Volume 55 · Issue 04 · 2019

This issue focuses on the research progress in the diagnosis and treatment of fundus diseases. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Wei Wenbin.

In recent years, the incidence of tuberculosis, HIV, syphilis and other infectious diseases has a "rising" trend. The incidence of infectious fundus diseases is also increasing, and missed diagnosis and misdiagnosis are becoming more common. How to diagnose infectious fundus diseases accurately, avoid missed diagnosis and misdiagnosis, carry out standardized treatment in time, carry out research on infectious fundus diseases related to systemic infectious diseases, and save the visual function of patients are the problems we are facing. This article discusses the related issues. (Chin J Ophthalmol, 2019, 55: 241-245)

With the rapid development of perinatology in China and the implementation of the two-child policy, the survival rate of premature and low weight infants is obviously improved, and the incidence of retinopathy of prematurity (ROP) in preterm infants has been increasing year by year. ROP can lead to blindness when it is serious. It is the first cause of blindness of children in our country, and it is a heavy burden on family and society. With novel insights in the pathogenesis of the disease, anti-vascular endothelial growth factor pharmacotherapy has blated its way into ophthalmological practice and significantly changed the management of ROP. However, facing such promising drugs, we still need to take caution with the safety and long-time efficacy, investigate more reasonable dosing schedules and study the follow-up time. (Chin J Ophthalmol, 2019, 55: 246-249)

Retinoblastoma (RB) is the most common intraocular malignancy in children, with 2/3 of patients developing within 3 years of age, with a neonatal incidence of 1:16 000 to 18 000. There are many different treatment options for RB, unilateral and bilateral RB in different stages. In addition, the medical level in various regions in China is unbalanced, and the treatment effect of RB is quite different. In view of the fact that RB is mainly in unilateral intraocular stage, the Ophthalmology and Orbitology Group of Ophthalmology Branch of Chinese Medical Association and relevant experts jointly put forward the expert consensus on the diagnosis and treatment of unilateral intraocular RB after careful discussion, in order to improve the clinical diagnosis and treatment level of RB in China.(Chinese Journal of Ophthalmology, 2019, 55:250-254)

The author put forward different opinions on the hardware requirements for screening institutions, the requirements for ophthalmology knowledge reserve for screeners, the standards for referring ophthalmology medical institutions and the potential value of artificial intelligence in future DR screening in the Guidelines for Image Collection and Film Reading for Screening of Diabetic Retinopathy in China (2017) formulated by the Ophthalmology Group of Ophthalmology Branch of Chinese Medical Association and the Ophthalmology Professional Committee of Ophthalmologists Branch of Chinese Medical Doctors Association, and discussed with the author.(Chinese Journal of Ophthalmology, 2019, 55:255-256)

In view of the opinions on the hardware requirements of screening institutions, the requirements of ophthalmology knowledge reserve for screeners, the standards for referring ophthalmology medical institutions and the potential value of artificial intelligence in future DR screening in the Guidelines for Image Collection and Film Reading for Screening of Diabetic Retinopathy in China (2017) put forward in the Discussion with the Authors of the Guidelines for Image Collection and Film Reading for Screening of Diabetic Retinopathy in China (2017), so as to promote relevant personnel' knowledge and understanding of the Guidelines.(Chinese Journal of Ophthalmology, 2019, 55:257-258)

To determine the efficacy and safety of vitrectomy combined with implantation of a foldable capsular vitreous body in the treatment of severe retinal detachment with early ocular atrophy in human eyes.

This study was a prospective, multicenter, and one-arm phase Ⅱ clinical trial. Patients with severe retinal detachment and early eyeball atrophy attending Beijing Tongren Eye Center from April 2011 to July 2012 were included. A standard three-port pars plana vitrectomy was performed, and a foldable capsular vitreous body was folded and sent into the vitreous cavity; silicone oil was injected into the capsule. Measurement of visual acuity and intraocular pressure, corneal endothelium count, color fundus photography, optical coherence tomography, and ocular ultrasonography were performed to observe retinal reattachment and adverse reactions after surgery. Wilcoxon signed rank test was performed to compare the baseline and postoperative visual acuity, intraocular pressure and corneal endothelium count.

