Volume 43 ·  Issue 06 ·  2007

Retinoblastoma (RB) is the most common intraocular malignant tumor occurring in infant and young childhood. With the emergence of new treatment methods, the traditional treatment goal and treatment mode of RB has gradually changed to a new individualized comprehensive treatment mode with preservation of eyeball and visual function as the premise. Compared with foreign developed countries, there is still a big gap in the new clinical treatment ideas and individualized comprehensive treatment methods of RB in China. At present, most hospitals still choose eyeball enucleation first, and external radiotherapy as the supplement, and its treatment mode is relatively lagged, limited and single. Therefore, domestic clinical ophthalmologists should pay attention to combining the actual incidence of RB in China, change the traditional treatment concept in the past, learn from foreign advanced treatment experience reasonably, and actively explore and gradually establish a feasible new individualized comprehensive treatment mode of RB.

After reading the article "Effect of Objective Visual Field Detection with AccuMap Multifocal Visual Evoked Potential on Visual Field Detection in Glaucoma" published in Chinese Journal of Ophthalmology, Volume 42, Issue 11, 2006, the following questions are discussed with the author of the article.

I carefully read the opinion of Dr. Li Jianjun. A new type of objective visual field examination instrument has been paid attention and questioned by readers, which reflects its innovative significance and importance. I am very willing to have in-depth exchanges with readers. I will elaborate the main focus issues below.

All kinds of eye charts currently adopted have different defects, which make ophthalmologists difficult to evaluate the visual data. Most of the problems are manifested in the application of statistical analysis methods in ophthalmology clinical research. The quantitative relationship between visual acuity and visual angle is different in different eye charts, and the data types of visual acuity and visual angle are also different, and the statistical methods adopted are also different. Only by clarifying the above problems can we understand the visual data correctly and deal with it reasonably.

Objective to investigate the risk factors associated with retinoblastoma (RB) invasion of optic nerve.Methods the clinical and pathological data of 381 children from 1990 to 2002 were retrospectively analyzed.The sex, age, eye difference, course of disease, clinical manifestations, clinical stage and histological classification and the degree of optic nerve invasion were analyzed.Results the degree of optic nerve invasion in children with RB was related to the clinical stage and histological classification of tumor (P<0.01).

Objective to investigate the effect of stable transfection of vascular endothelial growth factor (VEGF) short hairpin RNA (shRNA) expression plasmid on the expression of VEGF in retinoblastoma (RB) cells.Methods VEGF shRNA expression plasmid p4.1CMV-VEGF shRNA was constructed and transfected into two RB cell lines, SO-RB50 and HXO-RB44, by liposome mediated transfection. p4.1CMV-VEGF shRNA positive RB cells were obtained by neomycin screening and gradient dilution method. p4.1CMV-VEGF shRNA positive RB cells were established by culture and expansion. The expression of VEGF gene in RB cells was detected by fluorescence quantitative polymerase chain reaction (PCR), and the expression of VEGF protein in the supernatant of RB cells was detected by enzyme-linked immunosorbent assay (ELISA). The shRNA expression plasmid p4.1CMV-Neg shRNA, which has no homology with mammalian genome, was used as negative control, and the untreated group was used as blank control.Results p4.1CMV-VEGF shRNA was successfully constructed and positive RB cell clones were obtained.The expression levels of VEGF gene in SO-RB50 cells in the negative control group and the blank control group were 5.02 times and 6.32 times that in the experimental group, respectively; The concentration of VEGF protein in the supernatant of SO-RB50 cells in the experimental group was (187.69±83.89) μ g/L, which was significantly lower than that in the negative control group (822.98±187.98) μ g/L and the blank control group (865.76±170.33) μ g/L, and the difference was statistically significant (all P<0.01). The concentration of VEGF protein in the supernatant of HXO-RB44 cells in the experimental group was (162.20±66.33) μ g/L, and the difference was statistically significant compared with that in the negative control group (764.33±164.79) μ g/L and the blank control group (828.22±145.94) μ g/L (all P<0.01). Conclusion Stable transfection of VEGF shRNA expression plasmid can highly inhibit the expression of VEGF in RB cells, and RNA interference targeting VEGF can be used as an effective means to antagonize VEGF and treat RB.

