Table of Content

24 May 2024, Volume 33 Issue 3

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Progress in diagnosis and treatment of malignant glaucoma

Shi Yan, Zhong Hongyu, Yu Xiaowei, Fan Zhigang

2024, 33(3):  161-168.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.001

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 The fundamental pathophysiological mechanism of malignant glaucoma is the posterior misdirection of aqueous humor into the vitreous, which results in the forward displacement of the lens-iris diaphragm and the shallowing of the entire anterior chamber, with or without elevated intraocular pressure. The promotion and dissemination of the irido-zonulo-hyaloid-vitrectomy (IZHV) procedure, which is considered the gold standard for treating malignant glaucoma in clinical practice, have led to a deeper understanding of the role played by the structural and functional abnormalities of the ciliary body-zonules-crystalline lens-hyaloid-anterior vitreous complex (CZLHV) in the occurrence and progression of malignant glaucoma. In this review, we aim to elaborate the pathogenesis of malignant glaucoma from the view of this complex concept, and subsequently propose the modified management strategy that follows our understanding of the complex and significantly improve visual prognosis of patients with malignant glaucoma.  (Ophthalmol CHN, 2024, 33: 161-168)

Improving the recognition of posterior ciliary artery occlusion and choroidal ischemia (II)

Huang Houbin

2024, 33(3):  169-177.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.002

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 The posterior ciliary artery occlusion (PCAO) can manifest multiple patterns, with totally different clinical characteristics associated with stages, ranging from unrecognizable retinal abnormality to severe pigmented fundus. Great variability can be noted in the distributions, morphology, sizes and extents of ischemia lesions. What’s more, different degrees of ischemia can be appeared in a same fundus of PCAO because of complex compensatory mechanisms. The clinical features of optic nerve head ischemia caused by PCAO also varies depending on different etiologies, such as non-arteritic, arteritic, diabetic. (Ophthalmol CHN, 2024, 33: 169-177)



The occurrence of aqueous misdirection in primary angle-closure glaucoma and its effect on the disease

Tan Siyi, Wang Bingsong

2024, 33(3):  178-181.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.003

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 Primary angle-closure glaucoma (PACG) is highly prevalent in Chinese population, and some PACG has more serious conditions with persistent elevated intraocular pressure(IOP). The results of previous animal experiments showed that as IOP gradually increased, aqueous humor gradually diffused backwards. Previous clinical studies revealed that PACG is often accompanied by zonulopathy, vitreous zonule rupture and intravitreal fluid accumulation. We speculate that in some PACG, due to the closure of the anterior chamber angle, the aqueous misdirection happens. The aqueous flows backwards into the space between the lens zonular, into retrolental space, and even into the anterior vitreous body, pushing the lens-iris diaphragm forward, and further increasing the aqueous outflow resistance. A vicious cycle has formed, leading to refractory elevated IOP. Meanwhile, the anatomical abnormalities caused by aqueous misdirection also explain the increased risk of intraoperative complications and more challenging treatment in PACG patients with elevated IOP. (Ophthalmol CHN, 2024, 33: 178-181)

The efficacy of 532 nm micropulse laser trabeculoplasty for primary open angle glaucoma 