A total of 26 patients were enrolled, including 23 males and 3 females. The age was (37.5±11.5) years, with an average follow-up of 33 months. For each patient, only the left or right eye was included (13 left eyes and 13 right eyes). Retinal reattachment was found in all 24 eyes, and the eyeball atrophy was controlled in all patients. Visual acuity was improved in 4 patients (15.4%) and unchanged in 5 patients (19.2%). The mean intraocular pressure [(14.4±3.9) mmHg(1 mmHg=0.133 kPa)] at the last follow-up was higher than the baseline intraocular pressure [(12.0±6.5) mmHg], but the difference was not statistically significant (Z=-1.859, P=0.063). For the 16 patients with ocular atrophy at baseline, the last follow-up intraocular pressure [(14.6±3.9) mmHg] was significantly higher than the preoperative intraocular pressure [(8.5±2.4) mmHg] (t=-5.326, P<0.001). No obvious adverse reactions were observed.

Implantation of a foldable capsular vitreous body is an effective way to treat severe retinal detachment with early eyeball atrophy. It can help to reattach the retina, control eyeball atrophy, maintain the eye shape and intraocular pressure, while visual acuity improvement is limited. (Chin J Ophthalmol, 2019, 55: 259-266)

To investigate the ocular manifestations of human immunodeficiency virus (HIV) and syphilis coinfection.

A retrospective analysis of the ocular manifestations was carried out in 27 patients (54 eyes) diagnosed as syphilis and HIV coinfection by the Department of Infectious Medicine in Peking Union Medical College Hospital during the years of 2006-2017. The research included 26 males and 1 female, aging from 24 to 76 years old, with a mean age of 40.40±12.94 years old. Ocular anterior segments were examined with slit-lamp microscope. Fundus examinations were conducted with papillary dilation, fundus photography.

At the first visit, there were 2 eyes without light perception, 4 eyes with light perception, 1 eye with hand movement, 1 eye with finger counting, 2 eyes with 0.01-0.09 eyesight, 8 eyes with 0.1-0.2 eyesight, 12 eyes with 0.25-0.4 eyesight, 15 eyes with 0.5-0.9 eyesight, 9 eyes with 1.0-1.5 eyesight. Among the 27 patients (54 eyes) coinfected with HIV and syphilis, keratic precipitates were identified in 20 eyes, aqueous flare positive in 20 eyes, float positive in 15 eyes, and iris posterior synechias in 7 eyes. Nineteen eyes were diagnosed as syphilis uveitis, including 2 eyes with syphilis anterior uveitis and 17 eyes with syphilis panuveitis, among which, vitreous inflammatory opacity was observed in all 19 eyes, disk atrophy in 2 eyes, optic edema in 1 eye, vitreous hemorrhage in 1 eye, retinal detachment in 2 eyes, retinal hemorrhage and white vein in 1 eye. In addition, 8 eyes were diagnosed as HIV retinopathy, all manifested as cotton-wool spot. Among the 8 eyes, 4 were diagnosed as cytomegalovirus retinitis, 3 showed retinal yellow-white lesions, and 1 was in late phase which showed retinal pigmentation. The incidence of both HIV and syphilis coinfection patients and male homosexuality population increased. The most common ocular manifestation of HIV and syphilis coinfection was syphilis panuveitis. Six patients first visited the Department of Ophthalmology, and were then diagnosed as HIV and syphilis coinfection.

The ocular manifestations of HIV and syphilis coinfection are diversified, which can be manifested as fundus necrotic lesions as well as anterior and posterior inflammatory. For HIV positive patients, syphilis serologic test should be routinely performed. The same, syphilis positive patients should be tested for HIV serum antibodies, in order to improve the diagnosis level of HIV/syphilis coinfection and give timely etiological treatment, which is of vital importance for saving visual acuity. (Chin J Ophthalmol, 2019, 55:267-272)

To quantify optical coherence tomographic angiography (OCTA) images and to explore potential clinical values of each parameter in diabetic patients.

A case-control and cross-sectional study of diabetic (129 eyes) and healthy (32 eyes) subjects was conducted. 3-mm OCTA scan, fundus photography and best corrected visual acuity measurement were performed. Image-pro plus was used to calculate microvascular and foveal avascular indices in nonsegmented and segmented OCTA images. Intraclass correlation coefficient and relative standard deviation were used to examine the reliability, reproducibility and accuracy. Correlation of each parameter was calculated, and so was the area under the receiver operating characteristic curve.

