Volume 56 · Issue 09 · 2020

With the development of medical science, new techniques and methods of ophthalmic pathology are constantly emerging, which has greatly promoted the advancement of ophthalmology. The Chinese Journal of Ophthalmology has witnessed the growth of ophthalmic pathology in China since its founding 70 years ago. This article reviews the development of diagnostic techniques of ophthalmic pathology in China and speculates their future direction.（ Chin J Ophthalmol， 2020， 56: 641-645）

Ocular tumors include intraocular tumors and tumors of the eyelid, orbit, conjunctiva and lacrimal apparatus. After seventy years of continued growth, ocular oncology in China, from small to large and from weak to strong, has made great achievements. Especially since the beginning of the new century, there has been all-round and rapid development. The mechanism of ocular tumorigenesis has been elucidated based on the biobank and animal models. New therapeutic techniques and treatment modalities have been established based on multi-center cohort studies. The team competence and the discipline level have been improved based on academic organization constructions and international exchanges. Looking into the future, ocular oncology in China will move on in gene detection and early diagnosis, basic research and drug targeting, interdisciplinary, intelligent diagnosis and treatment, clinical research and translational medicine, with the support of national strategies and scientific and technological innovation, to further improve the survival rate, the ocular salvage rate and the quality of life for patients with ocular tumors. This article is written to congratulate the Chinese Journal of Ophthalmology on the 70th anniversary of its publication.(Chin J Ophthalmol, 2020, 56: 646-652)

This article was published ahead of print on the official website of Chinese Journal of Ophthalmology on March 14, 2020. Novel coronavirus pneumonia broke out and spread to the whole nation since December 2019. The fight against the virus is now at a critical stage. Previous epidemiological investigations and animal experiments suggested aerosol could perform as a virus transmitter. Based on the clinical observation, the possibility of aerosol transmission of 2019 novel coronavirus has aroused much attention. This article focuses on the feature of aerosol transmission and the pathogens involved in. We analyze the possibility of aerosol transmission of the novel coronavirus. Relevant strategies for preventing novel coronavirus pneumonia are established for the medical personnel and general public during their work or daily life. (Chin J Ophthalmol, 2020, 56:653-656)

Uveitis is a class of inflammatory reactive diseases with complex etiology, and the diagnosis is mainly based on clinical manifestations. As an invasive examination method, intraocular fluid testing is clinically suitable for the diagnosis of certain types of uveitis and endophthalmitis, and can be applied to clinical studies of virus-related uveitis with the approval of the ethics committee. In order to standardize the clinical application of intraocular fluid detection, the Ophthalmic Immunology Group of Ophthalmology Branch of Chinese Medical Association formulated a consensus to put forward guiding opinions on the concept, indications, interpretation of test results and problems needing attention of intraocular fluid detection.(Chinese Journal of Ophthalmology, 2020, 56:657-661)

This standard was developed and revised by the International Society for Clinical Visual Electrophysiology (ISCEV) to present the most recent ISCEV opinion for clinical full-field electroretinogram (ERG) testing. The main content of this revision is to modify the parameters of the standard stimulation flash to accommodate the stimulators of a variety of different light sources, including gas discharge lamps and light emitting diode lamps; Six ERG responses (i.e. six detection protocols) elicited by different stimulus flash intensities based on light adaptation and dark adaptation are specified, while ISCEV also encourages the use of other full-field ERG detection extension protocols.(Chinese Journal of Ophthalmology, 2020, 56:662-669)

To investigate the safety and efficacy of external scleral plaque radiotherapy (PRT) in the treatment of uveal melanoma (UM).

This was a retrospective case series study. The data of 819 patients who underwent ophthalmic PRT from July 2007 to November 2017 at Tongren Hospital Affiliated to Beijing Capital Medical University was collected, including preoperative visual acuity, intraocular pressure and slit lamp microscope, color fundus photography, indirect ophthalmoscopy, color Doppler ultrasound, fundus fluorescein angiography, indocyanine green angiography, orbital nuclear magnetic resonance imaging, PRT times and time, complications, follow-up time, the maximum basal diameter and height of the tumor UM half a year after the applicator was removed, tumor metastasis rate, mortality and visual acuity observed at the last follow-up. The tumor growth was considered when the tumor height increased by 2.0 mm or the extension of any boundary of the tumor was 2.5 mm; otherwise, the treatment was defined as effective. The paired t test and Kaplan-Meier survival curve were used for statistical analysis.

