Volume 53 · Issue 02 · 2017

This issue focuses on the clinical and basic research of glaucoma. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Sun Xinghuai.

The prevention of blindness caused by glaucoma is a difficult task. In order to accomplish the task better, we need the participation of whole society and popularize relevant medical knowledge. Popular science and related knowledge of glaucoma are needed to the people especially for high risk population. If people know glaucoma better and actively join the screening of glaucoma, we can find and diagnose glaucoma earlier, avoid late treatment and reduce the glaucomatous visual function impairment. For patients who had been diagnosed with glaucoma, they should aware and accept new medical concept and technique through systemic popular science education. They should actively participate the whole procedure of the disease management and improve their compliance and confidence. Academic organization of ophthalmology should participate and guide the patient education, improve the individualized comprehensive health care for the diagnosis and treatment and third-order health care system that is suitable for the condition of our country, help improving the prognosis of glaucoma and life quality related to vision for advanced and late glaucoma. (Chin J Ophthalmol, 2017, 53: 81-84)

Intraocular pressure is the most important and most easily controlled clinical parameters of glaucoma. It has a fluctuation and circadian rhythm. The 24 hours intraocular pressure measurement can better reflect the changes of intraocular pressure. It is clear that peak IOP is an independent risk factor for the progression of glaucoma, but the effect of IOP on glaucoma progression is worth exploring. This article focuses on whether IOP fluctuation is an independent risk factor for glaucoma progression, how to obtain the 24-hour intraocular pressure curve, the future direction of 24-hour intraocular pressure monitoring and other issues in order to cause clinical concern. (Chin J Ophthalmol, 2017, 53: 85-88)

The optic nerve tissue of human body is located in two pressure cavities, the intraocular cavity and the intracranial cavity, respectively. The intraocular pressure is slightly higher than the intracranial pressure, and the pressure difference between intraocular pressure and intracranial pressure crosses the sieve plate, forming a pressure gradient along the optic nerve, called the oculocranial pressure gradient, that is, the pressure difference across the sieve plate. In recent years, the research on the role of cranial pressure gradient in the mechanism of optic nerve injury in glaucoma has attracted more and more attention of glaucoma scholars at home and abroad, and has become a hot issue in the international glaucoma academic circle. Chinese scholars have carried out a lot of work in this field and achieved remarkable results.

To evaluate the usefulness of albumin correction in determination of cytomegalovirus IgG in the aqueous humor of Posner-Schlossman syndrome (PSS) patients.

Cases series studies. Forty-two patients (26 men and 16 women) who were diagnosed as PSS were enrolled from Oct. 2009 to Oct. 2015 at the Eye and ENT Hospital. During the same period, 20 patients with primary open-angle glaucoma (POAG) and 30 patients with bacterial endophthalmitis or retinal necrosis were enrolled as negative control group and inflammatory disease control group, respectively. Aqueous humor and serum samples were assayed to detect CMV IgG by enzyme-linked immunosorbent assay (ELISA), and albumin by scattering immunonephelometry. CMV DNA in aqueous humor was assayed by polymerase chain reaction (PCR). The ratio which was calculated as the (aqueous humor CMV IgG/serum CMV IgG)/(aqueous humor concentration of albumin/serum albumin concentration) over 0.6 was considered as intraocular antibody formation. Performance of differentiating control eyes from eyes with CMV-positive PSS was evaluated by the receiver operating characteristic curve. The ANOVA test, Mann-Whitney test and Chi-square test were performed to compare the differences among groups.

The detectable rate of CMV IgG antibody in the aqueous humor was 76.2%, 100.0% and 10.0% in PSS, inflammatory disease control and POAG groups, respectively. The levels of CMV IgG antibody in the PSS groups were significantly higher than that of POAG groups (Z=4.23, P<0.001).The positive rate corrected by the albumin was 71.4%, 3.3% and 0.0%.The corrected positive rate in PSS groups was significantly higher than that of the inflammatory disease control and POAG groups (χ²=30.38, P<0.01; χ ²= 24.89, P<0.01), with a sensitivity of 75.0% and a specificity of 98.0%. The area under the curve for calibrated ratio was 0.942 (95%CI: 0.859 to 0.984) which was higher than that of CMV IgG (Z=6.19, P<0.001).The corrected positive rate of CMV IgG antibody (71.4%) was higher than that of CMV DNA (47.6%, χ ²=4.003, P=0.045).