Objective to study the clinical characteristics and histopathological types of primary lacrimal sac tumors. Methods the clinical data and tissue sections of 96 patients with primary lacrimal sac tumors diagnosed by histopathological examination in our hospital from 1956 to 2005 were collected, and their clinical manifestations, imaging changes, histopathological characteristics and treatment were retrospectively analyzed. Results Among the 96 cases of primary lacrimal sac tumors, the incidence ratio of male and female was 1.8:1.0; the onset age was 11-80 years old, with an average of 46 years old. The clinical manifestations of the patients were mainly lacrimal overflow and lacrimal sac mass. Among the 96 cases of primary lacrimal sac tumors, 91 cases (94.8%) were malignant tumors, including 83 cases (86.5%) of epithelial tumors and 13 cases (13.5%) of non-epithelial tumors. Among the epithelial tumors, 64 cases (66.7%) were squamous cell carcinoma, ranking first in primary lacrimal sac tumors; 10 cases (10.4%) of undifferentiated carcinoma, ranking second in primary lacrimal sac tumors; 4 cases of mucoepidermoid carcinoma (4.2%); Adenocarcinoma in 4 cases (4.2%); Among the tumors of non-epithelial origin, 5 cases (5.2%) were B cell lymphoma (MALT lymphoma), 3 cases (3.1%) were melanoma, 2 cases (2.1%) were schwannoma, 2 cases (2.1%) were hemangioperithelioma, and 1 case (1.0%) were cavernous hemangioma. Conclusion Primary lacrimal sac tumors are rare, most of them are malignant, easily misdiagnosed as chronic dacryocystitis or lacrimal duct obstruction, which should be paid great attention by clinical ophthalmologists.

Objective to investigate the changes of retinal thickness in the area irradiated by laser after photodynamic therapy (PDT) in subfoveal choroidal neovascularization (CNV). Methods Twenty-five patients (27 eyes) with subfoveal CNV were treated with PDT. The laser spot diameter was 1.8~4.3 mm (mean 2.9 mm). The mean retinal thickness in the foveal area and the 3 mm laser irradiated area was measured by coherence optical tomography (OCT). The retinal thickness before and after PDT was compared at 24 h, 1 week, 1 and 3 months, respectively. Results The retinal thickness in the foveal area was (278.07±85.31), (324.52±96.08), (242.74±67.40), (234.26±51.04) μ m and (239.73±52.81) μ m at 24 h, 1 week, 1 and 3 months, respectively. The mean retinal thickness in the 3 mm laser irradiated area was (266.71±60.82), (309.25±82.69), (257.48±52.48), (245.44±47.54) μ m and (244.88±44.22) μ m, respectively. The difference was statistically significant between 24 h, 1 and 3 months after PDT treatment and 24 h, 1 week, 1 and 3 months after PDT treatment (P<0.01). Conclusion The retinal thickness in the PDT laser irradiated area was significantly thickened 24 h after treatment, and returned to the level before treatment 1 week after treatment.

Objective to observe the therapeutic effect of photodynamic therapy (PDT) on idiopathic choroidal neovascularization (CNV). Methods 61 cases (61 eyes) with idiopathic CNV diagnosed by fluorescein fundus angiography (FFA) and indocyanide green fundus angiography (ICGA) were treated with PDT. The fundus morphology, visual acuity, retinal thickness, FFA and ICGA images were observed and compared before and after treatment. The average number of PDT treatments was 1.2 times, and the follow-up time was 6-36 months, with an average of 19 months. Results At the last follow-up, 41 eyes (67.2%) had improved visual acuity, 15 eyes had no significant change (24.6%), and 5 eyes had decreased visual acuity (8.2%). After treatment, all eyes with macular hemorrhage and exudation were significantly reduced. FFA images showed that CNV fluorescein leakage completely disappeared, CNV closure or scar formation in 38 eyes (62.3%); CNV was partially closed in 4 eyes (6.6%), partially closed in 14 eyes (23.0%), and CNV relapsed in 5 eyes (8.2%). CNV was completely closed in 6 eyes after one PDT treatment. Neuroepithelial detachment in macular area and retinal edema disappeared by coherence optical tomography or retinal thickness examination. The follow-up time was up to 3 years, and no CNV relapsed, and visual acuity remained stable. The results of the study were analyzed by multiple linear regression analysis, which showed that the treatment effect was related to age (t =0.476, P =0.016), that is, the average visual acuity decreased by 0.008 (95% CI: 0.002~0.015) after treatment for each year of age increase. Conclusion PDT has a better therapeutic effect on idiopathic CNV, especially for young patients.

