Volume 55 · Issue 06 · 2019

This issue focuses on the research progress in the diagnosis and treatment of ocular surface diseases. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Shi Weiyun.

Keratoconus, which can lead to blindness, is an eye disease characterized by thinning and protrusion of the cornea. Keratoconus often begins during teenage with an incidence rate of about 1∶2 000. As no consensus on the diagnosis and treatment of keratoconus has never been reached in China, many doctors have not acquired a systemic knowledge of the diagnosis and treatment methods, thus various misunderstandings and problems in the clinical diagnosis and treatment of keratoconus still need our attention. By explaining the necessity and principles in the diagnosis and treatment of keratoconus, this article points out that clinicians should make efforts to comprehensively master the methods of clinical diagnosis and treatment of keratoconus and then provide patients with the most suitable treatment according to their different conditions, which are of great importance for the patients to maintain better visual acuity and quality of life for a long period. (Chin J Ophthalmol, 2019, 55: 401-404)

In recent years, the use of therapeutic bandage lens has been gradually popularized in clinical practice in China. In order to promote its reasonable and standardized application, the Professional Committee of Contact Lens Safety Monitoring and Visual Health of China Health Management Association, on the basis of referring to relevant literature and combining with experts' practical experience, after many full discussions, and gathering the opinions of experts from relevant professional groups of Ophthalmology Branch of Chinese Medical Association, after repeated letter review and modification, formed an expert consensus opinion on the clinical application of therapeutic bandage lens, including its indications, contraindications and usage methods, for clinicians' reference in their work.(Chinese Journal of Ophthalmology, 2019, 55:405-412)

To evaluate the clinical effect of rigid permeable contact lenses (RGPCL) in the correction of irregular astigmatism after keratoplasty.

Retrospective case study. From June 2012 to December 2016, 31 patients (37 eyes) who underwent corneal transplantation were tested and fitted with RGPCL. The patients′ data of primary disease, interval from keratoplasty to contact lens fitting, uncorrected visual acuity, best spectacle-corrected visual acuity, best RGPCL-corrected visual acuity, contrast visual acuity before and after RGPCL wear, corneal topography and corneal endothelium parameters before and after RGPCL wear were collected, including ocular complications and comfort of contact lenses.

Among the 31 patients, 24 were male and 7 were female, with age of (31.3±5.8) years. The mean interval between grafting and initial contact lens fitting was (4.6±2.3) years. Uncorrected visual acuity, best spectacle-corrected visual acuity, and best RGPCL-corrected visual acuity were 0.81±0.21, 0.54±0.13, and 0.10±0.07, respectively (t=7.170, 16.617, 17.866; all P<0.05). The average astigmatism was -5.76±2.23 D and -0.83±0.47 D before and after wearing RGPCL (t=8.531, P<0.05). After wearing RGPCL, the contrast visual acuity of 100%, 25%, 10%, and 5% was increased from 0.95±0.33, 1.18±0.21, 1.40±0.00, and 1.40±0.00 to 0.12±0.15, 0.37±0.17, 0.65±0.25, and 0.96±0.29, respectively (t=5.972, 8.473, 9.243, 5.104; all P<0. 05). There were no obvious changes of corneal endothelium parameters during the observation period. No obvious corneal allograft rejection or other complications occurred, and 94.6% (35/37) of the patients felt comfortable with wearing RGPCL.

RGPCL wear is safe and effective in correcting irregular astigmatism after corneal transplantation. We can obtain good corrected vision and improve contrast visual acuity, especially for patients who can not wear spectacles. (Chin J Ophthalmol, 2019, 55: 413-418)

To observe the effectiveness and safety of topical 0.1% tacrolimus(FK506) as immunosuppressant in high-risk penetrating corneal transplantation to prevent the immune rejection and to compare the outcomes with topical 1% Cyclosporin A (CsA).

The study consists of 49 patients (50 eyes), who were fitted with the high-risk corneal transplantation standard and undergone the penetrating keratoplasty(PKP) or combined operation in Beijing Tongren hospital between March 2015 to September. With the time sequence, the patients were divided into observation group (FK506 group) and the control group (CsA group). The observation group included 9 females and 16 males with an average age of 57.8±14.8. Twenty-four patients were in the control group (25 eyes), including 10 females and 14 males, with an average age of (45.1±16.2). Observation group was treated with topical 0.1% tacrolimus, and the control group treated with topical 1%CsA. Both groups′ treatment combined glucocorticoid as well. Two groups had 1 year follow-up observation. The incidence of rejection was compared by statistical methods of Cox regression. The adverse reactions were graded and compared using Mann-Whitney U test.

