Volume 55 · Issue 01 · 2019

Time flies, and we have ushered in a 2019 full of longing and hope. Looking back at the past few years, China's ophthalmology industry has developed rapidly, and the strongest voice of China's ophthalmology has been constantly issued on the international stage. In September 2018, the first "Belt and Road Ophthalmology Forum", which attracted much attention from the world ophthalmology community, was successfully held at the G20 venue in Hangzhou, which not only promoted mutual learning among ophthalmologists from various countries, but also enhanced friendship and strengthened cooperation and development between China and countries along the "Belt and Road". In the foreword of this issue, "Actively Practicing the Belt and Road Initiative to Expand the International Influence of Ophthalmology in China", Editor-in-Chief Yao Ke put forward that the development goal of China's ophthalmology is to actively explore and innovate. While absorbing and digesting foreign new technologies in time, it is more necessary to create new technologies and achievements with independent intellectual property rights, strive to lead the world in some ophthalmology research fields, and gradually become the leader of ophthalmology development in the world. The Belt and Road Initiative is a major strategic decision made by the CPC Central Committee and the State Council according to the changes of the global situation. Ophthalmologists in China should seize this great opportunity, conform to the development of history and the trend of the times, actively participate in and practice the important decisions made by the CPC Central Committee on the Belt and Road Initiative, and constantly expand the international influence of China's ophthalmology. At the same time, the Chinese Journal of Ophthalmology will also strengthen internal and external exchanges in an all-round way, strive to explore and forge ahead with determination, and jointly push the development of China's ophthalmology to a new height!

Time flies, and while sending off 2018, we ushered in a 2019 full of longing and hope. Looking back at the past few years, China's ophthalmology industry has developed rapidly, and the strongest voice of China's ophthalmology has been constantly issued on the international stage. In September 2018, the first "Belt and Road Ophthalmology Forum", which attracted much attention from the world's ophthalmology community, was successfully held at the G20 venue in Hangzhou. Twenty-four ophthalmologists from more than 10 countries and regions along the "Belt and Road", including Russia, Japan, Singapore, Malaysia, Pakistan, Thailand, Poland, India, Egypt, South Korea and China, attended the meeting, and jointly made special reports and discussions on today's popular artificial intelligence, children's cataract removal surgery, femtosecond laser cataract removal surgery, minimally invasive glaucoma surgery, and treatment of complex fundus diseases. The successful holding of the Belt and Road Ophthalmology Forum not only promoted mutual understanding and learning among ophthalmologists from various countries, but also enhanced friendship and strengthened cooperation and development between China and countries along the Belt and Road.

Neuro-ophthalmology is an interdisciplinary that covers neurology and ophthalmology. Neuro-ophthalmology involves not only visual afferent system disorders but also visual efferent system disorders. We have recognized that any disturbance in afferent system may result in vision decrease or loss. However, our understanding of visual efferent system disorders including strabismus, diplopia, ocular motility and abnormal head posture is incomplete. More attentions should be paid to ocular motor pathways disorders in neuro-ophthalmology including clinical characteristics, localization of potential lesion, nystagmus and pupillary abnormalities, in order to improve diagnosis and treatment of neuro-ophthalmology. (Chin J Ophthalmol, 2019, 55:3-6)

Retinal retinoplegy is the main part of refractive error examination in children with cycloplegia, and the selection and application of cycloplegia agents are crucial for the accuracy and safety of retinoplegia in children. For a long time, atropine has been the most commonly used cycloplegic agent for children in China. In recent decades, the synthetic anticholinergic drugs tropinamide and cyclopentolate have been used in clinical practice abroad one after another, especially cyclopentolate has become the first choice drug for optometry in most children with cycloplegia in western countries. In China, there is still a controversy among ophthalmologists on how to choose cycloplegic agents reasonably in children's optometry. In order to standardize the application of cycloplegic agents in children's refractive examination in China, ensure the reliability of refractive results and the safety of medication in children with cycloplegia, and provide convenience for patients to see a doctor, the Strabismus and Pediatric Ophthalmology Group of Ophthalmology Branch of Chinese Medical Association organized experts in relevant fields in China, based on the research results of evidence-based medicine at home and abroad, referring to the clinical experience of experts in this field, and combining the characteristics of finished cycloplegic preparations that can be used clinically in China, discussed and formulated an expert consensus, aiming at guiding ophthalmologists in China to choose and use cycloplegic agents reasonably in clinical work, so as to make the diagnosis and treatment of children's eye diseases in China more standardized and humanized. (Chinese Journal of Ophthalmology,2019，55：7-12）

