Volume 54 · Issue 11 · 2018

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

Glaucoma-related retinal imaging using frequency domain optical coherence tomography (OCT) has become an important but not the only basis for the diagnosis and follow-up of glaucoma. The circumpapillary retinal nerve fiber layer thickness and the macular ganglion cell thickness are two commonly used structural parameters in glaucoma. Their diagnostic efficacy is similar, but each has different influencing factors. Clinically, these two parameters should be analyzed together to improve the specificity and sensitivity for detecting glaucomatous optic nerve damage. Recently, there have been quite a few clinical studies on new OCT technologies and concepts related to glaucoma, but it is still necessary to further confirm the application value. Ophthalmologists should master the principle of glaucoma-related OCT retinal imaging, combining with other clinical evaluation methods, to improve early diagnosis and timely detection of glaucomatous progression.(Chin J Ophthalmol, 2018, 54: 801-805)

The filtration bleb dependent surgeries, such as trabeculectomy, are the main methods for glaucoma treatment in China. However, the filtration bleb scarring after the surgery has always been a challenge to long-term results. In recent years, with the application of anti-glaucoma non-filtering bleb dependent surgery, the surgery complications of filter bubble dependence have been avoided, such as shallow anterior chamber and leakage of filtering bleb. Researches are still needed on the indications, long-term effects and health economics evaluations. It also takes time to widely popularize its application in China. This article focuses on comparing the filtration bleb dependent surgeries with non-filtering bleb dependent surgeries to deeply state the characteristics, advantages and disadvantages of the two methods. (Chin J Ophthalmol, 2018, 54: 806-810)

To investigate the characteristics of impairment of the visual field (VF) and retinal nerve fiber layer (RNFL) and the differences of progression pattern of early, middle and late stages of primary open-angle glaucoma (POAG) and normal-tension glaucoma (NTG) , and to analyze the correspondence of structure and function.

Cross-sectional study. POAG patients, NTG patients and healthy volunteers who were enrolled from February 2008 to May 2017 at Department of Ophthalmology, Eye & ENT Hospital of Fudan University, underwent basic ophthalmic examination, Humphrey central 24-2 threshold test and optical coherence tomography. Patients were divided into early, middle and late stages according to the mean defect (MD) index of the VF test. According to the RNFL distributional characteristics, the pattern deviation map and RNFL were divided into 6 sectors. The differences of each sector′s MD and RNFL thickness in the healthy group and groups of patients at 3 stages were analyzed using the Kruskal-Wallis test, and the correlation of MD and RNFL thickness of each sector was analyzed using the Pearson coefficient.

