Desheng Diabetic Eye Study were enrolled in this study. Methods 21 subjects were excluded according to the inclusion and exclusion criteria. 189 patients with diabetes without retinopathy (DWR) and 252 patients with mild to moderate non proliferative diabetic retinopathy (NPDR) were included. Demographic and lifestyle characteristics were collected through questionnaires. All subjects underwent general physical and ophthalmic examinations. Serum carotenoid levels were detected by high performance liquid chromatography. The calibers of retinal vessels, including central retinal arteriolar equivalent (CRAE), central retinal vein equivalent (CRVE) and arteriovenous ratio (AVR), were measured by semi-automatic software. Variables of the two groups were compared. Multivariate Logistic regression analysis was used to analyze the association of serum carotenoid level with retinal vessel caliber. Main Outcome Measures CRAE, CRVE, AVR, serumcarotenoids level. Results The CRAE was 150.8±16.0 μm in DWR group and 149.9±14.4 μm in mild and moderate NPDR group (t=0.58, P=0.56). The CRVE was 220.9±22.2 μm in DWR group and 230.3±25.1 μm in mild and moderate NPDR group (t=3.97, P<0.001). The AVR were 0.68±0.06 in DWR group and 0.65±0.06 in mild and moderate NPDR group (t=4.85, P<0.001). After adjusting for other risk factors, serum zeaxanthin was positively associated with CRVE in DWR group (OR=4.03, 95%CI: 1.40, 19.62, P=0.01), and lycopene was positively associated with CRVE in mild and moderate NPDR group (OR=1.01, 95%CI: 1.0002, 1.02, P=0.01). Conclusions The CRVE of NPDR patients was significantly wider and the AVR was significantly lower than those of DWR subjects. Higher levels of serum zeaxanthin and lycopene were associated with wider CRVE. (Ophthalmol CHN, 2023, 32: 409-415)

Clinical features and etiological analysis of candida keratitis 

Wang Zhiqun, Deng Shijing, Zhang Yang, Liang Qingfeng, Chen Kexin, Sun Xuguang

2023, 32(5):  416-420.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.010

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 Objective To analyze the clinical and etiological characteristics of candida keratitis. Design Retrospective case series. Participants 18 patients (18 eyes) diagnosed with candida keratitis in the Beijing Tongren Hospital from January 2016 to December 2018 were enrolled. Methods Patient's medical records were reviewed. Clinical data was collected and the characteristics were observed by stages according to the severity. Corneal scraping, fungal culture or in vivo confocal microscopy was performed. Main Outcome Measures Clinical characteristics by stages, corneal scraping, fungal culture and identification of isolated strains, drug sensitivity results and result of laser confocal microscopy. Results 11 of the 18 (61.11%) patients had history of viral keratitis with long-term antiviral treatment. Of all the 11patients, 8 cases were combined with corticosteroids therapy and 3 cases were diabetes mellitus. 7/18 cases（38.89%） were in early stage with epithelial defect and multiple localized grey colonies like infiltration in epithelium and superficial stroma. 5/18 cases（27.78%） were in advanced stage with progressed infiltration and stromal ulcer, some were accompanied with hypopyon. 6/18 cases（33.33%） were in late stage, corneal ulcer enlarged and infiltration intensified, the edge of the ulcer became thinner and sulcus dissolved, often accompanied by hypopyon. 14 of the 18 patients were examined by confocal microscopy. Fungal spores were found in 13 patients and pseudohypha was found in 6 patients. Yeast-like fungi and / or pseudohyphae were detected in 11 cases (61.11%). 17 cases underwent fungal culture, 10 cases (58.82%) were Candida albicans, and 3 cases (17.64%) were Candida glabrata. The drug sensitivity of the isolated strains was more than 88.24%, and 100% to the voriconazole and amphotericin B. Conclusion Candida keratitis is more common in chronic recurrent viral keratitis patients. Clinical characteristics are aggravated colony like infiltrates and ulcer with hypopyon in severe cases. Corneal scraping, fungal culture combined with laser confocal microscopy can improve the diagnosis，and the main pathogen is Candida albicans and sensitive to voriconazole and Amphotericin B. (Ophthalmol CHN, 2023, 32: 416-420)

