Volume 54 · Issue 06 · 2018

This issue focuses on the research progress of ocular surface diseases. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Huang Yifei.

Ocular chemical burns are common and serious ocular emergencies which require immediate and intensive evaluation and treatment. Loss of vision and disfigurement affect the victims, bringing great sufferings to themselves and their families. China is the biggest developing country in the world with a large number of such cases. The prevention of ocular chemical burns is emphasized in different aspects. After emergency treatment, proper care of chemical burns is started by control of inflammation with corticosteroids. Topical and systemic ascorbic acid supplement is important. Re-epithelialization is critical to stabilize the ocular surface and to prevent corneal ulceration and melting. The goal of treatment is mainly to restore the ocular structure and function. Neuroprotection is important during the treatment course for control of both glaucoma and inflammation. Prognosis depends on the degree of limbal, corneal and conjunctival involvement at the time of injury as well as the management. Medical treatments only or with combination of surgical procedures, including amniotic membrane transplantation, epithelial or limbal stem cell transplantation, tenonplasty, keratoplasty and keratoprosthesis, are according to the classification of ocular chemical burns and the phases. Further investigations should be done in the future in both prevention and management of ocular chemical burns in China. (Chin J Ophthalmol, 2018, 54: 401-405)

Dry eye has become the most common ocular surface disease in China's clinical ophthalmology. However, dry eye in children has not achieved enough attention. It lacks related information of basic data and diagnostic criteria, and there is no standard for the clinical diagnosis and treatment. As dry eye in children has its own characteristics, its diagnosis and treatment are not exactly the same as adults. In recent years, due to the popularization and widespread usage of electronic products, coupled with some systemic factors, the incidence of dry eye in children has risen rapidly. To this end, it is urgent to improve the level of clinical diagnosis and treatment of dry eye in children in China, to establish the relevant basic data, to strengthen the basic research, and to promote the prevention and treatment of dry eye in children.(Chin J Ophthalmol, 2018, 54: 406-408)

In China, the diagnostic criteria and treatment plan of allergic conjunctivitis have lacked a unified understanding for a long time. Most ophthalmologists only rely on personal clinical experience for diagnosis and treatment, and the clinical effect is difficult to guarantee. In recent years, the diagnosis and treatment technology of ophthalmology in China has developed rapidly, and the basic and clinical research on allergic conjunctivitis has been deepened. It is necessary to standardize the diagnosis and treatment of allergic conjunctivitis by ophthalmologists in China in time. To this end, the Keratology Group of Ophthalmology Branch of Chinese Medical Association organized experts in the field of keratopathy in China, focusing on the hot spots of basic and clinical research of allergic conjunctivitis, based on the research results of evidence-based medicine at home and abroad, referring to the practical experience of experts, and after full discussion, expert consensus was reached.

The 2017 dry eye workshop (DEWS) II of the International Tear Film and Ocular Surface Association (TFOS) is the most cutting-edge and authoritative medical professional consensus on dry eye in the world. On the basis of the first edition of DEWS (DEWSⅠ), TFOS organized more than 150 top experts and scholars in the field of dry eye from many countries, and it took two and a half years to complete the clinical consensus. DEWS II in 2017 recorded new insights in the dry eye field after the promulgation of DEWS I. This consensus comprehensively explains the pathogenesis, pathophysiology, diagnosis and treatment of dry eye, and is a brand-new interpretation and another improvement of the understanding of dry eye. In 2013, the Keratology Group of Ophthalmology Branch of Chinese Medical Association issued the "Expert Consensus on Clinical Diagnosis and Treatment of Dry Eye (2013)" according to the characteristics of dry eye in China^[1]The diagnostic criteria and treatment principles of dry eye in China were pointed out. However, because there are not many research reports on the pathophysiology of dry eye in China, and the research is not in-depth enough, the pathophysiology of dry eye is not involved in the consensus of dry eye in China. Compared with DEWS II in 2017, there is still a gap in this aspect in China. In order to improve and deepen the clinical understanding of the pathogenesis of dry eye in China, this paper interpreted DEWS Ⅱ according to the research progress of pathophysiology of dry eye, and focused on the research results in this field after the promulgation of DEWS Ⅰ.