Vessel density (VD) of diabetic patients measured in the nonsegmented retinal layer (RL) and superficial retinal layer (SRL) was 49.146%±6.097%, 44.038%±5.641%, respectively, significantly lower than healthy subjects 52.212%±6.250%, 46.698%±5.417% (t=2.534, 2.405; P=0.012, 0.017), and vessel length (VL) was (19.905±2.285)mm, (17.596±2.149)mm, (14.479±2.091)mm in the three layers, which was significantly shorter than that in the healthy control group (21.037±2.185)mm, (18.739±1.994)mm, (15.343±2.266)mm (t=2.529, 2.731, 2.059; P=0.012, 0.007, 0.041). Compared with non-diabetes, foveal avascular zone (FAZ) in diabetes was (0.441±0.167)mm², larger compared to health eyes 0.352±0.109mm² (t=-2.831, P=0.005). FAZ demonstrated a negative correlation with VD and VL in RL or SRL(r=-0.227, -0.338; P<0.05) (r=-0.241, -0.332; P<0.05), while best corrected visual acuity showed a negative correlation with VL in each layer (r=-0.225, -0.201, -0.250; P=0.01, 0.022, 0.004), and VD in DRL (r=-0.197, P=0.026). All parameters showed high reproducibility between graders(intraclass correlation coefficient>0.965), while relative standard deviation was greater than 3.049%. AR had the highest area under the receiver operating characteristic curve (0.737), compared with AI (0.724).

Our study demonstrates good reliability, reproducibility and accuracy of quantification of OCTA images and reveals changes of VD, VL and FAZ in diabetes, which may occur earlier than vision impairment. AR and AL may have great values in prompting early diabetic retinopathy in diabetic patients. (Chin J Ophthalmol, 2019, 55:273-279)

To observe the incidence and severity of retinopathy of prematurity (ROP) in extremely low birth weight (ELBW) infants by strictly controlling the risk factors of ROP, such as oxygen inhalation after birth, to explore the related factors of ROP in ELBW infants.

This was a cross-sectional study. 166 ELBW infants underwent neonatal screening were enrolled in this study, whose birth weight was less than 1 000 g. There were 79 males and 87 females infants, whose average gestational age was (27.99±1.73)weeks, and average birth weight was (904.45±80.23)g. According to the final screening results, the ELBW infants were grouped as follows: (1)ROP group and non-ROP group; (2)severe ROP group and mild or no ROP group. Risk factors included gestational age, birth weight, test-tube infants, fetuses number, complications during pregnancy, delivery mode and Apgar scores in 1 to 10 minutes, weight and weight gain proportion at 1-6 weeks after birth, postnatal feeding mode, history of oxygen inhalation, anemia and blood transfusion, and other systemic diseases were recorded. And their correlation with severe ROP was analyzed by SPSS 20.0 statistical software.

Ninty-four (56.63%) ELBW infants developed ROP, 16 (9.64%) were severe ROP and 14(8.43%) received treatment. Average birth weight between ROP group (911.95±72.80)g and non-ROP group (894.67±88.58)g had no difference(t=1.379, P=0.170). Average gestational age between ROP group (27.49±1.53) weeks and non-ROP group (28.64±1.76) weeks had significant difference(t=-4.491,P<0.001).And pregnancy-induced hypertension during pregnancy (χ²=4.479, P=0.034), Apgar score in 5 minutes (t=-2.760, P=0.006) and 10 minutes (t=-2.099, P=0.043), pneumonia (χ²=6.233, P=0.013), neonatal pneumonia (χ²=18.026, P<0.001) had significant difference between ROP group and non-ROP group. There was no effect on weight (F=0.009,P=0.753) or weight gain proportion (F=2.394,P=0.124) at 1-6 weeks after birth in ELBW infants with or without ROP. Average birth weight between severe ROP group(875.63±74.85)g and mild or no ROP group(907.53±80.41)g had no difference(t=-1.518, P=0.131).Average gestational age between severe ROP group(26.88±1.31)weeks and mild or no ROP group (28.11±1.73)weeks had significant difference(t=-2.766,P=0.006).And only fundus hemorrhage (χ²=4.507,P=0.034) had significant difference between severe ROP group and mild or no ROP group. There was no effect on weight (F=2.683,P=0.103) or weight gain proportion (F=0.431,P=0.513) at 1-6 weeks after birth in ELBW infants with or without ROP. Logistic regression analysis revealed that only gestational age was correlated to the incidence (β=-0.437,P<0.001) and severity (β=-0.616,P=0.007) of ROP significantly.

