Volume 56 · Issue 04 · 2020

Novel coronavirus pneumonia is a major public health emergency with the fastest spread speed, the widest infection range and the most difficult prevention and control in China since the founding of New China. Ophthalmologists are also taking active actions in the fight against the epidemic. There are three articles related to novel coronavirus published in this issue, namely "Special Topic of Epidemic Prevention and Control: Strengthening Basic and Clinical Research on Eye Infection in Coronavirus" published in the expert review column (Xie Lixin et al.), "Special Topic of Epidemic Prevention and Control: Expert Suggestions on Ophthalmic Protection during the novel coronavirus epidemic" published in the discussion column of standards and norms (corresponding author: Wang Ningli) and "Special Topic of Epidemic Prevention and Control: Disinfection of Ophthalmic Examination Instruments during the novel coronavirus epidemic" published in the expert forum (Zhang Mingchang et al.), hoping to provide a reference for ophthalmologists' diagnosis and treatment activities during this epidemic. The above articles are pre-published in the official website of Chinese Journal of Ophthalmology, and are pushed to the majority of ophthalmologists through our WeChat official account (cjo-eye) at the first time.

To investigate the characteristics of retinal nerve fiber layer (RNFL) thickness in AIDS patients with normal fundus, HIV-related microvascular retinopathy (MVR), and cytomegalovirus retinitis (CMVR).

In this cross-sectional study, 111 patients were diagnosed with AIDS from 2012 to 2017 by infectious disease physicians in Beijing You′an Hospital. There were 105 males and 6 females, aged 20-65 years. According to the results of ophthalmic examination, the patients were divided into three groups: 31 patients in the active-stage CMVR group, 47 patients in the MVR group, and 33 patients with normal fundus in the control group. RNFL thickness was measured by optical coherence tomography in all patients. At the same time, visual acuity, intraocular pressure, and fundus were examined, and AIDS-related systemic examination (CD4⁺ T lymphocyte count, HAART treatment status, and blood cytomegalovirus DNA level) was performed. The measurement data were compared by t-test, variance analysis or rank sum test. The counting data were compared by chi square test or Fisher exact probability method.

In the control group, the thickness of RNFL in the superior quadrant in the left and right eyes was 145 (79, 231) μm and 142 (46, 179) μm, respectively; the difference was statistically significant ( Z=-2.481, P=0.013). The RNFL thickness of the diseased and healthy eyes in the MVR group was 116 (91, 138) μm and 122 (82, 192) μm, respectively, with no significant difference ( Z=-0.861, P=0.389); the best corrected visual acuity was 0.0 (0.0, 0.2) and 0.0 (0.0, 0.2), respectively, with no significant difference (Z=-0.378, P=0.705). In the CMVR group, the best corrected visual acuity of the diseased and healthy eyes was (0.23±0.48) and (0.02±0.82), respectively, and the difference was statistically significant (t=-2.944, P=0.003); the RNFL thickness was 133 (61, 219) μm and 121 (69, 146), respectively, in the whole optic disc, with statistically significant difference ( Z=-2.385, P=0.017), 104 (41, 374) μm and 82 (55, 121) μm, respectively, in the nasal quadrant, and 99 (14, 173) μm and 72 (36, 111) μm, respectively, in the temporal quadrant, with statistically significant difference ( Z=-2.045, -2.543; P=0.041, 0.011). The RNFL thickness in the CMVR group, the MVR group, and the control group was 149 (61, 350) μm, 126 (71, 304) μm, and 113 (87, 149) μm, respectively, with statistically significant difference ( H=20.908, P=0.000).

The fundus of AIDS patients had different characteristics on optical coherence tomography. In active CMVR patients, the thickness of RNFL was generally thickened. In MVR patients, the average thickness of RNFL was thicker than that in the normal control group.(Chin J Ophthalmol, 2020, 56:258-265)

To investigate the altered spontaneous brain activity in patients with retinal vein occlusion (RVO) during the resting state.