"Chinese Journal of Ophthalmology" published the 12th issue of 2016 "Expert Consensus on the Application of Glucocorticoid Ophthalmic Preparations in the Treatment of Corneal and Ocular Surface Diseases in China (2016)"^[1](hereinafter referred to as the Hormone Consensus). This consensus introduces expert opinions on the application of hormonal ophthalmic preparations in the treatment of corneal and ocular surface diseases from several aspects, such as commonly used clinical glucocorticoids (hereinafter referred to as hormones) ophthalmic preparations, their classification, indications, adverse reactions, use principles, contraindications, and application in common corneal and ocular surface diseases, which is of great significance to clinical ophthalmologists to understand and use hormonal ophthalmic preparations correctly. Study the Hormone Consensus carefully, and have questions about the application of hormone ophthalmic preparations in laser corneal refractive surgery. The following questions and opinions are put forward to discuss and discuss with experts and colleagues.

Thank you very much to readers for putting forward their own views and opinions through the study and understanding of the Expert Consensus on the Application of Glucocorticoid Ophthalmic Preparations in the Treatment of Corneal and Ocular Surface Diseases in China (2016) (hereinafter referred to as the Hormone Consensus). The positive response to the Hormone Consensus helps everyone better understand the application of glucocorticoid (hereinafter referred to as hormone) ophthalmic preparations in the treatment of corneal and ocular surface diseases, which is of great positive significance. Please refer to some answers to the discussion questions.

To evaluate the therapeutic effect of corneal collagen cross-linking (CXL) with preserved corneal epithelial flap and isotonic riboflavin for treatment of keratoconus eyes with thin corneas.

Prospective case-control study. Twenty two eyes of 20 patients (16 males and 4 females, with age of 23.5±4.9), who have been diagnosed with progressive keratoeonus and the comeal stroma thickness of whom were less than 400μm (without the epithelium), were included in this study. Corneal collagen crosslinking was performed under preserved corneal epithelial flap (8.5mm), followed by instillation of 0.1% riboflavin and then UV irradiation. The corneal epithelial flap must be restored prior to the application of UVA irradiation. Visual acuity, corneal topography and endothelial cell count were evaluated at baseline and at 12 months follow-up. Data were analyzed using paired samplest test.

Corneal topography results of 12m before and after the therapy revealed the significant reductions of Kmax from (54.73±4.39)D to (53.46±3.85)D and Kmin from (48.97±3.72)D to (48.41±3.17)D, and also Km from (51.67±3.77) D to (50.77±3.28) D (Kmax: t=-3.138, P<0.05; Kmin: t=-2.170, P<0.05; Km: t=-3.532, P<0.05). No statistically significant differences were found between the average corneal thickness of pre therapy [(400.6±14.9) μm] and post therapy [(396.5±16.3)μm] ( t=1.973, P>0.05). Endothelial cell counts of pre therapy [(2 824±308)/mm²] and post therapy [(2 753±372)/mm²] were of no statistical significance as well (t=0.928, P>0.05). No complications such as scarring lesions in the stroma and corneal endothelial damage were observed throughout the study period. Most of the patient's vision improved after treatment.

The application of isotonic ribonavin solution in a cross-linking procedure in thin corneas with preserved corneal epithelial flap seems to be safe and effective as keratoconus tend to be stable at 12 months after therapy and no endothelial cell damage was caused. (Chin J Ophthalmol, 2018, 54: 421-425)

To investigate the influence of blue light from visual display terminals (VDTs) on human ocular surface.

Prospective intervention test Thirty volunteers were recruited to watch videos on the same VDT in a dark environment, about 40 cm from the screen. Volunteers were supposed to watch videos in the night shift mode that reduces the amount of blue light for 1 hour. At the same time of the second day, they watched the same videos on the VDT in the normal mode for 1 hour. Tear film break-up time (BUT), corneal fluorescein staining scores, lipid layer thickness (LLT), times of blinking in 19.1 seconds and the ratio of partial blinking in 19.1 seconds were measured before and after each watching. Meanwhile, volunteers were asked to complete a questionnaire about their subjective experience after watching.

