Volume 53 · Issue 12 · 2017

This issue focuses on strabismus, amblyopia and pediatric ophthalmology research. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Kang Xiaoli.

Superior oblique palsy (SOP) has many anatomic variations, and the accompanied paralysis generalization could stimulate the secondary changes of other extra-ocular muscles. Therefore, the clinical manifestations of SOP can be various, and the surgical design is complicated and changeable. It is necessary to understand the clinical development, stages and types of SOP correctly, and to take into account the developmental characteristics of the superior oblique muscle and select the individualized treatment plan. In this article, the SOP manifestations, imaging features, clinical examination and personalized treatment options are discussed, in order to provide some reasonable treatment options for SOP surgery. (Chin J Ophthalmol, 2017, 53: 881-884)

Amblyopia is a common eye disease with a high prevalence in clinical practice of pediatric ophthalmology and strabismus. The primary treatment strategy for amblyopia is precise correction of refractive errors and patching of the dominant eye. The application of patching has a history of more than 200 years, and now is still the most effective method for treatment of amblyopia. Similar to the principle of traditional patching, atropine penalization has been testified that it can be used as an initial treatment for amblyopia with similar therapeutic effects as patching. In the past decade, binocular treatment has been proposed as a strategy for the treatment of amblyopia. Successively, different kinds of binocular treatment methods were reported by the researchers. This article systematically reviews all these methods reported in the recent years and their therapeutic effects. Most results about the therapeutic effect of binocular treatment are from the designers of the studies themselves, but in recent 2 years the results from monocenter or multicenter randomized controlled clinical trials to compare the therapeutic effects of binocular treatment and patching were reported. We hope to help colleagues have a comprehensive and objective understanding of the research progress on binocular treatment for amblyopia and thus keep a cool head on the question of whether binocular treatment could be a substitute for patching. (Chin J Ophthalmol, 2017, 53: 885-889)

1. The purpose, significance and necessity of diabetic retinopathy (DR) screening

To investigate clinical features and the long-term surgery results of Möbius syndrome patients.

This investigation presents a retrospective study of Möbius syndrome in 7 children we found since 2009. All 7 patients had MRI scan, ocular alignment in primary position, the limitation of versions and ductions and forced duction under general anesthesia. Early surgery is done to the 7 esotropia children. The pre-operative and post-operative outcomes, including the ocular alignment, deviation measurements and ocular rotations, were evaluated and compared.

MRI showed absence of uni- or bilateral CN6 and CN7 in all 7 patients. All 7 patients underwent extra large recession of medial rectus at the first surgery, (6.17±1.47) mm/eye. Variation of ocular deviation in the primary position within 6 months postoperatively in all patients, demonstrating that strabismus surgical stabilization needs time. Three patients with esotropia deviation≥40° preoperative were under corrected and needed the secondary operations. The average deviation in the primary position was +35.00°±16.58° before surgery and +2.14°±5.67° after surgery(t=6.040, P<0.01). The abduction in affected eye is limited both pre and postoperatively and a smaller limitation of adduction after surgery.

Möbius syndrome has been classified to congenital cranial dysinnervation disorders (CCDDs). We recommend MR recession as the first surgical choice because of the lack of abduction ability. Longterm surgical results were considered satisfactory, improving patient self-esteem and the parent satisfaction. (Chin J Ophthalmol, 2017, 53: 897-902)

To investigate the efficacy of Knapp procedure and modified Knapp procedure with Foster suture in the treatment of double elevator palsy(DEP).

Retrospective study. Twenty-two patients with congenital DEP were underwent Knapp procedure (n=15) and modified Knapp procedure(n=7). The clinical data were retrospectively analyzed, including the preoperative and postoperative vertical deviation in the primary position, ocular motility, and binocular vision.