In the POAG group, there were 84 cases (84 eyes) including 35 eyes of early stage, 20 eyes of middle stage and 29 eyes of late stage, with a male/female ratio of 43∶41, aged (45±15) years. In the NTG group, 69 cases (69 eyes) included 30 eyes of early stage, 20 eyes of middle stage and 19 eyes of late stage, with a male/female ratio of 33∶36, aged (49±13) years. The control group had 23 cases (23 eyes), with a male/female ratio of 16∶17 and an age of (44±10) years. There was no significant difference in male/female ratio, age or best corrected visual acuity among the three groups. (1) In the middle stage of POAG, the VF defects of inferior hemi-fields were more severe than the superior (t=21.62, P=0.000), which was opposite to the late stage of POAG (t=-3.28, P=0.003). In each stage of NTG, there was no significant difference between two hemi-fields. In the control group, the MD values(antilog) of VF in the superior peripheral arch (PEA), superior paracentral arch (PAA), inferior PEA and PAA, temporal and central regions were 0.87 (0.63-1.11)/L, 0.74 (0.61-0.83)/L, 0.72 (0.55-0.97)/L, 0.65 (0.51-0.87)/L, 0.69 (0.57-0.97)/L, and 0.82 (0.54-0.93)/L, respectively. The sectoral MD values in the VF sectors of POAG were significant compared with the control group (P<0.05): superior PAA for early stage [0.61 (0.18-0.92)/L, H=21.58], superior PEA and PAA for middle stage [0.61 (0.15-0.87)/L, 0.21 (0.00-0.78)/L, H=25.99, 34.91], superior PEA and PAA, inferior PEA and PAA for late stage [0.01 (0.00-1.13)/L, 0.00 (0.00-0.76)/L, 0.41 (0.00-1.07)/L, 0.21 (0.00-0.95)/L, H=46.27, 54.19, 25.64, 28.10]. With the aggravation of POAG, superior PAA had the largest reduction percentage of sectoral MD. The sectoral MD values in the VF sectors of NTG were significant compared with the control group (P<0.05): superior PAA for early stage [0.54 (0.19-0.80)/L, H=20.93], superior PAA for middle stage [0.60 (0.02-1.01)/L, H=22.13], superior PEA and PAA, inferior PEA and PAA for late stage [0.33 (0.00-0.90)/L, 0.05 (0.00-0.92)/L, 0.16 (0.01-0.87)/L, 0.64 (0.02-1.10)/L, H=37.66, 42.78, 35.15, 37.15]. With the aggravation of NTG, the largest reduction percentage of sectoral MD was found in superior PAA at the beginning but in inferior PAA at last. (2) The RNFL thickness of the control group in Region 1NI, 2TI, 3NS, 4TS, 5N, and 6T was 112.76 (63.54-150.99) μm, 134.89 (89.44-198.55) μm, 96.52 (57.32-158.79) μm, 120.96 (69.25-148.48) μm, 71.85 (65.03-95.47) μm, and 66.24 (55.44-90.97) μm, respectively. The sectoral thickness in the RNFL sectors of POAG were significant compared with the control group ( P<0.05): 2TI for early stage [109.17 (43.77-173.86) μm, H=31.50], 1NI, 2TI and 4TS for middle stage [71.54 (49.92-94.98) μm, 62.92 (42.33-102.73) μm, 84.20 (45.98-120.13) μm, H=38.91, 49.89, 30.60], 1NI, 2TI, 3NS, 4TS, 5N and 6T for late stage [61.76 (39.32-97.99) μm, 59.59 (42.80-108.69) μm, 67.28 (42.56-117.96) μm, 65.16 (41.96-138.02) μm, 59.45 (21.04-78.48) μm, 53.74 (27.88-92.71) μm, H=52.76, 55.06, 35.76, 41.72, 41.32, 29.93]. With the aggravation of POAG, at the beginning 2TI had the largest reduction percentage of RNFL thickness but 4TS had it at last. The sectoral thickness in the RNFL sectors of NTG were significantly different from the control group (P<0.05): 2TI for early stage [78.97 (47.77-131.45) μm, H=28.86], 1NI, 2TI, 3NS and 4TS for middle stage [61.46 (49.69-97.38) μm, 74.51 (40.25-135.16) μm, 86.36 (42.70-105.06) μm, 83.60 (54.75-117.35) μm, H=38.76, 35.64, 22.47, 24.14], 1NI, 2TI, 3NS, 4TS and 6T for late stage [61.45 (49.09-92.64) μm, 54.35 (37.40-102.62) μm, 63.72 (28.68-105.55) μm, 61.00 (44.92-108.49) μm, 50.33 (35.62-82.09) μm, H=42.56, 51.50, 36.11, 47.44, 25.50]. With the aggravation of NTG, the sector with the largest reduction percentage of thickness changed from 2TI to NI and 4TS. (3) The VF superior PAA-RNFL 2TI had the highest Pearson correlation coefficient in POAG (r=0.630, P<0.001), while it was the inferior PAA-4TS in NTG (r=0.645, P<0.001).

The impairment patterns of VF and RNFL in each stage of POAG and NTG are distinctly different from certain rules of aggravation. The sector with the strongest correlation of function-structure is the VF superior PAA-RNFL inferior temporal sector in POAG and inferior PAA-superior temporal sector in NTG. (Chin J Ophthalmol, 2018, 54: 811-819)

To compare the difference of anterior segment structure between Chinese Han people and American Caucasians, and to explore the confounding factors of anterior chamber angle.

Cross-sectional study. The study was designed to include two healthy groups of Chinese Han people (enrolled from Department of Ophthalmology, Peking University Third Hospital) and American Caucasians (enrolled from Department of Ophthalmology, University of California, San Francisco) from May 2008 to December 2010, each with approximately 120 participants, including 15 persons of each gender in each decade between 40 and 80 years of age. The parameters of the anterior segment were measured by the automatic refractive test, A-ultrasound and ultrasound biomicroscopy. Differences between the two groups were compared with the independent-sample t test or Wilcoxon two-sample test for continuous variable data and the χ ² test for classified variable data. Multiple linear regression models were performed to analyze the associated factors of anterior chamber angle.