BUT, corneal fluorescein staining scores and LLT showed no significant decreases in the volunteers after they watched videos on the VDT in the night shift mode [BUT before watching: (8.08±3.15)s, BUT after watching in the night shift mode: (5.31±2.49)s, t=-0.52, P>0.05], but there were significant decreases after they watched videos in the normal mode [BUT after watching in the normal mode: (3.35±1.95) s, t=2.40, P<0.05]. At the same time, there was a significant difference between night shift mode and normal mode[BUT after watching in the night shift mode (5.31±2.49)s, BUT after watching in the normal mode: (3.35±1.95)s, t=3.67, P<0.05). Times of blinking and the ratio of partial blinking in 19.1 seconds were increased modestly after watching in 2 different modes, but there was no significant difference(times of blinking after watching in the night shift mode were 5.55±3.27, times of blinking after watching in the normal mode were 5.93±3.59, t=-0.92, P>0.05). The questionnaire results showed that 70.0%(21) of the volunteers reported mild discomfort including eye dryness, itching, pain, foreign body sensation, redness and asthenopia, 46.7%(14) reported no difference between the 2 modes, 36.7%(11) preferred the night shift mode, 16.6%(5) felt better with the normal mode, and 80.0%(24) would like to try the night shift mode in their daily life.

Use of VDTs for a short period of time can lower the stability of tear film. The night shift mode may cause less damage to the ocular surface than the normal mode. High-energy blue light from VDTs can be a risk factor in the ocular surface damage, but the damage is reversible. (Chin J Ophthalmol, 2018, 54: 426-431)

To analyze the etiology, drug susceptibility and etiological changes of fungal keratitis so as to to provide reference for clinical diagnosis and treatment.

Retrospective case series study. A total of 5 654 copies of specimens for fungal culture were collected from Outpatients suspected of fungal keratitis in Beijing Tongren Ophthalmic Center during January 2007 and December 2016. Specimens were inoculated on Potato dextrose agar (PDA) slant medium, incubated at 30℃ and 40% humidity constantly for 3 to 10 days. Filamentous fungi isolated from positive cultures were identified according to morphological traits. Yeast-like fungi were identified by API 20 C Aux. Drug susceptibility tests were performed by using ROSCO disk diffusion method, which included natamycin, terbinafine, itraconazole, fluconazole, amphotericin B, voriconazole. The Chi-square test and Spearman correlation analysis were performed using SPSS 20.0 software.

The positive rate of culture was 26.1%. In positive patients, the ratio of male to female was 1.77∶1, and the age range was 11 days to 95 years. The mean age was 49.0±16.9 years. Among isolated fungi, Fusarium sp. was the most common genus, accounting for 53.5% (789 strains) , followed by 17.5% of Aspergillus sp. (259 stains) and 13.8% of Alternaria sp. (203 stains). The sensitive rate of natamycin was 92.3% (410 strains) , followed by that of terbinafine as 78.5% (1 093 strains), voriconazole as 41.0% (338 strains), amphotericin B as 40.7% (553 strains).

The predominant patients of fungal keratitis are adult and male. Fusarium sp., Aspergillus sp., and Alternaria sp. are three common species in northern china with seasonal changes in their proportion. Natamycin should be the preferred drug for empirical treatment. The preferred empirical treatment for Aspergillus sp. is terbinafine. Fluconazole should not be used alone due to the high resistant rate. (Chin J Ophthalmol, 2018, 54: 432-436)

To evaluate the short-term efficacy and psycological influence of elastic silicon punctal plugs on severe dry eye patients.

Prospective case series study. Twenty-eight severe dry eye patients (56 eyes) treated with elastic silicon punctal plugs (Snug Plugs^TM, FCI Ophthalmics, France) during January to September 2017 at the ophthalmology department of Peking Union Medical College Hospital were included. All the examination results were collected at baseline and 3 months after insertion. Uncorrected visual acuity (UCVA), silt lamp examination, conjunctiva grading (CG), lower tear meniscus height (TMS), tear break-up time (BUT), Schirmer Ⅰ test (SⅠt, without anesthesia), corneal fluoresce staining (FS) were recorded to evaluate the efficacy of the plugs. Meanwhile, Ocular Surface Disease Index (OSDI), Self-Rating Anxiety Scale (SAS) and Center for Epidemiological Survey-Depression Scale (CES-D) were collected to assess the changes of patients' symptoms and psychological status.