Ji Ang, Zhang Qi, Yuan Jiahong, Ma Ruixia, Wang Xinchao, Guo Yin

2024, 33(3):  182-186.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.004

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Objective To investigate the efficiency of 532nm micropulse laser trabeculoplasty (MLT) in reducing intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG). Design Retrospective case-series. Participants 43 patients with POAG. Methods 22 patients received MLT as the initial treatment, while 21 patients received topical medication as the initial treatment but failed to achieve the target IOP or showed progressive narrowing of visual field or thinning of the nerve fiber layer, and then MLT was used as additional treatment. All cases were treated with unified laser parameters and operated by the same ophthalmologist. Main Outcome Measures IOP reduction, treatment success rate. Results IOP after laser treatment 1 hour, 1 day, 1 week, 1 month, 3 month, and 6 month were (19.9±4.7) mmHg, (17.9±4.5) mmHg, (18.5±4.4) mmHg, (16.8±4.2) mmHg, (16.7±4.2) mmHg and (17.5±5.2) mmHg, respectively (F=3.088, P=0. 006). Both the MLT group and the drug combined MLT group reached the maximum IOP reduction at 1 month after laser surgery. Compared with the group with normal baseline IOP, the amplitude of postoperative IOP reduction was larger in patients with elevated IOP after 1 day, 1 week, 1 month, 3 month, and 6 month treatment (all P<0.001). The IOP decreased by about 17.8% from baseline at 1 month follow-up. The overall success rate was 50.0% at 6 months follow-up, 54.2% in the drug combined MLT group and 42.9% in the MLT group (χ2=1.42, P=0.39). Hyphema, cornea injuries were not observed in all treated patients. Conclusion 532 nm MLT is effective and safe to be used as an initial treatment in patients with POAG, also a good assistant treatment for patients with topical medication. (Ophthalmol CHN, 2024, 33: 182-186)



Axenfeld-Rieger syndrome with leukoencephalopathy and cutaneous amyloidosis caused by a novel mutation in the FOXC1 gene in a pedigree

Jia Hongyan, Peng Chuzhi, Zhang Ranran, Jiao Yonghong, Wang Tao

2024, 33(3):  187-192.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.005

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 Objective To analyze the clinical and genetic characteristics of a family with Axenfeld-Rieger syndrome (ARS). Design Pedigree investigation.  Participants Three subjects from a family with ARS were admitted to Beijing Tongren Hospital. Methods Detailed ophthalmic examination and general examination were performed for family members. Peripheral venous blood was collected and DNA was extracted. Whole exome sequencing (WES) was performed on the proband, and Sanger sequencing and family co-segregation were used to validate disease-causing mutation. Main Outcome Measures Ocular examination results, physical examination results, genotype, craniocerebral MRI. Results Three samples (proband and their parents) were collected in this study. The proband presented bilateral anterior segments dysplasia. Nystagmus, strabismus, glaucoma, fundus manifestations of high myopiaand posterior staphyloma were presented in the proband’s left eye. A general examination suggested mixed deafness in the left ear, mild aortic insufficiency, and cutaneous amyloidosis. Brain MRI showed multiple bilateral leukoencephalopathy. The proband also had craniofacial features such as telecanthus, a high and broad nasal root. The father of the proband had anterior segment manifestations and systemic abnormalities similar to those of the proband. The results of gene testing and bioinformatics analysis indicated that both the proband and his father had an unreported FOXC1 gene insertion mutation NM_001453: c.1043_1044insGGCGCTC, p. (Tyr353fs) (chr6:1611723T> TGGCGCTC, hg19). The variation was not included in GWAS, 1000g, ESP, GnomeAD, ExAC and HGMD databases. According to ACMG guidelines, the variation was pathogenic. The mutation was predicted to lead to the production of a truncated protein. This mutation co-segregated with disease phenotypes and was not detected in unaffected members.  Conclusion A novel insertion mutation of FOXC1 gene c.1043_1044insGGCGCTC (p.Tyr353fs) was the cause of ARS in this family. At the same time, this is also the first report of ARS patients with leukoencephalopathy and cutaneous amyloidosis, extending the genotype and phenotype spectrum of the disease. (Ophthalmol CHN, 2024, 33: 187-192)



Analysis on the health economics evaluation and budget impact of trabectome and canaloplasty in Beijing