There were 118 subjects (118 eyes) and 117 subjects (117 eyes) enrolled in the Chinese and American Caucasians groups, respectively. Compared to Caucasians, Chinese had smaller A-ultrasound measured anterior chamber depth [(3.03±0.34) mm vs. (3.38±0.36) mm, t=-5.791, P<0.001], smaller relative lens position [0.227 (0.198, 0.256) vs. 0.235 (0.191, 0.262), Z=-3.063, P=0.002], smaller axial length [23.3 (20.9,28.3) mm vs. 24.2 (20.8,28.5) mm, Z=-5.510, P<0.001], smaller iris root distance [0.111 (0.000, 0.401) mm vs. 0.142 (0.000, 0.451) mm, Z=-3.188, P=0.001], smaller ciliary body thickness at 1 mm posterior to the scleral spur [0.661 (0.424, 0.892) mm vs. 0.716 (0.467, 0.942) mm, Z=-3.456, P=0.001], smaller trabecular ciliary process distance [0.780 (0.410, 1.400) mm vs. 0.930 (0.420, 1.470) mm, Z=-3.191, P=0.001], smaller trabecular ciliary process angle [73.4° (36.3°, 115.3°) vs. 81.1° (47.9°, 147.9°), Z=-3.407, P=0.001], smaller angle opening distance at 500 μm (AOD500) [0.181 (0.000, 0.703) mm vs. 0.264 (0.000, 0.806) mm, Z=-3.444, P=0.001], smaller angle recess area (ARA) [0.118 (0.011, 0.457) mm²vs. 0.179 (0.000, 0.626) mm², Z=-3.814, P<0.001], larger spherical equivalent [0.40 (-5.80, 4.00) D vs. -0.70 (-8.00, 4.00) D, Z=-5.454, P<0.001], larger lens thickness [(4.62±0.40) mm vs. (4.52±0.40) mm, t=2.077, P=0.039] and larger iris thickness [0.430 (0.280, 0.600) mm vs. 0.410 (0.240, 0.580) mm, Z=-2.263, P=0.024]. On average, with each decade of the increased age, Chinese had a greater decrease in the AOD500 than Caucasians (0.040 mm in Chinese vs. 0.030 mm in Caucasians), while the angle recess area decreased at the same rate (0.020 mm² in both groups). After adjusted for age, gender, spherical equivalent, axial length and other parameters of the anterior segment, the trabecular ciliary process angle [for AOD500, standardized regression coefficient (SRC)=0.487, R²=0.549, P<0.001; for ARA, SRC=0.372, R²=0.502, P<0.001] and anterior chamber depth (for AOD500, SRC=0.413, R²=0.476, P<0.001; for ARA, SRC=0.331, R²=0.403, P<0.001) were the main factors of anterior chamber angle parameters for Chinese and Caucasians, respectively.

Compared with age and gender matched American Caucasians, Chinese Han people have more crowded anterior chambers and narrower anterior chamber angles. The more anteriorly positioned ciliary processes and shallower anterior chambers are the main factors that contributed to more crowded anterior chambers in Chinese Han people and American Caucasians, respectively. (Chin J Ophthalmol, 2018, 54: 820-826)

To investigate the ultrasonographic measurements of the optic nerve subarachnoid space (ONSAS) in patients with normal tension glaucoma (NTG).

Cross-sectional study. Patients with NTG or primary open-angle glaucoma (POAG) but without any anti-glaucoma treatment and the control group were collected from June 2016 to March 2017 at Beijing Tongren Hospital affiliated to Capital Medical University. Measurements of 24-h intraocular pressure, central corneal thickness, mean visual field damage, visual axis, blood pressure and body mass index and ocular ultrasound scans were performed. The differences in the ONSAS of the two-dimensional ultrasound images of the three groups of subjects and their correlation with various clinical variables were evaluated. Qualitative data were analyzed by the chi-square test for comparison between groups; quantitative data were analyzed by the one-way ANOVA for comparison between groups, and the LSD-t test was used for comparison between groups; the Pearson correlation analysis was used for correlation analysis of measurement data. The intra-group correlation coefficient was used to evaluate the reproducibility and repeatability of two measurements by different measurers or the same measurer.

A total of 35 patients (35 eyes) with NTG were enrolled in the NTG group, including 14 males and 21 females, aged (50±8) years; 32 patients (32 eyes) with POAG were enrolled in the POAG group, including 14 males and 18 females, aged (52±10) years; 37 healthy people (37 eyes) were enrolled in the control group, including 20 males and 17 females, aged (49±9) years. The ONSAS was (5.07±0.83) mm² in the retrobulbar 3- to 7-mm range in the NTG group, significantly smaller than the control group (6.57±1.43) mm² and the POAG group (6.19±0.90) mm² (t=1.17, 1.29; P=0.03, 0.01). There was no significant difference in the statistical results between the control group and the POAG group (t=1.31, P=0.75). Between the ONSAS and mean intraocular pressure and maximum intraocular pressure, there was a statistically positive correlation in the NTG group (r=0.66, 0.48; both P<0.01), but there was no linear correlation; there was no statistical correlation in the control group or the POAG group (all P>0.05). There was no statistically significant association between the ONSAS and age, mean arterial pressure, body mass index, central corneal thickness, visual axis length, and mean visual field loss in any group (all P>0.05).

Compared with the POAG group and the control group, the ONSAS is smaller in the NTG group, indicating lower retrobulbar cerebrospinal fluid pressure, and it is positively correlated with the mean intraocular pressure and the highest intraocular pressure. (Chin J Ophthalmol, 2018, 54: 827-832)

To observe the effect of 2% ganciclovir eye drops on Posner-Schlossman syndrome (PSS) patients with positive cytomegalovirus (CMV) in aqueous humor.