There were 408 males and 411 females. The age ranged from 13 to 85 years (mean, 47 years). Nine patients had ciliary body melanoma, 43 patients had choroidal melanoma involving the ciliary body, and 767 patients had choroidal melanoma. In all 819 eyes, the tumor was medium-sized in 697 eyes and large in 110 eyes. All patients were treated with PRT only one time. The average radiotherapy time was 15 days (range, 6 to 50 d). All operations were successfully completed, with no active bleeding, infection, adjacent tissue injury and other related complications. At 6 months after the treatment, the maximum basal diameter of the tumor was (12.41±3.20) mm, which was significantly different from that before treatment (12.82±3.21) mm (t=2.40, P<0.01); the tumor height was (6.18±2.55) mm, which was significantly different from that before treatment (7.21±2.57) mm (t=4.05, P<0.01). The average follow-up time was (34±24) months (range, 1 to 125 months). Twenty-five patients lost follow-up at 2 years after the PRT, and 71 patients underwent enucleation. The effective rate of the PRT treatment was 88.3% (723/819), and the eyeball retention rate was 91.1% (723/794). The visual acuity remained stable in 393 eyes, decreased in 344 eyes, and improved in 82 eyes. Sixty patients had systemic metastasis (liver, bone or breast metastasis). Twenty-two patients died of tumor metastasis. The 5-year metastasis rate was 12.8%; the 5-year mortality rate was 5.8%; the 10-year metastasis rate was 20.6%; the 10-year mortality rate was 5.8%.

PRT is safe and effective in the treatment for UM and can preserve some useful visual acuity. PRT can be used as the main treatment for medium-sized UM.(Chin J Ophthalmol, 2020, 56: 670-675)

To explore the role of the scoring and strain ratio methods of ultrasonic elastography in the differential diagnosis of choroidal melanoma and choroidal hemangioma.

A cross-sectional study. Twenty-five patients (25 eyes) with choroidal melanoma treated in the Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University from July to October 2016 were included in this study. There were 13 males and 12 females, with an average age of (48±12) years old. Twenty-five patients (25 eyes) with choroidal hemangioma treated in the same period were selected for differential diagnosis, including 12 males and 13 females, with an average age of (37±13) years. The lesions were examined by ultrasound elastography and scored, and the strain ratio of the tumor to the orbital tissue was measured. Two independent sample t test was used to compare the difference in the elasticity score and strain ratio between choroidal melanoma and choroidal hemangioma. The sensitivity, specificity and area under the receiver operating characteristic (ROC) curve were calculated to analyze the value of the two methods in the differential diagnosis of choroidal melanoma and choroidal hemangioma.

The elastography score of choroidal melanoma was (3.48±0.77) points, including 2 points in 3 cases, 3 points in 8 cases, 4 points in 13 cases, and 5 points in 1 case. The elastography score of hemangioma was (2.28±0.46) points, including 2 points in 18 cases and 3 points in 7 cases. The difference in the elasticity score between patients with the two kinds of tumors was statistically significant (t=6.694, P<0.01). The strain ratio was 42.97±15.83 and 12.21±9.24 in the patients with choroidal melanoma and choroidal hemangioma, respectively, and the difference was statistically significant (t=8.392, P<0.01). Using 3 points as the diagnostic critical point of the elastography score, the sensitivity was 88.0%, the specificity was 72.0%, and the area under the ROC curve was 0.80 (95% cofidence interval: 0.663 to 0.900,P<0.01). Using 21.67 as the diagnostic critical point of the strain ratio, the sensitivity was 92.0%, the specificity was 92.0%, and the area under the ROC curve was 0.92 (95% cofidence interval: 0.808 to 0.978,P<0.01).

Ultrasound elastography plays a role in the differential diagnosis of choroidal melanoma and choroidal hemangioma. The differential diagnostic value of the strain ratio method is higher than the scoring method. (Chin J Ophthalmol, 2020, 56: 676-680)

To evaluate the potential association between optic nerve invasion and optic nerve obscuration during treatment of advanced retinoblastoma.

