Volume 53 · Issue 04 · 2017

This issue focuses on the clinical and basic research of cataract and intraocular lens. Professor Bao Yongzhen, Department of Ophthalmology, Peking University People's Hospital, is responsible for the planning, composition and review of this issue.

With wide-spread performance of pars plana vitrectomy, cataract surgeries with no vitreous are getting more and more. This kind of surgery has great difference between individuals and it lacks randomized large sample clinical trial. Surgical strategy decision was basically relied on the surgeon's personal experience. We should fully aware the individual and common characteristics of no vitreous cataract surgery. Surgical time should be carefully decided. Complete ocular examination, evaluation, design of cataract surgical procedure and appropriate intra-ocular lens selection are needed. We must pay highly attention on the cataract surgery of no vitreous eyes.(Chin J Ophthalmol, 2017, 53: 241-243)

The occurrence of multifocal intraocular lens (MIOL) is known as an important period in the development of cataract surgery, which can provide a simultaneous vision without the use of spectacles or contact lenses. However, in the current stage, MIOL implantation may also lead to decreased visual acuity and increased risk of photic phenomena, thus in some instance a second procedure to exchange the MIOL is necessary. Optimizing visual outcomes of MIOL implantation and controlling adverse effects has become the focus for ophthalmologists. In the future, a more remarkable, flexible and high cost-effective intraocular lens (IOL), which can mimic human natural crystalline lens, should emerge. (Chin J Ophthalmol, 2017, 53: 244-248)

Trabeculectomy is the most important surgical method in the treatment of glaucoma. Postoperative complications were mainly related to the tightness of scleral flap suture. If the suture is loose, the filtration volume will be large and the intraocular pressure reduction effect will be good, but the incidence of complications such as shallow anterior chamber, low intraocular pressure, anterior chamber hemorrhage, choroidal leakage and hypotensive maculopathy after operation will be high. If the suture is tight, the filtration volume will be small. Although there are few early postoperative complications, the aqueous humor outflow resistance will be large, and the filtration tract will be easily scarred, resulting in operation failure. How to regulate postoperative filtration and reduce the occurrence of postoperative scarring has become the key point of success of trabeculectomy.

The occurrence of glaucoma is closely related to the pressure gradient of intraocular pressure and intracranial pressure^[1,2,3]。 At present, the detection methods of intracranial pressure are mainly invasive, and are prone to complications such as bleeding and infection. Therefore, it is of great significance to find a non-invasive and accurate method to monitor intracranial pressure in the diagnosis and treatment of glaucoma. Noninvasive measurement of intracranial pressure and transsieve pressure gradient based on MRI has been used in clinical practice^[4]Among them, the method with the diameter of the optic nerve subarachnoid space as the main parameter has attracted much attention and has potential clinical application value^[5]。

To discuss the correlation between axial length and corneal curvature and corneal spherical aberration in a group of cataract patients with axial length greater than 24 mm.

Retrospective case series. This study comprised 117 (234 eyes) age-related cataract patients. There were 51 men (43.59%) and 66 women (56.41%) with mean age of (69.0±8.7) years (range from 52.0 to 85.0 years). The average axial length was 27.6±1.8 (range from 24.2 to 31.9 mm). We devided them into four groups according to the axial length. A-scan was used to measure the axial length and Pentacam was used to get the corneal curvature and corneal spherical aberration of both anterior and posterior surface. kolmogorov-smirnov test was used to check the normal distribution. ANOVA test was used to compare eachcorneal parameter among different groups. Pearson correlation analysis was used to obtain the correlation of corneal parameters in groups.

