Volume 49 · Issue 06 · 2013

Clinical trial is an important medical research method,as well as the bridge of translational medicine.The results of scientific evidences are useful to make clinical practice guidelines.At present,much experience of carrying out ophthalmology clinical trials has been obtained and achieved,but there are still some scientific,practical and ethical problems to be solved,because of their impact on the authenticity and reliability of the results.Therefore,attaching great importance to design of the clinical research and implement of the standardization would be the goal and the development direction.Clinical trial design rely on objective,follow international design principles on the ethics,randomization,blinding and placebo setting.During the trial implementation,personnel training,project management and monitoring would help to reduce protocol deviation and ensure data authenticity. (Chin J Ophthalmol,2013,49:481-483)

Hereditary retinal disease (HRD) is a group of retinal degenerations seen frequently at clinic,which can lead to severe visual impairments or even blindness.Identifying genetic causes and developing advanced and applicable molecular diagnostic tools for HRD is essential to lower the prevalence of HRD,and to find the therapeutic method of HRD.HRD is known to be both clinically and genetically heterogeneous.The large number of causative genes together with the limitation of routine technique hinder the investigators from further investigating the genetic causes of HRD.Targeted genes capture with next-generation high throughput sequencing yield high sensitivity and speed for mutation detection.When compared with traditional techniques,targeted sequencing presents tremendous advantages.Therefore,the development of a powerful molecular diagnostic platform for HRD aims to improve the detection rate of causative genes/mutations in HRD patients,to further investigate the genetic causes for HRD,to better understand the pathological basis of HRD,and to promote the fast development of molecular diagnosis in China.Meanwhile,it will have significance for the clinical and prenatal diagnosis of HRD,and thus providing rationale for gene therapy on HRD. (Chin J Ophthalmol,2013,49:484-487)

To observe the choroidal thickness in eyes with chronic central serous chorioretinopathy (CSC) after half-dose photodynamic therapy (PDT).

Case series study.Consecutive 30 patients (35 eyes) with chronic CSC admitted from October 2010 to October 2011 in Zhongshan Ophthalmic Center were recruited in this study.Optical coherence tomography (OCT),fundus fluorescein angiography,indocyanine green angiography (ICGA) were performed in each patient to confirm the diagnosis.ICGA-guided PDT was performed in each patient.Choroidal thickness at subfoveal and 1500μm superior,inferior,nasal and temporal to the fovea were measured before PDT,1,3 and 6 months after PDT using enhanced depth imaging OCT.Data were analyzed with one-way repeated measures ANOVA and LSD-t test when pairwise comparison was needed.

Thirty patients,aged from 33 to 66 years old,including 26 males and 4 females (gender ratio 6.5∶1) were recruited.Subfoveal choroidal thickness (SFCT) in chronic CSC eyes was (435.54±102.91) μm at baseline,which decreased significantly to (373.63±106.01) μm,(360.69±111.06) μm and (369.00±108.12) μm at 1 month,3 months and 6 months after PDT respectively (F=108.34,P <0.01).At 6 months after PDT,SFCT was slightly thicker than that at the 3^rdmonth,but no statistical significance was noted (LSD-t test:P>0.05).The changing trends of choroidal thickness at the other 4 measuring points were similar to that of the SFCT.

Choroidal thickness is reduced within 6 months post-PDT in chronic CSC eyes. (Chin J Ophthalmol,2013,49:490-494)

To analyze the clinical features of acute zonal occult outer retinopathy (AZOOR) and the reasons for misdiagnosing as optic neuropathy or intracranial lesions.

Case series study.Twenty patients (23 eyes) who were all initially diagnosed as optic neuropathy or intracranial lesions were recruited in the ophthalmologic department of Beijing Tongren Hospital from November 2003 to June 2012,but they were ultimately diagnosed as AZOOR after the examinations including regular eye examination,fundus fluorescein angiography (FFA),optical coherence tomography (OCT),automatic perimetry,flash electroretinogram (F-ERG),multifocal electroretinogram (mf ERG),systemic rheumatism immunological examination and neuroimaging.

