Volume 53 · Issue 11 · 2017

This issue focuses on the research progress of cataract diagnosis and treatment. Professor Yao Ke is the responsible editorial committee responsible for the planning, composition and review of the key contents of this issue.

Surgical treatment of cataract is the emphasis of prevention of blindness in China. In the past ten years, cataract prevention work has made great strides. However, the cataract surgery rate (CSR) in one million people is still far away from the developed countries, and not enough to eliminate the blindness of cataract in our country. The CSR is related to many factors. In this article, the issue of the CSR increase is commented from four aspects, including improving the quantity and quality of cataract surgery, increasing the allocation of ophthalmic resources to primary hospitals, strengthening the cooperation between the urban and backward areas in ophthalmology, and the economic factors. It is hoped that our ophthalmic practitioners pay more attention to the prevention of blindness, and the quantity and quality of cataract surgery could be increased. (Chin J Ophthalmol, 2017, 53: 801-804)

Endophthalmitis is one of the most serious complications of cataract surgery. The surgeons try to reduce the incidence of endophthalmitis. In order to prevent postoperative infection, irrigation of the conjunctival sac with povidone iodine and injection of antibiotics into the anterior chamber before the end of the surgery are used. Although there are a lot of reports about the concentration, mode and duration of povidone iodine application, there is no consensus. There are many options for antibiotics, including cefuroxime, vancomycin and moxifloxacin. Side effects of using povidone iodine and antibiotics have also been reported. An aseptic surgical mask plays an important role in isolating bacteria for prevention of infection. However, whether it could completely isolate bacteria can not be determined. In this article, several issues concerning the prevention of infection after cataract surgery are discussed. We hope that there will be a multi-center and large-sample research to assist in drawing up operating specifications. (Chin J Ophthalmol, 2017, 53: 805-809)

In order to standardize the anti-infection process of cataract perioperative period and the treatment process of infectious endophthalmitis after cataract extraction surgery in China, the Cataract and Intraocular Lens Group of Ophthalmology Branch of Chinese Medical Association successively published "Expert Consensus on the Treatment of Acute Bacterial Endophthalmitis after Cataract Surgery in China (2010)" in the Chinese Journal of Ophthalmology^[1]and "Expert Recommendations on Standardization of Preventive Measures for Cataract Infection in Perioperative Period (2013)"^[2]。 Expert consensus and expert suggestions were welcomed by clinicians at all levels, and promoted the standardized prevention and treatment of endophthalmitis after cataract extraction surgery in hospitals at all levels. However, there is still a big gap in the medical level of hospitals at all levels in China. The incidence rate of acute infectious endophthalmitis after cataract extraction in large ophthalmology institutions in China is 0.033%^[3]While the incidence of acute infectious endophthalmitis after cataract extraction surgery in small and medium-sized ophthalmology institutions is as high as 0.11%^[4]It is more than three times the incidence rate of large ophthalmology institutions in China. According to related research reports, the incidence rate of infectious endophthalmitis after cataract extraction is 0.012% ~0.053% in developed countries^[5,6,7,8]There is still a gap between China's overall level and it. The level of prevention and treatment of endophthalmitis after cataract extraction in China needs to be further improved. Following the first promulgation of guidelines for the prevention and treatment of endophthalmitis after Cataract extraction surgery in 2007, the European Society of Cataract and Refractive Surgeons (ESCRS) further revised the prevention and treatment guidelines in 2013, and put forward new guidelines on the key and details of prevention and treatment^[9]。 Combined with the 2013 ESCRS guidelines and the latest international research results, the Cataract and Intraocular Lens Group of Ophthalmology Branch of Chinese Medical Association revised the principles and details of prevention and treatment of infectious endophthalmitis after cataract extraction in China after careful, comprehensive and sufficient discussion according to the current situation of intraocular infection after cataract extraction in China and the actual medical situation in China, for the reference of clinicians.

To describe the feasibility of individual IOL implantation guided by corneal Q value and observe patients postoperative visual quality under different residual spherical aberration.