There were correlations between the axial length and the anterior and posterior corneal curvature (r=-0.213, r=0.174, respectively, P<0.05). No correlation was found between the axial length and anterior or posterior corneal spherical aberration (r=-0.114, 0.055, respectively, P>0.05). Mean values of corneal anterior surface curvature were (45.26±1.60) D (group 1), (44.17±1.45) D (group 2), (44.40±1.99)D (group 3), and (44.53±1.69) D (group 4) respectively. Mean values of corneal posterior surface curvature were(-6.57±0.26)D (group 1), (-6.40±0.24)D (group 2), (-6.41±0.38)D (group 3), and (-6.43±0.26)D (group 4) respectively. There were significant difference of corneal anterior and posterior surface curvature among 4 groups (P=0.004, P=0.001). There was significant difference of corneal curvature of anterior surface in group 1 compared to group 2 and group 3(P<0.01, P=0.01). There was significant difference of curvature of posterior surface in group 1 compared to group 2 and group 3, respectively (P<0.01). Mean values of anterior surface corneal spherical aberration were (2.09±0.53) μm (group 1), (1.90±0.44) μm (group 2), (2.00±0.74) μm (group 3), and (1.78±0.52) μm (group 4) respectively. Mean values of posterior surface corneal spherical aberration were (2.69±1.15) μm (group 1), (2.46±1.16) μm (group 2), (2.92±2.51) μm (group 3), and (2.69±1.13) μm (group 4) respectively. No correlation was found in anterior and posterior surface corneal spherical aberration( P>0.05) among different groups.

The eye with a longer axial length have a flatter cornea. Cornea fails to compensate for axial length elongation when the axial length is longer than 28mm. The corneal spherical aberration varies among individuals, which suggests us to do the customized measurement before cataract surgery to make a decision on choosing the aspherical intraocular lens. (Chin J Ophthalmol, 2017, 53: 255-259)

To compare the accuracy of three different formulas for intraocular lens power calculation in high myopic eyes with cataract and analyze their influencial factors.

One hundred and three high myopic patients of cataract (103 eyes), with average age of 60.2±8.8 years old (39.0—77.0), including 45 male and 54 female and with axial length ≥ 26 mm were enrolled in this retrospective case-series study. All of them underwent routine ocular examination and IOLMastermeasurement preoperatively and then underwent phacoemulsification through temporal clear-corneal incision with implantation of HumanOptic posterior chamber Intraocular lens (IOL). All analyses were conducted using SPSS version 19.0. Repeated-measures analysis of variance was applied to compare the refractive results one month postoperatively with the predicted IOL powers calculated by SRK/T, Holladay 1, or Haigis formula before surgery. The differences were further compared based on different grouping of axial length (AXL), corneal curvature (K) and corneal astigmatism (CA). The accuracies of the three formulas were analyzed using Bland-Altman analyses and the possible error sources of each formula were analyzed using multiple regression model.

The majority of patients enrolled had hyperopic shift after cataract surgery. The mean errors (ME) of the three formulas were SRK/T: 0.70±0.89D, Holladay 1: (1.20±0.88) D and Haigis: (0.60±0.88) D; the mean absolute errors (MAE) of the three formulas were (0.81±0.79) D, (1.23±0.84) D and (0.76±0.74) D, respectively. Both ME and MAE of Holladay formula were significantly greater than the other two formulas (F=86.31, P<0.01). Besides, the proportion of patients having a prediction error within 0.50 D was lower in those using Holladay formula (20.4%, 21/103) than the other two (SRK/T: 38.8%, 40/103, χ ²=8.41, P<0.01, Haigis: 45.6%, 47/103, χ ²=14.84, P<0.01). Bland-Altman analyses showed that the accuracies of all the three formulas were acceptable in patients of cataract with high myopia in clinical practice. ME and MAE tended to be larger with longer axial length, larger corneal curvature and astigmatism of the patients in all three formulas. However, in eyes with axial length> 30 mm or corneal curvature ≤43.00 D, the MAE of Haigis formula was lower than that of SRK/T formula (F=63.26,63.94, both P<0.01). The prediction error of SRK/T formula was positively correlated with axial length and corneal astigmatism (F=33.97, r=0.66, β=0.48, P<0.01 and β=0.42, P<0.01), while for Holladay and Haigis formulas, in addition to the previous two factors, the errors were also positively correlated with mean corneal curvature (Holladay 1: F=31.26, r=0.72, AXL: β=0.52, P<0.01, K: β=0.20, P<0.05 and CA: β=0.37, P<0.01; Haigis: F=30.96, r=0.72, AXL: β=0.33, P<0.01, K: β=0.40, P<0.01 and CA: β=0.37, P<0.01).

In the selection of IOL formula for high myopic patients with cataract, Haigis or SRK/T would reduce the prediction error and serve as the more accurate formulas than Holladay 1. Haigis formula may be more accurate than SRK/T formula in case of AXL>30 mm or K≤43.00 D.(Chin J Ophthalmol, 2017, 53: 260-265)

To observe the long-term outcomes after congenital cataract surgery performed prior to 36 months of age.