At baseline and 3 months after punctal plugs insertion, mean OSDI score was 65.77±21.28 and 42.85±20.08; mean UCVA was 0.10 (0.30) and 0.06 (0.27), mean TMS was (0.17±0.09) and (0.35±0.17) mm;mean CG score was 2.96±1.13 and 1.57±0.99; mean BUT was (3.23±2.62) and (5.09±3.36) s;mean FS score was 7.32±4.46 and 5.15±4.02; mesn SⅠt was (4.09±3.48) and (8.15±5.96) mm; mean SAS score was 46.70±9.73 and 40.59±8.98, respectively. All the above differences between results of baseline and 3 months after insertion were of statistical significance (t=6.11, -6.31, 8.91, -8.97, -3.83, 5.06, -6.14, 3.04, P<0.01). The mean CES-D score at baseline was 21.25±10.82, which was statistically different from the result of 15.00±10.53 at 3 months after insertion (t=2.38, P<0.05). The number and the severity of patients with anxiety or depression were reduced after insertion. OSDI score was negatively correlated with UCVA, TMH and SⅠt (r=-0.42, -0.61, -0.31, P<0.05), and was positively correlated with FS, SAS and CES-D score (r=0.36, 0.31, 0.28, P<0.05). The main complication identified during this study was spontaneous loss of the punctal plugs (3 eyes, 8.82%).

Short term elastic silicon punctal plugs are effective for treating moderate to severe dry eye, and such treatment can partly alleviate the anxiety and depression of the patients. Still, more attentions to the psychological status of dry eye patients should be paid. (Chin J Ophthalmol, 2018, 54: 437-444)

To explore the clinical significance of ocular surface bacteria inhibition by cleaning eyelid margins before surgery in cataract patients.

Case-control study. Thirty-five patients (45 eyes) with age-related cataracts who were proposed to receive treatment of Phacoemulsification combined with cataract extraction and intraocular lens implantation at Peking University 3^rd hospital were included. The experimental group consisted of 9 males and 15 females with the average age of (69.8±11.5). The control group consisted of 6 males and 15 females with the average age of (61.8±16.2). In the experimental group, bacteria samples from the conjunctival sac and eyelid margins were collected at three times separately and were cultured for identification: first sampling was taken prior to application of any type of antimicrobial measures; second sampling was taken after application of lid scrub twice daily for 7 days to cleanse their eyelid margins by the patients;the last sampling was taken after patients' application of Levofloxacin antibiotic eye drops 3 times per day continuously for 3 days prior to surgery. In the control group, bacteria samples from the conjunctival sac and eyelid margins were collected at two times separately and were cultured for identification: first sampling was taken before application of any antimicrobial measures;second sampling was taken after patients' application of only Levofloxacin antibiotic eye drops successively for 3 days before surgery. Then the results of bacteria culture of the two groups above were compared.

