2013年 · 第126卷第08期

Retinal nerve fiber layer (RNFL),which originates from various locations of the retina and converge to form the optic nerve,makes up the innermost neural layer of the retina.RNFL defect,including localized and diffuse RNFL defect,is believed to be a characteristic feature of glaucoma and an important clue for the detection of early glaucoma,which may precede detectable optic disc changes and visual field loss.However,RNFL defect does not always equate to a diagnosis of glaucoma,and it can also be induced by vascular accidents or some other events in RNFL,1 such as hypertension,non-arteritic anterior ischemic optic neuropathy,multiple sclerosis,and so on。

The most common irreversible blindness diseases are age-related macular degeneration,glaucoma,and diabetic retinopathy which involve the optic nerve or retina.These diseases share a common condition of causing blindness-progressive neural cells loss of retina (photoreceptor cells,retinal ganglion cells (RGCs)).Although many advances in the treatment for these diseases have been achieved in recent years,the visual function often cannot be reversed.To improve the visual outcomes,the retinal neuron cells must be rescued.Optic nerve diseases including glaucoma were mostly studied for the effort to rescue the injured neurons and regenerate the neuron axons。

Abstract：Background Neovascular glaucoma (NVG) is a refractory disease which is difficult to manage.This study aimed at evaluating the efficacy and safety of adjunctive intravitreal bevacizumab (IVB) injection in conjunction with Ahmed glaucoma valve implantation (AGVI) in the management of NVG.Methods This was a retrospective study of patients with NVG in whom AGVI was performed between October 2008 and May 2012.The sample was divided into two groups according to the pretreatment:with adjunctive IVB injection (the IVB group,n=25 eyes) and without adjunctive IVB injection (the control group,n=28 eyes).The surgical success rate,number of antiglaucoma medications used,best-corrected visual acuity (BCVA),postoperative complications,regression,and recurrence of iris neovascularization (NVI) were analyzed between the groups.Results The surgical outcomes of the two groups were compared.The complete success rates in the IVB and control groups were 84.0％ and 64.3％ at 12 months and 80.0％ and 53.6％ at 18 months,respectively.There was a significant difference between the two groups (P=0.041).Mean postoperative intraocular pressures,mean number of postoperative antiglaucoma medications,and BCVA were not significant between the two groups.The NVI in 22 (88.0％) eyes had completely regressed within 2-8 days after IVB.However,NVI recurred in 10 eyes (40.0％) 2-9 months later after IVB.The IVB group had only 1 case (4.0％) of hyphema out of 25 eyes,while there were 8 (28.6％) cases of hyphema out of 28 eyes in the control group (P=0.026).Conclusions This study showed that preoperative IVB injection reduced NVI remarkably,decreased hyphema,and led to higher surgical success rates.Pre-operative IVB injection may be an effective adjunct to AGVI in the management of NVG。

Abstract：Background Surgical interventions are the main treatment for primary congenital glaucoma (PCG).This study aimed to compare the efficacy and safety between viscocanalostomy and mitomycin C (MMC)-trabeculectomy in patients with PCG.Methods A total number of 43 patients with PCG who underwent either viscocanalostomy (group 1) or MMC-trabeculectomy (group 2) between June 2003 and June 2008 were retrospectively reviewed.The patients' intraocular pressures (lOPs) were examined before surgery and on day 1,week 1,month 1,month 6,and month 12 post-operative.Mean horizontal corneal diameters,success rates,intra-and post-operative complications were compared between the two groups.Results Pre-operative lOPs were (31.96±3.90) mmHg in group 1 and (32.56±4.00) mmHg in group 2.At the last visit,lOPs were (16.78±2.20) mmHg and (15.77±2.60) mmHg,respectively (P ＜0.001); the complete success rates of group 1 and group 2 were 45.9％ and 67.4％,respectively,and the difference was not statistically significant (P=0.158).There were no major complications occurred in the two groups.Conclusions Both viscocanalostomy and trabeculectomy can lower lOP in PCG patients effectively.Although there was no major complications occurred in both groups,viscocanlostomy may decrease the probability of postoperative haemorrhage,hypotony,cataract,or choroid effusion。