A retrospective case study was conducted. Thirty-two cases (57 eyes) of congenital cataract were included from January 2004 to January 2012. All patients received intraocular lens (IOL) implantation with posterior continuous curvilinear capsulorhexies and anterior vitrectomy after cataract extraction and were followed up. At the last visit, the best corrected visual acuity (BCVA) was determined and postoperative complications were evaluated during follow-up with a longest time of 13 years. Non-normal distribution showed in median M (minimum and maximum). Data were analyzed by Kruskal Wallis single factor variance analysis and multiple comparison. The independent Mann-Witney U test was used to analyze non-normal distribution data.

There were thirty-two cases (57 eyes) of congenital cataract including 7 unilateral cases and 25 bilateral cases. The median age at cataract extraction was 6.0months; the median IOL implantation age was 28.0 months and the median duration of follow-up after cataract extraction was 67.0 months. The median postoperative BCVA was (LogMAR) 0.52. Unilateral and bilateral cataract postoperative BCVA difference had no statistical significance (U=107, P>0.05). Patients received cataract surgery in 2 to 4 months, the postoperative BCVA was better than in 5 to 8 months. The difference was statistical significance (H=-15.33, P<0.05). BCVA after IOL implantation before 24 months were significantly better than after 30 months. The difference had statistical significance(H=-20.61,-20.78, P<0.05). Postoperative complications were posterior capsular opacity (5 eyes; 8.77%), glaucoma (2 eyes; 3.51%), strabismus (17 eyes; 29.82%) and nystagmus (30 eyes; 52.63%).

Most infantile cataract surgeries performed prior to 36 mouths of life together with the implantation of IOL can achieve good visual acuity. No serious complications occurred. (Chin J Ophthalmol, 2017, 53: 266-273)

To compare visual quality and satisfaction after multifocal toric intraocular lens (Acrysof IQ Restor toric, ART) and monofocal toric intraocular lens implantation in patients.

It was a prospective nonrandomized Phase Ⅲ clinical trial. Patients with age-related cataract and corneal astigmatism were enrolled and accepted phacoemulsification combined with implantation of intraocular lens (IOL) in Henan Provincial Eye Hospital during March 2013 to December 2014. Fifty-six cases were divided into two groups according to which IOL they chose. ART group included 28 cases (3l eyes) aged from 41.0 to 72.0 years, with an average age of 61.5 years; toric group included 28 cases (33 eyes) aged from 42.0 to 75.0 years, with an average age of 63.5 years. Three months postoperatively, uncorrected distance visual acuity (UDVA) at 5, 70, 40 cm, corrected distance, intermediate, and near visual acuities, defocus curve, residual refractive astigmatism, rotational stability of the IOL, contrast sensitivity and patientsatisfaction were evaluated. All data were processed by statistic package deal SPSS 16.0. Postoperative visual acuity, residual astigmatism, IOL axial rotation and contrast sensitivity were compared by independent samples t test; preoperative and postoperative corneal astigmatism were compared by paired t-test; spectacle independency and halo incidence were processed by χ ² test; visual satisfaction score was analyzed by Mann-Whitney test.

At 3 months postoperatively, in ART group, UDVA was (0.04±0.05), UIVA was (0.24±0.15), UNVA was (0.20±0.24). While in Toric group, UDVA was (0.06±0.04), UIVA was (0.30±0.13), UNVA was (0.47±0.21). There was no significant difference in UDVA between two groups(t=0.79, P=0.433). But in ART group, UIVA and UNVA were markedly better than those in Toric group(t=2.74, P=0.008; t=3.45, P<0.01). Depth of focus was 5.50 D (+2.00—-3.50 D) in the ART group and 2.50 D (+1.00—-1.50 D) in the Toric group. Average postoperative residual astigmatism was (-0.45±0.41)D in ART group and (-0.41±0.32)D in the Toric group. There was no significant difference between two groups (t=1.05, P=0.304). Average IOL rotation test was (2.95°±1.34°) in the ART group and (2.75°±1.64°) in the Toric group. There was no significant difference between two groups (t=0.67, P=0.452). Spectacle independency was achieved by 85.7% of patients in the ART group and 32.1% in the Toric group. There was no signifcant difference in distant visual satisfaction scores between the two groups(Z=0.71, P>0.05), while the intermediate and near visual satisfaction scores were significantly different(Z=2.27, P<0.05;Z=2.60, P<0.05)

Both of the ART IOL and toric IOL can correct patients astigmatism. Implantation of ART IOL in patients with cataract and corneal astigmatism provided excellent distance, intermediate, and near visual outcomes. It provided better predictability of the refractive results, nice rotational stability, and good optical performance. At the same time, it improved the spectacle independency of cataract patients with astigmatism. (Chin J Ophthalmol, 2017, 53: 274-280)

To assess the effect of femtosecond laser-assisted anterior capsulotomy in intumescent white cataract surgery.