Prospective study. One hundred and twenty cases (171 eyes)cataract patients in our hospital were selected for the individual implantation of intraocular lens guided by corneal Q value which obtained by Oberscan before operation. Based on spherical aberration calculated by corneal Q value, choose appropriate IOL personalitily to make postoperative whole eye surface aberration +0.1 μm (group of positive spherical aberration) or 0 μm (group of zero spherical aberration). To observe spherical aberration, the uncorrected visual acuity, best corrected visual acuity and contrast sensitivity (including no glare and glare) 1 month and 3 months after surgery. Dates were analyzed with one-way ANOVA and LSD method for multiple comparisons between groups.

Spherical aberration after operation: group of positive spherical aberration: (0.111±0.023)μm, group of zero spherical aberration: (0.020±0.019)μm, control group: (0.299±0.073)μm. At 1 months and 3 months, uncorrected visual acuity, and corrected visual acuity were not statistically different between groups (t=0.474, 1.607, P>0.05). Contrast sensitivity (including no glare and glare) 3 months after surgery display: at whole space frequency, the group of positive spherical aberration(reserved +0.1 μm spherical aberration) contrast sensitivity is better than that of the group of zero spherical aberration(reserved 0.0 μm spherical aberration) and the control group( F=32.885, 35.493, 19.969, 20.572,P<0.05). The group of zero spherical aberration is better than control group at space frequency of 3 and 6 c/d(F=6.506, 7.521, P<0.05).

The individual implantation of introcular lens guided by corneal Q value is feasible. + 0.1 μm spherical aberration after surgery can achieve the best contrast sensitivity and stereo vision, and 0 spherical aberration after surgery can improve the postoperative contrast sensitivity and stereo vision than a traditional method, but its advantage mainly embodies in the middle and lower spatial frequency. (Chin J Ophthalmol, 2017, 53: 814-820)

To analyze the clinical manifestations, surgical approaches and postoperative prognosis for the cases of congenital aniridia combined with cataract.

In this retrospective case series, 26 patients diagnosed with congenital aniridia combined with cataract were collected from Zhongshan Ophthalmic Center from February 2002 to August 2016. The Clinical data were collected to analyze the clinical features, surgical approaches and postoperative prognosis. T-test was used for statistical analysis.

Twenty-six bilateral congenital aniridia patients were included in the case series, with 50% male cases. The average age for the first visit was (8.72±8.06) years old. Hereditary patients constitutes 30.8% (8/26) of the total number. The proportions for bilateral and unilateral cataracts were 88.5% (23/26) and 11.5% (3/26) respectively, and 49 eyes suffering from both congenital aniridia and cataract were therefore included in the final analysis. The most common morphology cataract subtypes were lamellar cataract (24.5%, 12/49), posterior subcapsular cataract (22.4%, 11/49), and total cataract (18.4%,9/49). The observed ocular comorbidities included nystagmus (36.7%, 18/49), vitreous opacity (28.6%, 14/49), foveal hypoplasia (20.4%, 10/49), ametropia (12.2%, 6/49), exotropia (12.2%, 6/49), congenital glaucoma (12.2%, 6/49), esotropia (4.1%, 2/49), congenital ptosis (4.1%, 2/49), lens ectopia (4.1%, 2/49), scleral staphyloma (2.0%, 1/49) and pigmentary degeneration of retina (2.0%, 1/49). 30.6% (15/49) eyes were performed the cataract extraction surgery. The percentage of postoperative best corrected visual acuity (BCVA) for ≥0.1 and ≥0.3 were 93.3% (14/15) and 20.0% (3/15) respectively. Evaluated ocular pressure (33.3%, 5/15), severe posterior capsular opacification (PCO) (13.3%, 2/15) and choroidal hemorrhage combined with choroidal detachment (6.7%, 1/15) were detected as the postoperative complications. Followed by cataract extraction, 80.0% (12/15) eyes were sequentially performed the intraocular lens implantation, while, 20.0% (3/12) eyes remained aphakia due to ocular comorbidities.

Congenital aniridia combined with cataract are rare diseases, calling for the precious retrospective researches. This disorder tended to affect both eyes and occurred hereditary. The clinical courses of the cases presented progressive features. Ocular comorbidities were the crucial factors to influence the surgical approaches and postoperative prognosis. (Chin J Ophthalmol, 2017, 53: 821-827)

To investigate the distribution of anterior corneal high-order aberrations (HOAs) in Chinese eyes with cataract and their correlations with age and axial length for the choice of aspheric intraocular lens.