The average vertical deviation in the primary position was (34.7±8.6) prism diopters(PD) before surgery and (6.5±6.5) PD after surgery (t=30.41, P=0.00) in the group underwent Knapp procedure. The mean preoperative and postoperative deviations of the group underwent modified procedure were respectively (38.6±14.6) PD and (5.7±9.3)PD (t=15.33, P=0.00). The mean corrected vertical deviation of the latter (32.8±5.7) PD was greater than that of the former (28.1±3.6) PD(t=-2.39, P=0.03). The mean improved upgaze in the modified group (2.6±0.5) was more obvious than that in the Knapp group (1.9±0.6) (t=2.41, P=0.02). There is no significant difference in the surgical effect on downgaze between two groups (U=43.00, P=0.54). Seven patients having binocular vision with abnormal head posture (AHP) before surgery obtained binocular single vision in the primary position and reading position after operations. AHP disappeared or reduced to less than 5°. The surgical outcomes were satisfied in 72.7% patients. But the patients with ≥40 PD preoperative vertical deviation were under-corrected and needed the further operations.

Knapp procedure and modified Knapp procedure with Foster suture were the efficient procedures for treatment of DEP without restriction of ipsilateral inferior rectus. Both procedures can obviously correct the vertical deviation and improve upgaze without remarkable limitation of downgaze, which is good to obtain the binocular single vision in the primary and reading position. The modified procedure has more powerful effect on the corrected vertical deviation and improved upgaze. (Chin J Ophthalmol, 2017, 53: 903-907)

To investigate the clinical features and surgical outcomes of patients with acute acquired concomitant esotropia (AACE) type Ⅱ(AACE-Ⅱ) and type Ⅲ (AACE-Ⅲ).

Retrospective case series analysis. Medical records of consecutive patients who underwent strabismus surgery for AACE-Ⅱ and AACE-Ⅲ in Shandong Provincial Hospital affiliated to Shandong University between January 2011 and June 2016 with a minimum follow-up time of 3 months were collected. Each patient underwent a complete ophthalmological and orthoptic examination to exclude esotropia resulting from other reasons, and a systemic assessment to exclude AACE related to intracranial and systemic diseases. Surgical procedures were determined according to the esodeviations measured at distance and near and the different dominant eye of patients. A successful surgical alignment was defined as the distant and near deviation in the primary gaze within 8 prism diopters (PD) of orthophoria and no diplopia.

Twenty-nine patients were enrolled in this study, including 17 males and 12 females. The mean age of the patients was 22.14±15.13 years (range, 5-63 years). The median corrected visual acuity (LogMAR) of patients with AACE-Ⅱwas 0 (range, 0.22 to 0), and that of patients with AACE-Ⅲ was 0 (range, 0.10 to 0). The median esodeviation of patients with AACE-Ⅱ at distance was 35 PD (range, 10 to 55 PD), and that at near was 35 PD (range, 20 to 60 PD). The median esodeviation of patients with AACE-Ⅲ at distance was 30 PD (range, 12 to 50 PD), and that at near was 30 PD (range, 6 to 50 PD). When tested with the red filter test preoperatively, all the patients had an uncrossed horizontal diplopia with the same distance in left and right lateral fixations. With a mean follow-up time of 12.0±12.6 months, of all the 29 patients, 24 patients (83%) achieved successful surgical alignment after one surgery, and 5 patients (17%) were undercorrected or had recurrence, in whom 4 were successfully aligned after repeated surgery (performed at a mean of 3.5 months after the first surgery) and 1 was treated with the Fresnel press-on prism. At the last follow-up, of all the 28 patients successfully aligned, 20 (71%) regained bifoveal fusion, 8 (29%) regained peripheral fusion, 17 (61%) regained normal stereopsis (stereoacuity ≤60"), and 11 regained a certain degree of stereopsis (stereoacuity 80"-400"). The constituent ratio of biocular central fusion and peripheral fusion in patients with AACE-Ⅱ had no significant difference from patients with AACE-Ⅲ (χ²=0.235, P>0.05), and the constituent ratio of central stereopsis, macular stereopsis, and peripheral stereopsis in patients with AACE-Ⅱ had no significant difference from patients with AACE-Ⅲ (χ²=0.762, P>0.05).