Prospective study. The cases clinically diagnosed as PSS with positive CMV were enrolled from August 2017 to January 2018 at Department of Ophthalmology, Eye & ENT Hospital of Fudan University. All patients underwent aqueous and serum analysis for CMV by the enzyme linked immunosorbent assay and polymerase chain reaction. The history and clinical signs were noted, 2% ganciclovir eye drops were prescribed for topical use (4 times per day), and the patients were followed up. The Pearson Chi-square test was used for the comparison of factors including keratic precipitates (KPs), and the Tyndall, and paired t test or Wilcoxon rank sum test was used for factors like intraocular pressure (IOP), corticoid dosage, and IOP lowering medication dosage.

Fifty cases (31 males and 19 females) clinically diagnosed as PSS with positive CMV had an average age of (38±13) years. Some characteristics could help to identify CMV-positive PSS: iris depigmentation (96%, 48/50), coin-shaped KPs, loss of corneal endothelium (an average loss rate of 10.8%±5.5%), and high IOP during attack[(47.8±9.9)mmHg,1 mmHg=0.133 kPa]. After topical antivirus therapy with the mean time of (5.4±2.7) weeks, the clinical manifestations of CMV positive PSS cases improved. The granulomatous or middle-sized KPs decreased from 94%(47/50) to 52%(26/50), the coin-shaped KPs almost disappeared [from 22%(11/50) to 2%(1/50)], and the Tyndall reaction disappeared [from 12%(6/50) to 0]. The mean IOP value decreased from (26.2±10.9) mmHg to (15.5±3.6) mmHg. Furthermore, corticoid use decreased (from 3 times per day to 0 time per day, by median value), the number of cases that did not use corticoids increased from 6% (3 cases) to 60% (30 cases), and 17 (65%) out of those 26 corticoid dependent patients could withdraw corticoids. The number of IOP lowering eye drops used also decreased (from 2 to 0, by median value), and the proportion of cases without IOP lowering medication increased from 24% (12 cases) to 58% (29 cases). There were statistical differences between post-treatment and pre-treameat (allP<0.05).Thirteen cases that accepted CMV re-test of aqueous humor were all CMV DNA negative after treatment.

Topical treatment with 2% ganciclovir eye drops has a good short-term effect on CMV-positive PSS patients by contributing to inflammation and IOP control. (Chin J Ophthalmol, 2018, 54: 833-838)

To investigate the clinical features of glucocorticoid eye drops induced ocular hypertension in pediatric and adult uveitic eyes.

Retrospective survey of consecutive uveitic patients attending referral service at Peking Union Medical College Hospital from March 2013 to August 2017. Incidences of glucocorticoid eye drops induced ocular hypertension were compared between the pediatric and adult uveitic groups. The clinical patterns of 1% prednisolone acetate eye drops induced ocular hypertension in pediatric and adult uveitic eyes were also investigated. Data were analyzed using the Mann-Whitney test and the χ ² test.

The clinical data of 1 138 uveitic eyes [677 patients; 331 males and 346 females; mean age (31±16) years]receiving corticosteroid eye drops were reviewed, among which 246 eyes (143 patients) had pediatric uveitis and 892 eyes (534 patients) had adult uveitis. The incidence of glucocorticoid eye drops induced ocular hypertension was higher in pediatric eyes (39.8%, 98/246) as compared to adults (29.1%, 260/892) (χ²=9.880, P=0.002). One hundred and thirty eyes (75 patients) with 1% prednisolone acetate induced ocular hypertension were included in the clinical pattern analysis, including 49 [28 patients; 15 males and 13 females; mean age (11±3) years] pediatric and 81 [47 patients; 22 males and 25 females;mean age (34±12) years] adult uveitic eyes. No differences were found in daily doses of 1% prednisolone acetate between the pediatric group [4.60 (3.46, 5.36) drops/day] and the adult group [4.00 (3.30, 4.88) drops/day;Z=-1.675, P=0.094]. But the duration of medication in pediatric eyes [4.71 (2.79, 6.36) weeks] was significantly shorter as compared to the adults [6.00 (4.86, 9.00) weeks;Z=-3.446, P<0.001]. The intraocular pressure (IOP) was 26.00 (24.00, 31.00) mmHg (1 mmHg=0.133 kPa) in pediatric uveitic eyes and 26.00 (23.30, 31.15) mmHg in the adults, which showed no statistical significance (Z=-0.231,P=0.818). To achieve effective IOP control, 79.6% (39/49) of pediatric and 54.3% (44/81) of adult eyes received IOP-lowering drug therapy (χ²=8.447,P=0.004). And during the follow-up, the withdrawal rate of IOP-lowering drugs was much lower in pediatric eyes (48.7%, 19/39) as compared to the adult group (72.7%, 32/44) (χ²=5.031, P=0.025).

Compared with adult patients with uveitis, children with uveitis are more prone to IOP elevation, which is more difficult to control after the use of glucocorticoid eye drops. (Chin J Ophthalmol, 2018, 54: 839-842)

To analyze the ultrasound diagnosis and differential diagnosis of medium and small choroidal melanomas.