To characterize the postoperative change of eyes related parameters of patients with infantile nystagmus syndrome(INS), so as to provide a reference for the clinical evaluation of postoperative effect and the rational arrangement of patients′ follow-up time after operation.

A retrospective study. Clinical and follow-up data of 17 patients diagnosed with INS at Department of Ophthalmology in Xinhua Hospital, School of Medicine, Shanghai Jiaotong University from June 2014 to December 2016 were collected. All patients with abnormal head posture (AHP) underwent null zone shift surgery. The operative methods were Parks 5-6-7-8, Anderson, Kestenbum 5-5-6-4,null zone shift combined with strabismus correction and vertical null zone transposition. Ophthalmological examination and eye movement were recorded, including best corrected binocular visual acuity (BCBVA), position of the null zone, expanded nystagmus acuity function (NAFX) and foveation time. Single factor repeated analysis of variance, independent sample t test and rank sum test were used for statistical analysis.

Among the 17 children, 6 were females and 11 were males. The age at surgery of the patients was 5-11 years.The follow-up time was (14.8±6.0) months. Preoperative BCBVA was 0.382±0.147 (corrected posture), 0.300±0.056 (AHP); foveation time was (0.594±0.011)s;position of null zone was 23.570°±0.118°. The BCBVA at three months after operation was 0.318±0.044 (corrected posture), 0.260±0.045 (AHP); foveation time was (0.950±0.146)s; position of null zone was 5.360°±1.107°. The BCBVA at six months after operation was 0.264±0.039 (corrected posture), 0.230±0.037 (AHP);foveation time was (1.496±0.233) s; position of null zone was 6.070°±1.303°. The BCBVA at twelve months after operation was 0.309±0.039 (corrected posture), 0.250±0.045 (AHP);foveation time was (1.455±0.201) s; position of null zone was 9.290°±8.520°. There was statistical difference between the data of pre-operation and post-operation(all P<0.05). Change of null zone position was identified in six patients after six months.The preoperative NAFX of patients with presence of change of null zone positon was 0.308±0.063 (the primary position), 0.393±0.210 (null zone); BCBVA was 0.450±0.043 (corrected posture), 0.417±0.031 (AHP); foveation time was 0.122 (0.080-1.014)s. The postoperative NAFX of those patients was 0.430±0.090(the primary position), 0.471±0.140 (null zone); foveation time was 0.438(0.170-1.450) s. The data above were lower than that of patients with no regression of null zone[0.523±0.142,0.601±0.110,0.200±0.063,0.250±0.076,0.725(0.230-1.440)s,0.610±0.160,0.680±0.120,0.975(0.380-2.000)s]. The difference was statistically significant(all P<0.05).

Null zone shifting surgery is an effective approach for treating INS. Reduction in the null zone position can be observed in some patients at 6 months after operation, which was related to NAFX, BCBVA and foveation time. It is recommended to extend the follow-up time to at least 6 months after the operation. (Chin J Ophthalmol, 2019, 55:13-19)

To observe the magnetic resonance imaging(MRI) changes of superior oblique muscle and to study the relationship between changes and clinical signs in superior oblique muscle palsy.

Cross-sectional study. Data was collected from January 2014 to January 2016 in Tianjin Eye Hospital. Twenty-three(30 eyes) patients who were diagnosed with superior oblique palsy included 15 patients with congenital superior oblique palsy [9 males and 6 females aged (32±13) years (range, 12-53 years)] and 8 cases with acquired superior oblique palsy [3 males and 5 females aged (36±15) years(range, 17-62 years)]. Twenty normal volunteers [11 males and 9 females aged (35±13) years (range, 15-60 years)] were also observed. Coronal MRI was used to detect superior oblique muscle morphological changes, as well as the maximum cross-sectional area and volume changes. The relationship between the morphological changes and vertical deviation and cyclotorsion in the primary gaze was analyzed. Rank sum test,t-test and Person correlation analysis were used for statistical analysis.