Retrospective case series study. One hundred and fifty cataract patients (150 eyes) from June 2014 to June 2015 in Wuhan Aier ophthalmology hospital were enrolled in this study. They were divided into three groups: 50 intumescent white cataract patients (50 eyes) in the study group were performed femtosecond laser-assisted capsulotomy (LenSx system) operation selectively. Fifty intumescent white cataract patients (50 eyes) underwent normal manual continuous circular capsulorhexis as the control group 1. Fifty other types cataract patients (50 eyes) underwent femtosecond laser-assisted capsulotomy as the control group 2. To observe the complications such as radial tear in anterior capsule, posterior capsule rupture and vitreous prolapse occurred during operations in each group respectively. The microscopic images of the free anterior capsule after dyeing were observed in the studygroup and the control group 2. Using the German company Oculus Pentacam three-dimensional anterior eye segment system to collect the Scheimplug images of each group at 1, 3, 6 months and 1 year after operation. The data were analyzed by SPSS19.0 software package. Complications during operations in all groups were compared with Fisher exact test. The eccentricity and tilt of IOL in each group were analyzed by single factor analysis of variance. The SNK-q test was used to compare the different follow-up time groups.

One hundred and fifty patients aged from 50 to 86 years old, including 72 male cases and 78 female cases. In study group, radial tear in anterior capsule occurred in 2 eyes (4%), adherent tongue-like capsule adhesion was found in 6 eyes (12%), incomplete capsulotomy button happened in 2 eyes (4%), and posterior capsule rupture and vitreous prolapse occurred in 1 eye (2%). In the control group 1, radial tear in anterior capsule occurred in 8 eyes (16%) and posterior capsule rupture and vitreous prolapse occurred in 3 eyes (6%). The cases number of radial tear in anterior capsule and posterior capsule rupture and vitreous prolapse in the study group was obviously lower than the control group 1. The difference was statistically significant (P<0.05). In the control group 2, all 50 eyes were successfully completed. The implantation was uneventful and the IOL was centered. And posterior capsular rupture and vitreous prolapse did not occur. The difference was statistically significant between the study group and the control group 2 (P<0.05). After 1 year follow-up, the study group and the control group 2 showed no significant IOL tilt and eccentricity. The eccentricity and tilt of IOL in horizontal and vertical direction in control group 1 were significantly higher than those in the study group (F was 2.31, 1.10, 2.78 and 2.90 respectively) and control group 2 (F was 2.50, 2.32, 2.56 and 2.18respectively). The difference was statistically significant (P<0.05).

Femtosecond laser-assisted anterior capsulotomy is accurate circle and center to avoid IOL eccentricity and tilt caused by capsular bag contraction asymmetrically after implantation, so as to ensure the long-term stability of the visual quality postoperatively. (Chin J Ophthalmol, 2017, 53: 281-287)

To explore the effect of the surgical removal of orbital deep cavernous hemangioma following the concept of minimal surgical invasion.

Retrospective case series study. Sixty-three cases with surgical removal of deep orbital cavernous hemangioma were collected in the Affiliated Eye Hospital of Nanchang University from May 2012 to August 2015. There were 29 males and 34 females. The age was from 17 to 69 years with mean age (45±11) years.The surgical methods the conjunctival approach orbital surgery, lateral orbital surgery, medial skin orbital surgery, lateral orbital conjunctiva conjunctival pathway and endoscopic nasal approach were chosen for different cases. The visual acuity, visual field and electrophysiological examination were analyzed before and after operation.

