Volume 49 · Issue 07 · 2013

World Heath Organization (WHO) put forward a global initiative to eliminate avoidable blindness by 2020.The avoidable blindness includes blindness in children such as amblyopia.The critical period of human visual development is from 0 to 3 years old when is just in the period of infancy and young childhood,therefore vision screening for infants and young children should be attached importance,which is critical significant to the children blindness prevention.Due to many aspects of causes,the vision and related risk factor screening for the infants and young children in China is still faced with many challenges.The article strengthened the aspects of the importance of vision screening for infants and young children and put forward some strategies and suggestions. (ChinJ Ophthalmol,2013,49:577-579)

Growing evidences show that the pathogenesis of majority human diseases is influenced by the abnormalities of epigenetic and genetic mechanism.The major epigenetic factors such as DNA methylation,histone modifications,and microRNA (miRNA) interact with each other to regulate gene expression and determine cell phenotype.Epigenetics is currently become a hot topic of biomedical research,which focus on how whole genome is regulated by epigenetics mechanism and its roles in life development,senescence,regeneration,tumorgenesis and the pathogenesis of complex disease.The occurrence of variety of eye diseases may be mediated through the interaction of environmental and genetic factors which in turn regulated by epigenetic mechanisms.Emphasizing the epigenetic research in eye may provide a new insight of the understanding of pathogenesis of complex eye disease and a novel approach of its treatment. (Chin J Ophthalmol,2013,49:580-585)

All head position disorders can be called abnormal head posture,but abnormal head posture is not equal to compensatory head posture.Only abnormal head posture in connection with extraocular muscle disorders can be called compensatory head posture.Compensatory head posture is usually adopted to optimize visual acuity or to obtain single binocular vision.Abnormal head postures involve not only extraocular muscle disorders but also skeletal,muscular,neurologic,otolaryngologic and some eye disorders. (Chin J Ophthalmol,2013,49:586-588)

Congenital esotropia is defined as an esotropia before the age of 6 months,because of its early onset and often constant angle,it cause heavier binocular visual function damage compared with other types of strabismus.Early surgery can improve binocular visual function,but demand reliable,accurate measurements which is difficult to achieve in children,and it may increase the risk of second surgery,amblyopia and anesthesia.Late surgery can gain reliable strabismus angle,but it reduced the likelihood of recovery binocular visual function,and the contracture of medial rectus after a long time esotropia increased mechanical limitation of adduction.Therefore,the choice of timing to do surgery has been controversy over the years.In this paper,we will combine the research status and clinical practice to discuss this issue,and present some point of view for the peer reference. (Chin J Ophthalmol,2013,49:589-592)

To demonstrate the surgical choices for patients with complicated head posture associated with nystagmus.

It was a retrospective clinical study.Thirty-eight cases of congenital nystagmus with abnormal head posture in all three axes without strabismus were retrospectively analyzed.Twenty-nine (76.32%) cases whose dominant head posture were with face turn,3 cases (7.89%) with chin up or down,respectively,were performed horizontal null zone shift as well as vertical null zone transposition; 2 cases (5.26%) with head tilt as the dominant position were underwent one tendon width transposition of all four vertical muscles;4 cases (10.53%) basically with the same degree for face turn and chip up or down,2 cases were profermed with recess a group of horizontal yoke muscles and a group of vertical yoke muscles,the other 2 cases were combined with weaken both synergistic oblique muscles.SPSS 13.0 was used to analyse the difference of them.

In 29 patients with horizontal head posture dominanted,15 cases (68.18%) with 25°-30°in horizontal head posture were corrected completely,5°-15°was the residue for 7 cases (31.82%) with 35°-40°degree in horizontal before surgery.15°-20°was residue for 3 cases larger than 40°before operation after modified Parks procedure.Anderson procedure can correct the angle of 15°-20°in 4 cases.The horizontal,vertical and torsional components of 22 cases whose predominant head posture were in horizontal with 25°-40° (3.18°±1.01°,4.32°±1.14°,4.55°±1.95°) were significantly reduced (t=63.13,3.57,3.95;P<0.01) after Parks procedure.Recession a group of vertical muscles 5mm or combined with oblique muscles in 3 patients could correct the 20°of vertical head posture,but the improvement of the other two axes was about 5°-10°.One tendon width transposition of all four vertical muscles in 2 cases could correct the 10°of head tilt and 10°-15°of chip up or down.Recession a group of horizontal and vertical muscles can correct 20°-25°of face turn and 20°of vertical head posture.