Retrospective case series study. Medical records of 77 patients (77 eyes) with advanced retinoblastoma (Group D/E) who were treated with primary or secondary enucleation in the Ophthalmology Department of Peking University People′s Hospital from January 1^st 2012 to December 31^th 2015 were retrospectively reviewed. RetCam photographs under general anesthesia at diagnosis and each subsequent follow-up were evaluated for complete obscuration of the optic nerve. The primary endpoints included prelaminar invasion, postlaminar invasion and optic nerve transection invasion. Group difference was calculated with chi-square.

There were 46 boys and 31 girls in the study. The mean age at the first diagnosis was (27.1±22.1) months. The optic nerve was obscured in 62 eyes (80.5%) at the first diagnosis and 61 eyes (79.2%) at the last ocular examination prior to enucleation. Twenty-nine eyes (37.7%) underwent primary enucleation. Forty-eight eyes (62.3%) were treated with eye-preserving therapy, followed by enucleation. Fourteen eyes (18.2%) were in Group D and 63 eyes (81.8%) were in Group E. Histopathologic analysis of enucleated eyes without optic nerve obscuration (16 eyes) showed prelaminar invasion in 7 eyes, postlaminar invasion in 2 eyes and optic nerve transection invasion in 0 eyes. Histopathologic analysis of enucleated eyes with optic nerve obscuration (61 eyes) showed prelaminar invasion in 26 eyes, postlaminar invasion in 9 eyes and optic nerve transection invasion in 4 eyes. The difference between two groups did not achieve statistical significance (P=0.935, 1.000, 0.296). Histopathologic analysis of enucleated eyes with persistent complete obscuration of the optic nerve showed a high risk factor in 10 eyes (10/40), while in 1 eye (1/8) the optic nerve was visible at the initial presentation and obscured before secondary enucleation (P=0.529).

Optic nerve obscuration at the last examination prior to enucleation may not be associated with postlaminar optic nerve invasion in advanced retinoblastoma. (Chin J Ophthalmol, 2020, 56: 681-687)

To summarize the clinical characteristics of congenital lacrimal fistula for reference in its clinical diagnosis and treatment.

Retrospective case series study. The clinical data of 27 patients (32 eyes) with congenital lacrimal fistula admitted to the Lacrimal Center of Third Medical Center of PLA General Hospital from July 2011 to November 2017 were analyzed, including gender, age of diagnosis, left eye or right eye, family history, physical examination, ophthalmic examination, fistula opening location and appearance, symptoms, results of lacrimal duct irrigation, three-dimensional reconstruction of the lacrimal drainage system with CT, lacrimal endoscopy, treatment, outcomes and follow-up.

In the 27 patients, the male to female ratio was 1∶2. The age of diagnosis was 1 to 74 years old, and the median was 32 years old. The ratio of unilateral fistula to bilateral fistula was 4.4∶1 (22/5), and the ratio of left eyes to right eyes was 1.2∶1 (12/10). The disease was sporadic in 22 patients, and 5 patients had a family history. Genetic analysis showed that congenital lacrimal fistula presented autosomal dominant inheritance. Fistulas were found on the skin surface of the lacrimal sac area under the medial canthus in 30 eyes, on the lacrimal caruncle in one eye, and on the conjunctiva of the medial canthus in one eye. All the patients presented with epihora, and irrigation liquid outflowed from the fistulas with purulence in 18 eyes. Lacrimal CT of the 27 patients showed contrast agents were left in the lacrimal sac. Lacrimal duct fistula was found open in the common canaliculus with concretions in the lacrimal system in four patients. Eight patients with mild symptoms underwent observation. Three patients underwent lacrimal therapeutic irrigation and probing. Sixteen patients underwent fistulectomy and were cured without recurrence during the follow-up of 1 to 6 years.

Congenital lacrimal fistula is usually unilateral, and the opening is mostly located on the skin surface of the lacrimal sac area under the inner canthus ligament. Most cases are sporadic, and some cases are of familial inheritance in an autosomal dominant condition.(Chin J Ophthalmol, 2020, 56: 688-692)

To determine the association between ocular dominance and myopic-astigmatic characteristics in myopic subjects.