Objective to observe the changes of limbus in patients who wore soft contact lenses for a long time by laser confocal microscope.Methods Twenty-two cases (22 eyes, aged 23-50 years) with refractive error and wearing soft contact lenses for more than 10 years were selected as long-term lens wearing group from October to November 2004 and May to October 2006 in the Department of Ophthalmology of Peking University First Hospital. Thirty-eight cases (38 eyes, aged 18-52 years) with refractive error but not wearing contact lenses were selected as the control group without lens. After routine slit lamp microscopy, the upper and lower limbs of the examined eyes were examined with laser confocal microscope. The images of each layer of limbus were recorded, the tissue structure and cell morphology were observed, and the cell density was counted and analyzed. Results the images of each layer of limbus obtained in all eyes were relatively clear. All 22 eyes showed strong intercellular reflective spots or strong reflective light, and 16 eyes showed the formation of intercellular microcapsules, while the limbal epithelial cells in the non-lens group were arranged neatly and the size was consistent; The mean density of Langerhans cells under the upper and lower limbal epithelium in the long-term wearing group was higher than that in the non-wearing group (P<0.05). The circular highly reflective spots were found in the limbal stroma of 22 eyes in the long-term wearing group, but no changes were observed in 38 eyes in the non-wearing group. The mean density of anterior and posterior limbal stromal cells and the mean thickness of limbal stromal layer in the upper and lower limbal stromal cells in the long-term wearing group were lower than those in the non-wearing group (P<0.05). Conclusion Long-term wearing of soft contact lenses can lead to a series of changes in the limbus, such as the formation of microcapsules between the limbal epithelium cells, the increase of the mean density of Langerhans cells under the epithelium, the appearance of microparticles in the matrix and the decrease of the density of stromal cells.

Objective to evaluate the medium and long-term clinical effect of implantation of capsular tension ring (CTR) in phacoemulsification cataract aspiration under abnormal lens suspensory ligament. Methods 19 patients (22 eyes) who underwent phacoemulsification cataract aspiration, CTR and intraocular lens (IOL) implantation due to laxity or partial rupture of lens suspensory ligament or cataract in our hospital from January 2003 to July 2004 were followed up for 2 years. The follow-up indexes were the best corrected visual acuity and refractive power, intraocular pressure, CTR and IOL, the position of capsular pocket complex, posterior capsular opacity (PCO) and the contraction degree of lens capsular pocket. Scheimpflug images of each eye were collected by Pentacam anterior segment imaging system, and the eccentricity and inclination of IOL were analyzed at 1, 6, 12 and 24 months after operation. Results The results of 2 years after operation: The best corrected visual acuity at the last follow-up was improved ≥2 walkers in 20 eyes (90.9%) and 1 walker in 2 eyes (9.1%). The IOL of 22 eyes was located in the capsular bag, 1 eye was slightly off-center at 1 month postoperatively, and 5 eyes were slightly off-center at 2 years postoperatively. PCO: At the last follow-up, 3 eyes (13.6%) underwent posterior capsulotomy with yttrium-doped neodymium garnet laser due to severe PCO, and the remaining 19 eyes had mild PCO, which did not need treatment. The degree of lens capsular bag contraction: At the last follow-up, 1 eye had moderate capsular bag contraction. The mean eccentricity of IOL at 1, 6, 12 and 24 months postoperatively was (0.393±0.094), (0.406±0.094), (0.415±0.093), (0.463±0.172) mm, respectively. The difference was statistically significant (P<0.05). The inclination was 2.637°±0.369°,2.653°±0.349°,2.682°±0.348°,2.714°±0.360°,respectively. The difference between the groups was not statistically significant (P =0.220). Conclusion CTR combined with IOL implantation can achieve good visual acuity in the treatment of abnormal lens suspensory ligament.