All patients exhibited the typical features of AACE, which included an acute onset of diplopia and comitant esotropia, a wide range of onset age of the patients, normal corrected visual acuity and ocular movements, a mean moderate level of esodeviation with a wide range, and a good binocular potential. According to the esodeviations measured at distance and near and the different dominant eye of patients, good oculomotor alignment and perceptual outcomes may be obtained in patients with AACE-Ⅱand AACE-Ⅲ. (Chin J Ophthalmol, 2017, 53: 908-916)

Strabismus with diplopia is the main orbital complication of functional endoscopic sinus surgery (FESS). This study was to analyze clinical findings, treatment and outcomes of such cases.

Retrospective case series. Twenty-three cases were divided into 3 groups based on the disease severity: group A, partial transection of the medial rectus muscle, group B, complete transection of the medical rectus, group C, transection of the medial rectus combined with the other orbital injuries. Complete ophthalmology examinations, including eye alignment, eye motility, force duction test, force generation test, general eye exam, and medical imaging (orbital CT or MRI), were performed for each case. The treatment included botulinum toxin (Botox) injection to the lateral rectus muscle, transposition of the vertical rectus muscle, and orbital surgery if needed.

In group A with Botox injection, all the cases achieved single vision in primary position, but still remained some adduction weakness. In group B treated by vertical transposition surgery combined with Botox, 22% of the cases got single vision in primary gaze. In group C, even with more efforts of treatment, the cases with orbital injury can only get cosmetic improvement, and diplopia and adduction dysfunction were found in most cases.

Due to the variety of the complications of FESS, force duction test is a crucial exam to detect the direction and severity of synechia in the orbit, which will give solid information to surgery approach as well as prognosis. Botox injection at early stage will minimize the contraction of antagonist lateral rectus, helping to postpone the transposition surgery which may cause anterior segment ischemia when performed right after the medial rectus transection injury. Botox may even reduce the synechia by minimizing the scarring process. Partial vertical rectus transposition combined with muscle resection may effectively correct the eye misalignment in primary gaze and improve eye motility. The prognosis of FESS induced orbital complications is quite related with the severity of the injury. Botox combined with surgery may help medial rectus transection cases to achieve single vision in primary gaze, but when there is any other orbital injury, treatment may only improve cosmetic appearance. (Chin J Ophthalmol, 2017, 53: 917-923)

To evaluate the effects of different surgical methods and postoperative eye positions on the quality of life of children with intermittent exotropia (IXT) and their parents 3 months following strabismus surgery.

Clinical observation. One-hundred and eighty children aged 2 to 17 years with IXT who received surgical treatment were recruited. One parent of each child was investigated by using 2 kinds of the Chinese version of the Intermittent Exotropia Questionnaires (CIXTQ) within 1 weeks before and at 3 months after surgery: the parent proxy scale (for parents to assess children's health related quality of life (HRQoL)) and the parent scale (containing functional, psychosocial and surgery subscales; for parents to assess their HRQoL). One hundred and eighty children were divided into different groups according to the surgical. Methods Monocular surgery group, binocular surgery group and eye position after 3 months: undercorrection group, successful group, overcorrection group, to explore: (1) the change of scores before and after surgery. (2) the difference of score changes after surgery between monocular and binocular surgery groups. (3) the difference of score changes after surgery between different postoperative eye position groups.

Significant improvement in median scores was seen from pre-operation to 3months post-operatively for all the proxy scale (t=-9.585, P<0.001), the functional (t=-11.361, P<0.001), psychosocial (t=-10.856, P<0.001) and surgery subscale (t=-11.622, P< 0.001) of parent scale. The change values from pre-operation to 3months post-operatively were not significantly different between monocular and binocular surgery groups for all the proxy scale (t=0.242, P=0.330), the functional (t=0.462, P=0.050), psychosocial (t=0.781, P=0.582) and surgery subscale (t=0.009, P=0.355) of parent scale, but significantly different between undercorrection, successful and overcorrection groups for the proxy scale (F=21.527, P<0.001), the functional (F=54.236, P<0.001), psychosocial (F=41.784, P<0.001) and surgery subscale (F=31.943, P<0.001). The scores of proxy scale and 3 parent subscales were all significantly improved (t=-13.639 to -6.059, P<0.05) after operation in both the undercorrection and successful groups, while significantly decreased in the overcorrection group (t=1.350—4.391, P<0.05).