In the experimental group, according to the eyelid margins bacteria cultures results of the first sampling (taken before application of any antibacterial measures), the total positive rate, positive rate of common bacteria and positive rate of rare bacteria found in the cultures were 83.3% (20/24), 70.8% (17/24), 45.8% (11/24), respectively; according to the bacteria cultures results of the second sampling (tanken after application of lid scrub for cleaning the eyelid margins for 7 days), the total positive rate, positive rate of common bacteria and positive rate of rare bacteria found in the cultures were 58.3% (14/24), 45.8% (11/24), 25% (6/24), respectively;According to the bacteria cultures results of the third sampling (taken after application of antibiotic eye drops for three days), the total positive rate, positive rate of common bacteria and positive rate of rare bacteria found in the cultures were 20.8% (5/24), 20.8% (5/24), 4.2% (1/24), respectively. In the experimental group, we compared the bacterial positive rate of the samples taken after patients' application of antibiotics for 3 days to the bacterial positive rate of the samples taken prior to application of any antibacterial measures to have found that the total positive rate, the positive rates of common bacteria and rare bacteria decreased significantly (P<0.05) and the difference in between are of statistical significance. In the control group, according to the eyelid margins bacteria cultures results of the first sampling (taken before application of any antibacterial measures, the total positive rate, positive rate of common bacteria and positive rate of rare bacteria found in the cultures were 81% (17/21), 66.7% (14/21), 19% (4/21), respectively;According to the bacteria cultures results of the second sampling (taken after the application of antibiotic eye drops for three days), the total positive rate, positive rate of common bacteria and positive rate of rare bacteria found in the cultures were 38.1% (8/21), 14.3% (3/21), 33.3% (7/21) respectively. When comparing the experimental group to the control group, the experimental group yielded significantly better results than the control group for the rate of reduction of rare bacteria in the eyelid margin after using antibiotics for 3 days. This is due to the lid scrub being used with the antibiotics. The difference are of statistical significance (χ²=6.518, P=0.017). There was no statistically significant difference between the experimental and control group in terms of the total positive rate as well as the positive rate of common bacteria and rare bacteria in the conjunctival sac.

The cleaning of the eyelid and eyelid margin with lid scrub prior to cataract surgery combined with antibiotics eye drops will achieve excellent antibacterial effects for common and rare bacteria in the eyelid and conjunctival sac. The antibacterial effect of using lid scrub with antibiotic eye drops is more favorable than that of using antibiotic eye drops only. However, the lid scrub eyelid hygiene products cannot replace preoperative antibiotics independently. (Chin J Ophthalmology, 2018, 54: 445-451)

To systematically analyze the innovation and development trend in the field of ophthalmology.

The latest ophthalmology funding program from the National Eye Institute and National Natural Science Foundation of China, and funding project for 2012 to 2016 from the National Institutes of Health, National Natural Science Foundation of China and National key research and development plan of China was collected. Using the comparative analysis method, the major ophthalmology funding areas at home and abroad were analyzed. Papers published in 2012 to 2016 in the field of ophthalmology were collected from the Web of Science Core Collection, among which ESI highly cited papers and hot papers were particularly selected. Using bibliometric methods, the time trend of the number of papers and the citation frequency were analyzed. Using the co-occurrence cluster analysis method, the continued focuses and emerging concerns of ophthalmology papers was analyzed.

The funding plan of the National Eye Institute mainly covers nine major diseases in ophthalmology. NSFC focuses on retinal damage and repair mechanisms. The National Key Research and Development Program of China focuses on research on high-end ophthalmic implants. NIH continues to focus on the molecular mechanisms of blinding eye disease such as diabetic retinopathy, age-related macular degeneration, glaucoma, corneal disease and cataracts, basic research in genetics, and advanced diagnostic techniques such as imaging. Latest areas of interest involve gene editing techniques and the application of stem cell technology in ophthalmology. In China, research and application of stem cells in ophthalmic diseases, intraocular sustained-release drug carrier, and precision medicine research in ophthalmology are emerging areas of funding. In 2012 to 2016, research topics of 168 papers collected by ESI focused on macular degeneration, retinal diseases, glaucoma and other eye diseases. How to quickly promote new drugs and new technological achievements to the clinical application is a problem in the field of ophthalmology. How to change the ophthalmology clinic model, so as to provide patients with convenient and quality service, has become a research topic that needs to be given attention to.