Retrospective study. Six hundred twenty-five Chinese patients with cataract[male: 260, female: 365, age: (71.2±8.0) years] were categorized into 4 groups in accordance with their axial lengths. Anterior corneal HOAs in the central 6- mm zone was measured with an iTrace wavefront analyzer. The correlations between axial length, age and total HOAs, spherical aberration, trefoil aberration, and coma aberration were analyzed using Spearman analysis. The differences in total HOAs, spherical aberration, trefoil aberration, and coma aberration among 4 groups were assessed using the Krusal-Wallis H test.

Anterior corneal HOAs showed the nonnormal distribution. The median of corneal total HOAs was 0.666 μm (range 0.246 to 4.115 μm). Medians of coma aberration, spherical aberration and trefoil aberration were 0.313 μm (range 0.015 to 1.879 μm), 0.275 μm (range 0.005 to 1.797 μm) and 0.341 μm (range 0.019 to 2.319 μm), respectively. A significant negative correlation was found between axial length and total HOAs, coma aberration, spherical aberration, trefoil aberration ( r=-0.230, -0.235, -0.143, -0.153, P<0.05). But no correlation was found between age and them (r=0.056, 0.045, 0.065, 0.022, P>0.05). Differences in total HOAs, coma aberration, spherical aberration, trefoil aberration were found among various axial groups (H=21.953, 20.665, 15.368, 16.881, P<0.05).

Anterior corneal HOAs varied greatly among the majority of the patients. A significant negative correlation was found between axial length and anterior corneal HOAs, but no correlation was found between age and them. (Chin J Ophthalmol, 2017, 53: 828-834)

This study was to observe the effect of SMP-30 on ultraviolet B (UVB)-induced apoptosis of human lens epithelial cells(HLE-B3) in vitro.

Experimental study. The SMP-30 cDNA was amplified by PCR and inserted into the pRFP-N1 expressing vector which had been double digested by XhoI/HindIII. HLE-B3 cells were cultured and divided into three groups: normal group, pRFP-N1 vector plasmid group and pRFP-N1-SMP-30 plasmid group (SMP-30). Then cells were exposed to UVB and the survival rate of cells was detected by MTT assay. The effects of SMP-30 on UVB-induced HLE-B3 apoptosis were measured by the Cell Death Detection ELISA kit. Meanwhile, the influence of SMP-30 on UVB-induced apoptosis-relative protein expression in HLE-B3 cells was tested by Western blots. Moreover, 2′, 7′-Dichlorofluorescin diacetate staining was performed to monitor the protective effects of SMP-30 on UVB-induced HLE-B3 reactive oxygen species(ROS). One-way analysis of variance combined with Dunnett's statistical method were performed to analyze the data.

The full length of PSF cDNA fragment was correctly inserted into the pRFP-N1 vector, which was confirmed by DNA sequencing. The SMP-30 fragment was inserted to the plasmid pRFP-N1 correctly, which was also confirmed by DNA sequencing. The PRFP-N1-SMP-30 plasmid was transfected into HLE-B3 successfully. SMP-30 expression was up-regulated in the transfection group, compared with the control group. Data showed that the survival rate of HLE-B3 after the pRFP-N1-SMP-30 plasmid transfection was 0.90±0.14, while the apoptosis rate was 0.43±0.06 and the ROS production was 0.52±0.02, showing significant difference in comparison with the vector plasmid group and the normal group(t=5.830, 9.934, 12.19, P<0.05). In the meantime, SMP-30 overexpression down-regulated the levels of Bax and cleav-caspase-3, but up-regulated the Bcl-2 and Pro-caspase-3 expression levels under UVB irradiation.

SMP-30 overexpression plays a protective role in UVB-induced apoptosis via regulating the expression of apoptosis-related proteins and inhibiting the production of ROS in HLE-B3 cells. (Chin J Ophthalmol, 2017, 53: 835-841)

To examine the features and values of ultrasonic diagnosis for retinal detachment in eyes with silicone oil tamponade (SOT).

A prospective study. A total of 257 eyes (257 patients) were filled with silicone oil between December 1, 2015 and August 1, 2016 in the Department of Ophthalmology at a hospital in Beijing. All of the patients underwent a color Doppler ultrasound examination in the supine and sitting positions a week prior to surgery. The pre-surgery conditions were compared with the subsequent observations during the surgery to analyze the features and values of ultrasonic diagnosis for retinal detachment in eyes with SOT.