When head turn with 25°-40°predominates over the vertical and torsional components,recess the horizontal muscles could be effective way in diminishing the abnormal head position on all three axes.When vertical or torsional head posture predominates for the complicated nystagmus,individual designs should be considered.When necessary,reoperations should be needed. (Chin J Ophthalmol,2013,49:593-598)

To investigate surgical approach for paralytic strabismus with lateral rectus muscles paralysis and evaluate its clinical effects.

Design retrospective,observational case series.28 patients (31 eyes) who underwent augmented partial rectus muscle transposition (APRMT) in the treatment of paralytic strabismus with lateral rectus muscles paralysis from May 2009 to May 2011 at Eye& ENT Hospital of Fudan University were included in this study.The following data were analyzed: (1) The procedure that was performed,(2) The angle of deviation of primary position,(3) The presence of compensatory head posture,(4) The presence of diploma in the primary position,(5) The binocular single visual fields,(6) The motility of the affected eye.

According to the results of rectus muscle forced traction test and examination before and after operation,among 31 eyes in 28 patients,8 eyes were treated with APRMT,10 eyes were treated with recession of antagonistic muscle of paralytic rectus muscle combined with APRMT,7 eyes were treated with APRMT and recession of yoke muscle,6 eyes were treated with APRMT and recession of yoke muscle combined with recession of antagonistic muscle.17 among 28 patients were orthotropia in the primary position while others were in mild undercorrection with deviation no more than 10 prism degrees during 5 months (range:3-8 months) follow-up in average.The diploma and abnormal head posture were eliminated in 26 patients except one patient who was appeared with 10 prism degrees undercorrection postoperatively and was resolved by wearing prisms thereafter.Binocular single visual fields were extended from 27.0°±6.4°preoperatively to 40.5°±4.8°postoperatively (t=-34.692,P<0.001).Ocular movement was improved from-4.9±0.4 to-2.9±0.9 postoperatively (t=-13.418,P<0.001).

APRMT can safely and effectively correct the primary position in paralytic strabismus with lateral rectus muscles paralysis,eliminate the presence of diploma in primary position and abnormal head posture,and improve the ability of the ocular movement,furthermore,significantly expand the scope of binocular single visual fields.The results also demonstrate that rectus muscle forced traction test is a key measurement to determine the surgical procedure. (Chin J Ophthalmol,2013,49:599-603)

To evaluate the effect of surgery to treat anti-elevation syndrome following anterior transposition of inferior oblique muscle (ATIO).

We retrospectively studied six cases of anti-elevation syndrome that had surgical history of anteriorization of inferior oblique muscle.We disinserted the inferior oblique from the transposed insertion and simultaneously weakened the contralateral inferior oblique for three cases with severe limited supraduction.We anteriorized the contralateral inferior oblique muscle for other three cases with mild or moderate limitation.The patients were followed up more than 6 months.

Six cases we aged from 5 to 22 years.Postoperatively,vertical deviation in primary position improved to less than 6 PD with no more abnormal head position.Three cases with severe limited supraduction showed great improvement.All patients showed no more overreaction of contralateral inferior oblique muscle.Three cases with previously DVD showed improved drift of contralateral eye.All patients were satisfied for the correction and no more surgery were done.The results persisted after six months follow up.

Disinserting the inferior oblique from the transposed insertion is an effective way to treat anti-elevation syndrome with severe limited supraduction.Unilateral anterization of inferior oblique should be avoided. (Chin J Ophthalmol,2013,49:604-608)

To compare the results of 4 methods for measuring angle of exodeviation including when fixating at indoor distance target of 6m,fixating at outdoor far distance target,after 1 hour diagnostic occulsion test (1h-DOT),and prism adaption test (PAT),in patients with intermittent exotropia.