It was a retrospective case series study. Thirty-six cases (36 eyes) with medium or small choroidal melanoma were collected between January 2016 and January 2017 in Beijing Tongren Hospital, including 16 males and 20 females aged (50±12) years old. All tumors′ apical heights were within 5 mm and the largest basal diameter was within 15 mm. Sixty-nine cases (69 eyes) with choroidal hemangioma, including 45 males and 24 females aged (45±11) years old, and 16 cases (19 eyes) with choroidal metastasis, including 4 males and 12 females aged (50±11) years old, of equal size were also analyzed as differential diagnosis. Univariate (Chi-square test, Fisher′s exact test, and analysis of variance) and multivariate analyses (Logistic regression) were used for statistical analysis.

There were significant differences in morphology, height, base-height ratio, internal echo, choroidal excavation and secondary retinal detachment among the three types of tumors(all P<0.05). Approximately 91.7% (33/36) of choroidal melanomas and 94.2% (65/69) of hemangiomas were flat or dome, while 63.2% (12/19) of metastatic tumors showed a polygonal shape and an irregular surface contour. The average height was (4.02±0.70) mm for choroidal melanoma, (3.10±1.08) mm for metastasis and (2.75±0.87) mm for hemangioma. The base-height ratio of choroidal melanoma, metastasis, and hemangioma was 2.62±0.48, 4.09±1.18 and 3.16±0.58, respectively. About 86.1% (31/36) of choroidal melanomas and 84.2% (16/19) of metastases showed lower echo than adjacent orbital tissue, while 92.8% (64/69) of hemangiomas had similar or higher echo. About 16.7% (6/36) of choroidal melanomas showed choroidal excavation, but no such signs were found in other tumors. Approximately 80.6% (29/36) of choroidal melanomas, 78.9% (15/19) of metastases and 52.2% (36/69) of hemangiomas showed secondary retinal detachment. The internal echo, height and base-height ratio were taken as significant independent influencing factors into the Logistic regression model. The low internal echo and large height were risk factors of choroidal melanoma (OR=0.016, 0.199, both P<0.05), while the low echo and large base-height ratio were risk factors of choroidal metastasis (OR=0.011, 0.073, both P<0.05).

Ultrasonography plays an important role in the diagnosis of medium and small choroidal melanomas, and the echo, height, and base-height ratio of the lesion can be helpful for the diagnosis and differential diagnosis. (Chin J Ophthalmol, 2018, 54: 843-848)

To investigate the clinical characteristics, surgical approaches and postoperative effects associated with congenital fibrovascular pupillary membranes.

A retrospective study design was used. Thirteen children (13 eyes) with congenital fibrovascular pupillary membranes, treated in Beijing Children's Hospital from January 2014 to December 2017 were included. The morphology of the membrane and the anterior chamber was evaluated using a digital wide-area fundus imaging system. The ophthalmic signs, examination results, operation methods, intraocular pressure and ocular position were analyzed.

There were 13 children (13 eyes) were enrolled, including 9 males and 4 females. The age at surgery ranged from 2.0 months to 34.5 months, with an median of 5.1 months. According to the degree of obstruction of the pupil and the intraocular pressure, the eyes were divided into three groups. In the 5 eyes of group A, the pupil membrane did not completely cover the pupil, and the depth of the anterior chamber was normal. Among them, 4 eyes had normal intraocular pressure (9-12 mmHg) (1 mmHg=0.133kPa), and 1 eye had elevated intraocular pressure (18 mmHg). In the 5 eyes of group B, the pupillary membrane completely covered the pupil into a pinhole, the anterior chamber was normal or slightly shallow, and the intraocular pressure was normal (6-16 mmHg). In the 3 eyes of group C, the pupillary membrane completely covered the pupil, the anterior chamber was shallow or disappeared, and the intraocular pressure was high (24-45 mmHg). Membranectomy and pupilloplasty were performed in group A, and trabeculectomy was combined when there was glaucoma; postoperative intraocular pressure was normal (4-10 mmHg). Membranectomy, pupilloplasty and iridectomy were performed in group B; postoperative intraocular pressure was normal (7-13 mmHg). Membranectomy, pupilloplasty, iridectomy and goniosychialysis were performed in group C; after surgery, intraocular pressure was normal in 2 eyes (10 mmHg and 13 mmHg) and 25 mmHg in 1 eye. All eyes were orthophoric before and after operation in group A. In group B, 1 eye was esotropic, 2 eyes were exotropic (worse after surgery in 1 eye), and 2 eyes were orthophoric before surgery. In group C, one eye was esotropic, one eye was exotropic, and one eye was orthophoric before surgery, and all eyes were exotropic after operation.