By strictly controlling the risk factors of ROP, such as oxygen inhalation after birth, the severe rate of ROP in ELBW infants is low. However, gestational age is still the inevitable independent high risk factor for the incidence of ROP in ELBW infants. (Chin J Ophthalmol, 2019, 55:280-288)

To investigate the efficacy of 20% mannitol in reducing intraocular pressure (IOP) in eyes with different intraocular tamponades after pars plana vitrectomy (PPV).

Retrospective case-control study. Sixty-eight patients were administered with 20% mannitol and IOP was noted at regular intervals after simple PPV with ocular hypertension, including 24 males (26 eyes) and 44 females (46 eyes), aged (45.6±19.3) years. These cases were divided into three groups according to different tamponades: silicon-oil tamponade, 23 eyes; gas tamponade, 30 eyes; balanced salt solution (BSS), 19 eyes. The data were analyzed using the t test, variance and q test.

There was a significant decrease in IOP in all patients after using 20% mannitol. The IOP in the group of silicon-oil decreased from (33.25±2.56) mmHg (1 mmHg=0.133 kPa) to (23.21±1.85) mmHg, with a maximum decrease of 30.10%; the reduction in the group of C₃F₈ was from (33.25±2.84) mmHg to (12.15±1.12) mmHg, with a maximum decrease of 33.44%. The IOP of the two groups dropped to a minimum both at 75 minutes. In the group of BSS, the IOP decreased from (32.95±2.33) mmHg to (17.50±1.35) mmHg, and the maximum extent of the decrease was 45.82% at 45 minutes. The difference in the IOP among the three groups at 20 min, 30 min, 45 min and 60 min was statistically significant (F=34.02, 112.68, 122.07, 34.83, all P=0.00). There were significant differences between the BSS group and the silicone-oil group (q=6.44, 13.04, 15.00, 17.11, all P=0.00), and between the BSS group and the C₃F₈ group (q=7.68, 12.56, 12.93, 13.61, all P=0.00).

In eyes with different intraocular tamponades, 20% mannitol was useful for short-term IOP reduction after vitrectomy, especially in those with BSS within one hour. But after 75 minutes, there was no statistically significant difference between groups. (Chin J Ophthalmol, 2019, 55:289-293)

To investigate the treatment of retinopathy of incontinentia pigmenti by anti-vascular endothelial growth factor.

Retrospective study of 5 patients(8 eyes) diagnosed retinopathy of incontinentia pigmenti from 2005 to 2017, including 0 males and 5 females (8 eyes involved) with an average age of 2.4 months(range, 1-5 months). Medical history and family history were recorded in detail for all children. We did the examination of anterior segment of the eyeball, vitreous body,fundus and intraocular pressure for the 5 patients(8eyes).What′s more,wo also took pictures for fundus with the machine of Retcam. Fundus fluorescence angiography (FFA) was performed in 2 patients(4 eyes). Different surgical methods were selected according to the specific conditions of the eye and postoperative were observed.

At the time of initial diagnosis, preretinal hemorrhage did not affect the macular region in 3 cases (5 eyes), pre retinal hemorrhage affected the macular region in 1 case(1 eye), the retinal neovascularization in 3 cases(5 eyes), the retinal detachment in 2 cases(2 eyes), and nonvascular zone of peripheral retinal in 5cases(8 eyes). Treatment and drug selection: 3 cases(5 eyes) were treated with injection anti-VEGF drug into vitreous body cavity, 1 case(1 eye) was treated with injection anti-VEGF drug into vitreous body cavity plus laser photocoagulation, 1 case(1 eye) was treated with anti-VEGF drugs plus vitrectomy. 1 case(1 eye) was treated with anti-VEGF drugs plus retinal cryotherapy and sclera bucking. In patients of injection anti-VEGF drug into vitreous body cavity, 2 cases(3 eyes) were given a single dose and 1 case (2 eyes) was given a repeated dose. Drug selection: 4 cases(6 eyes) ranibizumab injection (injection dose 0.025 ml), 1 case (2 eyes)conbercept injection (injection dose 0.025 ml). To follow-up date, etina was flat in 4 patients (7 eyes), epiretinal membrane in 2 patients(2 eyes), retinal detachment in 1 patient(1 eye).