Abstract：Background Fundus changes associated with high myopia (HM) may mask those associated with primary open-angle glaucoma (POAG).This study aim to determine the characteristics of RNFL thickness changes in patients with both POAG and HM and compare these to changes in patients with only HM.The diagnostic capabilities of both OCT and GDxVCC in this subset of patients are also evaluated.Methods Twenty-two eyes with POAG and HM (spherical equivalent (SE) between-6.0 and-12.0 D) were evaluated,and 22 eyes with HM were used for comparison.Characteristic retinal nerve fiber layer (RNFL) thickness profiles in patients with POAG and HM were examined using optical coherence tomography (OCT) and scanning laser polarimetry with variable corneal compensation (GDxVCC),and the diagnostic capabilities of these imaging modalities were compared.RNFL parameters evaluated included superior average (Savg-GDx),inferior average (lavg-GDx),temporal-superior-nasal-inferior-temporal (TSNIT) average,and nerve fiber indicator (NFI) on GDxVCC and superior average (Savg-OCT),inferior average (lavg-OCT),nasal average (Navg-OCT),temporal average (Tavg-OCT),and average thickness (AvgThick-OCT) on OCT (fast RNFL scan).Visual field testing was performed and defects were evaluated using mean defect (MD) and pattern standard deviation (PSD).Results The RNFL parameters (P ＜0.05) significantly different between groups included Savg-GDx,lavg-GDx,TSNIT average,NFI,Savg-OCT,lavg-OCT,Tavg-OCT,and AvgThick-OCT.Significant correlations existed between TSNIT average and AvgThick-OCT (r=0.778),TSNIT average and MD (r=0.749),AvgThick-OCT and MD (r=0.647),TSNIT average and PSD (r=-0.756),and AvgThick-OCT and PSD (r=-0.784).The area under the receiver operating characteristic curve (AUROC) values of TSNIT average,Savg-GDx,lavg-GDx,NFI,Savg-OCT,lavg-OCT,Navg-OCT,Tavg-OCT,and AvgThick-OCT were 0.947,0.962,0.973,0.994,0.909,0.917,0.511,0.906,and 0.913,respectively.The NFI AUROC was the highest value.Conclusions RNFL thickness was significantly lower in all but the nasal quadrant in patients with POAG and HM,compared to patients with only HM.Measurements with OCT and GDxVCC were well-correlated,and both modalities detected RNFL thickness changes.However,GDxVCC was better than OCT in detecting POAG in HM patients。

Abstract：Background Non-infectious endophthalmitis was reported to occur after cataract surgery or intravitreal injections.This study reported a series of patients having non-infectious endophthalmitis after pars plana vitrectomy in the same two operation rooms during the same period to estimate the risk factors for non-infectious endophthalmitis after vitrectomy.Methods Medical records of patients who presented with severe non-infectious endophthalmitis following vitrectomy between May 13 and June 8,2011,were reviewed.The presenting symptoms and signs were collected,including visual acuity,intraocular pressure,cornea and anterior chamber activity.The treatments and results of microbiology examination were also recorded and analyzed.Results Ten patients were identified with severe non-infectious endophthalmitis,presenting 1 day after pars plana vitrectomy.Three eyes (30％) had previous intraocular surgeries,four (40％) had proliferative diabetic retinopathy,and one (10％) got pars plana vitrectomy combinded with phacoemulsification and intraocular lens implantation.All the patients were initially treated with topical and/or oral steroids.Only two patients had intravenous antibiotics because of the atypical presentation.One eye had paracentesis because of high intraocular pressure and the aqueous sample was sent for microbiological examination.The culture of the aqueous,air in the operation room,the swab from hand of surgeons,infusion fluid,and vitrectomy effluent were all negative for bacteria and fungi.The inflammation regressed rapidly after the initial treatment.Conclusions Intraocular surgery history,poor general health status,longer operation time,and more surgical procedures are the risk factors for non-infectious endophthalmitis after vitrectomy.It responds well to steroids。