Two morphological changes were obtained using MRI in superior oblique muscle palsy, including round (19 eyes) and oval changes (11 eyes). The maximum cross-sectional area in eyes with the palsied superior oblique muscle [round, (10.38±1.76) mm²; oval, (11.16±2.02) mm²] was significantly smaller than fellow eyes [(14.16±1.88) mm²; Z=6.208, 5.178, both P<0.001] and eyes with normal superior oblique muscle [(15.40±1.71) mm²; Z=8.215, 6.330, both P<0.001], and the volume changes [round, (104.92±13.36) mm³; oval, (110.43±16.11) mm³] were also significantly different from fellow eyes [(254.57±20.15) mm³; Z=7.511, 5.396, both P<0.001] and eyes with normal superior oblique muscle [(258.04±16.36) mm³; Z=10.040, 6.936, both P<0.001]. There was no significant difference in vertical deviation between round and oval superior oblique muscle palsies (P>0.05). The cyclotorsion effect of the round change in superior oblique muscle palsy was significantly less than that of the oval change (5.47°±1.05° vs. 7.36°±0.97°, t=3.083, P=0.005). The correlation of the volume changes with vertical deviation angle in the primary gaze was not significantly different (round and oval, both P<0.05), but there was a correlation between the morphological changes and cyclotorsion strabismus (r=0.631, P=0.004; r=0.801, P=0.003).

In the patients with superior oblique palsy, MRI scans shows that the maximum cross-sectional area decreased and the volume was smaller, which indicated superior oblique muscle atrophy. Deformation of superior oblique muscle do not significantly affect the vertical deviation, but is in correlation with cyclodeviation. (Chin J Ophthalmol, 2019, 55:20-24)

To study the correlations between the distance stereoacuity and the levels of control at different far distance fixations in children with intermittent exotropia.

In this prospective, non-interventional case series study, 52 children with intermittent exotropia (basic, divergence excess and pseudo-divergence excess types, exodeviation angles≥15 PD) admitted to the Shandong Provincial Hospital Affiliated to Shandong University for surgery between August 2014 and March 2015 were enrolled. The distance stereoacuity was tested with the distance Randot stereotest, and the control of exodeviation was assessed at outdoor far distance fixation of 50 m, indoor far distance fixation of 30 m, and indoor distance fixation of 3 m, respectively, using the office-based 6-point control scale proposed by Mohney and Holmes. The distance stereoacuity and control scores of every intermittent exotropia child were tested 3-4 times in a single day with an interval of at least 2 hours. Nonparametric Spearman rank method was used to analyze the correlations between distance stereoacuity and levels of control at three different far distances in children with intermittent exotropia.

The mean age of 52 enrolled children (26 males, 26 females) was 7 years (range, 5-12 years), and 192 groups of distance stereoacuity and control scores were got for the 52 children. Positive correlations between the distance stereoacuity and the levels of control at outdoor far distance fixation of 50 m, indoor far distance fixation of 30 m, and indoor distance fixation of 3 m were observed (coefficients of correlations; r=0.489, 0.472, 0.282, all P<0.001).

There are correlations between the distance stereoacuity and the levels of control at outdoor far distance fixation of 50 m, indoor far distance fixation of 30 m and indoor distance fixation of 3 m in children with intermittent exotropia, and the former two are found to be stronger than the latter one. (Chin J Ophthalmol, 2019, 55:25-30)

To investigate the changes of life quality in children with intermittent exotropia (IXT) and their parents 1 year after surgical treatment.

Retrospective study. The scores of Chinese version of the intermittent exotropia questionnaire (CIXTQ) and follow-up visits at 1 week preoperatively and 3 months, 12 months postoperatively were collected from 122 IXT children with successful eye positions 3 months postoperatively and their parents in Department of Ophthalmology, the First Affiliated Hospital of Nanjing Medical University from December 2015 to July 2016. The CIXTQ scores of children with different eye positions 1 year postoperatively, the impact of parent CIXTQ scores and 1-year postoperative eye positions on children′s CIXTQ scores and parents′ proxy CIXTQ scores, were analyzed. Repeated measures anova was used for the analysis.