These 20 patients with an average age of 32.9 years (range 15 to 55 years) consisted of 17 females (85%) and 3 males (15.0%).Among them,17 patients (85.0%) were affected unilaterally,while 3 patients (15.0%) were affected bilaterally.Sixteen of 23 eyes (69.6%) had myopia.Ten eyes (58.8%) showed relative afferent papillary defect.Inflammatory response was not found by slit lamp and fundus examination.Besides the other abnormal fundus changes of high myopia,fundus angioid streaks were found in 4 eyes and retinal pigment epithelium dystrophy was found in 3 eyes by fundus examination.FFA revealed that there was mild fluorescein leakage around the retinal vascular arch in one eye.The patterns of visual field detect in these patients were various,while temporal scotoma and blind spot enlargement were most common.Twelve of 14 patients who had been performed F-ERG showed abnormal F-ERG.mf ERG of all patients showed the decreased amplitude densities of the retina in accordance with the areas of visual field defect.IS/OS layer of 17 patients who went through OCT examination were found abnormal in the corresponding areas of visual field defect.Neuroimaging examination revealed there was nothing abnormal in the patients who were diagnosed as intracranial lesions.Immunological parameters in these patients were almost normal except for one patient with an increased level of rheumatoid factor.

AZOOR patients in this study rarely has ocular or systemic inflammatory.AZOOR occurs predominantly in the unilateral eye of young female patients,and are easily misdiagnosed as optic neuropathy due to the almost normal appearances of fundus.The examinations of retinal functional and morphological changes are the key to its diagnosis and differential diagnosis. (Chin J Ophthalmol,2013,49:495-499)

To investigate the association of diabetic self-management with the risk of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus.

Cross-sectional study.Recruited patients with type 2 diabetes mellitus in the Desheng community of urban Beijing between November 2009 and May 2011.All patients were surveyed using a standardized questionnaire and underwent detailed ophthalmic examination.Patients were classified into DR group or diabetic without retinopathy (DWR) group according to the grading of fundus color photographs using the Early Treatment of Diabetic Retinopathy Study (ETDRS) standard grading protocol.In the DR group,proliferative diabetic retinopathy (PDR) was further defined.The overall levels of diabetes selfmanagement in the study population were assessed and compared for the differences between DR and DWR,PDR and NPDR groups.

One thousand one hundred patients with type 2 diabetes mellitus were recruited.The prevalence of DR was 32.1% (353/1100) in the study population.Sixtythree percent (652/1035) of patients had glycated hemoglobin (Hb A1c) level less than 7.0%.The majority of patients (85.4%,916/1072) conducted a diet control,77.3% (827/1070) exercised,56.0% (609/1088) monitored blood glucose regularly,56.8% (416/733) detected Hb A1c more than once every six months,71.7% (762/1062) had ophthalmologic examination after the diagnosis of diabetes mellitus,and 47.9% (525/1097) had mydriatic check-up.Increased risk of DR was associated with longer duration of diabetes (more than 10 years) (OR=3.90,95%CI:2.97-5.51,P<0.05),higher Hb A1c level of≥7.0% (OR=3.23,95% CI:2.44-4.28,P<0.05),insulin therapy (OR=4.82,95%CI:3.55-6.57,P<0.05),male gender (OR=1.41,95%CI:1.08-1.84,P<0.05),lower level of education (OR=1.90,95%CI:1.39-2.62,P<0.05),lower monthly income (OR=1.46,95%CI:1.12-1.91,P<0.05),lower obedience to diet control (OR=1.72,95%CI:1.22-2.43,P<0.05),no exercise (OR=1.42,95%CI:1.04-1.94,P<0.05),change of therapeutic protocol during the last five years (OR=1.78,95%CI:1.32-2.41,P<0.05),and family history of diabetes (OR=1.35,95%CI:1.01-1.78,P<0.05).Increased risk of PDR was associated with the diagnosis age of diabetes (OR=0.92,95%CI:0.89-0.95,P<0.05),longer duration of diabetes (more than 10 years) (OR=4.54,95%CI:1.95-12.32,P<0.05),and insulin therapy (OR=4.85,95%CI:2.34-10.90,P<0.05).In the multifactor logistic regression model,male gender (OR=2.21,95%CI: 1.57-3.11,P<0.05),lower level of education (OR=1.98,95%CI:1.33-2.94,P<0.05),lower monthly income (OR=1.66,95%CI:1.15-2.39,P<0.05),longer duration of diabetes (more than 10 years) (OR=2.46,95%CI:1.77-3.41,P<0.05),Hb A1c≥7.0% (OR=2.24,95%CI:1.64-3.07,P<0.05) and insulin therapy (OR=3.38,95%CI:2.38-4.8,P<0.05) were associated with higher risk of DR.The diagnosis age of diabetes (OR=0.94,95%CI:0.91-0.98,P<0.05) and insulin therapy (OR=3.49,95%CI:1.47-8.27,P<0.05) were associated with PDR.