Abstract：Background The mechanism of retinal neovascularization is not understood completely.Many growth factors are involved in the process of retinal neovascularization,such as vascular endothelial growth factor (VEGF) and pigment epithelium-deprived factor (PEDF),which are the representatives of angiogenic and antiangiogenic molecules respectively.Oxygen induced retinopathy (OIR) is a useful model to investigate retinal neovascularization.The present study was conducted to investigate the feasibility of small interference RNA (siRNA) targeting VEGF gene in attenuating oxygen induced retinopathy (OIR) by regulating VEGF to PEDF ratio (VEGF/PEDF).Methods In vitro,cultured EOMA cells were transfected with VEGF-siRNA (psi-HITM/EGFPNEGF siRNA) and LipofectamineTM 2000 for 24,48,and 72 hours,respectively.Expression of VEGF mRNA was evaluated by real time polymerase chain reaction (PCR) and the level of VEGF protein was analyzed by Western blotting.In vivo,OIR model mice were established,the mice (C57BL/6J) received an intra-vitreal injection of 1 μl of mixture of psi-HITM/EGFPNEGF siRNA and Lipofectamine 2000.Expressions of retinal VEGF and PEDF protein were measured by Western blotting,retinal neovascularization was observed by fluorescein angiography,and quantified.Results In vitro psi-HITM/EGFP/VEGF siRNA treatment significantly reduced VEGF mRNA and protein expression.In vivo,with decreased VEGF and VEGF-PEDF ratio,significant attenuation of neovascular tufts,avascular regions,tortuous,and dilated blood vessels were observed in the interfered animals.Conclusions VEGF plays an important role in OIR,and the transfection of VEGF-siRNA can effectively downregulate VEGF expression in vivo,accompanied by the downregulation of VEGF-PEDF ratio,and simultaneous attenuation of retinal neovascularization was also observed.These findings suggest that VEGF/PEDF may serve as a potential target in the treatment of retinal neovascularization and RNA interference targeting VEGF expression,which represents a possible therapeutic strategy。

Abstract：Background Haze or corneal subepithelial fibrosis is one of the common complications after refractive surgery procedures,such as photorefractive keratectomy (PRK),laser epithelial keratomileusis,and epipolis laser in situ keratomileusis,which would result in refractive regression,decreased visual quality,and corneal opacification.Haze directly resulted from corneal fibrosis mediated by transforming growth factor β (TGFβ).Smad7,an inhibitory Smad,can inhibit TGFβ signal transduction.Recently,the effects of Smad7 on the inhibition of fibrosis in several organs have been studied,while little is known about the effects on cornea after PRK.This study was aimed to determine the effects of lentiviral-mediated Smad7 gene expression on corneal fibrosis in rats after PRK.Methods Four different experimental groups were established using right eyes of Sprague-Dawley rats.Thirty-two eyes underwent de-epithelialization only and served as a sham operation group (group 1).Ninety-six eyes underwent PRK operation and were further divided into group 2 (the PRK group) without lentivector administration,group 3 (the Lv-blank group) with control lentiviral vector without Smad7 administration,and group 4 (the Lv-Smad7 group) with Smad7 expressing lentiviral vector Smad7 administration.At 1 day,1 week,1 month,and 3 months after PRK,the transfection efficiency was determined by measuring the fluorescence signal as well as Smad7 protein and mRNA levels.Corneas were further processed for immunoblotting to assess the phosphorylation of Smad2 as a downstream event of TGFβ/Smad signaling.The expression of fibrotic markers,such as α-smooth muscle actin (α-SMA),Type Ⅲ collagen (collagen Ⅲ),and cell cycle-related marker Ki67,was measured by quantitative real-time reverse transcription polymerase chain reaction (RT-PCR).Results Lentivirus-mediated exogenous Smad7 gene expression in rat corneal tissue resulted in reduced activation of TGFβ/Smad signaling caused by downregulation of phosphorylation of Smad2.Smad7 also downregulated the expression of TGFβ2.Markers of cell proliferation and fibrosis,including Ki67,α-SMA,and collagen Ⅲ,were inhibited by Smad7 up to 3 months after PRK operation.Conclusion Smad7 gene transfer inhibits fibrogenic responses of cornea in rats after PRK。