Fan Xiang, WeiXia, Zhang Chun, Yang Li

2024, 33(3):  193-199.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.006

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 Objective To conduct health economic evaluation analysis for trabectome, canaloplasty and to analyze the budget impact of applying for prices of trabectome. Design  health economics evaluation. Participants 3 patients diagnosed as primary open-angle glaucoma that underwent day case anti-glaucoma surgery in February 2022 with completed 12-months-follow-up in Peking University Third Hospital. Methods The evaluated effectiveness was measured by the success rate of the surgical procedures. The evaluated cost was the direct medical costs of surgeries and post operationally follow-up within 12 months. The minimum cost analysis was used to compare trabectome with canaloplasty, while the cost-effectiveness analysis was used by calculating the incremental cost-effectiveness ratio (ICER) to compare both trabectome and canaloplasty with trabeculectomy, respectively. The difference in total costs of various types of surgery before and after the price application for trabectome was calculated based on the amount of canaloplasty and trabeculectomy, as well as the substitution of trabectome. Main Outcome Measures Success rate of the surgical procedures, direct medical costs, ICER. Results The total cost per case for trabectome and canaloplasty was ￥13729 and ￥28793, respectively, which showed an ￥15064 decrease in cost from tebectome to canaloplasty. Using the total cost per case of ￥14281for trabeculectomy as a reference, the ICER was -￥87.6 for trabectome and ￥767.8 for canaloplasty. Prospectively replacing at least 50% of canaloplasty and trabeculectomy with trabectome, the total cost of the hospital was saved by￥384080 annually. Conclusion In Beijing, trabectome was more cost-effective than canaloplasty and trabeculectomy for primary open-angle glaucoma. The total costs of surgical treatment relevant for primary open-angle glaucoma could be saved after the price of trabectome was applied. (Ophthalmol CHN, 2024, 33: 193-199)



The impact of primary posterior capsulotomy on the refractive outcomes and anterior chamber depth after phaco-vitrectomy

He Yuan, Zhu Jingfen, Zhao Shiqiang, Qi Biying, Yang Wenli, Liu Wu

2024, 33(3):  200-204.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.007

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 Objective To analyze the impact of primary posterior capsulotomy (PC) in phaco-vitrectomy on postoperative refractive outcomes and anterior chamber depth (ACD). Design Prospective non-randomized controlled study. Parcitipants Between September 1, 2021 and September 30, 2022, 50 patients (50 eyes) in the triple group who underwent Phaco-vitrectomy combined with PC surgery due to full-thickness macular hole, epiretinal membrane, or vitreoretinal traction syndrome, and 50 patients (50 eyes) in the control group who needed cataract extraction combined with IOL implantation due to cataracts were prospectively recruited. Methods The Barrett UII formula was used to calculate the IOL power for all the patients. The best corrected visual acuity, refractive error (PE), anterior chamber depth (ACD), standard deviation, mean absolute error, median absolute error, and percentage of eyes with PE within ±0.25 D, ±0.50 D, ±0.75 D, and ±1.00 D for all patients before and 1 month after surgery were checked and recorded. Main Outcome Measures Postoperative PE and ACD. Results The postoperative PE of the control group was 0.054 ± 0.397 D, and that of the triple group was -0.091±0.668 D. Both groups showed no systematic error compared to 0 (t=0.962, P=0.341, and t=-0.963, P=0.340, respectively). The postoperative ACD in both groups deepened compared to preoperative levels, with a control group of 4.407±0.324 mm and a triple group of 4.259±0.254 mm. However, the ACD in the triple group was shallower than that in the control group, with a significant difference (t=2.537, P=0.013). The accuracy of refractive prediction in the triple group patients was poor, manifested as higher standard deviation, mean absolute error, and median absolute error compared to the control group, while the percentage of eyes in all given PE ranges was lower than that in the cataract group. Conclusions Compared with the cataract group, simultaneous use of PC during phaco-vitrectomy resulted in a significant shallowness in ACD at 1 month post-surgery. Although the triple group did not show significant myopic or hyperopic errors, its accuracy in predicting refractive error was significantly lower than that of the cataract group. (Ophthalmol CHN, 2024, 33: 200-204)



