Volume 56 · Issue 07 · 2020

Vision is the receptive and cognitive process of converting light and pattern signals into nerve impulse signals. The main role of visual physiology is to elucidate the neural mechanism of vision. As an important part of visual physiology, visual electrophysiological examination, like electrocardiogram and electroencephalogram, is used to diagnose diseases through the bioelectrical phenomena generated during the activities of body organs and tissues. Since the founding of the People’s Republic of China, remarkable achievements have been made in basic research, translational research and clinical research of visual physiology with more than 70 years of heritage and efforts. But there are still many unknown areas that need further exploration. Looking back at the development history will encourage us to forge ahead and make more contributions to visual physiology in China. Congratulations on the 70th anniversary of the founding of Chinese Journal of Ophthalmology. （Chin J Ophthalmol， 2020， 56: 481-488）

Clinical visual electrophysiological examination is a method that can objectively reflect visual function. It has become one of the important methods of ophthalmological examination, and the operation process has strict specifications. This article introduces the history, formulation and content of international clinical visual electrophysiological examination standards, which will help ophthalmologists understand the importance of the standardization of the operation process, so as to better promote and standardize the clinical visual electrophysiological examination in China. ( Chin J Ophthalmol, 2020, 56: 489-491)

Clinical electrophysiological examination of the visual system includes a series of non-invasive and non-invasive tests to provide clinically objective indicators of the functions related to different locations and cell types of the visual system. This guide, developed by the International Society for Clinical Visual Electrophysiology, introduces the standard process of visual electrophysiology diagnosis, including full-field electroretinogram (ERG), graphic ERG, multifocal ERG, electrooculogram and visual evoked potentials generated by cerebral cortex, outlines the basic principles of visual electrophysiology examination, and illustrates the methods of visual electrophysiology examination of common diseases and their corresponding manifestations through examples.(Chinese Journal of Ophthalmology, 2020, 56:492-508)

To observe the effects of intravenous methylprednisolone pulse (IVMP) therapy on the recovery of visual acuity and its influencing factors in patients with the relapse of aquaporin (AQP) 4 antibody positive neuromyelitis optica related optic neuritis (NMO-ON).

Retrospective case series. Forty-eight eyes of 35 patients diagnosed as NMO-ON in the Neuro-ophthalmology Clinic of Beijing Tongren Hospital from September 2012 to April 2018 were included in this research. All patients were AQP4 antibody seropositive, and had clinical manifestations of acute optic neuritis, with a history of optic neuritis treated with glucocorticoids effectively. They received the treatment of IVMP 500 mg/d or 1 000 mg/d for 3 to 5 days. The post-treatment and pre-treatment visual acuities were compared. Improving four lines or more was considered as markedly effective, improving two or three lines as effective, and improving one line or no change or a decline as no effect. The impacts of age, visual acuity at onset, relapse rate and dosage on the acute exacerbation of NMO-ON were analyzed. Mann-Whitney U test and Kruskal-Wallis test were used for statistical analysis.

Among the 35 patients, there were 2 males and 33 females, aged from 15 to 73 years (median, 36 years). In the 48 eyes of recurrence, the treatment was effective 41.7% (20/48), effective 20.8% (10/48), and ineffective 37.5% (18/48). The IVMP therapy was effective in 25 of 34 eyes with one recurrence and 5 of 14 eyes with two or more recurrences, and the difference was statistically significant (Z=2.315, P=0.021). The efficacy in 13 eyes with preoperative visual acuity not lower than 0.05 (10/13) was better than 35 eyes with preoperative visual acuity lower than 0.05 (20/35), and the difference was statistically significant (Z=1.994, P=0.046). Different ages and doses (1 000 mg/d and 500 mg/d) made no significant difference in the efficacy (P=0.273,0.105).

The IVMP therapy is effective for the NMO-ON relapse in patients who were AQP4 antibody seropositive. The effect of IVMP treatment at doses of 500 mg/d and 1 000 mg/d is similar. Furthermore, visual acuity less than 0.05 and more relapses reduce the efficacy in relapsed NMO-ON patients. (Chin J Ophthalmol, 2020, 56: 509-513)

To investigate the features of the full-field electroretinogram (FERG) in patients with ocular surface alkaline injury, and to clarify the clinical significance of FERG examination in alkaline ocular trauma.