Abstract：Background Elevated intraocular pressure (lOP) is primarily due to increased aqueous outflow resistance,but how aqueous outflow resistance is generated and regulated are still not fully understood.The aim of this study is to determine whether changes in outflow facility,outflow pattern,and morphology following acute lOP elevation were reversible when the lOP was returned to a normal level in bovine eyes using a two-color tracer technique to label outflow patterns within the same eye.Methods Twelve fresh enucleated bovine eyes were perfused with Dulbecco's phosphate buffer saline (PBS) containing 5.5 mmol/L glucose (DBG) at 30 mmHg first to establish the baseline outflow facility followed by a fixed volume of red fluorescent microspheres (0.5 μm,0.002％ v/v).After the red tracer being replaced with DBG in the anterior chamber,perfusion was continued at 7 mmHg with the same volume of green tracer,followed by a fixative.In two control groups,the eyes were constantly perfused at either 30 mmHg (n=6) or 7 mmHg (n=6) using the same methods.The outflow facility (C,μl·min·-1 mmHg-1),was continuously recorded.Confocal images were taken along the inner wall (IW) of the aqueous plexus (AP) in frontal sections.The percent of the effective filtration length (PEFL,PEFL=IW length exhibiting tracer labelingltotal length of (W) was measured.Sections with AP were processed and examined by light microscopy.The total length of IW and the length exhibiting separation (SL) in the juxtacanalicular connective tissue (JCT) were measured.A minimum of eight collector channel (CC) ostia per eye were analyzed for herniations.Results In the experimental (30-7 mmHg) group,the outflow facility was significantly higher at 7 mmHg ((4.81±1.33)μl·min·-1 mmHg-1) than that at 30 mmHg ((0.99±0.15) μl·min·-1 mmH9-1,P=0.002),corresponding to a significant increase in the PEFL (P=0.0003).The percent of CC ostia exhibiting herniations in the experimental group ((67.40±8.90)μl·min·-1 mmHg-1) decreased significantly compared to that in the control at 30 mmHg ((94.44±3.33) μl·min·-1mmHg-1,P=0.03),but higher than that in the control at 7 mmHg ((29.43±4.60) μl·min·-1mmHg-1,P=0.01).Washout-associated separation between the IW and JCT was found by light microscopy and percent separation length (PSL,PSL=SL/total length of IW) was decreased in the control at 30 mmHg compared to that in the experimental group and control at 7 mmHg.Conclusions The pressure-induced morphological and hydrodynamic changes were reversible.Changes (collapse of AP,separation between the JCT and IW,and herniation into CC ostia) influence the effective filtration area that regulates outflow facility。

