Volume 56 · Issue 01 · 2020

2020 marks the 70th anniversary of the founding of Chinese Journal of Ophthalmology. Thanks to the efforts of previous editors-in-chief, editorial board and editorial department, Chinese Journal of Ophthalmology has not forgotten its original intention, kept pace with the times, and guided and witnessed the history of rapid development of modern ophthalmology in China. Editor-in-chief Yao Ke in the foreword of this issue, "Concentrate and set sail again:<The article "70th Anniversary of the Founding of Chinese Journal of Ophthalmology" put forward that "Chinese Journal of Ophthalmology" has always implemented the journal running policy of combining theory with practice, popularization and improvement, adhering to the fine tradition of "dedication, truth and endeavor", and achieved extraordinary achievements step by step. In the new year, we will constantly summarize the experience, correct the shortcomings, and strive towards the goal of world-class science and technology journals!

Chinese Journal of Ophthalmology was founded on October 1, 1950, and grew up with New China. This year, it has celebrated its 70th anniversary. At the beginning of the founding of New China 70 years ago, there was a lot of waste waiting to be done. With the full preparation and unremitting efforts of Professor Bi Huade, the first editor-in-chief, and the strong support of ophthalmology and all sectors of society all over the country, Chinese Journal of Ophthalmology was officially launched, becoming one of the earlier journals in the series of Chinese Medical Association journals. In the course of running more than half a century, Chinese Journal of Ophthalmology has experienced ups and downs with New China. During the three years of natural disasters from 1960 to 1963 and the "Cultural Revolution" from 1966 to 1977, the magazine has been suspended twice. After its resumption in 1978, the Chinese Journal of Ophthalmology ushered in a new era with the people of the whole country, and then entered a period of rapid development with the east wind of reform and opening up. Thanks to the efforts of successive editors-in-chief, editorial boards and editorial departments, we have made extraordinary achievements step by step, guiding and witnessing the history of rapid development of modern ophthalmology in China.

Glaucoma is a major irreversible blindness-causing disease. Traditional Chinese Medicine literature have mentioned glaucoma since Qin and Han Dynasties. Progress has been made since 1949, especially in these 50 years. Since 1990, rapid progress has been achieved in the field of glaucoma, including the research of pathogenesis, education, training and establishment of diagnosis and treatment standard for glaucoma. Nowadays, Chinese glaucoma specialists are giving out more and more voice in the international platform. Though the outcome is delightful, we realize that we are still lack of original innovations. After all, the road is still long and rugged, more efforts should be put into the fight against glaucoma.(Chin J Ophthalmol, 2020, 56: 3-8)

Primary angle-closure glaucoma (PACG) is the most common type of glaucoma in China. In recent years, lens extraction has gradually become one of the main means of PACG treatment. However, there are still some problems in specific applications. In this article, we analyze the problems and misunderstandings in lens extraction for treatment of PACG in China at present, hoping to achieve reasonable application and better serve patients with glaucoma. (Chin J Ophthalmol, 2020, 56: 9-12)

Glaucoma surgery is one of the main methods of glaucoma treatment. In recent years, glaucoma surgery has been greatly developed. Minimally invasive surgical procedures for glaucoma have emerged. Patients and surgeons have also increased their expectations of surgery. However, due to the limitation of surgical controllability, the prediction of postoperative efficacy is still not satisfactory. By analyzing the principles and limitations of the existing surgical procedures, the authors put forward the premise of the controllability of glaucoma extrafiltration surgery as that the intraoperative filtration excess can be restricted, so as to effectively avoid the early postoperative complications such as shallow anterior chamber, hypotony and strong inflammation. And within 1 month after surgery, through the filtration of the bubble and the removal of the adjustable suture, the ideal filtration state is gradually achieved. With the controllable maintenance of intraocular pressure at 1 month after surgery, it is possible to effectively predict the intraocular pressure level of 2 years or longer. (Chin J Ophthalmol, 2020, 56: 13-16)