Objective to investigate the correlation between exophthalm,equivalent spherical degree and axial length.Methods 189 patients with myopia and emmetropia were examined by dilated refractory.The exophthalm,corneal curvature and axial length were measured by Hertel exophthalmometer,and corneal curvature and axial length were measured by coherent light biometry (IOL-master). According to the different axial lengths, they were divided into emmetropia, mild myopia, moderate myopia and high myopia groups.The right eyes were taken to compare the exophthalm,and the relationship between exophthalm,equivalent spherical degree and axial length was analyzed.Results The axial length of the eyes in emmetropia and mild myopia group was<25.00 mm, with an average of (23.54 ± 0.73) mm, and the equivalent spherical degree was (-0.76 ± 1.29) D. The axial length of eye in the moderate myopia group was 25.00~27.00 mm, the average (25.77±0.53) mm, and the equivalent spherical degree was (-5.33±2.37) D. The axial length of eye in the high myopia group was ≥27.00 mm, the average (30.08±2.09) mm, and the equivalent spherical degree was (-15.92±5.12) D. The average exophthalmos of eye in the emmetropia and mild myopia group was 10.50~19.50 mm, the average (14.66±1.94) mm, the average exophthalmos of eye in the moderate myopia group was 13.00~19.50 mm, the average (16.16±1.40) mm, and the average exophthalmos of eye in the high myopia group was 14.00~23.00 mm, the average (18.30±1.63) mm. The exophthalmos of eye in the high myopia group was greater than that in the moderate myopia group, emmetropia group and mild myopia group respectively (P<0.01). The exophthalmos of eye in the moderate myopia group was greater than that in the emmetropia and mild myopia group (P<0.01). There was a linear correlation between exophthalmos, equivalent spherical degree and axial degree of eye, and the univariate linear regression equation was exophthalmos =0.616× AL (axial length of eye) ( Exophthalmos =14.65-0.227× SE (equivalent spherical degree) (R2=0.500, F =187.05, P<0.01); Equivalent spherical lens degree =52.06-2.24× AL (axial length) (R2=0.892, F =1537.83, P<0.01). Conclusion With the increase of axial length and equivalent spherical lens degree, the exophthalmos of myopia increases linearly. With the increase of axial length, the eyeball expands backward, the eyeball protrudes forward, and the eyeball protrudes forward more obviously.

Objective to compare the recovery of corneal perception in hypermyopic eyes after LASEK and Epi-LASIK. Methods Thirty-seven eyes (37 eyes) with myopic degree ranging from-9.50 to-12.50 DS were selected and divided into two groups according to the operative methods. The edema of corneal epithelial flap was observed after operation and divided into two subgroups: obvious edema and no obvious edema. The corneal perception was examined at 2 weeks and 1, 2, 3 and 6 months after operation, and the effects of the two operative methods and postoperative epithelial edema on the recovery of corneal perception were compared. Results The corneal epithelial edema was obvious in 6 eyes in LASEK group, and the corneal epithelial flap was broken in 3 eyes, while the corneal epithelial edema was not obvious in Epi-LASIK group after operation. The recovery of corneal perception in Epi-LASIK group reached 79.31%, 84.49%, 87.92%, 92.24% and 92.24% respectively at 2 weeks and 1, 2, 3 and 6 months after operation The LASEK group reached 69.64%, 78.57%, 83.21%, 85.70% and 87.86%, respectively, and the difference was statistically significant compared with the Epi-LASIK group at 2 weeks after operation (P<0.05); In the LASEK group, the corneal perception recovery was significantly slower in 6 eyes with obvious corneal epithelial edema compared with those without obvious edema, and the difference was statistically significant from 2 weeks to 6 months after operation (P<0.05). Conclusion After Epi-LASEK and LASEK, the corneal perception recovered rapidly within 3 months after operation, and then gradually shifted to the recovery plateau stage. The recovery of corneal perception after Epi-LASEK was faster than that after LASEK; Obvious edema of the corneal epithelial flap can affect the recovery of corneal perception.