Congenital fibrovascular pupillary membranes are unilaterally a continuation of the iris covering the pupil at different degrees, with or without glaucoma. Surgical treatment should be performed promptly when there is obscuring of the visual axis or incorporating of glaucoma. The main surgical procedures are membranectomy and pupilloplasty and iridectomy. Postoperative intraocular pressure can be well controlled, and strabismus has no improvement. (Chin J Ophthalmol, 2018, 54:849-854)

Example 1The child was a female, 3 years old. He was admitted to Lanzhou General Hospital of the People's Liberation Army in December 2012 due to tearing in both eyes for half a year, aggravation and significant decrease in visual acuity for 2 weeks. The patient's visual acuity in both eyes was lower than that of children of the same age since childhood. He visited the local hospital in March 2011 and was diagnosed with corneal dysplasia in both eyes. Medication was ineffective. One year ago, he was diagnosed with mucopolysaccharidosis type 1 (Hurler-Sheie syndrome) in our pediatric department due to growth retardation and deformity of both hands. Admission examination: The patient's general condition was good, and there was no significant difference in weight and development between them and children of the same age. Distal enlargement of the long bones of the extremities; Chest X-ray showed that the upper end of the right humerus was slightly wider, the surgical cervical cortex was not smooth, the residual bone density was normal, and there were no signs of bone destruction and fracture. The epiphysis of the distal shaft of the right ulnar flexural bone is wide and slightly rough, and the cortex of the 1st to 5th metacarpal bones is twisted; Brain CT revealed supratentorial ventricle enlargement (Figure 1）。 Eye examination: visual acuity was 0.05 in the right eye and 0.01 in the left eye, and both eyes did not receive correction; IOP was 33 mmHg (1 mmHg =0.133 kPa) in the right eye and 29 mmHg in the left eye. Moderate opacity of the whole thickness of cornea in both eyes, mild edema of corneal endothelium, and corneal thickness measured by A-ultrasound was 490-510 μ m; The axial depth of the anterior chamber is 1.5~2.0 CT, the texture of the iris is not clear, the pupil is 3~4 mm under natural light, and the light response is slightly dull. The parent of the child refused UBM examination. Admission diagnosis: secondary glaucoma in both eyes; Mucopolysaccharidosis. Treatment strategy: The anterior and posterior diameter of the lens of the patient is significantly enlarged. Therefore, the patient is given atropine sulfate ophthalmic gel to improve ciliary muscle tone. Brinzolamide eye drops and betalolol hydrochloride eye drops were given for eye treatment. After treatment, the intraocular pressure of the patient was 20~24 mmHg in the right eye and 19~23 mmHg in the left eye, and the corneal edema in both eyes was improved. Anterior chamber depth and axial length remained unchanged.

Example 1The patient was a 47-year-old male. Due to the discovery of bilateral orbital masses for more than 20 years, he went to the Ophthalmology Center of the Second Affiliated Hospital of Zhejiang University on January 10, 2017. The patient developed orbital masses in both eyes more than 20 years ago. He underwent surgical resection in a local hospital 18 years ago. More than 15 years ago, the orbital masses in both eyes reappeared. Recently, he felt that the masses increased progressively, so he came to see a doctor. The patient had a 15-year history of hypertension and no family genetic history. There were no obvious abnormalities in the whole body examination. Laboratory test: peripheral blood eosinophils 1.01×10⁹/L, total IgE: 617 000 U/L. Eye examination: visual acuity in the right eye was 0.8 and visual acuity in the left eye was 1.0. Multiple masses can be accessed above and below both eyelids, with a maximum of about 10 mm ×15 mm ×30 mm. The surface is smooth, medium in quality, clearly defined, mobile, and no tenderness (Figure 1）。 No obvious abnormalities were observed in the rest of the eye. Ultrasound of superficial soft tissue masses showed that multiple hypoechoic nodules were detected around the parotid glands on both sides, the larger one on the right side was 17 mm ×10 mm, and the larger one on the left side was 16 mm ×9 mm. Orbital magnetic resonance plain scan showed that the upper eyelids of both eyes were thickened, T₁The weighted image showed low signal, T₂The weighted image showed a slightly high signal; Approximately 15.2 mm ×29.7 mm long T was seen in the anterior wall of the left maxillary sinus₁Long T₂Mass, still uniform signal, clear boundary, slightly compressed depressed anterior wall of maxillary sinus (Figure 2）。 Preliminary diagnosis: orbital tumor in both eyes (eosinophilic lymphogranuloma considered); Hypertensive disease. After admission and complete relevant examinations, bilateral upper eyelid tumor removal + pathological biopsy + upper eyelid reconstruction were performed under local anesthesia. Postoperative pathology: lymphoproliferative lesions with lymphoid follicular formation, hyperplasia of interstitial collagen fibers, fibrosis, eosinophilic deposition, small eosinophil infiltration (Figure 3）； Immunohistochemical results: CD20+, CD3+, CD79a +, CD21 follicle +, CD23 follicle +, B-cell lymphoma (Bcl) -2+, Bcl-6 germinal center +, κ light chain +, λ light chain +, Ki-67 50% +, cytokeratin (CK) (AE1/AE3) -, CD10+, CD5+, cyclin D1 scattered in individual cells +, CD138+, multiple myeloma oncogene 1 (MUM1) +, IgG +, IgG4-, CD56-. Pathological diagnosis: eosinophilic lymphogranuloma. The patient was discharged on the first postoperative day, and no recurrence was observed after 3 months of follow-up.