Higher risk of DR is associated with longer duration of diabetes,insulin therapy,higher HbA1c level,male gender,and lower level of education,whereas higher risk of DR is also associated with lower obedience to diet control and less exercise,which suggest that lower level of diabetic self-management increased the risk of DR. (Chin J Ophthalmol,2013,49:500-506)

To analyze the clinical characteristics of paraneoplastic retinopathy and optic neuropathy (PRON).

Case series study.Eight patients were enrolled from October 2006 to March 2012 visited in ophthalmology department,the People Liberation Army General Hospital.The patients were underwent a series of examinations,including fundus photography,visual electrophysiology,fundus fluorescein angiography,optic coherent tomography,fundus autofluorescent imaging,perimetry,ultrasonography,magnetic resonance imaging,spinal tap and cerebrospinal fluid test,paraneoplastic syndrome (PNS) antibody test.The patients were followed up in outpatient department and (or) by phone.The clinical manifestation,entity types,and treatment were analyzed.

Of the eight patients,there were cancer associated retinopathy (CAR) 3 cases,bilateral diffuse uveal melanocytic proliferation (BDUMP) 2 cases and paraneoplastic optic neuropathy (PON) 3 cases.Five patients were detected the PNS antibodies and revealed three patients with positive results.As for the primary malignancy,four of the eight patients were lung carcinoma,others included invasive thymoma,kidney cancer,acute lymphocytic leukemia and cervical cancer,each for one case.All the patients complained vision blurring or progressive visual decrease.Other complaints included dark shadow in two patients,shimmering,dazzling,double vision and eye pain,each in one patient.One patient complained progressive decreased vision in both eyes prior to the diagnosis of lung cancer.Of the 16 eyes of the eight patients,there were six patients with no light perception vision,five from light perception to 0.05,and other five with no less than 0.4 vision,in the end of the follow up.Five patients were treated with steroid with unsatisfactory efficacy.

Each entity of PRON has its own clinical characteristics.PRON especially BDUMP may be a pre-metastatic disease. (Chin J Ophthalmol,2013,49:507-513)

To investigate the change of optic retinal nerve fiber layer (RNFL) thickness in nonproliferative diabetic retinopathy (NPDR) and to evaluate the correlation between the optic RNFL structural change and visual function.

A cross-sectional study.All cases came from ophthalmology department of Zhejiang Province Traditional Chinese Medical Hospital,and the First People's Hospital of Ningbo,and Zhongshan Ophthalmic Center,Sun Yat-Sen University from December 2009 to October 2012.All the disease and control cases were coming from the same hospitals at the same period.Subjects were divided into 3 different groups:patients with NPDR (n=89,89 eyes),patients with diabetic mellitus but without diabetic retinopathy (NRD) (n=96,96 eyes) and disease-free controls (n=115,115 eyes).One eye of each subject was randomly selected for study.Participants aged from 40 to 70 years at baseline and all diabetic patients had a diabetic history of at least 5 years.Optic RNFL thickness of each subject was measured by spectral domain optical coherence tomography (SD-OCT).Visual function examinations including contrast sensitivity test in spatial frequencies of 1.5,3.0,6.0,12.0,18.0 cycles per degree (c/d),pattern electroretinograms (PERG) and best corrected visual acuity (BCVA) assay.The analysis of RNFL thickness in each group was performed at four preset locations of the optic disc (i.e.,temporally,superiorly,nasally,and inferiorly).To assess the structure-function relationship,the BCVA,contrast sensitivity,PERG-P50 amplitude and latency to optic RNFL thickness at each quadrant were analyzed in both NPDR and NRD groups.