Objective to screen for the mutation of FOXL2 gene in patients with small palpebral fissure syndrome (BPES), and to predict the protein structure before and after the mutation, to study the influence of gene mutation on the primary and secondary structures of the encoded protein, and to explore the molecular mechanism of the disease. Methods Seven patients with clinically confirmed BPES were studied. Genomic DNA was extracted from peripheral blood, and the open reading frame and 5' untranslated region of FOXL2 were amplified by PCR. The products were sequenced directly or after cloning. The structures of normal and mutated proteins were predicted by PDH and ExPASy software packages, and the differences of primary and secondary structures were compared. Results We found the repeated insertion mutation of FOXL2 901-930 in 2 patients and 1 sporadic patient in a small family of type Ⅱ, but no mutation was found in normal controls. The primary structure analysis showed that the relative molecular mass of FOXL2 protein changed obviously before and after the mutation, but the isoelectric point of protein did not change. The secondary structure analysis showed that FOXL2 was a transmembrane protein, Its polyalanine peptide comprises an α-helix region, which is located in the transmembrane region; The proportion of α-helix in the secondary structure of the whole protein increased by 4.1% compared with that before the mutation, while the proportion of β-fold and random curl decreased correspondingly. Conclusion The repeated insertion mutation of FOXL2 901-930 was verified as a new mutation, which led to the amplification of the polyalanine peptide (222-232 insertion 10); The prediction of protein structure showed significant differences in the secondary structure of the encoded protein before and after mutation, which may be closely related to the pathogenesis of BPES.

The occurrence of retinoblastoma (RB) is related to the inactivation of Rb1 gene in 13q14, and about 90% of the inactivation of Rb1 gene is caused by the deletion, point mutation or methylation of Rb1 gene.The new denaturing high performance liquid chromatography (DHPLC) technology can detect the point mutation, methylation status and its content simply, rapidly and accurately.At present, DHPLC has played an important role in the genetic diagnosis and genetic counseling of RB patients and their family members.

The First Affiliated People's Hospital of Shanghai Jiaotong University will hold the "National Symposium on Retinal Detachment, Diabetic Retinopathy, New Ophthalmology Technology Application and Minimally Invasive Vitreous Surgery and Continuing Medical Education Study Class" in the ever-changing Shanghai from July 12 to 18, 2007.

survivin is a new member of the inhibitor of apoptosis protein (IAP) family discovered in recent years. It has anti-apoptosis and participates in the regulation of G2 phase of cell cycle, and has an important relationship with chemoresistance and prognosis.

Case 1: A 16-year-old female came to our hospital on February 7, 2006 due to multiple yellow nodules and white rings around the cornea, which were progressively aggravated for 15 years. When the patient was 3 years old, white bands began to appear around the cornea, which were located above and below the cornea at first, and gradually developed to both sides, without any discomfort in the eyes, and good vision. At the same time, the distal interphalangeal joints, metacarpophalangeal joints, bilateral elbow joints, bilateral ankle joints, metatarsophalangeal joints, and buttocks of both hands were mostly dispersed in yellow nodules, which were distributed on the extension and lateral surfaces of the joints. The texture of the nodules was soft, without redness, swelling, heat, pain, or ulceration, and gradually increased, and the number increased, but had no effect on joint movement.

The patient was a 74-year-old female who came to our hospital on December 6, 2006 due to visual decrease, photophobia and tearing in her left eye for 15 days. Before 16 days, her left eye underwent trabeculectomy in an external hospital due to angle-closure glaucoma. The visual decrease, photophobia and tearing were obvious 1 day after the operation. She was diagnosed as posterior corneal elastic layer detachment. Several surgical reductions (three times of anterior chamber air injection, sodium hyaluronate injection and two times of posterior corneal elastic layer suture) failed.

Since the invention of phacoemulsification cataract aspiration, phacoemulsification technology has been in the process of continuous improvement. From the early low negative pressure and high energy to high negative pressure and low energy, from the etching technology of lens core to interception and splitting technology to the widely used rapid splitting technology at present, ophthalmologists have continuously explored how to make cataract surgery more safe and effective.