Retrospective series of case study. A total of 22 patients with chemical ocular surface injury who were treated in the Department of Ophthalmology of Peking University Third Hospital from May 2018 to January 2020 were selected, including 20 males (25 eyes) and 2 females (2 eyes). The age ranged from 19 to 60 years old (average, 41). There were 17 eyes with alkaline ocular trauma, 7 eyes with thermal burn, and 3 eyes with acid ocular trauma. Seventeen contralateral healthy eyes in patients with unilateral mechanical trauma were used as controls. Fourteen alkaline trauma eyes with visual acuity records were further observed according to the degree of visual impairment. All patients were subjected to different flash intensity stimuli in accordance with a standard of the International Society for Clinical Electrophysiology of Vision for dark-adapted and light-adapted full-field FERG. One-way ANOVA and SNK-q was used for the comparison between groups. The unpaired t test was used for the comparison of patients with different vision.

Compared with healthy eyes the injured eyes’ amplitude of dark adaption FERG b-wave under the dark stimulation of 0.01 cd·s·m^-2 in alkaline ocular trauma, thermal burn, acid ocular trauma was (135±85), (169±55), and (112±43) versus (341±53) μV, respectively; compared with healthy eyes, the differences were statistically significant (F=31.38; q=8.94, 5.70， 5.45；all P<0.01). Compared with healthy eyes the injured eyes’ amplitude of dark adaption FERG a-wave under the dark stimulation of 3.00 cd·s·m^-2 in alkaline ocular trauma, thermal burn, acid ocular trauma was (178±78), (172±35), and (99±53) versus (334±60) μV, respectively; compared with healthy eyes, the differences were statistically significant (F=24.33; q=7.04， 5.60， 5.80；all P<0.01). Compared with healthy eyes the injured eyes’ amplitude of dark adaption FERG b-wave under the dark stimulation of 3.00 cd·s·m^-2 in alkaline ocular trauma, thermal burn, acid ocular trauma was (354±79), (342±77), and (352±201) versus (600±78) μV, respectively; compared with healthy eyes, the differences were statistically significant (F=27.68; q=8.11， 6.51， 4.48； all P<0.01). Compared with healthy eyes the injured eyes’ amplitude of dark adaption FERG OPs under the dark stimulation of 3.00 cd·s·m^-2 in alkaline ocular trauma, thermal burn, acid ocular trauma was (97±54), (107±41), and (45±22) versus (206±32) μV, respectively; compared with healthy eyes, the differences were statistically significant (F=25.03; q=7.36， 5.13， 5.96； all P<0.01).There was no significant difference in FERG between patients with visual acuity≥0.2 and those with visual acuity<0.2 (P>0.05) after alkaline ocular trauma.

By detecting the amplitude change of FERG wave form of chemical ocular trauma, in this study, the amplitude of FERG wave form in alkaline ocular trauma was generally decreased. It’s suggested that alkaline ocular trauma can cause damage to the rod and cone systems of retinal. (Chin J Ophthalmol, 2020, 56: 514-518)

To investigate the role of metagenomic sequencing in the diagnosis of infectious uveitis.

Cross-sectional study. A total of 19 vitreous specimens of patients with suspected infectious uveitis from March 2016 to July 2018 in Beijing Tongren Hospital were collected, including 8 males and 11 females, 19 to 68 years old. There were 10 cases in the right eye, 8 cases in the left eye and 1 case in both eyes. Acute retinal necrosis was clinically diagnosed in 8 patients (9 eyes), and the diagnosis was unknown in 11 patients (11 eyes). About 1 ml of the vitreous fluid was reserved for each specimen, 800 μl for metagenomic sequencing and 200 μl for real-time fluorescence quantitative PCR verification. The TIANamp Micro DNA Kit was used to extract the sample DNA for metagenomic sequencing, and the ultrasonic fragment was broken to 200-300 bp. The BGISEQ-500 platform was used for sequencing. The data with low quality and length less than 35 bp were cleared from the sequencing data to obtain high-quality data. Through biological authentication software, the reference human genome sequence and low complexity were removed from high-quality data. The data obtained were compared with a special microorganism database regarding the percentage of microbial sequences, the number of unique sequences, coverage and sequencing depth, so as to determine positive sequencing parameters, which were classified into bacteria, viruses, fungi and parasites. Real-time fluorescence quantitative PCR was performed to validate the accuracy.

A variety of microorganisms were detected by metagenomic sequencing in 19 specimens, including 3 cases of varicella zoster virus, 2 cases of Candida albicans, 1 case of Propionibacterium acnes and 1 case of Haemophilus parainfluenzae. The percentage of microbial sequences was 77.93% （1 794/2 302）, 99.98% （12 843/12 845） and 98.88%（5 733/5 798）, and the number of unique sequences was 1 794, 12 843 and 57 33 in varicella zoster virus cases, respectively. The verification of varicella zoster virus by PCR was consistent with that by metagenomic sequencing.

Metagenomic sequencing can be used as an alternative method for laboratory diagnosis of infectious uveitis. (Chin J Ophthalmol, 2020, 56: 519-523)

To evaluate the efficacy of triamcinolone acetonide deep fornix injection for the treatment of upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO).