Lamina cribrosa (LC) is considered as the original site of glaucomatous damage of axons of retinal ganglion cells, and therefore understanding the morphological changes in the LC will help to uncover the pathogenesis of glaucoma. Previous studies have indicated that the progress of glaucomatous optic neuropathy may be associated with the LC defects. Based on imaging by swept source optical coherence tomography B-Scan of the optic discs of patients with glaucoma, for the first time the spontaneous local LC defects have been found to balance the gradient between intraocular and cerebrospinal fluid pressures, which in turn can slow down the progress of glaucomatous optic neuropathy. This article provides the direct evidence supporting the role of intraocular and cerebrospinal fluid pressure gradient in the pathogenesis of glaucoma. This finding will increase our understanding of the mechanisms underlying glaucoma and help to develop novel strategies for its treatment and prognosis analysis. (Chin J Ophthalmol, 2020, 56: 17-20)

Increased intraocular pressure is the main risk factor for glaucoma progression, but high intraocular pressure is not equivalent to glaucoma. Only high intraocular pressure without glaucoma is ocular hypertension. In order to reduce the risk of disease progression and provide a reference for the standardization and scientific diagnosis and treatment of ocular hypertension in China, the Glaucoma Group of Ophthalmology Branch of Chinese Medical Association put forward consensus opinions and suggestions on the screening diagnosis of ocular hypertension, identification of high-risk people, individualized preventive treatment and monitoring. (Chinese Journal of Ophthalmology,2020，56：21-24）

To explore the effect of listening to different types of music on intraocular pressure (IOP) and the underlying mechanism.

Cross-sectional study. Participants were students from Sun Yat-sen University from October 2017 to May 2018. The study consisted of two parts. In part 1, three types of music, including relaxing, positive and negative music, were used to find out which kind of music could reduce IOP. IOP was measured before and after listening to music. A self-report questionnaire was used to evaluate emotional responses to each type of music. In part 2, the diurnal curve of IOP at 6 time points of 7:30, 9:30, 11:30, 13:30, 15:30 and 17:30 was measured to determine when the individual's IOP peaked. On the second day, the subject listened to the music that could reduce IOP for 15 minutes at his/her IOP peak time. IOP, blood pressure (BP) and heart rate (HR) were measured, and morphology of the chamber angle was captured by swept-source optical coherence tomography before and after listening to music. Image J software was used to measure the diameter and cross-sectional area of Schlemm's canal (SC). Pairedt-test was used to compare BP, HR and SC measurements prior to and post-music intervention.

In part 1, fifteen subjects, including 7 males and 8 females, were enrolled, with an average age of (23±1) years. Relaxation music could significantly lower IOP [(11.62±2.51) vs. (12.65±2.49) mmHg (1 mmHg=0.133 kPa) , t=-2.39, P=0.032]. Positive music had no effect on IOP [(12.45±2.77) vs. (12.65±2.46) mmHg, P=0.566] and negative music increased IOP [(12.13±1.60) vs. (10.86±2.78) mmHg, t=2.45, P=0.029]. Relaxation music could also arouse relaxation emotions in 14 out of 15 subjects. In part 2, 55 subjects, including 20 males and 35 females, were enrolled, with an average age of (26±10) years. The diurnal curve of IOP at 6 time points of every participant was measured. At each individual's peak time point, listening to relaxation music could decrease IOP [(12.66±4.32)vs. (13.99±4.47) mmHg, t=-5.72, P<0.01]. HR before and after listening to relaxation music was (79.57±10.43) and (75.57±9.62) beats/min, respectively (t=-3.68, P=0.001). Systolic BP was (118.11±13.92) and (110.82±12.67) mmHg, respectively (t=-5.10, P<0.01). Diastolic BP significantly declined from (70.07±9.96) to (66.14±8.48) mmHg (t=-3.65, P=0.001). Average SC area significantly increased after listening to relaxation music [(255.96±93.36) vs. (230.07±92.20) pixels, t=2.88, P=0.006]. Average SC diameter was (8.62±1.89) and (9.41±2.37) pixels, respectively before and after listening to relaxation music (t=3.39, P=0.001).