Abstract：Background Small noncoding microRNAs regulate gene expression in cardiac development and disease and have been implicated in the aging process and in the regulation of extracellular matrix proteins.However,their role in age-related cardiac remodeling and atrial fibrillation (AF) was not well understood.The present study was designed to decipher molecular mechanisms underlying age-related atrial structural remodeling and AF.Methods Three groups of dogs were studied:adult and aged dogs in sinus rhythm and with persistent AF induced by rapid atrial pacing.The expressions of microRNAs were measured by quantitative real-time polymerase chain reaction.Pathohistological and ultrastructural changes were tested by light and electron microscopy.Apoptosis index of myocytes was detected by TUNEL.Results Samples of atrial tissue showed the abnormal pathohistological and ultrastructural changes,the accelerated fibrosis,and apoptosis with aging and/or in AF dogs.Compared to the adult group,the expressions of microRNAs-21 and -29 were significantly increased,whereas the expressions of microRNAs-1 and-133 showed obvious downregulation tendency in the aged group.Compared to the aged group,the expressions of microRNAs-1,-21,and-29 was significantly increased in the old group in AF; contrastingly,the expressions of microRNA-133 showed obvious downregulation tendency.Conclusion These multiple aberrantly expressed microRNAs may be responsible for modulating the transition from adaptation to pathological atrial remodeling with aging and/or in AF。

Abstract：Background A few inflammatory markers were studied to evaluate their possible prognostic roles in various cancers.The neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are hypothesized to reflect the systemic inflammation.The objective of the present study was to investigate whether or not the pretreatment neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio can predict the survival of patients with cervical cancer treated with neoadjuvant chemotherapy and radical hysterectomy.Methods We performed a retrospective study on cervical cancer patients (FIGO stage Ib2-Ⅱb) who had undergone neoadjuvant chemotherapy and radical hysterectomy at Peking Union Medical College Hospital between January 1999 and December 2010.Data on demographics,clinical prognostic markers and histopathology were collected and analyzed.Urivariate and multivariate analyses for prognostic factors were performed.Results A total of 111 patients were identified.The median neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios were 2.4 and 142.2,respectively.Overall survival and progression-free survival were neither significantly different between patients with high and low neutrophil-to-lymphocyte ratio (P=0.149 and P=0.108) nor in high and low platelet-to-lymphocyte ratio (P=0.336 and P=0.510).On multivariate analysis,lymph node status (P=0.000 and P=0.007)and lymphovascular space involvement (P=0.001 and P=0.001) were independent prognostic factors of progression-free survival and overall survival.Conclusions Lymph node status and lymphovascular space involvement were found to be independent prognostic factors for patients with cervical cancer who underwent neoadjuvant chemotherapy and radical hysterectomy.The pretreatment neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios seemed not to predict the survival of patients with cervical cancer treated with neoadjuvant chemotherapy and radical hysterectomy。

Abstract：Background Contrast sensitivity (CS) testing can detect differences in functional vision and is highly correlated with visual performance.This study was designed to investigate the association between CS and the grading score using the lens opacities classification system (LOCS) Ⅲ as well as the association between CS and visual acuity (VA) in nuclear or cortical age-related cataract (ARC) patients.Methods A total of 270 eyes with ARC and 30 control eyes were divided into nuclear opacity (NO),nuclear color (NC),cortical cataract (C) based on LOCS Ⅲ.The CS values measured at all spatial frequencies under photopic and glare conditions that resulted in contrast sensitivity function (CSF) were evaluated,and LogMAR VA was tested with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart.The correlation between CSF and LOCS Ⅲ grading scores,and between CSF and LogMAR VA were analyzed.Results Compared to the controls,CSF of the nuclear or cortical ARC significantly declined.There are significant correlation between CSF and LogMAR VA,and between CSF and LOCS Ⅲ grading scores.Compared to the VA,a stronger correlation existed between CSF and LOCS Ⅲ grading score than that of LogMAR VA and LOCS Ⅲ grading score.CS at some spatial frequencies is significantly influenced with LOCS Ⅲ grading score.Conclusions CSF significantly declined with the increasing ARC grading scores.Comparing to VA,CSF reflected the severity of cataract more comprehensively.CS at low spatial frequency is significantly influenced by ARC.Therefore,CS is more precise than VA in assessing the visual function of ARC patients。