Case-control study. A retrospective analysis was conducted on 64 eyes in 53 patients with upper eyelid retraction caused by TAO from October 2015 to December 2018. Thirty-nine eyes in 33 patients diagnosed with TAO with upper eyelid retraction were treated with triamcinolone acetonide deep fornix injection (20 mg), once per month until the therapeutic effect was stable, as the treatment group. Twenty-five eyes in 20 patients were not treated (the observation group). The ocular examination indexes of the two groups were compared. Paired t-test and independent sample t-test were used for statistical analysis.

There were 6 males and 27 females in the treatment group, aged (43±12) years, and 5 males and 15 females in the observation group, aged (40±13) years. There was no significant difference in gender, age, history and baseline ocular examination indexes between the two groups (all P>0.05). In the treatment group, the number of injections was (2.18±0.94) times (range, 1 to 5 times). After (6.74±3.89) months of follow-up, the marginal reflex distance (MRD1) was reduced from (6.85±0.88) mm to (4.38±1.04) mm, the score of quality of life in thyroid eye disease (TED-QOL) was reduced from 22.03±4.33 to 7.91±3.25, and the clinical activity score (CAS) was reduced from 2.82±0.39 to 0.97±0.39 (t=14.68, 21.36, 20.92; all P<0.01). There was no statistically significant difference in the degree of exophthalmos, intraocular pressure, the diameter of the rectus muscle measured by B-ultrasound before and after treatment (all P>0.05). After (8.65±5.15) months of follow-up, the eyelid retraction also improved in the observation group, but the improvement was more obvious in the treatment group. The differences of MRD₁, TED-QOL and CAS before and after treatment in the treatment group were (2.46±1.05) mm, 14.06±3.80 and 1.85±0.51 respectively, which were significantly higher than those before and after the follow-up in the observation group [(0.32±0.75) mm, 3.24±2.86 and 0.56±0.58, respectively; t=8.86, 11.90, 8.98; all P<0.01]. There was no recurrence in the two groups. In the treatment group, 5 patients (6 eyes) showed a transient intraocular pressure rise, which was controlled after medication; 3 women had menstrual changes.

Deep fornix injection of triamcinolone acetonide for treating upper eyelid retraction is convenient and effective. It can significantly reduce symptoms and improve patients' quality of life. (Chin J Ophthalmol, 2020, 56:524-529)

To evaluate the operability and clinical application effects of femtosecond laser-assisted cataract surgery systems of LenSx and LenSAR.

This was a randomized controlled study. A total of 86 patients (90 eyes) who underwent femtosecond laser-assisted cataract surgery in Wuhan Aier Eye Hospital from April 2018 to November 2018 were enrolled and divided into two groups randomly, including 44 patients (45 eyes) in the LenSx group and 42 patients (45 eyes) in the LenSAR group. During the operation, the following observation indexes were obtained. Operational indicators included the number of docking attempts, anterior capsulotomy time, nucleus pre-treatment time, total femtosecond laser emission time, and total vacuum suction duration. Clinical outcome indicators included changes in the patient's intraocular pressure during femtosecond laser surgery, the rate of subconjunctival hemorrhage, capsulotomy integrity (yes/no), roundness and centricity of the anterior capsule opening (yes/no), the rate of anterior capsule opening tear, and the rate of posterior capsule rupture. Thet-test, rank-sum test or chi-square test were used for statistical analysis.

There were no significant differences between groups in the age and the lens density (both P>0.05). The number of docking attempts in the LenSx group was 1 (1 to 4) and in the LenSAR group was 1 (1 to 2); there was statistically significant difference (Z =-2.23, P<0.05). The difference in the anterior capsulotomy time between the two groups was statistically significant [13.00 (10.00 to 22.00) s compared with 3.00 (1.00 to 3.00) s,Z=-8.71, P<0.05]. The femtosecond laser pre-nucleation time and total femtosecond laser emission time of the LenSx group were (16.67±3.36) s and (30.49±3.53) s, and those of the LenSAR group were (12.38±4.36) s and (15.36±4.29) s, respectively; the differences between the two groups were statistically significant (t=-5.23, -18.26; both P<0.05). The total vacuum suction duration in the LenSx group was (97.23±19.96) s, shorter than that in the LenSAR group [(123.76±16.81) s] (t=6.82, P<0.05). The intraocular pressure after femtosecond laser surgery in both groups was higher than that before surgery. The increase of intraocular pressure in the LenSAR group was (5.64±5.42) mmHg (1 mmHg=0.133 kPa), higher than that in the LenSx group [(2.99±4.66) mmHg] (t=-2.49, P<0.05). The rate of subconjunctival hemorrhage in the LenSx group was 33.3% (15/45), while it was 8.9% (4/45) in the LenSAR group; the difference between the two groups was statistically significant (χ²=6.67,P<0.05). There were no significant differences between groups in capsulotomy integrity, roundness and centricity of the anterior capsule opening, the rate of anterior capsule opening tear, and the rate of posterior capsule rupture (allP>0.05).