Prospective case series study.Inpatients with intermittent exotropia was recruited from Sep 2011 to May 2012 in the Eye Center of Provincial Hospital Affiliated to Shandong University.Fifty involved patients included 26 males and 24 females with average age (10.1±6.9) years.Prism and alternative cover test was used to evaluate the exodeviation on the primary position in patients with intermittent exotropia.All the patients were measured when fixating at indoor distance target of 6m and near target of 33 cm,fixating at outdoor far distance target,after 1h-DOT,and PAT.The mean deviations measured with 4 methods for distance and 3 methods for near were analysed statistically with levene test.LSD test was applied to compare the differences between each two methods.Positive increased angle of exodeviation was defined as equal to and more than 10 prism diopters (PD) when tested with fixating at outdoor far distance target,after 1h-DOT,and PAT,compared with the results of primary measurement of fixating at indoor distance target of 6 m and near target of 33 cm.A Chi-square test was applied to compare the distribution of sub-types of intermittent exotropia in 4 methods of measuring angle of exodeviation.

(1) The exodeviations tested with fixating at indoor distance target of 6 m,after 1h-DOT,fixating at outdoor far distance target,and PAT were (28.2±8.4),(30.8±9.7),(32.3±8.8),(36.5±9.5) PD,respectively (F=7.235,P=0.000).The exodeviation tested with fixating at outdoor far distance target (P=0.027) and PAT (P=0.000) were greater than that tested with the primary measurement of fixating at indoor distance target of 6m.There are no significant difference between the exodeviation tested after 1h-DOT and that tested with fixating at indoor distance target of 6 m (P=0.164).Compared with the primary measurement of fixating at indoor distance target of 6 m,the increased angles of deviation measured with the methods of after 1 h-DOT,fixating at outdoor far distance target,and PAT were (2.5±3.7),(4.1±3.7),and (8.3±4.3) PD,with positive rate of increased angles of deviation 8%,16%,and 44%,respectively.The exodeviations tested with the primary measurement fixating at near target of 33 cm,after 1h-DOT,PAT were (29.7±8.0),(35.3±9.5) and (41.6±10.5) PD,respectively.The exodeviations tested with fixating at near target of 33cm after 1h-DOT (P=0.003) and PAT (P=0.000) were greater than that tested with the primary measurement. (2) Compared with the primary measurement of fixating at indoor near target of 33 cm,the increased angles of deviation measured with the methods of after 1h-DOT and PAT were (5.6±4.7) and (11.8±6.7) PD,with positive rate of increased angles of deviation 38% and 66%,respectively. (3) The distributions of intermittent exotropia sub-types tested with evaluation of fixating at indoor targets of 6 m and 33 cm,outdoor target of far distance and indoor target of 33 cm,indoor targets of 6 m and 33 cm after 1h-DOT,and indoor targets of 6 m and 33cm with PAT have significant difference (χ²=18.53,P=0.001).

Both the measurement with fixating at outdoor far distance target and the measurement with PAT can elicit larger angle of exodeviations for distance,while both the measurement after 1h-DOT and the measurement with PAT can elicit larger angle of exodeviations for near in patients with intermittent exotropia.The measurement with PAT can elicit the maximal angle of exodeviations both for distance and for near in patients intermittent exotropia. (Chin J Ophthalmol,2013,49:609-614)

To elucidate the difference in the pathogenesis between strabismic and anisometropic amblyopia.

It was a case-control study.We used psychophysical methods,including grating acuity,edge contrast sensitivity,contrast sensitivity function tests,and examined the visual functions of 150 cases from 8 to 40-year-old.Then we applied the Origin 8.0 software for statistical analysis of experimental data,we did the correlation analysis between the grating acuity,edge contrast sensitivity and optotype acuity,and the similarity comparison of the contrast sensitivity function curve between the strabismic and anisometropic amblyopia.

The grating acuity had a strong correlation with optotype acuity,the correlation value was 0.81.The grating acuity of the srabismic group was roughly 15% lower than the whole abnormal population,for any given level of optotype acuity; the edge contrast threshold had a weak correlation with optotype acuity,the correlation value was 0.24.Anisometropes,for a given level of optotype acuity,had edge contrast thresholds that were 15% higher (worse) than the whole population,while strabismic and strabismicanisometropes had edge contrast thresholds that are 17% lower (better) than the whole population.The CSF of all amblyopic eyes were reduced in comparison with the non-amblyopic eye of the same person,the peak sensitivity shifted toward to the low spatial frequency region,the CS curve was depressed especially in the middle and high spatial frequencies,there were no significant difference,but at low frequency area (1.0 c/d) there were statistically significant between the two types of amblyopia (t=2.239,P<0.05).