A total of 122 IXT children were collected in this study, there were 64 boys and 58 girls, age (2-15) years, mean (7±3) year. The eye positions of 88 (72.1%) children were successful 1 year postoperatively, and 34 (27.9%) were undercorrected 1 year postoperatively. The CIXTQ scores of children with different eye positions 1 year postoperatively were significantly higher than that at 1 week preoperatively and at 3 months postoperatively(scores of all children, 83.27±9.49 vs. 57.30±8.37 and 69.19±7.95; successful children, 84.12±8.80 vs. 57.36±8.16 and 69.99±7.85; undercorrected children, 81.07±10.95 vs. 57.14±9.04 and 67.10±7.98), with statistical significance (compared with 1 week preoperatively, t=22.44, 22.13, 8.73; compared with 3 months postoperatively, t=12.42, 11.40, 5.49; all P<0.001). However, the parent′ CIXTQ scores of children with recurrent strabismus showed no significant differences when compared to those at 3 months postoperatively (P>0.05). The CIXTQ scores of parents and eye positions 1 year postoperatively showed no impact on children′s CIXTQ and parents′ proxy CIXTQ scores (all P>0.05).

The orthodontic surgery can effectively improve the life quality of children with IXT and their parents 1 year after surgical treatment, and there is no correlation between the life quality of children and their parents. (Chin J Ophthalmol, 2019, 55:31-36)

To investigate the postnatal development of perineuronal net (PNN), Nogo receptor (Nogo R) in visual development and the effect of fluoxetine(Flx) on remodeling it in the visual cortex of adult rats.

Experimental study. (1) Wistar rats were divided into postnatal weeks (PW)1,PW3,PW5,PW7,PW9 group (8 rats in each group) according to the age of PW. The changes of PNN and Nogo R were observed in the visual cortex of each group. (2) The adult rats (10 weeks after birth) were randomized into Flx 0W, Flx 2W, Flx 4W, Flx 6W and Flx 8W group (8 rats in each group) according to Flx administrational weeks. The influence of Flx on the expression of PNN and Nogo receptor in the visual cortex was detected by immunofluorescence and western blots. (3) The adult rats were randomized into Cont (negative control), Flx, binocular form deprivation(BFD,positive control) and BFD+Flx group (8 rats in each group). Flx group accepted oral administration at the dosage of 0.2 mg/ml once per day for 4 weeks. The eyelids were binocularly sutured for 2 weeks to form the BFD group, and the combination of Flx administration and BFD was performed in the BFD+Flx group.No intervention was conducted in the control group (Cont group). Immunofluorescence was used to observe the expression pattern of PNN staining by biotinylated wisteria floribunda lectin (WFA). The expression of Nogo R in the visual cortex was detected by immunofluorescence and Western blots. The expression of PNN and Nogo R were examined in each group. And t test, analysis of variance and rank sum test were employed for inter-group comparison based on the homogeneity of variance. Bonferroni method was used for multiple comparison and simple linear regression analysis was used for the trend.

(1) The expression of PNN (standardized b=0.97, P=0.005) and Nogo R (standardized b=0.96, P=0.010) increased during the postnatal development and the Nogo R reached the matured level at PW7 (PW7 vs. PW9, 131.83±3.78 vs. 135.11±3.92, Z=1.93, P=0.062). (2) Flx significantly decreased PNN in the visual cortex of adult rats. The density of PNN-positive cells in the visual cortex of healthy adult rats fed with Flx for 4 weeks was (86.22±7.68)/mm², which was similar to that of 3 weeks old rats [(84.21±6.68)/mm², t=2.08, P=0.073]. The expression of PNN (standardized b=-0.88, P=0.040) and it′s receptor Nogo R (standardized b=-0.90, P=0.007) decreased with prolongation of Flx use. (3) The expression of Nogo R (t=13.42,11.47, 18.13; P=0.012, 0.013, 0.001; Flx, BFD and BFD+Flx group vs. Cont group) and the density of PNN (t=10.09, 7.64, 13.01; P=0.007, 0.011, 0.001; Flx, BFD and BFD+Flx group vs. Cont group) could be modulated by Flx and BFD after the critical period. There are no differences in BFD and Flx group on Nogo R changes (t=2.41, P=0.153). The expression of Nogo R protein was also different among the 4 groups (H=5.69, P=0.041). The effect of Flx combined with BFD was better than the Flx or BFD alone (Flx vs. BFD+Flx, Z=4.22, P=0.005; BFD vs. BFD+Flx, Z=3.09, P=0.010).