HRQoL can be improved significantly in both the undercorrection and successful groups, while decreased in the overcorrection group. (Chin J Ophthalmol, 2017, 53: 924-930)

To investigate the protection effects of the activation of NMDAR1(NMDA receptor 1)/ERK1/2 signal pathway on visual cortex nerve cells induced by levodopa in amblyopia rats.

SD rats of SPF grade, were randomly divided into for groups of 9, group A. Control, B. MD group, C. L-levodopa(20 mg·kg^-1)+MD group, D. H-levodopa (80 mg·kg^-1)+MD group, E. H-levodopa+MD+MK801 group, F. H-levodopa+MD+PD98059 group, G. MD+MK801 group, H. MD+PD98059 group, I. MD+DMSO group. Amblyopia rats were made by suture of the right eye. Levodopa was used to treatment amblyopia by gavage, and intervened by intracerebroventricular injection of MK801 and PD98059 respectively. The expression of NR1, p-ERK1/2, ERK1/2, NGF and c-FOS were detected by Western blotting. Nissl staining was used to detect morphological changes of neurons. Neuronal apoptosis was detected by TUNEL method, and detected the expression of Caspase-3, NGF and c-FOS by immunohistochemical staining. One/Two way Chi-square analysis was used for data analysis. LSD-t test was used as comparison between every two groups.

The morphology of Nissl bodies in neurons was complete and clear in A group, and the size of Nissl bodies got smaller, and caused karyopyknosis and loss of neurons in visual cortex of B group. Compared with A group, the apoptosis of visual cortical neurons(23.09±2.00 vs. 2.20±0.35, t=12.120, P=0.000) and the number of Caspase-3 postive cells (22.70±1.50 vs. 3.30±0.54, t=12.120, P=0.000)were significantly increased, the expression of NGF(0.31±0.04 vs. 0.74±0.09, t=7.674, P=0.000) and c-FOS(0.25±0.03 vs. 0.57±0.07, t=5.919, P=0.000) and the rats of NGF(8.30±0.82 vs. 35.18±2.01, t=12.37, P=0.0000) and c-FOS (10.84±1.02 vs. 35.68±2.55, t=9.056, P=0.0001) postive cell were decreased significantly in B group. After treatment with levodopa, the morphology of neurons recovered, the apoptosis of visual cortical neurons relieved, the expression of NR1(0.75±0.09 vs. 0.40±0.05, t=8.528, P=0.001) and p-ERK1/2(2.13±0.26 vs. 0.68±0.17, t=3.488, P=0.008) were increased significantly, and the rats of NGF (18.07±0.87 vs. 8.30±0.82, t=8.18, P=0.0000) and c-FOS (19.78±0.91 vs. 10.84±1.02, t=6.543, P=0.0001) postive cells were significantly increased. MK-801 or PD98059 intervention could effectively attenuate the effect of levodopa. It could effectively down-regulated the expression of NR1 (0.53±0.06 vs. 0.95±0.12, t=5.647, P=0.005) and p-ERK1/2(1.52±0.18 vs. 2.58±0.30, t=3.091, P=0.013) interference with MK801 or PD98059 in MD rats. MK-801 or PD98059 intervention further promote the Nissl body volume reduced, neurons karyopyknosis, the apoptosis of visual cortical neurons and Caspase-3 expression, and restrain the expression of NGF and c-FOS.

Levodopa played a protective role in visual cortex nerve cells of amblyopia rats at least partially through activation of NMDA-ERK1/2 signal pathway. (Chin J Ophthalmol, 2017, 53: 931-940)

To report the clinical results of pediatric penetrating keratoplasty (PKP) in patients under 3 years old with congenital corneal opacity.

Retrospective study. Sixteen eyes of 12 patients who were treated with PKP in Aier Eye Hospital Group from June 2009 to December 2016 were enrolled in this study. All the patients were diagnosed as congenital corneal opacities: 8 cases (11 eyes) with Peter's anomaly I, 2 cases (3 eyes) with sclerocornea, and 2 cases (2 eyes) with corneal dermoid tumor combined with iris synechia. Seven cases (7 eyes) were under 1 year old. Eight cases (10 eyes) could not follow the light. Only 1 case (2 eyes) received PKP with extracapsular cataract extraction, and the others only had PKP. Postoperative examinations were performed more frequently than in adults, and sometimes general anesthesia was needed.