There were differences in the patterns of visual loss between strabismic and anisometropic amblyopic patients. (Chin J Ophthalmol,2013,49:616-621)

To identify TUBB3 gene mutations in a Chinese family with congenital fibrosis of the extraocular muscle associated with corpus callosum agenesis.

We have found a family with CFEOM associated with corpus callosum agenesis,including 4 affected individuals in three generations of 11 familial members.4 affected individuals were sequenced by direct TUBB3 sequencing,4 inaffected individuals in the family and 100 cases of unrelated normal person as a control.

This family is in line with Mendelian autosomal dominant inheritance.Clinical manifestations belongs to CFEOM3.All affected individuals were detected with TUBB3 c.1249G>A mutation,the mutation is in exon 4,resulting in wild-type gene encoding the Aspartic acid ( Asp or D) replaced.by Asparagine (Asn or N).

Our study supports that TUBB3 gene mutation c.1249G>A (p.Asp417Asn),is the underlying molecular pathogenesis of this family with CFEOM3. (Chin J Ophthalmol,2013,49:621-626)

To investigate the ciliary sulcus diameters in horizontal and vertical axes and to analyze the correlation between white-to-white diameter and horizontal ciliary sulcus diameter for high myopia eyes at different anterior chamber depths.

IOL-Master was used to measure white-to-white diameters and anterior chamber depths of 108 high myopia eyes and verified by digital caliper.Based on the depth of central anterior chamber not including corneal thickness,the testing eyes were divided into three groups: shallow AC group (3.0 mm<ACD≤3.2 mm),medium AC group (3.2 mm<ACD≤3.4 mm),and deep AC group (ACD>3.4 mm).Furthermore,the horizontal and vertical ciliary sulcus diameters were checked by full-scale 50-Hz ultrasound biomicroscopy.The data of three AC groups were analyzed separately.The paired sample t-test was used to compare: white-to-white diameters and horizontal sulcus diameters,horizontal and vertical suclus diameters.The correlations between white-to-white diameters and horizontal sulcus diameters were assessed using linear regression analysis.The difference in the three groups of white-to-white diameters and ciliary sulcus diameters were compared by Student Newman Keuls test.

The mean diameters and standard deviations of WTW diameters and horizontal ciliary sulcus diameters in the shallow AC group was,respectively,(11.46±0.38) and (11.57±0.32) mm (t=-2.849,P=0.007).Linear regression analysis found a statistically significant correlation between white-to-white diameters and horizontal sulcus diameters with a coefficient of determinant of 0.797 (P=0.000).The mean vertical suclus diameters was (12.27±0.48) mm.The difference between horizontal and vertical suclus diameters was statistically significant (t=-15.522,P=0.000).The mean diameters and standard deviations of WTW diameters and horizontal ciliary sulcus diameters in the medium AC group was,respectively,(11.58±0.31) and (11.77±0.26) mm. (t=-4.523,P=0.000).Linear regression analysis found a statistically significant correlation between white-to-white diameters and horizontal sulcus diameters with a coefficient of determinant of 0.639 (P=0.000).The mean vertical suclus diameters was (12.52±0.37) mm.The difference between horizontal and vertical suclus diameters was statistically significant (t=-13.987,P=0.001).The mean diameters and standard deviations of WTW diameters and horizontal ciliary sulcus diameters in the medium AC group was,respectively,(11.68±0.22) and (11.91±0.23) mm (t=-5.157,P=0.000).Linear regression did not reveal horizontal sulcus diameters were a significant predictor of white-to-white diameters with a coefficient of determinant of 0.253 (P=0.126).The mean vertical suclus diameters was (12.69±0.36) mm.The difference between horizontal and vertical suclus diameters was statistically significant (t=-18.433,P=0.000).