Based on the multidimensional analysis of innovation and development in the field of ophthalmology, cross application and integration of ophthalmology and high - tech fields such as advanced imaging technology, stem cell technology, gene editing technology, molecular targeting, and artificial intelligence will provide a strong basis for the enhancement of China's ophthalmology research innovation and international competitiveness. Research efforts for ophthalmic transformation should be strengthened, in order to realize the clinical application of the achievements as soon as possible.(Chin J Ophthalmol, 2018, 54: 452-463)

The patient was a male, 18 years old. On August 4, 2017, he underwent femtosecond laser small-incision lenticule extraction (SMILE) in an external hospital due to refractive error in both eyes. On the first day after surgery, the naked eye visual acuity of both eyes was 1.0. On the third day after surgery, he went to another hospital due to photophobia and tearing in his right eye and visual acuity decrease. He was given levofloxacin and other antibiotics without significant improvement. On August 10, 2017, he was transferred to the Department of Ophthalmology of Peking Union Medical College Hospital. Ophthalmological examination: The visual acuity of the right eye was manual, the left eye was 1.0, and the intraocular pressure measured by the finger was normal. Mixed conjunctival congestion in the right eye, localized white dense infiltration in the upper temporal area of the cornea, opacity and edema in the central area of the cornea, upper and lower infiltration of the capsular bag, melting and thinning of the corneal flap, massive inflammatory exudation in the anterior chamber, and empyema (Figure 1，Figure 2）。 Under confocal microscope, a large number of moderately and highly reflective necrotic tissue in the corneal stroma can be seen, which is intercalated with a large number of highly reflective inflammatory cells (Figure 3）。 Initial diagnosis: Infectious keratitis (bacterial) in the right eye after SMILE in both eyes. Considering the serious infiltration of the patient's corneal lesions and no significant improvement after using broad-spectrum antibiotics in other hospitals, the right corneal infection was removed on August 10, 2017. At the same time, the conjunctival sac and the tissue in the sac were taken for bacteriological culture and drug susceptibility. During the operation, the corneal flap ruptured when the original SMILE incision was irrigated by perfusion with amikacin balanced saline solution. The necrotic tissue on the stromal bed was scraped off, fully irrigated with amikacin balanced saline solution, and the surrounding residual corneal flap was reset. After completion, hydrophilic contact lenses were put on, and amikacin was injected subconjunctivally. Postoperatively, tobramycin eye drops and levofloxacin eye drops were alternately administered once in 15 minutes, gatifloxacin eye ointment 2 to 3 times/d, and ceftazidime intravenous infusion and atropine eye ointment were administered systemically 3 times/d. The results of bacteriological culture 3 days after operation showed streptococcal infection. After 1 week of treatment with sensitive antibiotics, the symptoms of photophobia and lacrimation were alleviated, the conjunctival congestion was improved, the hypema was absorbed, the corneal epithelium healed, and the central corneal scar remained (Figure 4）。 After the corneal infection is controlled, low-concentration glucocorticoids (loteprednol suspension eye drops twice a day) will be added to reduce the inflammatory response.