Relaxation music reduces IOP in healthy subjects probably by dilating the SC.(Chin J Ophthalmol, 2020, 56: 25-31)

To investigate the role and mechanism of microglial activation in the process of retinal ganglion cell (RGC) death in the oxygen-glucose deprivation/reperfusion (OGD/R) model which mimicked retinal ischemia/reperfusion injury in vitro.

Experimental study. Primary RGCs from C57BL/6 mice and BV2 microglia were co-cultured or cultured alone. The OGD/R model was established in vitro (reoxygenation time was set to 6 h, 24 h, 36 h, 48 h). BV2 microglial activation was assessed by immunofluorescence staining of ionized calcium binding adapter molecule 1 (iba1), and the survival rate of RGCs was detected by the Cell Counting Kit-8. The apoptosis rate of RGC was detected by using apoptosis detection kit. The levels of Toll-like receptor-4 (TLR4) and Nod-like receptor family pyrin domain containing protein 3 (NLRP3) in BV2 cells were detected by PCR, Western-blot and immunofluorescence staining. The activity of caspase-8 in BV2 cells was detected by the CaspGLOW Kit, and the content of interleukine-1β (IL-1β) in the supernatant was detected by enzyme linked immunosorbent assay. After the corresponding pathways were blocked by TLR4 small interfering RNA (siRNA) transfection or caspase-8 inhibitor, the expression changes of TLR4 and NLRP3, the activity of caspase-8, and the difference of IL-1β content could be observed as well as the activity of RGCs co-cultured with BV2. Statistical analysis was performed using analysis of variance.

Under co-culture of RGC and BV2 cells, cellular immunofluorescence detection showed that the expression of iba1 in BV2 cells increased, which indicated BV2 cells were activated significantly in the OGD/R model. In the OGD/R model, the apoptosis rate of RGC co-cultured with BV2 cells (71.1%±3.2%) was significantly higher than that of RGC cultured alone (35.1%±1.8%) (t=10.10, P<0.01). Cellular immunofluorescence detection showed that the expression of TLR4 and NLRP3 in BV2 cells in the OGD/R model increased significantly when BV2 cells were cultured alone, and their mRNA levels increased significantly with prolongation of reoxygenation time (F=64.45, 72.74; P<0.01), and peaked at OGD/R 24 h (TLR4 mRNA, relative ratio to control was 2.83±0.23; NLRP3 mRNA, relative ratio to control was 3.12±0.27). Caspase-8 activity also increased with prolonged reoxygenation time, the difference was statistically significant (F=93.57, P<0.01), and peaked at OGD/R 24 h (relative ratio to control was 2.92±0.31). After transfection of BV2 cells with TLR4 siRNA, its caspase-8 activity was significantly inhibited, but using caspase-8 inhibitor did not affect the up-regulation of TLR4 expression in BV2 cells. However, the mature IL-1β secreted by BV2 cells exposed to OGD/R was significantly reduced by using caspase-8 inhibitor (from 3.52±0.55 to 1.39±0.37,t=7.19, P<0.01), meanwhile, the expression of NLRP3 was also significantly decreased after caspase-8 inhibitor pretreatment (from 2.79±0.23 to 1.37±0.19, t=9.37, P<0.01). In the OGD/R model, the activity of RGC cells co-cultured with TLR4 siRNA-transfected BV2 cells was 74.5%±1.2%, and the activity of RGC cells co-cultured with BV2 cells treated with caspase-8 inhibitor was 62.8%±1.5%, those were both higher than that of RGC cells co-cultured with untreated BV2 cells (36.7%±0.3%), and the difference was statistically significant (t=11.60, 6.83; both P<0.01).

TLR4-caspase-8-NLRP3 inflammasome pathway is activated in microglia exposed to OGD/R, resulting in the production of IL-1β, thereby contributing to the death of RGCs.(Chin J Ophthalmol, 2020, 56: 32-40)

To evaluate the rotational stability of the Toric intraocular lens (TIOL) and influencing factors in cataract patients with different axial length.