Sixty-three patients underwent complete surgically removal of the tumor. Among them, 32 cases were conducted by conjunctival approach, 24 cases had improved visual acuity, 5 cases had no change of visual acuity, 3 cases had decreased visual acuity. Seventeen cases performed with lateral open orbital surgery had improved visual acuity in 11 cases, no change in visual acuity in 3 cases and decreased visual acuity in 3 cases postoperatively. Six cases with approach of the medial orbital surgery had improved visual acuity in 4 cases, no change of visual acuity in 1 case and decreased visual acuity in 1 case postoperatively. Six cases with approach of outside open orbital surgery combined with medial conjunctival pathway had improved visual acuity in 4 cases, no change of visual acuity in 1 case and decreased visual acuity in 1 case postoperatively. Two cases performed with endoscopic nasal approach. One of them had normal visual function and no change after surgery. Another had impaired visual function pre-operatively and it came back to normal postoperatively.

With the concept of minimal surgical invasion, the choice of appropriate surgical approach can save patients with the greatest degree of visual function and even improve the visual function of the patients with orbital cavernous hemangioma. (Chin J Ophthalmol, 2017, 53: 288-293)

To evaluate the association of LOXL gene and XFS/XFG in Chinese population.

Experimental research. Fifty unrelated patients from shenzhen Eye Hospital and Beijing Tongren Hospital with exfoliation syndrome or exfoliation glaucoma and 100 control subjects were included. All the seven exons and the splicing region were amplified by polymerase chain reaction (PCR) and were directly sequenced. The comparison of allelic frequencies and genotype frequencies between case and control groups was performed using standard χ ² test.

Allelic association analysis showed that there were significant differences in the allelic distributions between the two groups for two loci in the LOXL gene: int6: 25975 C>A and ex7:26145 G>A. The frequency of A allele at int6: 25975 C>A was significantly higher in cases than in controls (χ²=92.31, P<0.01), OR=1.66(95%CI:1.42—1.96). The frequency of genotype CA was significantly higher in cases than in controls (χ²=109.09, P<0.01), OR=5.00 (95%CI: 2.87—8.70). The frequency of A allele of ex7: 26145 G>A was significantly higher in cases than in controls (χ²=79.25, P<0.01), OR=1.54 (95%CI: 1.33—1.78). The frequency of genotype GA was significantly higher in cases than in controls(χ²=91.30, P<0.01), OR=3.33 (95%CI: 2.18—5.09). Haplotype AA and AG were risk and haplotype CG was protective for the disease.

Two loci in the LOXL1 gene were found to be associated with XFS/XFG. Further study is needed to unravel the effect of LOXL1 on thedevelopment of the disease.(Chin J Ophthalmol, 2017, 53: 294-299)

To investigate and analyze the status of off-label drug use in department of ophthalmology of Beijing Tongren Hospital.

Cross-sectional study. Prescription evaluation, off-label drug use application and temporary medicine purchase application were collected from January 2013 to March 2015. The off-label use of medication in department of ophthalmology were filtered out and analyzed according to the category of medications, the category of the off-label use of medication and the strength of evidence for the off-label use of medication.

Thirty-seven items of off-label uses of medication were included in this study. The off-label use of medication focused on the indications (19 items, 51.4%) and route of administration (18 items, 48.6%) in this study. Nineteen category of medication were involved, which accounted for 1.3% (19/1 462) drugs in the hospital formulary.The top 2 category of medication were adrenocorticoid drugs (21.1%, 4/19) and antitumor drugs (21.1%, 4/19). There are evidence to support 37 items of off-label drug uses. 5 items (13.5%) of off-label drug uses were labeled uses approved by Food and Drug Administration. One item (2.7%) of off-label drug use was in accord with international guidelines. Twenty items (54.1%) of off-label drug uses were in accord with expert consensus. Eight off-labels were evaluated by Micromedex, while the other 78.4% (29 items) were not evaluated by Micromedex.

The off-label use of medications exists widely in department of ophthalmology, having its necessity and rationality. But we should pay attention to its standard management. (Chin J Ophthalmol, 2017, 53: 300-304)

To observe the early immunological rejection prevention effect of tacrolimus eye drops combined with glucocorticoids on fungal keratitis patients who received penetrating keratoplasty (PKP).