Abstract：Background Hyperinsulinemia,insulin-like growth factor (IGF)-Ⅰ and-Ⅱ (IGF-Ⅱ) are associated with increased risk of endometrial carcinoma.Insulin receptor isoform A (IR-A) is more frequently expressed in endometrial carcinoma than in normal endometrial tissues.To better understand their roles in endometrial carcinoma,we investigated the effects of insulin,IGF-Ⅰ,and IGF-Ⅱ in endometrial carcinomas cells with different IR-A expression levels.Methods To explore the role of IR-A in mediating the activity of IGF-Ⅰ,IGF-Ⅱ,and insulin,we investigate the cellular proliferation of endometrial carcinoma cell lines RL95-2 and RL95-2-IR-A by MTS assays.Then we examined the protein kinase Akt phosphorylation and extracellular signal-regulated kinase (ERK) 1/2 phosphorylation in both cell lines by Western blotting.The effect of IGF-Ⅱ and AG1024 on cell cycle progression and apoptosis was assessed by flowcytometry.To examine whether the effects of IGFs were mediated by IR-A,we blocked IGF-Ⅰ receptor (IGF-IR) in both cell lines using AG1024,an IGF-IR-specific inhibitor.Results IGF-Ⅰ and IGF-Ⅱ significantly enhanced proliferation of both cell lines (P ＜0.05).By contrast,insulin significantly increased proliferation of RL95-2-IR-A cells only (P ＜0.05).IGF-Ⅰ and IGF-Ⅱ significantly increased pAkt levels in RL95-2 cells and pERK1/2 levels in RL95-2-IR-A cells (all,P ＜0.05).Insulin increased pERK1/2 levels in RL95-2-IR-A cells only (P ＜0.05).LY294002 and PD98059 inhibited the specific signaling activities and cellular proliferation.After AG1024 pretreatment,neither IGF-Ⅰ nor IGF-Ⅱ affected pAkt levels in RL95-2 cells.IGF-Ⅱ,but not IGF-Ⅰ,increased pERK1/2 levels in RL95-2-IR-A cells.After AG1024 pretreatment,the proliferation rate and DNA content corresponding to the S phase increased and apoptosis decreased significantly in IGF-Ⅱ-treated RL95-2-IR-A cells only (P ＜0.05).Conclusions The proliferation effect of insulin is mediated by IR-A.When IR-A dominates in a cell line,IGF-Ⅱ activated cell proliferation mainly through the ERK1/2 pathway.On the other hand,IGF-1 activated cell proliferation mainly through the Akt pathway.IR-A can at least partly mediate the proliferative and anti-apoptotic effects of IGF-1 through the ERK1/2 pathway。

Abstract：Objective To review the updated research on neuroprotection in glaucoma,and summarize the potential agents investigated so far.Data sources The data in this review were collected from PubMed and Google Scholar databases published in English up to September 2012,with keywords including glaucoma,neuroprotection,and retinal ganglion cells,both alone and in combination.Publications from the past ten years were selected,but important older articles were not excluded.Study selection Articles about neuroprotection in glaucoma were selected and reviewed,and those that are cited in articles identified by this search strategy and judged relevant to this review were also included.Results Although lowering the intraocular pressure is the only therapy approved as being effective in the treatment of glaucoma,increasing numbers of studies have discovered various mechanisms of retinal ganglion cells death in the glaucoma and relevant neuroprotective strategies.These strategies target neurotrophic factor deprivation,excitotoxic damage,oxidative stress,mitochondrial dysfunction,inflammation,activation of intrinsic and extrinsic apoptotic signals,ischemia,and protein misfolding.Exploring the mechanism of axonal transport failure,synaptic dysfunction,the glial system in glaucoma,and stem cell used in glaucoma constitute promising research areas of the future.Conclusions Neuroprotective strategies continue to be refined,and future deep investment in researching the pathogenesis of glaucoma may provide novel and practical neuroprotection tactics.Establishing a system to assess the effects of neuroprotection treatments may further facilitate this research。