This retrospective cohort study consecutively enrolled patients who had phacoemulsification and AcrySof TIOL implantation in Peking University Third Hospital from May 2018 to January 2019. Based on axial length, patients were divided into two groups. Group A consisted of patients whose axial length was ≤ 24 mm. Patients whose axial length was >24 mm were included in group B. Data at three months postoperatively were used to evaluate the rotational stability of TIOL and its correlation with axial length, corneal white to white distance, lens thickness and TIOL spherical power. And t test, nonparametric test, chi-square test and Spearman test were used for statistical analysis.

Group A enrolled 39 patients (17 males and 22 females), with a median age of 74 years (range, 36-86 years). Group B enrolled 26 patients (11 males and 15 females), with a median age of 68 years (range, 36-86 years). For the efficacy of TIOL, in group A, the best corrected distance visual acuity (BCDVA, logarithm of the minimum angle of resolution) was 0.30 (0.10, 1.00) preoperatively and 0.10 (0.00, 0.60) postoperatively, and the astigmatism was 2.11 (0.95, 5.10) D preoperatively and 1.00 (0.00, 1.75) D postoperatively. In group B, the BCDVA was 0.36 (0.05, 1.00) preoperatively and 0.05 (0.00, 0.40) postoperatively, and the astigmatism was 2.00 (0.78, 3.76) D preoperatively and 0.75 (0.00, 2.25) D postoperatively. Between group A and group B, there were no significant differences in BCDVA (P=0.604) and astigmatism (P=0.789) preoperatively.In these two groups, postoperative BCDVA and astigmatism both significantly improved compared to preoperative parameters (both P<0.01). Between group A and group B, there were no significant differences in BCDVA (P=0.536) and astigmatism (P=0.076) postoperatively. In terms of rotational stability, the rotation in group A was 5.15°±3.62°, and that in group B was 6.50°±4.66°. There was no statistical difference between two groups (P=0.195). As for predictability, the percentage of eyes with rotation ≤5° was 59.0% (23 eyes) in group A and 50.0% (13 eyes) in group B. There was no statistical difference between the two groups (P=0.647). There was no significant correlation between the rotational stability of TIOL and axial length, corneal white to white distance, lens thickness or TIOL spherical power (P=0.836, 0.568, 0.170, 0.365).

The rotational stability of TIOL at three months postoperatively in patients whose axial length >24 mm is of no difference with patients whose axial length ≤ 24 mm. It has no correlation with axial length, corneal white to white distance, lens thickness and TIOL spherical power. (Chin J Ophthalmol, 2020, 56: 41-46)

To compare the keratometric measurements of the Verion image guided system with the partial coherence interferometry (IOLMaster700) and the scheimpflug corneal topography (Pentacam).

In this cross-sectional study, 146 eyes of 88 patients [mean age, (69±10) years; 62 eyes of male patients and 84 eyes of female patients] with cataract were examined before cataract extraction and IOL implantation surgery in the Tenth People′s Hospital Affiliated to Tongji University from January 2016 to March 2017. Corneal curvature values acquired by the Verion optical imaging system were compared with the IOLMaster700 and the Pentacam. Keratometric data, magnitude of astigmatism, and steep astigmatic axis measurements from all three instruments were also compared. According to the steep axis of astigmatism, the eyes were divided into groups of with the rule (WTR), against the rule (ATR), and oblique astigmatism. The parameter differences between the Verion and the other devices in the three groups were analyzed. The data were evaluated using repeated measures analysis of variance and Bland-Altman plots.