患者女性，73岁。因左眼白内障术后20余d、视力下降伴眼异物感3 d，于2016年7月就诊于陆军军医大学第三附属医院（野战外科研究所）眼科。患者20 d前曾行左眼白内障超声乳化联合人工晶状体植入术，手术顺利，术后第1天复查左眼视力0.6，常规给予左氧氟沙星滴眼液（4次/日）、醋酸泼尼松龙滴眼液（4次/日）和普拉洛芬滴眼液（4次/日）点眼，术后20 d停用局部用药，3 d前患者自觉左眼视力下降伴眼异物感。患者全身情况及既往史均无特殊。门诊眼部检查：视力右眼0.6，左眼0.07，双眼矫正无提高；眼压右眼13 mmHg（1 mmHg=0.133 kPa），左眼15 mmHg；裂隙灯显微镜检查右眼未见明显异常，左眼结膜轻充血，角膜中央水肿，前房深度正常，房水闪光（-），浮游物（-）（图1A），瞳孔圆，直径3 mm，光反射灵敏，人工晶状体位正。B超：双眼玻璃体轻度混浊及后脱离（图1B）；眼底因角膜水肿遮挡模糊，隐约见视盘色略淡，视网膜平伏（图1C）。黄斑OCT检查未见异常。门诊初步诊断为：左眼眼内炎？双眼人工晶状体眼。收住入院后初步处理：因怀疑为眼内炎，故给予患者头孢唑啉钠2 g静脉滴注（1次/日），左氧氟沙星滴眼液（6次/日）、醋酸泼尼松滴眼液（4次/日）、重组人表皮生长因子滴眼液（4次/日）点眼、妥布霉素地塞米松眼膏（1次/晚）涂眼，连续用药5 d。5 d后复查及处理：患者左眼视力0.06，无提高；角膜中央水肿区稍扩大，房水闪光（+++），浮游物（-），人工晶状体表面未见渗出及膜性物（图2），玻璃体和眼底检查结果同前。给予稀释万古霉素（0.02 g/L）前房内灌洗，灌洗前抽取房水标本行细菌、真菌涂片和培养及药物敏感试验，灌洗后调整用药为：万古霉素1 g静脉滴注（1次/日）、头孢唑啉钠2 g静脉滴注（2次/日）、地塞米松10 mg静脉滴注（1次/日），左氧氟沙星滴眼液（6次/日）、妥布霉素滴眼液（6次/日）、醋酸泼尼松滴眼液（6次/日）、重组人表皮生长因子滴眼液（4次/日）点眼，妥布霉素地塞米松眼膏（1次/晚）涂眼。房水涂片结果回报：未查见细菌及真菌。8 d后复查及处理：万古霉素等用药3 d后，患者自觉左眼视力无提高，眼异物感明显。左眼视力0.06，角膜中央水肿，睑裂区角膜上皮点片状染色（+），房水闪光（+++），浮游物（-），人工晶状体表面未见渗出及膜性物，玻璃体腔和眼底检查同前（图3）。细菌培养+药物敏感试验结果回报：检出鲍曼不动杆菌复合菌，药敏显示为多重耐药菌，对多种抗生素均耐药。给予此患者全身头孢哌酮/舒巴坦1.5 g静脉滴注（2次/日），地塞米松5 mg静脉滴注（1次/日），局部应用左氧氟沙星滴眼液（6次/日）、妥布霉素滴眼液（6次/日）点眼，同时，由于患者角膜出现上皮病变，不排除药物性角膜上皮病变，故停用重组人表皮生长因子滴眼液、普拉洛芬滴眼液、醋酸泼尼松滴眼液和妥布霉素地塞米松眼膏，加用0.3%玻璃酸钠滴眼液（6次/日）点眼和小牛血去蛋白眼用凝胶（1次/晚）涂眼。13 d后复查及处理：头孢哌酮/舒巴坦1.5 g输液5 d后，患者自觉左眼视物较前清晰，眼异物感稍好转。左眼视力0.3，角膜中央水肿减轻，睑裂区角膜上皮点状染色，房水闪光（+），浮游物（-），人工晶状体表面无渗出及膜性物（图4），玻璃体和眼底检查结果同前。给予患者左氧氟沙星片0.1 g口服（2次/日），醋酸泼尼松片30 mg口服（1次/早），局部应用左氧氟沙星滴眼液（6次/日）、0.3%玻璃酸钠滴眼液（6次/日）点眼和小牛血去蛋白眼用凝胶（4次/日）涂眼后，安排患者带药出院。27 d后复查及处理：患者诉左眼视物清晰，眼异物感同前。左眼视力0.6，角膜透明，睑裂区角膜上皮点状染色同前，房水闪光（-），人工晶状体表面无渗出及膜性物，玻璃体轻度混浊同前，眼底未见明显异常。行睑板腺功能检查示左眼上睑中周部睑板腺缺失范围1/3，下睑中周部睑板腺缺失范围1/3~2/3，下睑板腺挤压仅见中央1~2根腺管少许分泌物排出，考虑睑板腺功能障碍，给予25%自体血清点眼，嘱患者自行热敷。37 d后复查及处理：25%自体血清点眼10 d后，患者诉左眼视物清晰，无眼异物感等不适。左眼视力0.6，角膜透明，睑裂区角膜上皮已愈合，染色（-），房水闪光（-），余同前（图5）。