The follow-up period was from 8 months to 6 years (33.17±22.60 months). The postoperative visual acuity improvement was found in all eyes from 1 week to 1 month after surgery except a 3-year-old patient with corneal dermoid tumor with serious esotropia. All the surgeries were successful without intraoperative complications. Graft rejection occurred in 4 cases (4 eyes). The graft of a 33-month-old patient became semitransparent. The grafts of 2 cases under 1 year old were clear after drug therapy. And the vision of a 3-year-old patient with Peter anomaly improved obviously, but immune rejection occurred 2 years after surgery. The second PKP was performed, but rejection occurred again. Secondary glaucoma was found in the other eye early after operation; anti-glaucoma surgery failed, and the graft became cloudy. Graft infection associated with loosened sutures was observed in one case (2 eyes) of sclerocornea, and the second PKP failed.

For the patients with congenital corneal opacities, there is often a noticeable visual improvement after PKP. Good postoperative care, appropriate amblyopia treatment and timely examination are the keys to success. (Chin J Ophthalmol, 2017, 53: 941-946)

The patient was a 55-year-old female. Due to red eye and foreign body sensation in his left eye for half a month, he went to another hospital on October 3, 2015. The patient had a history of diabetes mellitus for 10 years, had poor glycemic control, and fasting blood glucose>9 mmol/L. Physical examination revealed opacity, edema, neovascularization at the edge of the nasal cornea, and dusty deposits in the corneal endothelium. The initial diagnosis was "herpes simplex keratitis of the left eye", which was treated with antiviral and low-concentration glucocorticoid eye fluid. After treatment, the above symptoms did not improve.

The patient was a male, 30 years old. He went to the Department of Ophthalmology of Peking Union Medical College Hospital due to decreased visual acuity and visual deformation in his right eye for 1 week. Eye examination: visual acuity was 0.8 for the right eye and 1.2 for the left eye; IOP in both eyes normal; The external eyes of both eyes are normal, the cornea is transparent, the anterior chamber is clear, the pupil is round, and the lens is transparent; The vitreous body of both eyes is transparent, and the fundus of the right eye is shown inQuintessence Picture 1No abnormalities were observed in the left fundus. Clinical diagnosis: retinal neuroepithelial detachment in the right eye.

microRNA-184 (miR-184) is a small, non-coding, endogenic RNA molecule of 22 nucleotides in length. It is a highly conserved sequence throughout many different species. Multiple studies have demonstrated that miR-184 is an important factor in regulating gene expression at the post-transcriptional level. miR-184 plays vital roles in many biological processes, including development and differentiation in many tissues and organs. Meanwhile, the research on the physiological and pathological role of miR-184 in eyes draws more and more attention lately. Recent research indicates that miR-184 is highly expressed in the cornea and lens of mice. miR-184 plays crucial regulatory roles in several ocular diseases, such as neovascularization, keratoconus, endothelial dystrophy-iris hypoplasia-congenital cataract-stromal thinning syndrome, corneal squamous cell carcinoma, age-related macular degeneration and cataract. Here we summarize and discuss the recent findings of miR-184 in its gene structure, gene expression and regulation, biological function and its relevance with ocular diseases. (Chin J Ophthalmol, 2017, 53: 950-955)

Optical coherence tomography (OCT) is able to obtain the cross-sectional image of the fundus noninvasively and quickly. The cross-sectional image in vivo almost matches the histological section of the retina. OCT has become the most important imaging tool in ophthalmology. Based on the latest OCT technology, en face OCT is a new imaging technique that reveals the structure of retinal and choroidal sections approximately paralleled to the retina surface. Compared to the conventional OCT, en face OCT provides more comprehensive information and makes more accurate diagnosis and assessment of the prognosis. En face OCT is widely used in ocular fundus diseases, such as macular epiretinal membrane, macular hole, macular edema, age-related macular degeneration and retinal vascular disease, glaucoma and neuro-ophthalmology. This article reviews the related concepts, principles and clinical applications of en face OCT. (Chin J Ophthalmol, 2017, 53: 956-960)