Myopia is the most common refractive disorder.High myopia affects 27％-33％ of all myopic eyes in Asia.1,2 The pathologic myopia (PM) is the most severe vision-threatening phenotype of high myopia.3 It is also the second most common cause of choroidal neovascularization (CNV) in Asia.Unlike age-related macular degeneration (AMD) which mostly effecting elders,PM causes severe vision loss in young adults,resulting in a significant impairment of their working ability.4 PM has become the second leading cause of low vision and blindness particularly among those aged at 40-49 years in some Asia countries。

The one-phase therapy for calculous pyonephrosis through percutaneous nephrolithotomy (PCNL) is currently vigorously debated.After a definite preoperative diagnosis of pyonephrosis,the traditional approach1 has been initial drainage through puncture and nephrostomy.Upon the stabilization of symptoms,a second-phase operation is performed.If pus is discovered during an intra-operative puncture,a nephrostomy tube is deposited until a second elective operation.With the advancements of science and technology,the third generation EMS LithoClast master is capable of not only efficiently crushing and removing the stones,but also lowering the intra-pelvic pressure through vacuum suction.Thus the surgical risks have been greatly reduced so that many one-phase operations for calculous pyonephrosis may be completed.2 Ever since the application of EMS LithoClast master at our department since 2006,a total of 128 patients with calculous pyonephrosis have been surgically cured within one single phase.No overt complication was observed.In conjunction with the study results of high-pressure perfusion in animal models of pyonephrosis,a report was compiled as below。

According to Reese-Ellsworth Classification for retinoblastoma,retinoblastoma with vitreous seeding is grade 5B with poor prognosis and was initially proposed for enucleation.Chemotherapy combined with local treatment for retinoblastoma has been proposed as conservative treatment.1 Because of the lack of blood supply to vitreous seeding,the chemotherapy drugs could not reach the vitreous body through blood-retinal barrier.This has been one of the important limiting factors in the treatment of children with retinoblastoma with vitreous seeding.Melphalan proved to be one of the 12 kinds of chemosensitive drugs for anti-retinoblastoma cell colony formation.2 So,we used intravitreal melphalan injection to observe the therapeutic effect on the vitreous seeding。

In contrast to the so-called intraocular pressure,which is the transcorneal pressure difference,it is the trans-lamina cribrosa pressure difference,which is of importance for physiology and pathophysiology of the optic nerve head.The trans-lamina cribrosa pressure difference is the difference between the pressure in the intraocular compartment (i.e.,the so-called intraocular pressure) minus the retrobulbar pressure,which is formed by the orbital cerebrospinal fluid (CSF) pressure and the retrobulbar optic nerve tissue pressure.1 This anatomical fact has been the basis for the speculation that some patients with so-called normal intraocular pressure glaucoma have an abnormally low orbital CSF pressure.Previous clinical studies have supported this hypothesis.2'3 The purpose of this study is to report on a patient with low CSF pressure and co-existent open-angle glaucoma with normal intraocular pressure。

Pulmonary artery intimal sarcoma (PAIS) is a very rare but lethal disease,firstly described by Mandelstamm in 1923.1 Since then,less than 300 cases have been reported worldwide.Due to similar clinical presentations,it is very difficult to distinguish with pulmonary thromboembolism (PTE),leading to inappropriate treatments such as anticoagulation and thrombolysis.2-5Although with improvement of imaging modalities,the diagnosis of PAIS is still based on pathological examination,and the majority of specimens are taken by surgery or autopsy。