The expression of PNN and Nogo R increase during the postnatal development. Chronic Flx treatment decrease the expression of PNN and Nogo R after the critical period in the visual cortex of adult rats, that is the same as BFD. (Chin J Ophthalmol, 2019, 55:37-45)

To explore the best surgical approach for infant with congenital cataract by comparing long-term follow-up results of bilateral congenital cataract surgery by different approaches conducted during infant age at last time of visit.

This retrospective case control study includes 108 eyes of 54 infants with bilateral congenital cataract who received bilateral cataract triple procedure (vitrector lensectomy, posterior capsulotomy and anterior vitrectomy) performed by a single surgeon, by either anterior or posterior approach, followed by refractive correction by aphakic glasses or intraocular lens (if suitable)during the follow-up periods (at least for 3 years), between January 2002 and February 2013 in Department of Ophthalmology, Peking University People′s Hospital. The unilateral and bilateral best corrected visual acuity (BCVA), intraocular pressure, anterior segment and fundus exam of each visit and post-operative complications were evaluated, and data collected at patients′ last visit were compared between two approaches (Student′s t test for continuous variables, chi-squeare test for constitutional variables).

A total of 44 cases (33 males) were included in anterior approach group, median age of primary surgery was 3.0 (0.5-10.0) months. The rest 10 cases (7 males) were included in the posterior approach group, median age of primary surgery was 4.0 (1.0-11.0) months. At last visit, longest follow up period of anterior and posterior group were 3.5 (3.0-8.5) years and 4.0 (3.0-7.0) years, respectively. Neither unilateral nor bilateral BCVA (logarithm of minimum angle of resolution) of both anterior and posterior approach groups at last visit showed any difference(both P>0.05).Long-term post-operation complications of anterior and posterior group include strabismus (8 cases and 2 cases), nystagmus(8 cases and 6 cases), optical opaque (4 cases and 2 cases), and ocular hypertension(2 cases and 1 case). Nystagmus (P<0.001) and optical opaque (P=0.041) was more prevalent in posterior approach group.

For bilateral congenital cataract surgery during infant age, anterior approach would produce less post-operation complications as compared to posterior approach, and is recommended for infants without other abnormalities of posterior segment of the eye. (Chin J Ophthalmol, 2019, 55:46-50)

One child with main complaint of swelling and pain in the right eye for 3 days and fever for 2 days went to the ophthalmology department. Scattered red rashes were seen on both hands and feet of the child during physical examination. Eye examination revealed redness and swelling of the right eyelid, difficulty in opening eyes, and skin damage on the eyelid. After routine blood routine, orbital CT scan, bacterial culture examination of eye and skin secretions, he was diagnosed as right orbital cellulitis and Streptococcus pyogenes infection. (Chinese Journal of Ophthalmology,2019，55:51-52）

One patient with a complaint of blurred vision in his right eye for more than 1 year went to the ophthalmology department. Ocular examination and ultrasound biomicroscopy showed that brown-black pigment particles diffusely attached to the iris surface, spreading to the anterior capsule of the lens in the pupil area and the underlying corneal endothelial surface, and high intraocular pressure in his right eye. He was diagnosed as congenital hyperplasia of iris pigment in his right eye and secondary glaucoma in his right eye. (Chinese Journal of Ophthalmology,2019，55:53-54）

One patient with complaint of right eye dryness and foreign body sensation for 3 months was seen in the ophthalmology department. After eye examination, B-ultrasound, ultrasound biomicroscopy and coherence light tomography, he was diagnosed with retinoschisis in the right eye, old uveitis in the right eye, and dry eye in both eyes. Panuveitis with mid-peripheral retinoschisis is clinically rare. (Chinese Journal of Ophthalmology,2019，55：55-57）