A case-control study. Forty-five patients with RVO [24 males and 21 females; age, (51.24±5.86) years] diagnosed from May 2018 to July 2019 in Renmin Hospital of Wuhan University were recruited in the RVO group. Meanwhile, forty-three healthy controls [19 males and 24 females; age, (49.79±7.31) years] who were closely matched in age and sex to patients with RVO were recruited in the healthy control group. Each subject underwent a whole-brain resting-state functional magnetic resonance imaging scan to detect the values of fractional amplitude of low-frequency fluctuations (fALFF). The altered spontaneous brain activity between RVO patients and healthy controls were analyzed. The intra-and inter-group comparisons of two sets of fALFF values were conducted using one-samplet-test and two-sample t-test, respectively.

Compared with the healthy control group, the fALFF values of RVO patients were significantly changed. The fALFF values of left cerebellum (-0.68±0.48, t=3.8081), right cerebellum (-0.79±0.47, t=4.590), right brainstem (-0.57±0.50, t=3.964) and left insula (-0.22±0.27, t=3.587) increased, while the fALFF values of right calcarinesulcus (0.60±0.72, t=-3.521), right thalamus (-0.68±0.43, t=-3.846) and left lingual gyrus (-0.12±0.33, t=-3.876) decreased. The differences were statistically significant (voxel-level P<0.01, Gaussian random field correction, cluster-level P<0.05).

Patients with RVO have abnormal spontaneous neural activity in multiple brain areas, including visual pathways and emotion-cognition processing regions. Moreover, there may be compensatory brain function enhancement in local brain areas. The results provide new insights into the understanding of the mechanism for the occurrence and development of RVO.(Chin J Ophthalmol, 2020, 56:266-271)

To evaluate the treatment of vasoproliferative tumors of the retina (VPTR).

Retrospective case series study. The clinical data of 20 VPTR patients (20 eyes) were retrospectively analyzed, including 2 eyes only treated by cryotherapy, 1 eye only treated by photocoagulation and 1 eye only treated by ruthenium-106 brachytherapy. The remaining 16 eyes had combined treatment of ruthenium-106 brachytherapy, photodynamic therapy, anti-VEGF therapy, photocoagulation and cryotherapy. Nine eyes were also treated by vitrectomy because of complications such as retinal detachment and vitreous hemorrhage.

Single or multiple yellow white or orange red, highly vascular tumor lesions were found in ocular fundi of the 20 eyes. All eyes were accompanied by complications, including intraretinal and subretinal exudations (100%), macular edema (n=19, 95%), epiretinal membrane (n=4, 20%), retinal detachment (n=8, 40%), vitreous hemorrhage (n=6, 30%), abnormal blood vessels (n=16, 80%) and proliferative membrane (n=7, 35%). In the follow-up, the tumor in the eye treated by ruthenium-106 brachytherapy alone was atrophied and the vision improved. Regarding the 2 eyes treated by cryotherapy alone, macular edema and abnormal blood vessels decreased and visual acuity improved in 1 eye, and visual acuity did not change significantly in another eye. More leakages and increased visual acuity were found in the eye treated by photocoagulation alone. Among the 16 eyes treated with combined therapy, 9 eyes had decreased complications and improved visual acuity, 3 eyes did not change significantly, and 2 eyes had increased complications and decreased visual acuity.

The conditions of VPTR are complex and difficult to treat. According to the specific conditions, clinicians should choose appropriate treatment methods; different treatment methods can be combined. Laser photocoagulation and cryotherapy may be chosen to treat small tumors complicated with abnormal blood vessels. Ruthenium-106 brachytherapy could treat big tumors complicated with exudative retinal detachment. Vitreous surgery can be used in hemorrhage and tractional retinal detachment. Anti-VEGF therapy is effective in the treatment of macular edema. (Chin J Ophthalmol, 2020, 56:272-278)

To elevated the retinal toxicity of intravitreal ganciclovir in albino rabbit eyes.

Experimental study. Twenty-four New Zealand albino rabbits (forty-eight eyes) were divided into four groups by random. Three groups were prepared for ganciclovir experiment, named A, B, C. Each group received intravitreal injection ganciclovir dose at 400 μg/0.05 ml, 2 mg/0.05 ml and 5 mg/0.05 ml respectively. The other group named D served as a control accepted intravitreal injection 0.9% normal saline 0.1 ml. Before and after 1, 2 and 4 weeks, flicker full field electroretina gram (ERG) was recorded. After 1, 2 and 4 weeks light and electron microscopic tests were recorded for further toxicity study.