After one year, 22 cases of the observation group and 23 cases of the control group were accomplished all observations. The rejection rate was 4.54% in observation group and 27.23% in control group. The difference between the groups was statistically significant (χ²=4.291, P=0.038). Control group had high rejection rate. Besides, there was no severe side effects happened in both groups. After 1 month after surgery, 36.4% of the observation group showed mild corneal edema. The ratio of mild to moderate corneal edema in the control group was 26.1% and 8.7%. Three months after surgery, 4.5% of the observation group showed mild corneal edema, while 13.0% and 13.0% of the control group was found mild to moderate corneal edema. Six months after surgery, 4.5% of the observation group showed moderate corneal edema. The ratio of mild, moderate to severe corneal edema in the control group was 17.4%, 17.4% and 8.7%. The degree of corneal edema in the control group was more serious in three monthes(Z=-2.770, -2.018, -2.941, P<0.05). The differences in both monthes were statistically significant. Mild neovascularization occurred in the 13.6% of observation group. Mild to severe neovascularization occurred in the 13.0%, 4.3%, and 4.3% control groups. The degree of neovascularization in the control group was higher than that in the observation group(Z=-3.221, P=0.001). The differences in both months were statistically significant. Mild to moderate neovascularization occurred in the 18.2% and 9.1% of observation group. Mild to extremely severe neovascularization occurred in the 17.4%, 26.1%, 4.3% and 4.3% control groups. The degree of neovascularization in the control group was higher than that in the observation group(Z=-1.988, P=0.047).The differences in both monthes were statistically significant.

Both 0.1% tacrolimus and 1% cyclosporine A are safe and effective in reducing the rejection after high-risk corneal transplantation. (Chin J Ophthalmol, 2019, 55: 419-427)

To explore graft survival rate and its associated factors of DSAEK in patients with endothelial decompensation after penetrating keratoplasty (PKP).

A retrospective case study was conducted, including 51 patients (51 eyes) that underwent DSAEK for endothelial decompensation after PKP in Department of Ophthalmology in Peking University Third Hospital from June 2009 to September 2017. The mean recipient age was (43.3±21.0) years. There were 36 males and 15 females. Data comprising demographic details,surgical methods, complications,follow-up durations,final states of grafts,preoperative and postoperative risk factors were collected. Kaplan-Meier analysis was used to determine the cumulative probability of graft survival. Cox regression model was developed to examine for factors associated with graft survival.

Among 51 eyes,the overall graft survival rate was 78%(40/51). The cumulative probability was 85% (95%CI: 0.73-0.96) and 69% (95%CI: 0.52-0.86) at 1 year and 2 years, respectively. The median survival time was 42 months. The diameter of DSAEK graft and postoperative intraocular pressure correlated with the long-term survival of graft. Larger diameter of DSAEK graft was a protective factor for graft survival (HR=0.29, 95%CI: 0.12-0.73), while postoperative high intraocular pressure was a risk factor (HR=1.08, 95%CI: 1.00-1.16, HR=1.10, 95%CI:1.01-1.12). Recipient age, sex, lens status, the number of previous PKPs and previous glaucoma surgery had no significant effect on long-term survival (P>0.05).

DSAEK is an effective treatment for endothelial decompensation after PKP,with favorable graft survival rate. Larger diameter of graft is beneficial to the long-term survival,while high postoperative intraocular pressure is a risk factor for graft failure. (Chin J Ophthalmol, 2019, 55: 428-434)

To evaluate the changes of corneal transparency undergoing overnight orthokeratology treatment.

Prospective cohort study. Right eyes of juvenile myopic patients fitted with Ortho-K CL at Qingdao Eye Hospital were enrolled. Corneal optical density values were measured by the Pentacam Scheimpflug system before orthokeratology and at 1 day, 1 week, and 1, 3, 6, and 12 months after wearing. Four concentric radial zones centered on the apex of the cornea (≤2 mm, >2 mm and ≤6 mm, >6 mm and ≤10 mm, and>10 mm and ≤12 mm diameter) were applied. Anterior layer (anterior 120 μm), central layer, and posterior layer (posterior 60 μm) were defined according to corneal depth. The data analysis were used One-Way Repeated Measures ANOVA and LSD test.