患者男性，51岁。因左眼视力下降1个月余，于2016年10月9日被第四军医大学西京医院眼科收入院。患者既往40年前右眼外伤史，视力轻度下降，未行进一步检查及治疗；4个月前因铁屑溅入左眼于当地医院行左眼角膜异物剔除术及结膜囊冲洗，术后给予抗生素眼液治疗，患者眼压、视力无变化。约1个月之前无明显诱因出现左眼视力下降，于当地医院诊断角膜炎，给予对症处理后视力无明显改善。患者无特殊个人史及家族史。入院查体：全身检查无特殊，眼科检查：视力：右眼0.08，左眼0.08，矫正：右眼0.1，左眼0.1，眼压：右眼19 mmHg（1 mmHg=0.133 kPa），左眼14 mmHg。右眼结膜无充血，角膜下方片状云翳，前房中深，瞳孔欠圆，直径约3 mm，对光反应迟钝，晶状体皮质片状混浊，玻璃体混浊，眼底未见明显异常。左眼结膜充血，角膜中央及颞侧基质水肿混浊，内皮皱褶（++），鼻侧内皮反光增强，中央偏颞侧见一针尖大小凹陷，累及浅基质层，前房中深，瞳孔圆，直径约3 mm，对光反应灵敏，晶状体皮质轻混，玻璃体及眼底窥不清（图1）。初步拟诊为左眼角膜炎、左眼角膜内皮失代偿。门诊相关检查：角膜共聚焦显微镜检查示：右眼下方病变区角膜上皮细胞层粗糙、干燥，上皮下神经纤维较稀少，病变区浅基质细胞层可见片状高反光（瘢痕组织结构），病变区其余基质细胞及内皮细胞尚可。左眼中央病变区角膜上皮细胞层可见上皮水泡、水肿，上皮下神经纤维缺失，基质细胞肿胀模糊，基质水肿明显，内皮细胞不成像，鼻侧透明区内皮细胞尚可（图2）。考虑患者左眼病毒性角膜炎可能性大，给予更昔洛韦眼用凝胶点左眼4次/d，醋酸泼尼松龙眼液点左眼4次/d，阿昔洛韦片0.4g，口服，3次/d，治疗3天后患者症状无缓解。进一步进行超声生物显微镜检查可见双眼全周房角开放，左眼角膜水肿，左眼角膜后弹力层脱离（descemet membrane detachment，DMD），右眼晶状体混浊（图3）。前节OCT检查结果可见左眼DMD达2/3范围（图4）。修正诊断为左眼DMD。经患者及家属知情同意后于表面麻醉下行左眼前房注气术，术前行左眼激光周边虹膜切除术预防术后高眼压，术中注入消毒空气0.8 ml，嘱患者平卧位。术后第1天左眼视力0.12，矫正至0.3，眼压18 mmHg，坐位时前房上3/4气体填充，角膜后弹力层基本复位；术后第2天左眼视力0.2，矫正至0.4，眼压15 mmHg，坐位时前房上1/2气体填充（图5），前节OCT检查结果可见左眼角膜后弹力层完全复位（图6），患者出院。术后1周门诊复查，左眼视力0.4，矫正至0.8，眼压13 mmHg，角膜透明，角膜水肿基本消失，后弹力层完全复位，前房气体完全吸收。术后1个月门诊复查，左眼视力0.6，矫正至1.0，眼压13 mmHg，角膜水肿消失，恢复透明（图7），后弹力层完全复位（图8）。经过半年规律随访，患者视力稳定，角膜后弹力层完全复位。

The patient, a 32-year-old man, went to the Department of Ophthalmology of Peking Union Medical College Hospital for the first time in February 2014 because he lost sight for nearly half a year after left eye trauma. The previous patient underwent two vitrectomies combined with silicone oil filling in an external hospital in September and October 2013 due to penetrating eyeball injury in his left eye. Retina detached again after silicone oil removal in the left eye in January 2014. When he visited our outpatient clinic in February 2014, he had visual acuity and light perception in his left eye, intraocular pressure of 4 mmHg (1 mmHg =0.133 kPa), aqueous humor flash (+ +), planktonic body (+ +), organized membrane in the pupil area, absence of lens, total retinal detachment with extensive fixed folds; The visual acuity of the right eye was 1.5, the intraocular pressure was 14 mmHg, and the anterior segment and fundus were roughly normal. On March 10, 2014, he underwent pupiloplasty + vitreous exploration + peeling + intraocular laser photocoagulation + silicone oil filling in his left eye. The postoperative inflammatory reaction was severe, and the periiris incision was closed. Twice neodymium yttrium aluminum garnet (Nd:YAG) laser periiris reaming was unsuccessful. In January 2015, he underwent peripheral iris resection of the left eye + tearing of organized membrane in the pupil area. At the reexamination one month later, the visual acuity of the left eye was 20 cm manually, the periiris incision was unobstructed, and the retina was in place. After that, the patient will be followed up in the future.