The ocular manifestations of patients with neurofibromatosis type 1

Liang Xiaofang, Wang Kaiyue, Yang Liu, Zhang Xuxiang

2023, 32(5):  421-424.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.011

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 Objective To investigate the ocular clinical manifestations of patients with neurofibromatosis type 1 (NF1). Design Retrospective case series. Participants 17 cases (34 eyes) of NF1 in Beijing Tiantan Hospital from October 2021 to February 2022. Methods Clinical data of 17 patients diagnosed with NF1 were retrospectively analyzed. All patients underwent detailed ophthalmic examination and related general check-up. Main outcome measures The incidence of iris hamartoma and ocular and systemic related clinical manifestations. Results 17 patients ranged in age from 10 to 52 years were enrolled in this study, including 9 males (18 eyes) and 8 females (16 eyes). The best corrected vision acuities were from no light perception to 1.2. The intraocular pressures of all patients were normal. 11 patients (64.7%) suffered iris hamartomatain of both eyes, presenting as light brown to dark brown slightly raised nodules with clear boundaries, and ranged in number from 3 to 25, with diameters ranging from 0.5 mm to 1.5 mm. Their positions ranged from close to the pupil margin to any part of the iris, 73.3% distributed on inferior part of the iris. One patient suffered eyelid and orbital plexiform neurofibroma and one patient suffered choroidal abnormalities. The systemic manifestations also included milk coffee spots and neurofibroma of multiple types, and 12 cases combined with axillary groin freckles. Conclusion We found that 65% of patients presented with iris hamartoma of both eyes, which was manifested as brown micro-raised nodules of varying size and number. Iris hamartoma is one of the most important clinical manifestations of NF1, and this study provides a reference for clinicians to fully understand NF1 and determine the disease condition and classification. (Ophthalmol CHN, 2023, 32: 421-424)

Assessment of ocular torsion in patients with intermittent exotropia

Liu Peipei, Dai Wei, Fu Jing

2023, 32(5):  425-429.  doi:10.13281/j.cnki.issn.1004-4469.2023.05.012

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 Objective To evaluate the distribution of ocular torsion in intermittently exotropic patients. Design Retrospective case series. Participants 108 patients with intermittent exotropia aged 5~16 years presented from October 2021 to July 2022, and 108 patients without strabismus were collected as the control group in Beijing Tongren Hospital. Method All subjects underwent non-mydriatic fundus photography. The disc-foveal angle (DFA) was measured using Image J software. Photographs of the fundus were classified as normal (no torsion) when the fovea lay between the center and the inferior margin of the optic disc. There was an intorsion when the fovea was above the disc center. Extorsion when the fovea was situated below its inferior margin. The correlation between DFA and the Revised Newcastle Control Score (RNCS) and strabismus angle, stereoacuity was analyzed. Main Outcome Measures DFA, ocular torsion and correlation with RNCS, strabismus angle, and stereopsis. Results The mean DFA in the intermittent exotropia group was significantly greater than that in the normal control group (6.17°± 3.18 °; 5.36 °± 2.50°, respectively, P=0.003), and the incidence of ocular torsion (extorsion or intorsion) in the intermittent exotropia group was significantly higher than that in the control group (33 eyes, 15.28%; 14 eyes, 6.48%, P=0.003). DFA size has significant positive correlation with RNCS, strabismus angle and stereoacuity in patients with intermittent exotropia (r=0.634, P＜0.001; r=0.353, P＜0.001; r=0.370, P＜0.001; r=0.271, P=0.005). Conclusion Intermittent exotropia patients exist more obvious the ocular torsion when their control scores were poor, their strabismus angles were larger, and their stereoacuities were poorer. (Ophthalmol CHN, 2023, 32: 425-429)