CMV IgG antibody ratio which was corrected by aqueous humor and serum albumin could effectively improve aqueous antibody specificity in PSS patients. Furthermore, CMV IgG antibody ratio combined with PCR could improve the sensitivity of CMV detection. All of which help clarify the CMV infection in PSS in CMV DNA negative eyes. (Chin J Ophthalmol, 2017, 53: 104-108)

To investigate the relationships among illness perception, medication beliefs and medication adherence in primary angle closure glaucoma patients.

It was a cross-sectional study. Morisky 8-item Medication Adherence Questionnaire Chinese Revised, the Brief Illness Perceptions Questionnaire, the Specific Section of the Beliefs about Medicine Questionnaire Chinese Revised were administered to 156 primary angle closure glaucoma patients from Tianjin Eye Hospital. Chi-square test was used to analyze the types of glaucoma, gender, prescription complexity, medicine schedule, other disease and course of disease between the group of adherence and non-adherence. Pearson correlation method was used to analyze the correlations among the illness perception, necessity belief, concerns belief and medication adherence. Structural equation model was used to analyze the mediational role of medication belief between illness perception and medication adherence.

In the 156 primary angle closure glaucoma patients being investigated, 37 male and 119 female, the average age was (61.3±8.3) years old. The medication adherence of patients was 83 (53.2%) , the medication non-adherence of patients was 73 (46.8%) . It was showed that prescription complexity and medicine schedule were significantly correlated with medicine adherence (χ²=13.64, 11.31; P<0.05); gender, other disease and course of disease were not correlated with medication adherence (χ²=1.02, 1.73, 6.08; P>0.05). The scores of illness perception were positively correlated with the necessity belief of medication scores, the scores of concerns belief (r=0.18、0.45, P<0.05), and were negatively associated with medication adherence (r=-0.22, P<0.01). The concerns belief of medication scores were negatively correlated with the medication adherence (r=-0.47, P<0.01). Concerns belief mediates the relationship between illness perception and medication adherence wholly (χ²/df=1.73, RMSEA=0.069, NNFI=0.98, CFI=0.98, IFI=0.98) .

The types of medicines and the number of glaucoma medication used have a significant influence to the medication adherence in the patients with primary angle closure glaucoma. The patients with greater illness perception performed greater non-adherence can be explained by their higher concerns blief. (Chin J Ophthalmol, 2017, 53: 109-114)

To investigate the present situation of diagnosis and treatment for primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG) and awareness of the relevant progress among Chinese ophthalmologists.

This study was a cross-sectional, non-randomized sampling survey. Participants were ophthalmologists who attended the 11st Chinese Glaucoma Society Congress during November 11 to 12, 2016. They were invited to fill out a questionnaire. The questionnaire included participants' basic information and their knowledge about glaucoma diagnosis and treatment. The data collected through questionnaire were analyzed with SAS9.4.

A total of 450 questionnaires were distributed and 372 valid questionnaires were retrieved, with a response rate of 82. 7%(372/450). ISGEO classification system was adopted by 58.9% (219/372) of the participants as the diagnostic criteria for PACG. Of the respondents, 48.1% (179/372) of the participants believed that "anterior chamber angle closure mechanism-based PACG classification system" was more instructive for treatment, the percentage was higher than ISGEO classification system (42.2%, 157/372). Most (72.3%, 269/372) of the participants knew the 3-minute dark room prone test, but only 27.7%(103/372) of them applied it in clinical practice. A total of 83.4%(310/372) of the participants believed that low cerebrospinal fluid pressure is a risk factor for POAG. In all, 71.8% (267/372) of the participants reported that their institutes had applied compound trabeculectomy with adjustable suture, with 76.9%(286/372) of the participants agreeing that the adjustable suture reduced the rate of complications after trabeculectomy.

Currently, both ISGEO classification system and anterior chamber angle closure mechanism-based PACG classification system were adopted in the diagnosis and treatment of glaucoma. Low cerebrospinal fluid pressure as new risk factors for POAG has been widely acknowledged and given attentions by Chinese ophthalmologists. The 3-minute darkroom prone test and compound trabeculectomy with adjustable suture still need to be promoted. (Chin J Ophthalmol, 2017, 53: 115-120)

To summarize the clinical features, treatment and prognosis of retinoblastoma (RB) patients in distant metastasis stage.

Retrospective case series study. Clinical data of 24 cases (30 eyes) with diagnosis of distant metastasis stage RB were collected in pediatrics department of Beijing Tongren Hospital affiliated with Capital Medical University, from September 2005 to December 2013. In these cases, including 11 male cases and 13 female cases, the treatment age ranged from 7 months to 9 years with the median of 26 months. There were 18 unilateral cases (12 cases of right eye and 6 cases of left eye) and 6 bilateral cases. All cases were treated with surgery, chemotherapy and radiotherapy. The adverse reaction, blood routine and biochemical routine were monitored dynamically and regularly during treatment. The clinical manifestations and auxiliary examination were combined to evaluate the therapeutic effect. Determining the prognosis with death and survival, the survival curve and the median survival time were calculated by the product limit method.