The RNFL thickness at four preset locations of the optic disc (meanly,nasally,temporally,superiorly,and inferiorly) were (97.7±13.0),(71.7±10.3),(70.9±13.3),(118.3±19.7),and (123.1±20.8) μm in the NPDR group; (98.6±15.3),(74.8±13.1),(71.8±14.6),(119.5±17.2),and (125.6±19.9) μm in the NRD group;and (99.1±11.8),(77.4±12.6),(72.6±13.2),(119.1±18.1),and (127.1±19.3) μm in the normal group.The nasally optic RNFL thickness was significantly different among the three groups (F=8.56,P=0.000).The thickness in the NPDR and in the NRD group were significantly thinner than that in the normal group (SNK-q test:q=3.16,3.11,respectively; bothP<0.05).In the NPDR group,the nasally optic RNFL thickness was significantly thinner than that in the NRD group (SNK-q test:q=3.07,P<0.05).The inferiorly optic RNFL thickness was also significantly different among the three groups (F=3.841,P=0.035).The thickness in the NPDR group was significantly thinner than that in the normal group (SNK-q test:q=3.090,P<0.05).Yet,the difference of inferiorly optic RNFL thickness between the NRD group and the normal or the NPDR group did not reach the level of statistical significance (SNK-q test:q=2.101,1.955,P>0.05).The temporally or superiorly optic RNFL thickness,or the average thickness of optic RNFL did not differ significantly among the three groups (F=0.985,P=0.375;F=0.333,P=0.71;F=0.975,P=0.379,respectively).Contrast sensitivities (1.5,3.0,6.0,12.0,18.0 c/d),PERG-P50 amplitude and latency were all significantly correlated with the RNFL thickness of the nasal quadrant (r _nasal=0.28,0.26,0.3,0.25,0.45,0.65,0.48,respectively;P<0.05) and the inferior quadrant (r _inferior=0.25,0.28,0.27,0.26,0.28,0.37,0.71;P<0.05) in the NPDR group.Contrast sensitivities in high spatial frequencies (6.0,12.0,18.0 c/d),PERG-P50 amplitude were also significantly correlated with the RNFL thickness of the nasal quadrant (r _nasal=0.59,0.45,0.66,0.33,respectively;P<0.05) and the inferior quadrant (r _inferior=0.46,0.71,0.52,0.41,respectively;P<0.05) in the NRD group.

The optic RNFL thickness of the nasal and inferior quadrant have been already reduced in patients with NPRD and are significantly correlated with the change of vision function. (Chin J Ophthalmol,2013,49:514-520)

To investigate the distribution and biological roles of voltage-dependent calcium channel (VDCC) α₁F subunit in murine retina.

Experimental study.α₁F^-/- (homozygous mutant) mice (n=35) andα₁F^+/+ (wild type) mice (n=35) were used in this study.Immunohistochemistry was performed to determine the expression of VDCCα₁F subunit in the mouse retina.Retinae inα₁F^-/-mice and age-matched control mice at 3,6,9,14-day and 3-month after birth were paraffin embedded,sectioned and HE stained,and full-field electroretinogram (ERG) were also recorded at these time points.Statistics were based on independent samples t-test.

(1) α₁F subunit was absent inα₁F^-/-mice retina.But inα₁F^+/+mice retina,α₁F subunit was expressed most strongly in the outer plexiform layer (OPL),less in the inner plexiform layer (IPL) and ganglion cell layer (GCL). (2) OPL thickness in the subunit deficient mice gradually reduced after birth and lost at adult age. (3) In dark-adapted ERGs,standard response showed that the b-wave amplitude ofα₁F^-/-mice[ (163.8±26.7) μV]significantly decreased compared with that ofα₁F^+/+mice[ (408.4±54.5) μV] (t=-9.017,P=0.000),whereas the a-wave amplitude ofα₁F^-/-group[ (208.2±27.3) μV] was similar to that of control group[ (196.0±24.2) μV] (t=0.748,P=0.476).

This study demonstrates that the lack of VDCCα₁F subunit affect the structure and function in the OPL of the murine retina. (Chin J Ophthalmol,2013,49:521-525)

To determine the characteristics of optic nerve meningiomas in medicalimageology (including CT and MRI),histopathology and immunohistochemical expression of Vimentin,CK,S-100,EMA in tumor cells.

This was a retrospective study on a serial of clinical cases.Forty-eight cases were collected from the past 21 years at the Department of Ophthalmology,West China Hospital,Sichuan University.All the cases underwent surgery and were confirmed as optic nerve meningiomas by histopathological test,including paraffin imbedded sectioning and HE staining.In addition,all the cases had medical records on CT and 17 cases had MIR scan.Immunohistochemical staining for VIMENTIN,CK,S-100,EMA was performed in the 21 cases.