The patient was a 36-year-old male. Due to the abnormality of fundus in both eyes found by physical examination, he went to the Affiliated Optometry Hospital of Wenzhou Medical University in December 2015. The patient had poor visual acuity at night, good visual acuity during the day and no other ocular discomfort since childhood. The patient had no history of systemic disease, both parents were in healthy health, were not married by close relatives, and had no history of similar eye disease in the family. Ophthalmologist physical examination: naked visual acuity of right eye 0.5, -1.00 DS corrected to 1.0; Left eye naked visual acuity 1.0, -0.50 DC ×160° corrected to 1.0. IOP was 15.0 mmHg (1 mmHg =0.133 kPa) in the right eye and 17.1 mmHg in the left eye. There was no protrusion of the eyeballs in both eyes, the eye position was right, the eye movement was good, and there was no obvious abnormality in the anterior segment of both eyes. The dilated pupil examination of the fundus shows that the vitreous body is transparent, the optic disc is light in color, the boundary is clear, the cup-to-disc ratio is about 0.3, there is no abnormality in the flow of blood vessels, and the artery/vein is about 2:3. Diffusely distributed white spots are seen from the posterior pole of the retina to the equator, starting from the edge of the optic disc on the nasal side, starting from the outside of the vascular arches above and below the macular area on the temporal side, and reaching the equator. The spots are most dense at the edge of the posterior pole and gradually decrease to the periphery; The white spots are uniform in size, symmetrically distributed in both eyes, similar in diameter to the retinal arterioles, and located below the retinal blood vessels. There is no pigmentation in the whole retina, and there is reflection in the fovea (Figure 1）。 Auxiliary examination: OCT examination showed no obvious abnormalities in the scanning range of the macular area of both eyes, and the foveal shape was acceptable. White spot lesions in the peripheral retina were located in the retinal pigment epithelium, showing cluster-like protuberances and passing through the ellipsoid area (Figure 2）。 Visual field examination: There were no obvious abnormalities in the visual field of both eyes. Fluorescein sodium fundus angiography: normal arm-retina circulation time in both eyes, diffuse hyperfluorescence in the retina outside the macular area, no obvious correspondence with spots, and weakened background fluorescence, no fluorescence leakage in late stage (Figure 3）。 Indocyanine green fundus angiography: Choroidal circulation is normal, and there is a boundary between the posterior pole of the fundus and its periphery in the early stage, and it is more obvious in the late stage (Figure 4）。 electroretinogram (ERG): Dark vision: The amplitude of A and b waves in both eyes decreased. Photopia: Right eye: A and b wave amplitude decreased; Left eye: A wave amplitude normal, b wave amplitude decreased. Reexamination of ERG after 3 h of dark adaptation showed: darkopia: the amplitude of A and b waves in both eyes was normal; Photopia: normal A wave in both eyes, decreased b wave amplitude (Figure 5）。 Diagnosis: White dotted fundus in both eyes, the patient is recommended to be followed up regularly.

The patient was a 39-year-old male. Because of the inconsistent color of his eyes since childhood, he went to Weifang Eye Hospital. Family history of similar eye disease denied. Eye examination: visual acuity right eye 0.8 (-0.50 DS-1.25 DC ×120° =1.2), left eye 0.2 (-1.00 DS-1.50 DC ×65° =1.2), with intraocular pressure of 20 mmHg in both eyes (1 mmHg =0.133 kPa); The cornea of the right eye is transparent, the anterior chamber is middle and deep, the aqueous humor is clear, the iris is brown-black, the texture is clear, the pupil is round, the light response is sensitive, the lens is transparent, the retina is orange-yellow, the optic disc boundary is clear and acceptable, C/D is about 0.3, the blood vessels run normally, and the foveal reflection is visible; The cornea of the left eye is transparent, the anterior chamber is medium-deep, the aqueous humor is clear, the iris is light blue, the texture is clear, the pupil is round, and the light response is sensitive, the lens is transparent, the retina is bright red, the optic disc boundary is clear and acceptable, C/D is about 0.3, the blood vessels run normally, and the foveal reflection is visible (Quintessence Picture 1,Quintessence Picture 2,Quintessence Picture 3）。 Clinical diagnosis: congenital heterochromatic iridis in left eye^{[1,2,3,4,5,6]}。

Diabetic keratopathy is a common ocular complication of patients with a long-term history of diabetes and it will have a negative effect on the visual quality and function. A study reported that the incidence of diabetic keratopathy in diabetic patients ranged from 47% to 64%, but the precise underlying pathogenesis remains unclear. There is evidence that advanced glycation end products contribute substantially to the onset and progress of various diabetic complications and it is a key factor for the mechanism of the hyperglycemic memory. This review focuses primarily on the present research state and prospect of advanced glycation end products and their role in the pathological changes of the cornea. (Chin J Ophthalmol, 2018, 54: 475-480)