Ultrasound manifestations of eyes with SOT included pseudo extension of the ocular axis and an arc-shaped echo between the eye wall and silicone oil. Diagnostic accuracy was 85.6% in the supine position and 93.8% in the sitting position.

Ultrasound diagnosis for retinal detachment in eyes with SOT manifests itself in certain patterns. Compared with the traditional ultrasound examination in the supine position, the sitting position examination can be used to further increase the diagnostic accuracy in the ultrasound diagnosis for retinal detachment in eyes with SOT, providing reliable evidence for clinical and differential diagnosis. (Chin J Ophthalmol, 2017, 53: 842-846)

To analysis, the clinical characteristics, refractive changes, and clinical treatment of interface fluid syndrome after laser lamellar corneal refractive surgery.

During Dec. 2010 to Apr. 2016. In total 6 cases(9 eyes), 3 cases were bilateral, 3 cases were unilateral. Five patients were male and 1 was female. The age of the patients ranged from 20 to 29 years was (24.83±4.02) years. Six cases(9 eyes)of IFS were diagnosed at our hospital. The history and complete ophthalmic examination that include Slit-lamp examination, Slit-lamp photography, refraction, corneal thickness measurement, corneal endothelial cell counting, IOP, anterior segment OCT(AS-OCT), exams were recorded.

Post-lasik Primary open angle glaucoma was 2 eyes in 1 patient. 1 patient(1 eye)was Posner-Schlossmann Syndrome and 1 patient(1 eye)was iritis after femtosecond laser. Post-small incision lenticule extraction by steroid drops induced elevated IOP were 5 eyes in 3 patients. Slit-lamp exam indicated edematous corneal flap or cap, lamellar haze, interface fluids accumulation. AS-OCT showed obvious interface dark area. The corneal flap or cap thickening and wrinkles, IOP change, diopter myopic shift, Corneal thickening.

IFS is a rare but serious complication after Laser lamellar corneal refractive surgery. The main causes are high intraocular pressure and/or dysfunction of corneal endothelium. For patients with high IOP after laser lamellar corneal refractive surgery, follow up should be observed closely. accurate diagnosis by OCT and corneal endothelial cell counting. Early diagnosis, accurate treatment, its prognosis is good. (Chin J Ophthalmol, 2017, 53: 847-854)

The child was a 12-year-old male. Mainly due to painless progressive visual loss in his right eye for 1 year, he went to the Department of Ophthalmology of Peking University First Hospital in August 2015. History of eye trauma denied. Ophthalmological examination: Right eye naked eye visual acuity manual/1 m, Jr7 invisible, light sensing 6 m, light localization normal, visual acuity correction not improved. Left eye naked eye vision 0.3, Jr1, plus-3.50 DS-4.00 DC x 180 to 0.6. Lens cortical debris can be seen in the anterior chamber and the pupil margin of the right eye, the lens is opaque, the lens cortex overflows, and the fundus is invisible (FIG. 1A,FIG. 1B,Figure 1C）。 The center of the anterior surface of the lens of the left eye is slightly convex into the anterior chamber (Figure 1D), and no abnormalities were observed in the fundus of the left eye. Ultrasound biomicroscopy showed that the right eye lens was structurally confused, and the left eye lens anterior surface central confinement was convex forward (Figure 2）。 The child was delivered naturally at term with no history of asphyxia or oxygen inhalation after birth. Hematuria, proteinuria, renal function damage and hearing loss were found in previous physical examination. Alport syndrome was diagnosed after transmission electron microscopy and immunofluorescence staining of renal tissue puncture.