The values of steep keratometry (Ks) of the Verion, IOLMaster700, and Pentacam were (44.60±1.32), (44.73±1.37), (44.43±1.35) D, respectively. The values of flat keratometry (Kf) of the Verion, IOLMaster700, and Pentacam were (43.51±1.41), (43.51±1.52), (43.40±1.45) D, respectively. The values of mean keratometry (Km) of the Verion, IOLMaster700, and Pentacam were (44.60±1.32), (44.12±1.35), (43.92±1.34) D, respectively. The values of astigmatism magnitude were (1.09±0.87), (1.24±1.02), (1.04±0.80) D, respectively. The F values were 1.81, 0.31, 0.93 and 2.22 in relation to Ks, Kf, Km and corneal astigmatism magnitude among the three instruments, respectively (all P>0.05). The 95% confidence intervals of Kf, Ks and astigmatism magnitude between the Verion and the other two devices were -1.10 to 0.80 D, -0.55 to 0.88 D; -1.10 D to 1.10 D, -0.80 to 1.04 D; -1.21 to 0.90 D, -0.92 to 1.02 D. The outcomes were considered acceptable. There were no statistically differences in steep astigmatic axis measurements between the Verion and the other two instruments among the WTR (62 eyes), ATR (45 eyes) and oblique (15 eyes) groups (F=0.63, 0.37; P=0.54, 0.72, respectively).

The Verion image guided system is a reliable system for the measurement of keratometry values and astigmatism. The keratometric power, magnitude and steep axis of astigmatism have no significant difference, and there is a good agreement among the Verion, IOL Master 700, and Pentacam. (Chin J Ophthalmol, 2020, 56: 47-52)

To summarize clinical experience on the clinical feature, etiology and treatment of patients with spontaneous bloody tears as the initial symptom.

Retrospective series of case studies. The clinical data and follow-up data of 27 cases of bloody tears as the first symptom in Lacrimal Center of Ophthalmology, the Third Medical Center of Chinese PLA General Hospital from June 2015 to December 2018 were reviewed. The clinical feature, specific cause, diagnosis, treatment and prognosis of these cases were evaluated.

A total of 27 cases were collected in this study. The patients were 10 males (37.0%) and 17 females (63.0%), including 21 adults (≥ 18 years old, 77.8%) and 6 minors (<18 years old, 22.2%). There were 22 monocular cases (81.5%) and 5 binocular cases (18.5%). Five cases (18.5%) were bleeding from the eye and other parts of the body, and 22 cases (81.5%) were bleeding only from the eye. There were 19 cases (70.4%) with hematic epiphora and secretions from the punctum, 3 cases (11.1%) with blood-stained tears, and 7 cases (25.9%) with blood-like tears. With regard to etiology, 6 cases (22.2%) were combined with systemic lesions, one of which was granulomatosis with polyangiitis and five of which (<18 years old) were idiopathic bloody tears. Twenty-one cases (77.8%) were local lesions, including 18 cases only involving the lacrimal system, 2 cases only involving the ocular surface, and 1 case involving both the lacrimal system and the ocular surface. Among the 21 cases with local lesions, 5 cases were induced by foreign body, 6 cases were induced by simple inflammation, and 10 cases were induced by tumor including 1 case with conjunctival benign tumor and 9 cases with tumor of the lacrimal system (5 with malignant tumor and 4 with benign tumor). Patients with idiopathic bloody tears received psychological and medical treatment, and interictal discharge was lengthened. One case of granulomatosis with polyangiitis was treated by trans-nasal endoscopic dacryocystorhinostomy. With the recurrence of granulomatosis and polyangiitis, bloody tears recurred after surgery. One patient with conjunctival hemangioma was untreated. Lesions in the lacrimal duct system were removed and dacryocystorhinostomy was performed. In this study, 2 patients (1 with small cell neuroendocrine carcinoma and 1 with adenoid cystic adenocarcinoma) died and the other had a good prognosis.