The docking process of the LenSAR system is convenient, and there is less subconjunctival hemorrhage; the total vacuum suction duration of LenSx is short, and the increase of intraocular pressure is low. (Chin J Ophthalmol, 2020, 56: 530-535)

A 19-year-old woman presented sudden visual loss in the left eye for 1 day. Ophthalmic examination showed superior hemi-retinal whitening with thickening of the inner retinal layer and shadowing of the outer retina layer and delayed perfusion of the superior hemi-retinal artery and cilioretinal artery. We performed surgery at 34 hours after the onset. After vitrectomy, a 48G micro-needle was connected to the 1-cc syringe of the viscous fluid control unit of the vitrectomy machine. The needle tip was inserted into the lumen of the superior peripapillary branch retinal vein. Then balanced salt solution was injected without tissue-type plasminogen activator, till it entered the vein and nearby artery. After surgery, the patient’s visual acuity restored to 1.0 at 7 days and kept unchanged for 4 weeks. This is the first report on intra-retinal vein cannulation without tissue-type plasminogen activator for 34 hours of hemi-central retinal artery occlusion. It is worth trying for improving visual acuity despite certain morphologic damage.( Chin J Ophthalmol, 2020, 56: 536-538)

The patient was a male, 18 years old. I went to the Department of Ophthalmology of the First Affiliated Hospital of Hainan Medical College because I suddenly felt blurred vision in my right eye for 3 days when I stayed up late and got up in the morning. There were no symptoms such as red eyes and eye pain, and there was no history of trauma. No abnormalities were found on the whole body examination. Eye examination: visual acuity was 20 cm manual in the right eye and 1.0 in the left eye; IOP was 15 mmHg (1 mmHg =0.133 kPa) in the right eye and 16 mmHg in the left eye; The cornea of both eyes is transparent, the anterior chamber depth is normal, the pupil diameter is about 3 cm, the response to light is normal, and the lens is transparent; No obvious opacity was observed in the vitreous body; The right fundus is shown in A and B in Essence Picture 1, and there is no obvious abnormality in the left fundus. Fluorescein fundus angiography in the right eye is shown inQuintessence Picture 1Medium C. Clinical diagnosis: macular preretinal hemorrhage in the right eye.

Neuromyelitis optica spectrum disorders (NMOSD) related optic neuritis (NMOSD-ON) is a common neuro-ophthalmic disease which often results in permanent blindness. NMOSD is characterized by high recurrence rate and poor prognosis. Therefore the two key objectives of the therapeutic approach for patients with NMOSD are treatment of the acute attacks and prevention of the relapses. With the in-depth study of the pathogenesis of NMOSD, new treatments developed for different stages of the disease are emerging. This review gives an update of latest knowledge of NMOSD-ON, emphasizing both current and future therapeutic approaches. (Chin J Ophthalmol, 2020, 56: 539-543)

Crouzon syndrome is an autosomal dominant disorder characterized by acrocephaly, exophthalmos, hypertelorism, strabismus, parrot-beaked nose, and hypoplastic maxilla. It is usually caused by a pathogenic mutation in the fibroblast growth factor receptor 2 gene and premature fusion of the sutures of the cranium and the base of the skull. This article documents the ophthalmic complications in patients with Crouzon syndrome before and after the influence of craniofacial surgery with particular emphasis on the different mechanisms and treatments involved. It is important to perform timely decompressive surgery before the presence of optic atrophy and corneal defects, and make early detection and adequate management of amblyopia, ptosis and strabismus.(Chin J Ophthalmol, 2020, 56: 544-548)

Glaucoma is an irreversible neurodegenerative disease caused by visual field defect due to optic neuropathy. Its typical pathological manifestation is the loss of retinal ganglion cells. Pathologically elevated intraocular pressure as a major risk factor for glaucoma. However, in many normal intraocular pressure glaucoma, even if intraocular pressure is normal, patients still have progressive optic nerve injury and visual field defect, which indicates that in addition to intraocular hypertension factors, non-intraocular pressure factors play a vital role in the pathogenesis of glaucoma. This paper introduces the role of non-intraocular pressure factors such as microcirculation disorder, free radicals, pressure gradient change across sieve plate, excitotoxicity, neurotrophic factor deprivation, axoplasmic devascularization, immune imbalance and glial cell activation in the process of optic nerve injury in glaucoma.(Chinese Journal of Ophthalmology, 2020, 56:549-556)