The efficacy of anti-vascular endothelial growth factor in the treatment of retinopathy of incontinentia pigmenti was prelininarily confimed.However,the optimal use timing,dosage,local and systemic safety issues were needed to be further studied. (Chin J Ophthalmol, 2019, 55:294-301)

The patient was a 13-year-old male. One year ago, his right eye was irradiated with a high-power laser pen for a short time. Now, the naked eye visual acuity of his right eye was 0.1, and the correction did not improve. A full-thickness hole was seen in the macular area of the right eye. After admission, vitrectomy, inner limiting membrane tear and gas-liquid exchange were performed in the right eye. The foveal morphology was recovered after operation, and the visual acuity was not improved.(Chinese Journal of Ophthalmology, 2019, 55:302-303)

A 3-year-old female was seen due to poor visual acuity. The corrected visual acuity of the left eye was 0.2. Coherence light tomography showed that the choroidal vascular layer at the lesion site of the left eye was thinned and partially disappeared, the retinal structure of the corresponding site was disordered, the outer retinal layer was cleaved obviously, and the ellipsoid structure was abnormal. The preocular index of visual acuity of the left eye of the mother of the child, and choroidal defects were found in fundus examination.(Chinese Journal of Ophthalmology, 2019, 55:304-305)

The patient was a 44-year-old female. Because his left eye suddenly lost sight for half an hour, he went to the Department of Ophthalmology, Jizhou District People's Hospital, Tianjin. Ocular examination: anterior index of left eye visual acuity, intraocular pressure 12 mmHg (1 mmHg =0.133 kPa), transparent cornea, medium-deep anterior chamber, clear aqueous humor, pupil diameter 3 mm, slightly obtuse in direct light response; Examination of the fundus under the small pupil shows that the retinal artery is slender and the whole retina is light in color, which is considered to be occlusion of the central retinal artery. Eye massage treatment is performed urgently, and the pupil is dilated at the same time. During the eyeball massage, fundus photography is performed intermittently (Quintessence Picture 1）。 After eye massage treatment, the visual acuity of the patient's left eye gradually returned to 1.0.

Optical coherence tomography angiography (OCTA) is a new technology of angiography which features multiple advantages over the traditional ones. It can provide a rapid and noninvasive approach to observing the vascular morphology and blood vessel density of the optic disc, peripapillary and macular area. Nonarteritic ischemic optic neuropathy (NAION) is an acute optic neuropathy characterized by a sudden, painless decrease in vision and a typical visual field defect. It has been widely accepted that the circulatory insufficiency of the optic nerve head (ONH) mainly supplied by the posterior ciliary arteries (PCA) results in ischemic damage. Relevant researches are necessary for exploring the pathogenesis, diagnosis and treatment of NAION, and this review summarizes the results of recent studies on application of OCTA in analyzing the blood flow in the optic and macular area in NAION patients. (Chin J Ophthalmol, 2019, 55:306-310)

Acute macular neuroretinopathy (AMN) is a rare macular disorder. The clinical diagnosis of AMN is difficult and complicated since the retinal symptoms of patients with AMN are usually unclear or untypical. Spectral domain optical coherence tomography (SD-OCT) is a reliable examination for imaging the retinal structure, which improved the insight of AMN in etiology and pathogenesis. This review summarizes and analyzes the recent clinical reports and research progress, in an effort to present a more accurate clinical recognition of AMN. (Chin J Ophthalmol, 2019, 55:311-315)

In recent years, a series of research achievements have been made in uveitis research in China. In terms of clinical research, the clinical lineage of uveitis in China was summarized, and the clinical characteristics of uveitis patients in China were summarized based on the observation and study of Chinese patients. In terms of basic research, the theoretical framework for the occurrence of uveitis was updated. In the study of the genetic background and immunological mechanism of uveitis, China has been in the international advanced ranks. This article summarizes, analyzes and reviews the main achievements of Chinese scholars in uveitis related research, so that more readers can understand and carry out more in-depth research.(Chinese Journal of Ophthalmology, 2019, 55:316-320)