Characteristics of the CT scan include that,in 39 cases,among them 26 cases the tumors filled in the orbit especially at the orbital apex,which led to the disappearance of the black triangle.Three cases showed enlargement and calcification of optic nerve and therefore train track sign was seen.Three cases showed that the masses of optic nerve were close to the globe and another three cases showed that the masses were located in the peripheral orbit.Thirteen of 17 cases MRI disclosed the big orbital tumors and 5 cases could better show tumor extension to optic cross or intracranium.Histopathological tests demonstrated meningothelial or syncytial type in 39 cases,transitional or mixing type in 8 cases,fiber or fibroblast type in 3 cases and vascular type in 2 cases.Immunohistochemistry study verified the positive staining rate of VIMENTIN as 90.5% (21 cases), EMA 66.7% (15 cases),CK 42.8% (9 cases) and S-100 23.8% (5 cases),respectively.

Characteristics of CT and MRI include enlargement and tumor-like expansion of optic nerve.Most of the tumors reach to orbital apex and show uneven density.Calcification may occur in the tumor.The main pathological type of the tumors is meningothelial.Positive immunohistochemiscal staining for VIMENTIN and EMA may be helpful in diagnosis. (Chin J Ophthalmol,2013,49:526-530)

To investigate the clinical manifestations,imageological features,surgical approaches and prognosis of cranio-orbital communicating tumors.

The retrospective analysis was performed in the 22 patients of cranio-orbital communicating tumors in the past three years.CT and MRI examnations were applied in all cases.Of 16 patients were treated by surgical approaches,Of 6 patients were for radiation therapy.

Of 22 cases,2 cases were osteoid osteoma,3 cases were meningioma,1 case was aneurysmal bone cyst,2 cases were mucous cyst,2 cases were schwannoma,2 cases were adenoid cystic carcinoma of lacrimal gland,2 cases were metastatic carcinoma,and 2 cases were rhabdomyosarcoma.Other 6 cases were treated by radiotherapy without pathological diagnosis.8 cases for orbital operation including excision of orbital contents 1/8,anterior orbitotomy 3/8,and lateral orbitotomy 4/8,and 8 cases for transcranial operation including frontotemporal orbital roof approach 3/8 and pterion approach 5/8.After operation,the vision acuity of 3 cases was improved,of 10 cases was unchanged and of 3 cases was decreased.Two patients died of metastasis.Among 8 cases of transcranial operation,the complaints such as eye movement disorder,proptosis and conjunctival edema emerged in 1 case.However,among 8 cases of orbital operation,such above complaints were respectively found in 7,5 and 6 cases.

CT and MRI have the great value for diagnosis of cranio-orbital communicating tumors,especially combined with enhanced contrast MRI.Resection of cranio-orbital communicating tumors via the transcranial surgical approach is the effective surgical approach for cranio-orbital communicating tumors. (Chin J Ophthalmol,2013,49:531-535)

Reading is a visual function human being used to understand environmental events based on writing materials.This study investigated the feasibility of reading visual acuity chart in assessment of reading ability by analysis of the key factors involved in the design of the visual acuity chart.

The reading level was determined as grade 3 primary school with Song as the font and 30 characters included in the sentences.Each of the sentences consisted of 27 commonly-used Chinese characters (9 characters between any two punctuations) and 3 punctuations.There were no contextual clues between the 80 sentences selected.The characters had 13 different sizes with an increment of 0.1 log unit (e.g.1.2589) and 2.5 pt was determined as the critical threshold.Readable test for visual target was followed as①29 candidates with a raw or corrected visual acuity (VA) of at least 1.0 were selected to read 80 selected sentences with the size of characters of 2.5 pt at a distance of 40 cm,②the time used for reading with the number of characters wrongly read was recorded,③39 sentences were selected as visual targets based on reading speed,effective reading position and total number of character strokes,④The 39 selected sentences were then randomly divided into 3 groups with no significant difference among the groups in the 3 factors listed at③with paired t-test.