The white-to-white diameter measuring technique is not identical to the horizontal diameter of the ciliary sulcus and the potential difference between them is increased with deepening anterior chamber depth.Our preliminary study illustrated that the ciliary sculus is not circular and a vertical diameter is longer than horizontal one. (Chin J Ophthalmol,2013,49:627-632)

To evaluate the change of accommodation function after phakic posterior chamber implantable contact lens (PPC-ICL) implantation for high myopic eyes.

It was a retrospective case series study.PPC-ICL implantation surgery was performed in 36 eyes of 18 high myopic patients.Uncorrected visual acuity,best-corrected visual accuracy,amplitude of accommodation,pupil distance were tested and AC/A was calculated before,one month and three months after operation.Rank-sum test and variance analysis test was performed for statistic study.

Before surgery,long-distance best corrected visual acuity was 0.55 (0.20,1.50) for left eyes and 0.60 (0.10,1.20) for right eyes.One and six months after surgery,it was 0.80 (0.40,1.20),0.85 (0.50,1.50) for left eyes and 1.00 (0.30,1.50),0.95 (0.30,1.50) for right eyes,all were improved.The difference between left and right eyes was statistically significant (Wvalue 6.36,6.18,P<0.05).One and six months after surgery,uncorrected close-distance visual acuity was 1.00 (1.00,4.00),1.00 (1.00,3.00) for left eyes and 1.00 (1.00,4.00),1.00 (1.00,4.00) for right eyes.The difference for both eyes was not statistically significant compared with preoperative (Wvalue 1.61,2.72,P>0.05).At one and six months after surgery,amplitude of accommodation was (8.28±2.12) D,(8.28±2.16) D for left eyes and (8.58±1.98) D,(8.49±2.10) D for right eyes,much better than the result (6.78±1.96) D and (6.69±2.14) D before surgery.The difference was statistically significant (F=4.36,P<0.05 andF=4.04,P<0.05).At one and six months after surgery,near and distant AC/A ratio were (3.96±1.37),(4.22±1.33),(4.78±1.06) and (5.04±1.01),higher than (4.87±0.97) and (5.23±0.92) before surgery.The difference of near and distant AC/A ratio was statistically significant (F=3.31,P<0.05 andF=4.10,P<0.05).At one month and six months after surgery,near and distant pupil distance was (58.72±2.78) mm,(61.56±2.50) mm,(58.56±2.4) mm and (61.61±2.52) mm,smaller than that of (59.78±2.39) mm and (62.44±2.48) mm before surgery,but the difference was not statistically significant (F=1.28,P>0.05 andF=0.76,P>0.05).

Accommodation parameters after PPC-ICL implantation are improved obviously compared with those before surgery. (Chin J Ophthalmol,2013,49:633-636)

To summarize the misdiagnosis and missed diagnosis of iridocorneal endothelial syndrome (ICE syndrome) and analyze the main reasons.

Retrospective case series.The records of 65 patients (65 eyes) who were diagnosed to suffer from ICE syndrome in Beijing Tongren Hospital during Jan.2008 to Dec.2011 were studied retrospectively.The international diagnostic standards were used.The situations of misdiagnosis and missed diagnosis were evaluated and the main reasons and the related clinical characters were analyzed.

The correct preliminary diagnosis was found in 9 cases (13.8%).Misdiagnosis included primary angle closure glaucoma (PACG) in 14 cases (21.5%),primary open angle glaucoma (POAG) in 14 cases (21.5%),uveitis in seven cases (10.8%),etc.The contralateral eye received operation or laser therapy in 12 of 56 cases who didn't get the correct preliminary diagnosis.There were many atypical and special presentations in our patients.There was no or mild atrophy of iris in 54 cases (83.1%).Secondary open angle glaucoma was found in eleven cases (16.9%).The maximal intraocular pressure (IOP) was≥40 mm Hg (1 mm Hg=0.133 kPa) in 41 cases (63.1%).And there was no corneal edema when the IOP is lower than 30 mm Hg in 48 cases (73.8%).There is some abnormal black pigment in the anterior chamber angle in some cases.

ICE syndrome is a disease with high rate of misdiagnosis or missed diagnosis.The main reasons of misdiagnosis and missed diagnosis include that ICE syndrome has many different clinical manifestations and the doctors pay little attention of to the atypical presentations of ICE cases. (Chin J Ophthalmol,2013,49:637-641)

To study the production and the role of annexin A2 (ANXA2) in the process of retinal neovascularization of mouse.