The patient was a 29-year-old male. He was admitted to the Department of Ophthalmology of the Third Hospital of Peking University because of painless visual loss in both eyes and night blindness for 2 years. A family history of illness is denied. There were no obvious abnormalities in the whole body examination. Eye examination: visual acuity was 0.2 in the right eye and 0.1 in the left eye, both of which were corrected without improvement; IOP was 18.6 mmHg in the right eye and 16.2 mmHg in the left eye (1 mmHg =0.133 kPa), and no structural abnormalities were observed in the anterior segment of both eyes. Fundus examination seeQuintessence Picture 1。 Octopus static visual field examination showed defects in the right lateral central, inferior and temporal visual fields within 60° of the right eye; Most of the visual fields of the left eye were defective except the peripheral area of the nasal side. The amplitudes of the five responses of flash electroretinogram were moderately to severely reduced, especially in the left eye. The genetic test report showed a heterozygous mutation in the cyp4v2 gene: c.802-8_810del17bpinsGC. Diagnosis: Bietti crystalline retinal degeneration in both eyes.

Glaucoma is the leading cause of irreversible blindness throughout the world. Primary angle closure glaucoma (PACG) is one of the common types of this disease. Research indicates that its prevalence is always associated with many factors, including ocular anatomical characteristics and the genetic susceptibility. According to many studies, phenotypes related to PACG, such as anterior chamber depth, relative lens position and thickness, chamber angle state, and axial length, are heritable. Heritability is an important indicator to quantify this genetic tendency. Therefore, the study of heritability plays an important role in explaining the genetic susceptibility and understanding the mechanism of these diseases. This article reviews the heritability of the phenotypes that relate to PACG. (Chin J Ophthalmol, 2018, 54:864-867)

Glaucoma can lead to irreversible visual impairment. The pathogenesis of glaucoma is complicated and it is difficult to diagnose early. As an objective and functional examination tool, visual electrophysiology has its own advantages to detect early glaucomatous damage. It can indicate early functional degeneration of retinal ganglion cells and can direct doctors to diagnose and give treatment to glaucoma patients. It has been proved that the pattern electroretinogram, photopic negative response and multifocal electroretinogram can provide most of the information in the early diagnosis of glaucoma. This article overviews the latest application progress of these three visual electrophysiological techniques.(Chin J Ophthalmol, 2018, 54:868-872)

The response to anti-vascular endothelial growth factor (VEGF) treatment is variable. It is generally measured in terms of changes in correlated functional and/or anatomical outcomes, and patients are then classified as optimal response, poor response and non-response. The precise cause of non-response remains undetermined. A variety of factors could account for poor or non-response to anti-VEGF therapy, such as age, baseline vision, disease course, lesion characteristics and genomic polymorphism. At the present time, many studies on the genetic factors of non-response or poor response to anti-VEGF treatment mainly focus on VEGF genes (VEGF-A, VEGFR-2), complement factor H (CFH), age-related maculopathy susceptibility 2 (LOC387715/ARMS2), high temperature factor A-1 (HTRA1), interleukin-related gene (IL-8 rs4073) and so forth. It is still worthy of further investigations that how to assess genetic reasons for non-response or poor response, so that we can provide individualized treatment sequences and predict the response to anti-VEGF therapy. (Chin J Ophthalmol, 2018, 54:873-878)

Professor Zhang Chengfen left us on 20 July 2018. We feel sorry and sad about her departure. We always felt that she was still in the ophthalmology department of Peking Union Medical College Hospital and was still with us. After she died of serious illness, many experts of her own generation in the national ophthalmology community, such as Professor Zhang Shiyuan and Professor Fan Xueding, as well as many young and middle-aged doctors who had studied with her or read her works, and the patients she had treated, all wrote eulogies and memorial articles, which made us feel her academic influence and personality strength. In her body embodied the spirit of the Concord, the style of the Concord, the style of the Concord, the pursuit of the Concord! It is her strong characteristics of "Xiehe person" that make her image and personality sublimate, and she becomes a "Xiehe famous doctor" and is highly respected by the national ophthalmology circle. After her death, I have been wondering why she has such strong Concord characteristics in her body. What inspiration does her life have for us to train excellent ophthalmologists in the future?