Forty patients (40 eyes) with myopia (24 male and 16 female, age 10.76±1.74 years) were in enrolled. Corneal optical density value was 13.18±0.23 before orthokeratology, then showed a decreasing trend at the early stage, but there was no statistical difference (within 3months: t=-1.594, -1.472, 0.064, 1.971; P>0.05). The value increased significantly and reached the peak (15.31±0.23, t=7.613, P<0.01) at 6-month, and was still maintained in a high value at 1-year (15.15±0.24, t=7.227, P<0.01). Anterior, central, and posterior layer of corneal optical density values had a downward trend at early stage, and increased significantly in 6-and 12-month (anterior layer t=7.143, 6.177, central layer t=7.508, 6.563, posterior layer t=6.722, 8.533;P<0.01). Only the values decreased significantly in posterior layer at 1-week (baseline 10.21±0.14 vs. 1-week 9.91±0.14, t=-2.348, P=0.024). The corneal optical density value of ≤2 mm diameter began to increase significantly at 1-month (baseline 12.88±0.14 vs. 1-month 13.31±0.19, t=2.158, P=0.037),>2 mm and ≤6 mm diameter at 3-month (baseline 11.71±0.13vs. 3-month 12.50±0.19, t=3.213, P=0.003), and>6 mm and ≤10 mm diameter at 6-month (baseline 11.40±0.30vs. 6-month 13.70±0.33, t=7.635, P=0.000). The high values lasted for 1 year at this three areas. However, >10 mm and ≤12 mm diameter had no obvious change in optical density ( F=1.668, P>0.05). In addition, the significant reduction of optical density values at early stage were mainly concentrated in the posterior layer of the cornea and the>6 mm and ≤10 mm diameter.

Orthokeratology transiently increases corneal transparency of the posterior layer and the>6 mm and ≤10 mm diameter at early stage. However, long-term wearing can cause a decrease of transparency within a 10 mm diameter range. The corneal transparency changes first at the center of the optical zone, then gradually expanding to the periphery, and the anterior, central and posterior layers of cornea are all affected. We speculate orthokeratology affect the corneal oxygen supply and compress cornea mechanically, that leads to corneal stromal remodeling.(Chin J Ophthalmol, 2019, 55:435-441)

To explore the characteristics and significance of corneal biomechanics in patients with suspicious total deviation value in Belin/Ambrosio Enhanced Ectasia Display of Pentacam corneal topography.

In this cross-sectional study, 206 patients (325 eyes) with myopia or myopic astigmatism were collected from refractive surgery center of Tianjin Eye Hospital. Among them, 110 males(213 eyes) and 96 females (153 eyes) were aged (22.68±5.20) years. 57 patients (71 eyes) with a total deviation value of 1.6-3.0 in the Pentacam corneal topography were included in the suspicious group, and 149 patients (254 eyes) of<1.6 were included in the control group. The values of the first applanation time (A1-Time), first applanation length (A1-Length), first applanation velocity (A1-Velocity), second applanation time (A2-Time), second applanation length (A2-Length), second applanation velocity(A2-Velocity), highest concavity time (HC-time), highest concavity deformation amplitude (DA), highest concavity peak distance (PD), highest concavity radius (HC-Radius, RoC), intraocular pressure were measured using the corneal visualization Scheimpflug technology. The total deviation value in Belin/Ambrosio Enhanced Ectasia Display were measured with a Pentacam. The biomechanical parameters of the suspicious group were compared with the normal group by the two independent samplest test and the identity regression analyses. The data correlation was performed using Pearson linear correlation analysis.

Compared with the D normal group, the K1, K2 and Km of D suspicious group were significantly increased (P<0.001). A1-Velocity [(0.152±0.015) m/s] and DA[(1.050±0.090) mm] were significantly increased (t=4.348, 2.708; P<0.001, 0.007), while the CCT, A1-Length, A2-Length and RoC were significantly decreased (P<0.01) in suspicious group. In suspicious group, there was a significant correlation between A1-Time, A1-Length, A2-Length, A2-Velocity, IOP and CCT(r=0.305, 0.324, 0.238, 0.346, 0.316; P<0.05). There was a significant correlation between the anterior surface refractive power K1 and the A1-Length (r=-0.361, P=0.002), and there was a significant correlation between the A1-Length, RoC and anterior surface refractive power K2 (r=-0.369, -0.242; P=0.002, 0.043). There was a significant correlation between anterior surface refractive power Km and A1-Length (r=-0.373, P=0.001). After adjusting the confounding factors between two groups by the identity regression analyses, the A1-Length (P=0.003), A1-Velocity (P<0.001) and DA (P=0.002) were still significant differences.

In total deviation value suspicious group, the corneal thickness was thinner, corneal curvature became steeper and the corneal biomechanical properties were weaker. It is important to screen keratoconus before corneal refractive surgery and choose a reasonable surgical procedure to reduce corneal dilatation after refractive surgery. (Chin J Ophthalmol,2019, 55: 442-447)

To evaluate the preliminary efficacy and safety of penetrating canaloplasty for treating primary angle-closure glaucoma (PACG).