There was significant difference in amplitude of maximal combined response a wave in one week(χ²=8.319, P=0.04), and pairwise comparison the 5 mg group (140.50 μV) was significantly lower than the control group (165.00 μV) (χ ²=-2.830, P=0.028). Maximal combined response b wave in four weeks(χ²=-10.626, P=0.014), and pairwise comparison the 5 mg group (261.50 μV) was significantly lower than the control group (398.00 μV) (χ ²=-2.973, P=0.018). 30 Hz flicker response in one, two and four weeks(χ²=17.589, 8.225, 8.997, P=0.001, 0.042, 0.02), and pairwise comparison the 5 mg group (71.3μV, 106.00μV, 63.60μV) was significantly lower than the control group (118.50μV, 129.00μV, 116.50μV) (χ²=-4.142, -2.826, -2.713, P=0.000, 0.028, 0.040). There was no histologic retinal toxicity evidence of group 400 μg and control group observed by light microscopy in any stage of the study. Histologic changes of group 2 mg four week later, group 5 mg two and four week later include inner nuclear layer loose arranged, nuclear of ganglia were widened and outer plexiform layer stained less in four week later. By electron microscopic observation, the ultrastructure of retina changed to different degrees and became worse in each experimental group with significant mitochondrial swelling and hydropic changes were seen in the inner segments of photoreceptors, loosely arranged and disordered in the outer segment of photoreceptors four weeks later.

The retinal function and morphology were normal in group 400 μg. Group 2 mg and 5 mg had retinal toxicity, and 5 mg was more severe. Therefore, the clinical application of ganciclovir in the treatment of acute retinal necrosis (ARN) should select the minimum effective dose to avoid the occurrence of retinal toxicity. (Chin J Ophthalmol, 2020, 56:279-285)

To discuss clinical features and treatments of fungal keratitis, and to provide statistical data for clinical therapy and increase the therapeutic effects.

This is a retrospective case series study. An analysis was performed by collecting patients′ demography features, risk factors, onset time, lab results, clinical features and treatment from 1 414 cases of fungal keratitis from January 2006 to October 2016 in Qingdao Eye Hospital, Shandong Eye Institute.

In the 1 414 cases (1 414 patients), 1 174 patients (83.0%) came from different areas in Shandong Province, and the rest mainly from provinces on the north of Yangtze River. The age was 40 to 60 years in 874 cases (61.4%). The onset time was often in autumn and winter. The average duration between the onset and treatment was 1 to 74 days; 942 patients (67.1%) visited our hospital in 8-30 days after the appearance of the symptoms. Corneal trauma was the most common risk factor, especially injury by plants (367 cases, 26.4%). The positive rate of direct microscopic examination of potassium hydroxide wet mounts was 96.4%. The positive rate of confocal microscopy was 89.8%. Fungi were detected in corneal ulcer scrapings and (or) diseased corneal tissues obtained during surgery from 973 patients (68.8%). Most of the fungi were Fusarium (595 cases, 61.1%), followed by Alternaria (184 cases, 18.9%) and Aspergillus (119 cases, 12.2%). There were 603 cases (42.7%) of superficial and middle stromal infiltration, 614 cases (43.4%) of deep stromal infiltration and 197 cases (13.9%) of full-thickness corneal infiltration. Diameters of the corneal ulcer lesion were mostly between 4 and 6 mm (725 cases, 51.6%), followed by<3 mm (372 cases, 26.4%) and>6 mm (302 cases, 22.0%). Hypopyon was combined in 498 cases (35.2%), corneal perforation in 34 cases (2.4%), and endophthalmitis in 58 cases (4.1%). Surgery was performed in 1 198 cases (84.8%), including penetrating keratoplasty in 416 cases (29.4%), lamellar keratoplasty in 199 cases (14.1%), and corneal ulcer debridement in 532 cases (37.6%), with an effective rate of 98.1% (408 cases), 97.0% (193 cases) and 92.8% (494 cases), respectively. Two hundred and fifteen cases (15.2%) were treated with medical therapy alone, of which 147 cases (68.4%) were cured. Fifty-six patients (3.9%) finally lost their eye balls, including 54 cases of evisceration and 2 cases of ophthalmectomy.