Cardiac contusion and valvular injuries are the most common cardiac injuries after a blunt traumatic chest injury.1 But ventricular septal rupture (VSR) is a rare finding after a blunt chest wall trauma.2 Here we report a 16 years old young man with no medical history who sustained a chest wall injury after a bookshelf falling on his left chest.He was hospitalized because of his chest pain and heaviness.Initial physical examination showed parastemal Ⅲ-Ⅳ systolic murmur.ECG showed a complete right bundle branch conduction blockage.Chest X-ray showed bilateral pulmonary contusion without rib fracture.MB isoenzyme of creatine kinase (CKMB) was raised (80 U/L).Transthoracic echocardiography revealed a apical VSR with a diameter of 17 mm and significant left-to-right shunt (Figure 1A) without pericardial effusion.The VSR edge was irregular.The left ventricular tear was identified at about 38 mm long and 17 mm wide,extending along the short axis from VSR to the inferior wall of the left ventricle but not reaching the outmost muscular layer (Figure 1B).Mitral valve prolapse was found with a mild regurgitation during systolic contraction.The patient's symptom improved with conservative treatment in the hospital。

Many potential complications resulting from retrobulbar injection have been reported,from the more commonly encountered retrobulbar hemorrhage to the life-threatening respiratory arrest.As one of the major complications,the occurrence of amaurosis fugax may not be noted by the doctor during surgery since the patient may take it as normal and not report it to the surgeon after injection.Fortunately,in most of the cases the visual loss is transient and the patients with amaurosis fugax may recover their vision soon after an injection.We searched PubMed and several other databases for investigations about amaurosis fugax,but found that relevant reports about the complication in the literature were very limited in number.Herein,we aim to analyze the predisposing cause of amaurosis fugax,to find out whether amaurosis fugax could be self-healing without treatment,and to determine in which situation surgery could be allowed to proceed after the complication happens。

To the editor:Acute pyelonephritis is a common kidney disease in female adult,but an unusual cause of acute renal failure (ARF).We reported one woman suffered from acute pyelonephritis due to Klebsiella pneumoniae infection presented with ARF and unremarkable abdominal signs,however with a favorable prognosis after appropriate antibiotic treatment。

To the editor:It is well known that outgrowth of collateral sprouts is a natural process during regeneration of the peripheral nervous system.However,current knowledge about this phenomenon was that aberrant growth of axonal sprouts may lead to the formation of persistent neuromas.1,2 From our previous work3-5 verified effectively in clinical environment for nerve repairing and related experiments by small gap sleeve neurorrhaphy,we made a possible inference for peripheral nerve collateral regeneration and functional repairing;the hypothesis of using these collateral sprouts as an auto graft resource to recover the injured nerve.This study focuses on the multiplication limit of the collaterals that could be maintained during peripheral nerve regeneration,and the possibility of using partial axons from an intact nerve to repair a nearby nerve with little influence on the donor nerve disfunction。

To the editor:A 38-year-old woman suffered from repeatedly episodes of headache,palpitations and sweating for 5 days before admission.Her elder sister has pheochromocytoma and medullary thyroid cancer (MTC),while her niece has MTC.Further physical examinations disclosed paroxysmal hypertension and bilateral thyroid large nodules.An enhanced computed tomography (CT) revealed adrenal mass in both sides,with 7 cm by 8 cm in the left and 1 cm by 2 cm in the right (Figure 1A).An octreotide somatostatin receptor image only confirmed a focus of intense uptake in the left side of adrenal.Meanwhile,plasma calcitonin was 352.84ng/L (reference range 0-100).Both ultrasonography and CT (Figure 1E) disclosed thyroid malignant nodules in both lobules.Moreover,the parathyroid hormone was 146 pg/ml (15-683);a parathyroid ultrasonography revealed a left lower dorsal lobe parathyroid adenoma.Therefore,laparoscopic left adrenalectomy was first performed followed by total thyroidectomy and parathyroidectomy two weeks later。

To the editor:Cardiac sarcoma is an extremely rare and lethal entity.Consequently,there is no uniform guideline for its treatment.There was no primary cardiac sarcoma metastasizing to the palatal tonsil documented in literature,though theoretically,a cardiac malignancy could spread anywhere throughout the body via circulation.In stead,there was only one case of tonsil reticulosarcoma metastasizing to the heart documented in literature.1 Here we report a case of concomitant sarcomas of left cardiac atrium and palatal tonsil。