The patient was a 58-year-old male. Due to progressive visual acuity loss in both eyes for 2 years and poor intraocular pressure control with two intraocular pressure lowering drugs (carteolol hydrochloride eye drops and brinzolamide eye drops), he went to Sun Yat-sen Ophthalmology Center of Sun Yat-sen University on August 5, 2015. Specialist examination: visual acuity 0.4 in the right eye and 0.1 in the left eye; IOP was 20 mmHg in the right eye (1 mmHg =0.133 kPa) and 21 mmHg in the left eye; External eye of both eyes (-), clear cornea, pigmented retrocorneal deposit (kp) (-), deep anterior chamber, planktonic pigment particles in anterior chamber (-), circular and centered pupil, 3 mm in diameter, pigment on pupil margin (-), opacity of lens (right cortex 2, nucleus 2, posterior capsule 1; left cortex 2, nucleus 2, posterior capsule 1), punctate opacity of vitreous body, pale color of optic discs in both eyes after mydriasis, C/D>0.9. Auxiliary examinations: (1) Gonioscopy: wide angle of the right eye, trabecular meshwork pigmentation grade II. The left eye was wide-angled throughout the circumference, and the trabecular meshwork pigmentation was grade 0 or I, which was sparsely light brown. (2) UBM examination: Anterior chamber depth: 2.54 mm in right eye and 2.67 mm in left eye, with open angles in both eyes. (3) OCT examination: diffuse thinning of retinal nerve fiber layer thickness in both eyes: 42 μ m in the center of the right eye, 60 μ m in the superior temporal, 29 μ m in the superior nose, 41 μ m in the inferior temporal, 50 μ m in the inferior nose, 33 μ m in the temporal side and 44 μ m in the nasal side; The left eye was 40 μ m central, 54 μ m supranasal, 66 μ m supratemporal, 46 μ m subnasal, 39 μ m subtemporal, 25 μ m nasal and 32 μ m temporal. (4) Visual field examination: central tubular visual field of both eyes. (5) Corneal thickness examination: 582 μ mm in right eye and 579 μ m in left eye. (6) Corneal endothelial cell density: 2 496.2 cells/mm in right eye²2 692.8/mm in left eye²。 (7) B-ultrasound examination: sound image of vitreous opacity in both eyes, sound image of small depression of optic disc in both eyes. (8) A-ultrasound examination: the axial length of the eye is 23.88 mm in the right eye and 23.23 mm in the left eye.

The patient was a 77-year-old male. Due to painless visual loss in his left eye for 2 months, he was admitted to the Department of Ophthalmology of the First Affiliated Hospital of Suzhou University on May 9, 2016. Four months ago, phacoemulsification and IOL implantation were performed in our hospital due to senile cataract in the right eye, and recovered well after operation. A history of systemic disease and previous ocular disease is denied. No abnormalities were found on the whole body examination. Eye examination: the naked eye visual acuity of the left eye was 60 cm index in front of the eye, and there was no improvement in correction; The intraocular pressure (measured by non-contact tonometer) was 12.0 mmHg (1 mmHg =0.133 kPa), there was no redness, swelling, entropion and trichiasis in the eyelids, clear meibomian gland structure, no conjunctiva congestion and edema, senile ring was visible in the cornea, no corneal pannus was seen, superficial nodular gelatinous bulge was visible at 3:30 in the temporal side, with unclear boundaries, negative fluorescein sodium staining, no retrocorneal deposition, deep anterior chamber, clear aqueous humor, no aqueous humor flash, clear iris texture, round pupil, 3 mm in diameter, sensitive to light, opaque lens, no abnormalities in the fundus (Figure 1）。 OCT examination of the anterior segment of the left eye: slightly higher density nodules located under the corneal epithelium and before the Bowman layer (Figure 2）。 Corneal topography examination: highly irregular astigmatism of the cornea of the left eye (Figure 3）。 The naked eye visual acuity of the right eye was 0.6, the intraocular pressure was 14.0 mmHg, the cornea was transparent, the anterior chamber was deep, the iris texture was clear, the pupil was round, the pupil diameter was 3 mm, the response to light was sensitive, the IOL was in place, and no obvious abnormalities were observed. Clinical diagnosis: Salzmann's nodular degeneration (SND) in the left eye, senile cataract in both eyes, and cataract removal and IOL implantation in the right eye. Due to the patient's strong request for cataract extraction surgery, after full communication with the patient and his family, he underwent a keratectomy on the surface of the left eye on May 13, 2016. He wore a bandage lens after the surgery, and the tissue was removed during the surgery for pathological examination (Figure 4,Figure 5,Figure 6,Figure 7）。 Three weeks after surgery, phacoemulsification and IOL implantation were performed in the left eye. One month after surgery, the left eye naked eye visual acuity was 0.5.