Comparative study on the measurement of papillary offset values with Scansys and Pentacam anterior segment analyzers

Liu Yin, Zeng Bo, Jiang Wenshan, Wu Jintao, Xu Chi, Han Yang

2024, 33(3):  205-211.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.008

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 Objective To evaluate the difference and consistency of papillary offset values of myopic patients measured by two anterior segment  analyzers: Scansys and Pentacam. Meanwhile, to discuss the correlation of increment of higher order abberations (HOAs) after SMILE and papillary offset values as well as the correlation of ablation induced decentration after SMILE and papillary offset values. Design Consistency evaluation study. Participants 185 eyes of 96 patients who received SMILE at General Hospital of Central Theater Command. Methods Parameters of papillary offset values were recorded preoperatively by Scansys and Pentacam. Ablation induced decentration and preoperative and postoperative HOAs were recorded by Pentacam. Wilcoxon signed rank test was used to compare the difference between Scansys and Pentacam, the intraclass correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate the agreement between Scansys and Pentacam. Pearson correlation analysis was used to discuss the correlation analysis. Main Outcome Measures ICC of papillary offset values by Scansys and Pentacam, correlation index. Results The highest proportion of the deviation of the pupil center from corneal vertex measured by Scansys and Pentacam was in the superotemporal and supernasal. The ICC for horizontal offset value, vertical offset value, total offset value and offset axis of the right eyes were 0.74, 0.78, 0.73 and 0.59; 0.77, 0.78, 0.84 and 0.66 for the left eyes; 0.75, 0.78, 0.79 and 0.63 for both eyes. The mean difference in horizontal offset value, vertical offset value, total offset value and offset axis for the right eyes were（-0.04±0.08）mm, （0.02±0.07）mm, （0.02±0.07）mm, （8.2±66）° (all P＜0.05); （0.01±0.09）mm (P=0.527), （0.02±0.07）mm (P＜0.05), （0.00±0.06）mm (P=0.650), （-20±72）° (P=0.527) for the left eyes; （-0.01±0.09）mm (P＜0.05),（0.02±0.07）mm (P＜0.05), （0.01±0.06）mm (P＜0.05), （-5.8±70）° (P=0.409) for both eyes. The total HOA, spherical aberration, vertical coma, trefoil 0 increased significantly after SMILE (all P＜0.05). There was no correlation between papillary offset values and HOAs increments or ablation induced decentration. Conclusion Results of papillary offset values of Scansys were slightly larger than the results of Pentacam, but the differences have no effect on the HOAs increments or ablation induced decentration. So, the results of two devices can be referred to each other. (Ophthalmol CHN, 2024, 33: 205-211)


Comparison of corneal epithelial remodeling between corneal lenticule implantation and corneal lenticule extraction

Liu Sijun, Dong Yahui, Hou Jie, Lei Yulin, Sun Fangfang, Liu Yuhe

2024, 33(3):  212-217.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.009

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Objective To investigate corneal epithelial remodeling after small incision lenticule extraction (SMILE) for moderate-high myopia and femtosecond laser-assisted microincision lenticule implantation for moderate-high hyperopia. Design retrospective comparative case series. Participants  15 patients (20 eyes) with moderate-high hyperopia who underwent femtosecond laser-assisted micro-incision lenticule implantation (lenticule implantation group), and 61 patients (115 eyes) with moderate-high myopia who underwent femtosecond laser-assisted micro-incision lenticule extraction (lenticule extraction group) were enrolled in Jinan Mingshui Eye Hospital from February 2021 to September 2022. Methods The Pachymetry mode of OCT (RTVue) was used to scan the corneal epithelial thickness values in each quadrant of the cornea before and 3~12 months after the surgery. Main Outcome Measures Corneal epithelial thickness in each quadrant. Results At the last follow-up, the epithelial thinning is more obvious in the lenticule implantation group within 5mm diameter, and the epithelial thickness is more significant in the lenticule extraction group within 7 mm diameter. Within the diameter of 5mm, the changes of corneal epithelial thickness were statistically significant (all P<0.05), and there was no significant difference between the two groups. Conclusions The epithelium of the lenticule implantation group was thinner than that before surgery, and the overall “concave lens” change was observed. The epithelium of the SMILE group was thicker than that before surgery, showing a “convex lens” change. The degree of epithelial remodeling was similar in the two groups. (Ophthalmol CHN, 2024, 33: 212-217)