In a retrospective case series study, medical records of fungal keratitis patients who received PKP in Shandong Eye Institute from March 2013 to December 2015 were reviewed. Twenty-six patients (26 eyes) were given tacrolimus eye drops, and 24 patients (24 eyes) were given 1% cyclosporine A eye drops immediately after PKP. Two weeks after PKP, these patients were given low concentration of glucocorticoids if no fungal recurrence was found. Immune rejection, fungal recurrence, intraocular pressure, and drug irritation symptoms were monitored. Data were analyzed by chi-square test and independent t-test.

The average follow-up was 7 months (range, 3 to 12 months) postoperatively. The rejection rate was 15.3% in the tacrolimus group and 47.8% in the cyclosporine A group (χ²=5.510, P<0.05). One patient in the tacrolimus group and two patients in the cyclosporine A group suffered fungal recurrence. Two patients in the tacrolimus group and four patients in the cyclosporine A group had secondary glaucoma. The intraocular pressure was controlled. Three patients receiving tacrolimus eye drops and 13 patients receiving cyclosporine A eye drops had mild irritation symptoms.

Tacrolimus eye drops combined with low concentration of glucocorticoids can prevent the early immunological rejection after PKP for fungalkeratitis effectively and safely. (Chin J Ophthalmol, 2017, 53:305-310)

True microphthalmos refers to a rare eye disease in which the volume of the eyeball is significantly smaller than normal after the embryo cleft is closed, without other ocular deformities^[1,2]Although the disease is clinically rare, its harm is very serious. Patients often have increased intraocular pressure and are difficult to control, which is likely to lead to choroidal leakage, expulsive bleeding, retinal detachment, persistent shallow anterior chamber and malignant glaucoma during or after internal eye surgery. Complications such as malignant glaucoma, but cases of acute non-arteritic anterior ischemic optic neuropathy (NAION) after internal eye surgery are rarely reported in China. The author once treated a patient with typical true microphthalmos, uveal leakage in both eyes, and NAION after exudative retinal detachment in the right eye. The clinical diagnosis and treatment are analyzed and reported as follows.

The patient was a 65-year-old female. The visual acuity of the left eye suddenly decreased 20 days after cataract extraction and IOL implantation, and he was seen in the Department of Ophthalmology of Bethune First Hospital of Jilin University. Eye examination, left eye corrected visual acuity 0.3 (+7.0+4.0 DC ×180°); The conjunctiva was not obviously congested, the cornea was transparent, the intraocular pressure was normal, and no IOL was seen in the pupil area. B-ultrasound examination: strong linear anterior retinal echo in the posterior pole of the left eye. Retcam-Ⅱ examination: IOL shedding can be seen in the dilated pupil of the left eye, located at the posterior pole of the fundus, moving with body position; No obvious abnormalities were observed in the optic disc, retina and blood vessels (Quintessence Picture 1）。 Clinical diagnosis: Left eye cataract extraction after IOL implantation; IOL dislocation in left eye.

Alzheimer disease (AD) is a progressive neurodegenerative disease and is a leading cause of dementia among elders. In the early phase of AD, even if neuropathological changes presented, but little to none clinical symptoms were found. Therefore, it is difficult to diagnose AD in the beginning of the disease. It is vital to find a noninvasive way for both diagnose and prognosis of AD. Studies have found that β-amyloid (Aβ) works as a connection between AD and cataract. This review will discuss AD and its associated markers which may be present in the lens and cataract related AD to provide more basis for early diagnosis of AD. (Chin J Ophthalmol, 2017, 53: 314-316)

Vogt-Koyanagi-Harada disease(VKH) is a bilateral, granulomatous panuveitis associated with central nervous system, auditory, and integumentary manifestations. Clinically, VKH usually responds well to early aggressive glucocorticosteroid treatment and may be cured without any clinically significant sequelae. Some patients, however, may enter the chronic recurrent phase, which may result in marked loss of vision due to complications such as complicated cataract, secondary glaucoma and maculopathy. Recurrent VKH is mainly characterized by anterior uveitis associated with thickening of the choroid. Initial poor visual acuity, severe anterior chamber reaction, choroidal folds,rapid tapering of systemic corticosteroids or inadequate duration of treatment, and development of extraocular manifestations may be risk factors of disease recurrence. Prolonged glucocorticosteroid treatment has been suggested as effective strategy for recurrence of VKH. The positive effects of other immunosuppressive agents and biologic agents on treatment of chronic recurrent and refractory VKH have been gradually recognized by the uveitis community. (Chin J Ophthalmol, 2017, 53: 317-320)