The results of pathologic examination of 13 cases showed 11 cases of optic nerve involvement, 6 cases of optic nerve and choroid involvement, 1 case of post laminar involvement, 1 case of cornea and conjunctiva involvement. The most common metastatic site was central nerve system (CNS) (23 cases), followed by orbital involvement (10 cases). Other metastatic sites included bone (9 cases), bone marrow (1 case), pleura (1 case) and lymph node (1 case). 23 patients with CNS metastasis underwent systemic chemotherapy and intrathecal injection. The toxicity and side effects of radiotherapy and chemotherapy were evaluated and classified as grade I-II. Those adverse effects were tolerated by all cases. Followed up to December 31, 2015, all patients with CNS metastasis died and the median survival time was 6 months. Only 1 patient without CNS metastasis disease-free survived for 64 months.

The most common metastasis site of RB was CNS. The overall prognosis of RB with distant metastasis was poor, in spite of given combined treatment mainly including surgery, chemotherapy and radiotherapy. But the prognosis of RB patients without CNS metastasis in distant metastasis stage was better than with CNS metastasis. (Chin J Ophthalmol, 2017, 53: 121-126)

To evaluate the efficacy of orbital decompression by transconjunctival medial and inferior wall combined transpalpebral lateral wall for disfiguring proptosis with mild or moderate thyroid eye disease (TED).

It is a retrospective case series study. The clinical data of 18 TED cases (28 orbits) between Dec 2013 and Dec 2015 at the Institute of Orbital Diseases of the General Hospital of the Armed Police were reviewed. All the patients underwent mulit-wall orbital decompression to relieve remarkable proptosis, widen eyelid fissure, and swollen eyelid. Inclusion criteria: 1. Hertel value was 14-23 mm or over 2-7 mm than contralateral eye; 2.Orbitalpathy has been inactive with normal thyroid function for at least 6 months; 3.Orbital pressure is normal or (+). Clinical outcomes were recorded including best-corrected visual acuity, exophthalmometry, margin-to-central distance of upper and lower lids, diplopia, and CT scans before and 3 months after surgery.

The mean protosis of pre-and postoperation were (19.2±2.3) mm and (14.7±1.4) mm with mean reduction was (4.6±1.7) mm (t=14.08, P<0.01). Margin-to-central distance of the upperlid of pre- and postoperation were (5.1±1.2) mm and (4.9±1.3) mm with mean reduction was (0.2±0.5) mm (t=1.73, P=0.095). Margin-to-central distance of the lowerlid of pre-and postoperation were (5.9±0.9) mm and 4.3±0.7 mm with mean reduction was (1.6±0.8) mm (t=10.09, P<0.01). The difference of bilateral exophthalmos after surgery is 0-2.5 mm (median=1 mm). None of the patients showed new-onset diplopia at primary gaze and two patient showed surrounding gaze diplopia postoperatively. Two patients with diplopia relieved after surgery (Z=743.00, P=0.458).

Transconjunctival and transpalpebral medial, inferior, and lateral walls decompression with a hidden incision was a controllable, safe, effective technique with minimal complications in relieving not only mild, moderate proptosis, but also retraction of lowerlid, and swollen eyelids. (Chin J Ophthalmol, 2017, 53: 128-135)

To explore the ultrastructural alteration of extraocular muscle proprioceptor in congenital idiopathic nystagmus (CIN).

Case-control study. Ten extraocular muscle samples were collected from five CIN children who underwent nystagmus surgeries in Beijing Children's Hospital from March 2015 to March 2016. Another ten extraocular muscle specimens were collected from five strabismus children in surgery at the same period as normal contrast. There were 3 male patients and 2 female patients of CIN with age of 61—147 months (median age: 91 months). The ultrastructure of extraocular muscle proprioceptors was compared between these two groups by transmission electron microscope.

Twenty-three proprioceptors were found in extraocular muscle specimens of CIN children, whereas thirty-three proprioceptors were detected in strabismus children. The ultrastructure of extraocular muscle proprioceptor of CIN altered greatly comparing with that of the control. Fourteen extraocular muscle proprioceptors of CIN were discovered much smaller and vacuolated not only at inner capsules but also at the space between inner and outer capsules with lipofuscins and myeloid bodies in the intrafusal muscle fibers. Sensory nerve fibers degenerated greatly with a lot of lipofuscins and myeloid bodies in these sensory nerve fibers. Demyelination also appeared in some severe cases. Nine extraocular muscle proprioceptors of CIN showed significant dissolving degeneration of myofibrils and proliferation of collagen fibrils. The normal structures could not be distinguished in these proprioceptors. And these structural disorders also appeared in extrafusal muscle fibers and nerve endings.