Fusarium is the main causative agent of fungal keratitis in Shandong Province. Direct microscopic examination of potassium hydroxide wet mounts is a simple, rapid and effective test method. Early diagnosis can be made if the result of corneal ulcer scraping examination is positive. Antifungal drug treatments can be done in early onset time. If the drug efficacy is poor or the patient′s condition gets worse, immediate surgery is the key to controlling fungal keratitis. (Chin J Ophthalmol, 2020, 56:286-293)

To investigate the clinical characteristics and therapeutic effect of neurotrophic keratitis (NK).

A retrospective case series study. A total of 46 patients (48 eyes) with clinically diagnosed NK in Beijing Tongren Hospital from May 2013 to July 2016 were analyzed, including 26 males (26 eyes) and 20 females (22 eyes), aged (51±18) years. The general condition, etiology, clinical features, stage of disease and curative effect of NK patients were summarized. Corneal sensation was measured by Cochet-Bonnet corneal sensor for 25 patients (26 eyes), and the correlation between corneal sensation and clinical staging was analyzed. The χ ² test was performed on the distribution characteristics of patients with different clinical stages of NK. Correlation analysis of corneal sensation and the disease stage was performed using Spearman correlation analysis.

Forty-four cases of monocular disease (96.65%) and 2 cases (4.35%) of bilateral disease were enrolled. Four eyes (8.33%) were from young patients (aged 18-29 years), 23 (47.92%) were from middle-aged patients (aged 30-59 years), and 21 (43.75%) were from elderly patients (aged ≥60 years). The disease was at stage Ⅰ in 8 eyes (16.67%), at stage Ⅱ in 21 eyes (43.75%), and stage Ⅲ in 19 eyes (39.58%). There was no significant difference in clinical staging between the three age groups (χ²=2.452, P=0.658). The most common cause of NK was virus infection (17 eyes,35.42%), followed by neurosurgical sequelae (11 eyes, 22.92%) and diabetes in 10 eyes(20.83%). Corneal sensation of 26 eyes ranged from 0-3 cm. There was no significant correlation between clinical stage and corneal sensation (r²=0.284, P=0.753). The patients were followed up for an average of 7 months. Thirty-four eyes (70.83%) received conservative treatment, and 8 eyes(16.67%) had surgery. Six patients (6 eyes) were lost for follow-up.

NK can occur in all ages, mainly in the elderly. The clinical manifestations are diverse. If time delays in the diagnosis and treatment, it often causes corneal ulcers. There is no significant correlation between corneal sensation and clinical stage. Early diagnosis and targeted treatment are important for protecting patients′ visual function.(Chin J Ophthalmol, 2020, 56:274-298)

Surgeon IntroductionWei Wenbin, MD, is vice president of Beijing Tongren Hospital affiliated to Capital Medical University, deputy director and director of ophthalmology of Beijing Tongren Eye Center, professor, doctoral supervisor and vice president of College of Ophthalmology of Capital Medical University. Young and middle-aged experts with outstanding contributions from the National Health Commission, enjoying government subsidies from the State Council, winners of Bethune Medal, and experts in central health consultation. Selected into the first batch of national and Beijing New Century "Hundreds and Thousands" Talent Project, the first batch of leading talents of the National Ten Thousand Talents Project. Standing Committee member of Ophthalmology Branch of Chinese Medical Association, deputy leader of fundus diseases group; Deputy editor-in-chief and editorial board member of Chinese Journal of Ophthalmology and Chinese Journal of Fundus Diseases. He has been engaged in ophthalmology clinical work for more than 30 years, and is good at clinical diagnosis and treatment of fundus diseases.

The patient was a 12-year-old female. For many years, I went to the Department of Ophthalmology of Peking Union Medical College Hospital because of the dark shadow in front of my left eye with visual loss (the dark shadow disappeared after more than 10 days and visual acuity recovered). Eye examination: visual acuity was 1.0 for the right eye and 0.25 for the left eye; No abnormalities were observed in the anterior segment of both eyes; The boundary of the optic disc in the left eye was clear and normal, with tangled vascular haptics on the surface of the upper edge of the optic disc, no reflection in the fovea, and no bleeding or exudation in the peripheral retina (Quintessence Picture 1）； No abnormalities were observed in the right fundus. Fluorescein fundus angiography examination is shown inQuintessence Picture 2。 Clinical diagnosis: anterior optic disc haptic of left eye.