One patient complained of swelling of the right orbit for 20 days, headache and vomiting for 12 hours. The eye examination revealed a mass in the right orbit. After general examination, CT and MRI examination, and histopathological examination after resection of the mass in the right orbit, the patient was diagnosed as periampullary carcinoma (poorly differentiated adenocarcinoma), with multiple metastases in the orbit, cervical lymph nodes, abdominal lymph nodes and bones. Clinically, periampullary carcinoma diagnosed for the first time with ocular manifestations is extremely rare. (Chinese Journal of Ophthalmology,2019，55：58-59）

One patient with the main complaint of "white pupil" in the right eye for 2 years was seen in the ophthalmology department. The eye examination of the right eye was prominent and atrophic, and the mass was palpable around the whole orbit. After orbital CT, MRI and histopathological examination after tumor resection in the right orbit, it was diagnosed as right orbital teratoma. (Chinese Journal of Ophthalmology,2019，55：60-62）

The patient was a 43-year-old male. Due to the decrease of vision in his left eye for 2 weeks, he went to the Department of Ophthalmology, Dushanzi People's Hospital, Karamay City, Xinjiang. Upper respiratory tract infection was diagnosed in an individual clinic due to fever, cough, headache 1 month ago and was not treated, the symptoms disappeared after 1 week. Past physical fitness. The whole body examination showed no abnormalities. Eye examination: visual acuity was 1.2 in the right eye and 0.5 in the left eye (uncorrectable); No abnormalities were observed in the anterior segment of both eyes; There were no obvious abnormalities in the right fundus; For the left fundus, seeQuintessence Picture 1Medium A, fluorescein fundus angiography is shown inQuintessence Picture 1Middle B. Clinical diagnosis: Acute posterior multifocal squamous retinal pigment epitheliopathy in the left eye.

Synergistic divergence is a rare condition characterized by complete absence of adduction that is associated with simultaneous abduction of the affected eye on attempted adduction. This causes the affected eye to move further into abduction on gaze to the normal side and results in extreme divergence of both eyes. It is sometimes referred to as exotropic Duane syndrome with synergistic divergence (type 4 Duane syndrome) or congenital fibrosis syndrome with synergistic divergence. Diseases combined with synergistic divergence fall within the category of congenital cranial dysinnervation disorders (CCDDs). The ocular associations reported with synergistic divergence are uncommon and include Horner syndrome, ocular albinism, foveal hypoplasia, Goldenhar syndrome and pupillary abnormalities. MRI and electro-oculographic study suggested that this is the result of CCDDs. Various surgical techniques have been tried in individual cases including large recession of the lateral rectus muscle, lateral rectus muscle extirpation, large resection of the medial rectus (MR) muscle, weakening procedures of the oblique muscles, combination of lateral rectus orbital wall fixation with MR resection, but further investigations with large-scale samples are needed. Recent research advances in the definition, etiology, and treatment of synergistic divergence are reviewed in this article. (Chin J Ophthalmol, 2019, 55:63-67)

Macular telangiectasia type 2 (MacTel 2) is an idiopathic entity which is characterized by dilated capillary network near, or around, the fovea of the macula. The spectrums secondary to macular retinal vascular inflammation or obstruction are excluded. It is a binocular disease in general. MacTel 2 is now widely recognized as a macular neurodegenerative disease rather than a simple vascular disease. This article reviews the epidemiological features, clinical features, staging, special examinations, pathogenesis and treatment of MacTel 2. (Chin J Ophthalmol, 2019, 55:68-73)

The Strabismus and Pediatric Ophthalmology Group of the Ophthalmology Branch of the Chinese Medical Association formulated and promulgated the "Expert Consensus on Optometry and Safe Medication of Children with Ciliary Muscle Palsy in China (2019)" in order to standardize the medication of children with ciliary muscle palsy in China, which provided targeted guidance on the problems existing in the medication of children with ciliary muscle palsy in China. In order to facilitate everyone to understand and better grasp its content, relevant supplementary explanations and in-depth interpretation are given. (Chinese Journal of Ophthalmology,2019，55：74-76）