Experimental study.C57BL/6J mice were classified into four groups:normal group (80 mice),oxygen induced retinopathy (OIR) mock group (80 mice),siANXA2 group (transfected with siRNA target ANXA2) (50 mice),and siANXA2_M group (50 mice).Stretched preparation of retina after angiography was used to observe the morphology change of retinal neovascularization from 12 to 30 days after birth in normal group and OIR mock group,and real-time PCR was used to test the expression of ANXA2 in these days.On 17 days old,the mRNA and protein production of vascular endothelial growth factor (VEGF) -α,matrix metalloproteinase (MMP) -2,MMP-9,and tissue inhibitor of metalloproteinase (TIMP) -2 in 4 groups were assessed by real-time PCR and Western blot.The results of all factors among four groups were analyzed by one way ANOVA and SNK-q test.

The retinal neovascularization of si ANXA2 group in 17 days old was more regular than that in OIR mock group.The production of ANXA2 in mouse retina was associated with the stage of retinal neovascularization.The expression of ANXA2 was in high level when neovessels grew and in low level when neovessels stopped growing.The mRNA expressions of ANXA2,VEGF-α,MMP-2,MMP-9 and TIMP-2 showed statistical difference among 4 groups (F=8.122-74.009,P<0.05).Significant statistics difference was found in multiple comparison:the expressions of VEGF-α (0.22±0.04),MMP-2 (11.08±1.28),MMP-9 (4.64±0.38) in OIR mock group were significantly higher than that in normal group (0.16±0.02,2.18±1.39,1.17±0.25) (SNK-qtest:P<0.01).In siANXA2 group,the productions of VEGF-α (0.02±0.01),MMP-2 (2.21±0.42),MMP-9 (1.33±0.10) were significantly lower than that in OIR mock group (SNK-qtest:P<0.01).The mRNA expression of TIMP-2 (0.59±0.15) in OIR mock group was significantly lower than that in normal group (1.35±0.01) (SNK-q test:P<0.05).In si ANXA2 group,the production of TIMP-2 was higher than that in OIR mock group (SNK-q test:P<0.05).The results of Western blot were similar to that in real-time PCR.

ANXA2 is overexpressed in oxygen-induced retinal neovascularization in a mouse model.The overexpression of ANXA2 may affect the expression of proangiogenic factors.ANXA2 may involve in the development of the retinal neovascularization.The production of ANXA2 may be inhibited by siRNA.ANXA2 maybe a new target for inhibition of retinal neovascularization. (Chin J Ophthalmol,2013,49:642-648)

Infantile nystagmus syndrome (INS) is an ocular motor disorder that presents at birth or early infancy.It is clinically characterized by involuntary and conjugated oscillation of the eyes,which often causes several complications such as amblyopia,lateral view,strabismus and torticollis.The etiology of INS is not fully understood,and this disease cannot be cured completely.This paper reviews the progress of research on the concept,etiology and pathogenesis,clinical manifestations,common examination methods,diagnosis and treatment of INS. (Chin J Ophthalmol,2013,49:653-660)

The biological activities of complement system,which are activated mainly through classical pathway,alternative pathway and mannose-binding lectin pathway,include cytotoxicity,bacteriolysis,sterilization,cell regulation,immune adherence,neutralization and dissolution of virus and inflammatory mediators.It is well known that diabetic retinopathy (DR) is one of the common complications of diabetes mellitus and is the leading cause of blindness among working-age adults in the developed countries and regions,but the mechanism underling its pathogenesis is not yet fully understood.Until now,numbers of studies showed that the activation of complement system is involved in the pathogenesis of DR.Naturally,these finding paves a way for the prevention and treatment of DR in the future. (Chin J Ophthalmol,2013,49:661-664)

Retinal ganglion cells (RGC) is only neuron in retina which mediate information from retina and project to the brain.Markers specific to individual retinal neuronal cell types have not been forthcoming,so the most general method remains neuronal morphology which is simple and observational.The synaptic connectivity and physiology characteristic can be described.The diversity of RGSis reviewed. (Chin J Ophthalmol,2013,49:665-668)