Clinical characteristics and treatment efficacy in children with acute acquired concomitant esotropia

Zhang Guiou, Zhang Lu, Li Namin, Zhou Jian, Guo Changmei

2024, 33(3):  218-222.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.010

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 Objective To explore clinical characteristics and treatment efficacy in children patients with acute acquired concomitant esotropia. Design Retrospective case series. Participants 31 children patients with acute acquired concomitant esotropia between Jan 2019 and Oct 2022 in Xijing Hospital. Methods The different categorization data, including strabismus degree, stereopsis, and treatment plan were reviewed. Onset age, strabismus degree, visual function, treatment outcomes in different subgroups according to the Burian and Miller classification was compared. Main Outcome Measures strabismus degree and near and distance stereopsis before and after treatment. Results There was no difference in the far and near strabismus degree between type II patients (n=19) (P>0.05), while type III patients (n=12) had a higher onset age than type II patients (P<0.05) with a lower near strabismus degree than the far strabismus degree (P<0.05). There was no difference in strabismus degree and stereopsis between type II and III patients (P>0.05). After botulinum toxin injection and strabismus surgery, the degree of strabismus can be significantly reduced and visual function can be improved. Conclusion Acute concomitant esotropia in children can occur in types II, and III, with type II being more common. Type II patients are younger with the similar degree of far and near strabismus degree. Type III patients are older with a lower near strabismus degree than far strabismus degree. Acute concomitant esotropia patients with different types have visual function abnormalities and need to be treated as early as possible, which can lead to a better therapeutic effect. (Ophthalmol CHN, 2024, 33: 218-222)



Application of generative adversarial network in clinical teaching of ophthalmology

Wei Wenbin, Dong Li, Zhang Ruiheng, Wang Haiyan

2024, 33(3):  223-225.  doi:10.13281/j.cnki.issn.1004-4469.2024.03.011

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Objective To investigate whether ophthalmologists with different experience levels can distinguish authentic retinal photographs from those generated by Generative Adversarial Networks (GANs), so as to explore whether GAN can be applied in clinical teaching of ophthalmology. Design Diagnostic test. Participants 70 generated virtual retinal images and 70 real retinal photographs. Methods 20 participants including ophthalmologists, ophthalmology postgraduate students, and non-ophthalmologist physicians from Beijing Tongren Hospital were included in the present study. After training a model using real retinal photographs to create a high-quality image generator. Subsequently, 70 generated virtual retinal photographs are mixed in a 1:1 ratio with real retinal images. The participants, representing various levels of experience in ophthalmology, are then tasked with identifying the authenticity of the retinal photographs. Main Outcome Measures Sensitivity, specificity, and accuracy in distinguishing real and generated retinal images. Results The average sensitivity, specificity and accuracy were 0.578 (range: 0.314~0.871), 0.471 (range: 0.014~0.729), and 0.524 (range: 0.236~0.707) among the participating physicians respectively. There is no statistically significant difference in accuracy between the senior ophthalmologists and other ophthalmologist group (P>0.05). Conclusion Virtual retinal photographs generated by GAN models exhibit detailed features similar to real retinal images. In the future, these models could be utilized for producing high-quality retinal images to assist in ophthalmic education and training for primary care retinal specialists. (Ophthalmol CHN, 2024, 33: 223-225)