It is a prospective interventional case series study. Twenty-two patients (24 eyes) with PACG were treated with penetrating canaloplasty (video attached) at the Eye Hospital of Wenzhou Medical University from June 2015 to August 2018. This modified canaloplasty was performed by making a window at the corneal-scleral bed. Aqueous was redirected to the opening of Schlemm′s canal after the canaloplasty with intension sutures. Postoperative follow-up was made at 1 day, 7 days, 1 month, 3 months, and 6 months. Surgical success was defined as intraocular pressure (IOP) ≤ 21 mmHg (1 mmHg=0.133 kPa) with glaucoma medication (quantified success) and without any glaucoma medication (complete success). Main outcome measures included IOP, number of medication, surgical success rate, complications, and filtering bleb status. One-way repeated measure ANOVA and rank sum test were used in statistical analysis.

Due to the failure of circumferential catheterization of the canal, 4 eyes converted to trabeculectomy. A total of 19 PACG patients (20 eyes) achieved the successful 360-degree catheterization of the canal, including 11 males and 8 females. The mean age was (54±7) years old (range: 41-65 years old), and the mean angle-closure range was (326.3±46.6) degrees. The mean preoperative IOP was (38.0±11.9) mmHg with the median medication number of 3 (range: 2-5). The mean postoperative IOP was (14.5±11.1), (16.1±6.0), (17.7±5.5), (15.7±5.0), and (15.4±3.7) mmHg at 1 day, 7 days, 1 month, 3 months, and 6 months, respectively. There was significant difference in IOP between postoperative and preoperative (all P<0.01). The median medication number (range) was 0 (0-3), 0 (0-2), 0(0-3), 0(0-2), and 0 (0-2) at the 5 time points, respectively. There was significant difference in medication number between postoperative and preoperative (all P<0.01). The quantified success rate was 95%(19/20), and the complete success rate was 90%(18/20) at 6 months. Postoperative complications were observed in 7 eyes (35%) of 20 PACG eyes, including 3 eyes (15%) with hyphema, 2 eyes (10%) with shallow anterior chamber, 1 eye (5%) with Descemet membrane detachment, and 1 eye (5%) with filtration obstruction at the trabeculum ostium. According to the results of slit lamp and ultrasound biomicroscopy examinations, 70% of the eyes (14/20) had no filtering bleb. Eight eyes (40%) with IOP spike were observed.

Preliminary study shows penetrating canaloplasty is safe and effective in the treatment of PACG, but needs a longer follow-up. (Chin J Ophthalmol, 2019, 55: 448-453)

Ocular ischemic syndrome is not uncommon in clinic, but due to its complex and diverse clinical manifestations, different clinical characteristics in different periods, it is easy to be misdiagnosed and missed, delayed treatment, and poor prognosis. Two patients with ocular ischemic syndrome were diagnosed with ocular ischemic syndrome after the consultation of vascular surgery and neurology department, carotid artery color Doppler ultrasound imaging and carotid artery computed tomography angiography. According to the patient's condition, the patient was given medication and surgical treatment, and the patient improved.(Chinese Journal of Ophthalmology, 2019, 55:454-457)

A 55-year-old male patient was seen for more than 5 years due to visual loss in his right eye. A solitary aneurysm-like lesion was seen next to the macular fovea in the right eye, with a large amount of yellowish-white retina rigid exudation around it. After fluorescein fundus angiography, coherence light tomography scanning and coherence light tomography angiography, the diagnosis of right eye parafoveal exudative vascular abnormal complex was performed. No laser photocoagulation or anti-VEGF treatment was given, and regular follow-up observation was performed.(Chinese Journal of Ophthalmology, 2019, 55:458-459)

The patient was a 14-year-old male. When wearing glasses, it was found that the visual acuity of the right eye did not improve for 2 days. Fundus examination showed retinal detachment in both eyes, and coherence light tomography revealed separation of retinal neuroepithelium and pigment epithelium in the macula and posterior pole of the right eye, and the diagnosis was binocular retinal detachment. The left eye was treated with scleral buckling combined with condensation, and the spontaneous repositioning of the retina in the unoperated right eye was found at 16 days postoperatively.(Chinese Journal of Ophthalmology, 2019, 55:460-462)

Shi Weiyun, Chief Physician, Professor II. Party Secretary and Director of Shandong Institute of Ophthalmology, President of Shandong Eye Hospital. Member of the Standing Committee of Ophthalmology Branch of Chinese Medical Association and leader of keratology group, expert member of Chinese Ophthalmology Branch; Deputy Editor-in-Chief of the Editorial Board of Chinese Journal of Ophthalmology; Special experts of Shandong Taishan Post Climbing Program, young and middle-aged experts with outstanding contributions in the province, and the first medical leading talents in Shandong Province.