Among the cases of bloody tears, adults and local lesions are more common. Most of the lesions are located in the lacrimal system and are tumors. The main treatment is to remove the lesions, and if necessary, to expand the resection and reconstruct the lacrimal duct. Idiopathic bloody tears occur in minors, who are gave psychotherapy and necessary medical treatment. (Chin J Ophthalmol, 2020, 56: 53-58)

Sun Xinghuai, chief physician, professor of ophthalmology, doctoral supervisor. Department of Ophthalmology, Eye, Ear, Nose and Throat Hospital affiliated to Fudan University, Director of Key Laboratory of Myopia of National Health Commission/Chinese Academy of Medical Sciences, Director of Department of Ophthalmology and Vision Science, Shanghai Medical College, Fudan University; Chairman-designate of Ophthalmology Branch of Chinese Medical Association, Chairman of Ophthalmology and Vision Science Expert Committee of Chinese Research Hospital Association; Academician of Asia-Pacific Academy of Ophthalmology, Director of World Glaucoma Association. Winner of the second prize of the National Science and Technology Progress Award, the Outstanding Achievement Award of Chinese Ophthalmology, the Golden Apple Award of Sino-American Ophthalmology Society and the Outstanding Contribution Award of Asia-Pacific Ophthalmology Association.

The patient was a 17-year-old male. Due to glaucoma cyclitis syndrome in his left eye, he went to Beijing Tongren Eye Center in September 2016 and June 2019, respectively. On 5 Sep 2016, when the color fundus image of the left eye was taken, IOP was 31.7 mmHg (1 mmHg =0.133 kPa); On 3 Jun 2019, when the color fundus image of the left eye was taken, the intraocular pressure was 12.3 mmHg, which showed that the blood vessels at the boundary of the optic cup were displaced and the optic cup was slightly smaller (Quintessence Picture 1AndQuintessence Picture 2）。 It is suggested that the sieve plate of adolescent optic disc is more elastic and easily affected by intraocular pressure and other factors. It is speculated that when intraocular pressure increases, the optic cup is enlarged after the sieve plate is displaced, and when intraocular pressure returns to normal, the sieve plate is reset and the optic cup is reduced.

Visual evoked potential (VEP) is often used for the objective evaluation for impairment of visual function. Although these VEP-related tests have good results in the assessment of glaucoma, their application as routine tests in the clinical diagnosis of glaucoma is limited due to the time consumption and easy interference by the environment and the reliance on the experience of the doctors. However, several new VEP detection modes have emerged in the past decade, such as short-duration transient VEP and isolated check VEP. Preliminary studies have shown that both of them have good diagnostic ability in glaucoma, and more studies on the clinical application of these latest technologies are conducive to further understanding of their value in the visual function evaluation and follow-up of glaucoma. (Chin J Ophthalmol, 2020, 56: 61-65)

In recent years, with the improvement of high-intensity focused ultrasound technology, ultrasound cycloplasty has once again gained clinical recognition, becoming one of the non-invasive procedures for glaucoma treatment. Although high-level evidence is still lacking so far, the existing literature has shown that ultrasound cycloplasty can effectively and safely decreases the intraocular pressure in glaucoma by reducing the formation of aqueous humor and increasing the drainage of aqueous humor through the uveoscleral pathway. This article focuses on the efficacy and safety of ultrasound cycloplasty in the treatment of glaucoma, reviews the existing literature, and summarizes the information on the development of equipment, treatment mechanisms, surgical procedures, effectiveness of intraocular pressure reduction, and post-operative complications, with the purpose to provide reference for clinical research and application. (Chin J Ophthalmol, 2020, 56: 66-70)

The visual field is an important basis for the diagnosis of glaucoma. With the continuous development of computer automatic visual field meter, visual field detection procedures and strategies are constantly updated. From the earliest full threshold strategy to the Swedish Interactive Threshold Algorithm (SITA) strategy, from the most commonly used central 24-2 program for checking glaucoma to the central 10-2 program that emphasizes the macular area, and then to the latest SITA Faster strategy central 24-2C program, it continues to provide Faster and more effective detection methods for clinical diagnosis and treatment. In order to facilitate clinical ophthalmologists to understand and grasp the latest technological development and choose appropriate methods to detect visual field, and accurately detect possible visual field defects while improving visual field detection efficiency, this paper explains the new procedures and strategy changes of Humphrey perimetry. (Chinese Journal of Ophthalmology,2020，56：71-76）