The ultrastructure of extraocular muscle proprioceptor in CIN turned much smaller and had significantly structural disorder.(Chin J Ophthalmol, 2017, 53: 136-139)

To investigate the rationality of visual field morphological stages of glaucoma, its relationship with visual field index and their diagnostic value.

Retrospective series case study. Two hundred and seventy-four glaucoma patients and 100 normal control received visual field examination by Humphrey perimeter using standard automatic perimetry (SAP) program from March 2014 to September 2014. Glaucoma patients were graded into four stages according to characteristic morphological damage of visual field, distribution of mean defect (MD) and visual field index (VFI) of each stage were plotted and receiver operation characteristic curve (ROC) was used to explore its correlation with MD and VFI. The diagnostic value of MD and VFI was also compared. For the comparison of general data of subjects, categorical variables were compared using χ ² test, numerical variables were compared using F test. MD and VFI were compared using ANOVA among stages according to visual field, followed by multiple comparisons using LSD method. The correlation between MD and VFI and different stages according to visual field defined their diagnostic value, and compared using area under the curve (AUC) of ROC.

No characteristic visual field damage was found in normal control group, and MD and VFI was (-0.06±1.24) dB and (99.15±0.76)%, respectively. Glaucomatous visual field damage was graded into early, medium, late and end stage according to morphological characteristic. MD for each stage were (-2.83±2.00) dB, (-9.70±3.68) dB, (-18.46±2.90) dB, and (-27.96±2.76) dB, respectively. VFI for each stage were (93.84±3.61)%, (75.16±10.85)%, (49.36±11.26)% and (17.65±10.59)%, respectively. MD and VFI of each stage of glaucomatous group and normal control group were all significantly different (F=1 165.53 and P<0.01 for MD;F=1 028.04 and P<0.01 for VFI). AUC of ROC was A_MD=0.91 and Se_MD=0.01 (95% confident interval was 0.89—0.94) for MD, and A_VFI=0.97, Se_VFI=0.01 (95% confident interval was 0.94—0.10) for VFI. So, AUC_VFI>AUC_MD (P<0.05).

It is feasible and rational of glaucomatous visual field damage to be graded into early, medium, late and end stage using Humphrey perimeter. Distribution of MD and VFI for each stage was relatively concentrative. Both MD and VFI were useful for grading glaucomatous visual field damage with preference for VFI. (Chin J Ophthalmol, 2017, 53: 92-97)

To investigate the alteration of retinal microcirculation and structural damage at macular region and evaluate their associations in primary open angle glaucoma (POAG) eyes.

Cross-sectional study. Fifty-nine POAG patients (male/femal=35/24) were recruited from July 2015 to December 2015 in Eye, Ear, Nose and Throat Hospital of Fudan University. Twenty-eight eyes of early-stage POAG group (EG), 11 eyes of moderate-stage POAG group (MG) and 20 eyes of severe-stage POAG group (SG) were enrolled in this study. All patients underwent complete ophthalmological examinations and the general information was collected. The macular perfusion parameters (flow index & vessel area density) and the global/hemimacular retina thickness were derived from the 3D angio-retina and retina map procedures in the single optic coherence tomography (OCT) system with split-spectrum amplitude decorrelation angiography (SSADA) algorithm, respectively. One-way ANOVA analysis was conducted to compare the macular perfusion parameters, retinal thickness and visual field defects among three groups. Pearson partial regression analysis was used to calculate the correlations between different variables.

The mean flow index and vessel area density of MG eyes were 0.05±0.01 and 60.8%±7.9%, which were significantly lower than those indexes (0.06±0.01; 71.9%±4.6%) in EG eyes (t=5.11, P=0.001; t=5.05, P<0.01). The full and inner retinal layer thicknesses of MG eyes were (270.3±24.6) μm and (98.4±13.3) μm, which were obviously thinner than those indexes (293.0±12.0 μm, 113.0±7.4 μm) in EG eyes ( t=3.60, P<0.01; t=4.06, P<0.01). However, there was no significant alteration of macular perfusion parameters and retinal thickness between MG and SG eyes. Furthermore, there was a significantly positive correlation between macular perfusion (flow index/vessel area density) and the macular retina thickness (full/inner thickness) (R=0.35-0.71, All P<0.01).