The patient was a 56-year-old female. Because of the conscious increase in intraocular pressure in his right eye for 1 week, he came to Beijing Tongren Eye Center of Beijing Tongren Hospital affiliated to Capital Medical University for treatment. Previous cyclitis in both eyes, left eye due to secondary glaucoma, trabeculectomy 1 year ago, maximum postoperative intraocular pressure 28 mmHg (1 mmHg =0.133 kPa). There were no obvious abnormalities in the whole body examination. Ocular examination: IOP was 21 mmHg in the right eye and 19 mmHg in the left eye; The slit lamp microscope showed that the right cornea was transparent, with retrocorneal deposits visible in the center and above (Essence Picture 1A), the posterior corneal deposition was found to be coin-shaped by the post-illumination method (Quintessence Picture 1B）； No abnormalities were seen in the fundus of both eyes. In vivo laser confocal microscope was used to photograph the numismatic posterior corneal sediment area, and Hawkeye cells (cytomegalovirus nuclear replication inclusion bodies) were observed (Quintessence Picture 2）。 Clinical diagnosis: right eye cytomegalovirus corneal endotheliitis; After left eye trabeculectomy^{[1,2,3,4,5,6]}。

Meibomian gland dysfunction (MGD), as a chronic,diffuse Meibomian gland disease,is one of the most common ophthalmological clinical diseases. Symptoms can be mild,such as ocular discomfort, but severe cases resulting in ocular surface damage could affect patients′ visual function. Moreover,with the absence of a thorough examination of eyelid status and Meibomian gland prior to ocular surface surgery, it could cause severe postoperative complications. As a usual but easily overlooked disease, MGD and its associated ocular surface diseases have drawn greater attention,on the other hand,some emerging therapies,in addition to the clinically recognized treatments, provided doctors with more effective treatments at their disposal,and plenty of research achievements have been published. This article emphasizes on new physical approaches in the treatments of MGD and its associated ocular surface diseases. (Chin J Ophthalmol, 2019,55:465-468)

With the rapid development of global perinatal medicine and neonatal medicine, the survival rate of high-risk neonates (premature, and those who suffer neurologic lesion during or shortly after birth, et al.) improved significantly, however the incidence of cerebral visual impairment (CVI) also rose, which has become the most common cause of visual impairment in children in developed countries. Studies found that visual abnormalities of patients with CVI can be various. Since children′s cognition and motor development are inseparable from visual functions, children with CVI are usually characterized by abnormalities in sensory perception, cognition and even movement, other than visual impairment itself. Due to the characteristics of CVI, such as early onset, complex etiology, difficulty in diagnosis and treatment, and involvement with ophthalmology, pediatrics, rehabilitation medicine, genetic epidemiology and other multi-disciplinary content, current domestic research on CVI is limited. From the perspective of ophthalmologist, this paper reviews the progress of ophthalmology diagnosis and treatment in children with CVI in recent years, aiming to have better early recognition and individualized intervention, so as to help pediatrician and rehabilitation physicians to improve survival skills for CVI children and their quality of life. (Chin J Ophthalmol, 2019, 55:469-474)

Corneal endothelial transplantation is an important technical leap in the history of modern ophthalmic surgery. At present, the most widely used automatic keratotomy endothelial transplantation (DSAEK) is a minimally invasive surgical method for selectively removing the diseased corneal endothelial layer and posterior elastic membrane, preserving the patient's own healthy corneal stromal layer, and transplanting healthy corneal endothelial cells and a few posterior stromal corneal endothelial grafts. In this paper, the basic operation methods of DSAEK, including retrocorneal elastic membrane stripping, corneal endothelial graft preparation, corneal endothelial graft implantation, graft positioning and air bubble injection, are introduced in detail (with surgical operation video), in order to provide guidance for clinical work.(Chinese Journal of Ophthalmology, 2019, 55:475-478)

Professor Li Fengming, a famous ophthalmologist, ophthalmologist, ophthalmology educator, member of the Communist Party of China, former chairman of the Ophthalmology Society of Chinese Medical Association, member of the National Occupational Disease Diagnostic Standards Committee, visiting professor of the University of Illinois, the first director of the Department of Ophthalmology of Peking University Third Hospital, and honorary director of the Ophthalmology Center of Peking University Third Hospital (Figure 1), passed away at 1:00 a.m. on 23 March 2019, aged 104, due to illness.