The patient was a 28-year-old male. He went to the Department of Ophthalmology of the General Hospital of the People's Liberation Army because his left eye was blurred for 16 days after being injured by a badminton ball. No abnormalities were found on the whole body examination. Eye examination: the naked visual acuity of the right eye was 0.3 and the corrected visual acuity was 0.5; The naked eye visual acuity of the left eye was manual in front of the eye, and the corrected visual acuity was 0.3; IOP was 18 mmHg (1 mmHg =0.133 kPa) in the right eye and 34 mmHg in the left eye; The conjunctiva of both eyes was mildly congested, and the cornea of both eyes was transparent; The pupil of the left eye was moderately dilated, underrounded, approximately 4.0 mm in diameter, directly and indirectly unresponsive to light, and the lens was completely dislocated in the anterior chamber, in contact with the corneal endothelium (Quintessence Picture 1）； Fundus examination of both eyes showed no definite abnormalities. For Pentacam inspection, seeQuintessence Picture 2。 Admission diagnosis: traumatic total lens dislocation in left eye; Traumatic cataract of left eye; Secondary glaucoma of the left eye.

Postoperative glaucoma is one of the most common complications after congenital cataract surgery and an important cause of unsatisfactory long-term visual acuity rehabilitation. Recently, the diagnostic criteria of glaucoma after congenital cataract surgery have been gradually complemented; the measurement of intraocular pressure is improved and the follow-up is standardized. The risk factors of glaucoma after congenital cataract surgery include age at surgery, ocular abnormalities and central corneal thickness, some of which still remain controversial. The main treatment of postoperative glaucoma is surgery, while some patients need adjuvant medications in addition to surgery. (Chin J Ophthalmol, 2017, 53: 863-867)

Glaucoma is the second leading cause of blindness in the world next to cataract. Aging is a strong risk factor leading to elevated intraocular pressure (IOP). IOP is associated with aqueous humor circulation. Trabecular meshwork cells and Schlemm canal endothelial cells, which form the conventional outflow pathway, play an important role in maintaining the IOP. Cell senescence induces abnormalities of the aqueous humor dynamics, leading to elevated IOP. Trabecular meshwork cells cause increased intrinsic stiffness, autophagy dysfunction, abnormal expression of microRNA and mitochondrial dysfunction with senescence. The senescence of Schlemm canal endothelial cells decreases cell permeability and mechanotransduction and disrupts the endothelial nitric oxide synthase signaling pathway. The changes will increase aqueous humor outflow resistance and elevate IOP. This review discusses how cell senescence induces aqueous humor dynamics abnormalities and the relation with glaucoma. (Chin J Ophthalmol, 2017, 53: 868-873)

The incidence of neuromyelitis optica spectrum disorders (NMOSD) in the Asian population is much higher than in Europe and North America. Optic neuritis is the first sign of NMOSD for some people. Identification of aquaporin 4 antibody is a milestone in the research of NMOSD and has been included in the diagnosis standard of NMOSD, but about 20% to 30% of NMOSD patients is aquaporin 4 antibody-negative. With the cell-based assays, oligodendrocyte glycoprotein antibodies in demyelinating diseases of the central nervous system have aroused the attention of researchers. This article reviews the research history of oligodendrocyte glycoprotein antibodies in optic neuritis. (Chin J Ophthalmol, 2017, 53: 874-877)

The "30th Asia-Pacific Society of Cataract and Refractive Surgeons Annual Meeting and the 18th National Annual Conference on Cataract and Intraocular Lens" was co-sponsored by the Asia-Pacific Society of Cataract and Refractive Surgeons, Chinese Medical Association, Ophthalmology Branch of Chinese Medical Association and Cataract and Intraocular Lens Group of Ophthalmology Branch of Chinese Medical Association, and hosted by the Ophthalmology Center of the Second Affiliated Hospital of Zhejiang University School of Medicine. This conference was attended by more than 110 invited speakers, 2,800 registered representatives (more than 600 foreign representatives) and nearly 500 manufacturer representatives from Asia-Pacific, Europe and the United States.

Professor Zhang Wenhua, a well-known expert on keratopathy and external ophthalmology in China, a pioneer scholar of keratopathy and external ophthalmology, and a member of the editorial board of Chinese Journal of Ophthalmology, died in Beijing at 20: 45 on October 11, 2017 at the age of 81 due to ineffective treatment.