This reading visual chart was at level of Grade 3 primary school with a total stroke number of 165-210 (Mean 185±10),13 font sizes a 0.1 log unit increment,a song pattern and 2.5 pt as the critical threshold.All candidates achieved 100% correct in reading test under 2.5 pt with an effective reading speed as 120.65-162 wpm (Mean 142.93±11.80) and effective reading position as 36.03-61.48 (Mean 48.85±6.81).The reading test for the 3 groups of sentences showed effective reading speed as (142.49±12.14) wpm,(142.86±12.55) wpm and (143.44±11.63) wpm respectively (t_1-2=-0.899,t_2-3=-1.295,t_1-3=-1.435).The reading position was 48.55±6.69,48.99±7.49 and 49.00±6.76,respectively (t_1-2=-1.019,t_2-3=-0.019,t_1-3=-0.816).The total number of character strokes was 185.54±7.55,187.69±13.76 and 182.62±8.17,respectively (t_1-2=0.191,t_2-3=1.385,t_1-3=1.686).

A practical design of the Chinese reading visual chart should consider size,increment,legibility in selection of reading sentences.Reading visual acuity,critical threshold and effective reading speed could be used to express the reading visual function. (Chin J Ophthalmol,2013,49:536-540)

To detect long-term ocular alteration of children with malignant osteopetrosis after hematopoietic stem cell transplantation.

Children diagnosed as osteopetrosis from 5 months to 31 months underwent hematopoietic stem cell transplantation.Computed tomography of optic canal,FVEP,ERG and fundus examination were applied to assess the visual function.

Bone marrow transplantation was successful.Peripheral blood test,splenohepatomegalia and osteosclerosis improved gradually.The mean optic canal diameters of right eyes before transplantation was (1.7±0.4) mm.The mean optic canal diameters of right eyes was (3.2±0.7) mm after transplantation.The mean optic canal diameters of left eyes before transplantation was (1.9±0.5) mm.The mean optic canal diameters of left eyes was (3.1±0.8) mm after transplantation.The difference between above two groups was statistically significant (t=-5.204,-4.211;P<0.05).P2 latency period of FVEP prolonged in 7 cases before transplantation.Mean P2 latency period of FVEP decreased 21.13 ms in 5 cases after transplantation.Mean P2 latency period of FVEP prolonged 22.25 ms in 2 cases after transplantation.Under light adaptation and dark adaptation,ERG amplitude depressed obviously in 2 cases.Two cases with optic nerve atrophy did not change after transplantation.

Hematopoietic stem cell transplantation is an effective way to deal with malignant osteopetrosis.Successful transplantation has been shown to arrest visual deterioration in some cases. (Chin J Ophthalmol,2013,49:541-546)

Choroideremia and gyrate atrophy are two kinds of heritage primary retino-choroidal atrophy diseases.At advanced stage,their typical fundus lesions are conductive to identification.However,early diagnosis and intervention,which lead to improved prognosis and genetic benefits,are hindered by some similar clinical manifestation and optical examine results.Therefore,it is meaningful for ophthalmologists to have a comprehensive understand of these two diseases,and provide early diagnosis and proper intervention including genetic consulation. (Chin J Ophthalmol,2013,49:564-567)

Epigenetics is the emergence of a new branch of genetics.Epigenetic factors regulate gene function and phenotype by the modulation of DNA methylation,histone modification,non-coding RNA expression instead of changing the DNA sequence;more importantly,the regulation occurs under the influence of environment and diet and can be passed on to the next generation.Epigenetics is involved in life development,maintenance of normal physiological functions of the human body and the pathology of many complex phenomena,such as inflammation,aging,tumorgenesis,etc.There is no doubt that the pathogenesis of complex eye diseases such as recurrence of herpes simplex keratitis,glaucoma,uveitis and AMD may be associated with aberrant epigenetic regulations.Therefore effect in vigorously carrying eye research on epigenetics may provide new insight of the pathogenesis of those eye diseases and development of novel treatment options. (Chin J Ophthalmol,2013,49:568-573)

Since the use of femtosecond laser (FSL) in refractive surgery,it has been expanded to other corneal surgeries and most recently has been applied to cataract surgery.The FSL can create clear corneal incisions and limbus relaxing incisions in any space of different shapes,at a desired depth.This has started the application of the technology in the lens:after a clear image is taken of the lens through a previously dilated pupil,circular capsulotomy is done,with precision in shape and diameter,and then photofragmentation of the nucleus is done,without the risk of damaging the posterior capsule,because it is well visualized,to achieve the aspiration of the nuclear material in lower even without applying phaco energy.In summary,FSL is now used at the level of the lens,with the potentiality for very precise circular and adjustable diameter capsulotomies,and the fragmentation of the nuclear material,allowing the less use of forcep and phaco machine. (Chin J Ophthalmol,2013,49:574-576)