The microvascular perfusion and retinal thickness in MG eyes were lower than those in EG eyes. There was significant positive association between the retinal microvascular perfusion and structural damage. Furthermore, the association between microvascular perfusion and inner inferior retinal thickness is the strongest. (Chin J Ophthalmol, 2017, 53: 98-103)

The patient was a 60-year-old male. He was seen in Tianjin Eye Hospital due to swelling of his right eye with visual acuity decrease for 4 months. There were no obvious abnormalities in the whole body examination. Eye examination: visual acuity was 0.01 for the right eye and 0.6 for the left eye; The appearance of the right eye is normal, the eyelid is not red or swollen, and the eye surface and anterior segment are shownQuintessence Picture 1, the fundus of the eye can not see; The lens of the left eye was slightly opaque, and no obvious abnormalities were found in the anterior segment and fundus of the rest of the eye. The patient underwent enucleation of the right eye. Histopathological diagnosis: right eye ciliary body choroidal melanoma (mixed cell type predominantly spindle cells) (Quintessence Picture 2）。

Glaucoma is the first leading cause of irreversible blindness world widely, but the pathogenesis was still unclear. The collagen fibers from cornea and sclera connect to each other and both of them have similar extracellular matrix components. The biomechanical characteristics of optic nerve lamina cribrosa may associated with the biomechanical properties of the cornea. Therefore, the study of corneal physiological can indirectly reflex the compression and damage in optic nerve lamina cribrosa. The technical developments in corneal hysteresis examination had been updated these years constantly. Many researches implicated that low corneal hysteresis involved in pathogenesis and progression of glaucoma which refresh our recognition of the relationship between cornea and glaucoma. This review summarized the characteristics of corneal hysteresis, the examination and the connection with glaucoma to provide the reference for clinical work. (Chin J Ophthalmol, 2017, 53: 140-143)

Age-related macular degeneration(AMD) is one of the main leading causes of irreversible vision damage in patients over 50 years old. Genetic factors play an important role in the occurrence and development of AMD. Since the significant correlation between complement factor H (CFH) gene and AMD was found, the pharmacogenomics of CFH polymorphism was paid close attention by academic circles. Among which, studies concerning CFH Y402H were more deeply. Studies have found CFH Y402H genotypes might lead to differences toward the outcome of PDT and anti-VEGF treatment. In this article, we review the researches on the pharmacogenomics of CFH Y402H in wet AMD treatment. (Chin J Ophthalmol, 2017, 53: 144-147)

Retinitis pigmentosa (RP) is a genetically heterogeneous group of hereditary retinal disorders characterized by photoreceptor cell death, associated with night blindness, vision loss, progressive peripheral visual field loss and abnormalities in the electroretinogram. A number of gene defects have so far been associated with RP, which cause a progressive loss of rod photoreceptor function, followed by cone photoreceptor dysfunction and eventually complete blindness. The rate of blindness related to RP is high. At present there is no effective therapeutic strategy for RP. In recent years, with the progress of molecular biology technique, many new therapeutic approaches have become promising. This article summarizes the pathogenesis of RP and gives a brief overview of related research progress of RP therapeutic strategies. (Chin J Ophthalmol, 2017, 53: 148-153)

Surgery is one of the important methods to treat glaucoma in children. Glaucoma surgery in children is more challenging than surgery in adults, with a higher rate of failure and complications than in adults. Since the first surgery is often an important time for successful treatment, it is crucial to choose the best surgical method^[1]。 The choice of surgical methods for childhood glaucoma is influenced by factors such as the type, severity, age of onset or symptoms of childhood glaucoma and eye conditions^[1,2,3,4]。 Pediatric glaucoma surgery mainly includes anterior chamber angle surgery (anterior chamber goniotomy, traditional or total trabeculotomy), trabeculectomy, combined trabeculotomy-trabeculectomy surgery, aqueous humor drainage valve implantation, ciliary body photocoagulation surgery, lens surgery, etc. This lecture focuses on trabeculotomy, trabeculectomy, and combined trabeculotomy-trabeculectomy surgery.

Graves disease, also known as toxic diffuse goiter, is an autoimmune thyroid disease and a common cause of hyperthyroidism (hyperthyroidism). Graves' ophthalmopathy (GO) is the most common extrathyroid manifestation of Graves' disease. What we currently call thyroid associated ophthalmopathy (TAO) in clinical practice can occur in patients with normal thyroid function and Hashimoto's thyroiditis in addition to patients with Graves disease. The term GO used in this article only refers to TAO that occurs in Graves disease.