Cross-sectional study. A total of 1 503 myopic subjects visiting from the myopiac clinic from December 2011 to December 2012 were included. The spheres and cylinders were recorded. The ocular dominance was determined by the hole-in-the-card test. The average spherical equivalent (SE) and the cylinder between the dominant eyes and the non-dominant eyes were compared with the paired t test. The associations between ocular dominance laterality and refractive characters were analyzed with the crosstab Chi-square test.

There were 527 males and 976 females in this study. The median (min, max) of age was 24 (17, 49) years old. Among the subjects, 66.00% (992/1 503) of subjects were right-eye dominant, while 34.00% (511/1 503) of subjects were left-eye dominant. The dominant eyes had significantly lower average sphere powers ［(-5.01±1.91) D vs. (-5.10±1.99) D］ and lower average cylinder powers ［(-0.70±0.68) D vs. (-0.76±0.73) D］ than the non-dominant eyes (t=2.976, 4.319; both P<0.01). In the subgroups of |ΔSE|≤0.50 D, 0.50 D<|ΔSE|≤1.00 D, 1.00 D<|ΔSE|≤2.00 D and |ΔSE|>2.00 D, respectively, the dominant eyes were lower myopic in 49.37% (355/719), 51.10% (163/319), 58.48% (100/171) and 65.56% (59/90) of the subjects. The inter-group difference was statistically significant (χ²=11.588,P=0.009). In the subgroups of |ΔCyl|≤0.25 D, 0.25 D<|ΔCyl|≤0.50 D and |ΔCyl|>0.50 D, the dominant eyes had lower astigmatism in 53.94% (89/165), 65.66% (65/99) and 69.70% (46/66) of the subjects, respectively. The inter-group difference was statistically significant (χ²=6.414,P=0.040).

The ocular dominance laterality is significantly associated with lower myopia and lower astigmatism in the myopic subjects. (Chin J Ophthalmol, 2020, 56: 693-698)

A patient whose main complaint was that the tumor in the area near the lacrimal sac of the lower eyelid of the left eye was found to grow for 10 months was consulted to the ophthalmology department. After admission, the patient had a solid tumor in the area of the lacrimal sac of the left eye by ophthalmology and imaging examination, and the tumor was removed from the area of the lacrimal sac of the left eye by histopathological examination, which confirmed that it was transitional cell carcinoma. Seven months after surgery, the patient saw the doctor again because the left lower eyelid was swollen for more than 20 days. Ophthalmology and imaging examination revealed irregular space-occupying lesions in the left lower eyelid with unclear boundary, and the surrounding bone was compressed and deformed. Histopathological examination after left lower eyelid mass resection confirmed that it was transitional cell carcinoma.(Chinese Journal of Ophthalmology, 2020, 56:699-700)

A patient whose main complaint was that the right eye protrusion was found for half a year was seen in the ophthalmology department. After orbital mass resection, the histopathology and immunohistochemical staining of the mass agreed with clear cell myoepithelioma of lacrimal gland origin, so the clinical diagnosis was right lacrimal gland myoepithelioma. After 7 months follow-up, eyelid and eyeball movements were good, and there was no sign of recurrence.(Chinese Journal of Ophthalmology, 2020, 56:701-703)

One patient with left eye tearing for more than half a year, aggravated tearing with pus discharge, redness, swelling and pain of medial canthus skin and subcutaneous mass for more than 2 months went to the ophthalmology department. Inflammatory myofibroblastoma of the left eye was diagnosed by lacrimal duct exploration and irrigation, lacrimal duct CT + three-dimensional reconstruction, histopathological and immunohistochemical staining of the tumor in the lacrimal sac area.(Chinese Journal of Ophthalmology, 2020, 56:704-706)

A patient with right orbital pain accompanied by double vision for 2 months went to the ophthalmology department. The right orbital mass was found by orbital CT and MRI examination, and the right orbital mass was removed. The postoperative histopathological results showed that it was poorly differentiated adenocarcinoma. By immunohistochemical staining combined with the patient's rectal cancer history, the patient was finally diagnosed as orbital metastasis of rectal cancer.(Chinese Journal of Ophthalmology, 2020, 56:707-708)

Surgeon introduction Wang Ningli, chief physician, professor. Director of Beijing Tongren Ophthalmology Center, Beijing Tongren Hospital affiliated to Capital Medical University, and Dean of College of Ophthalmology, Capital Medical University. Former chairman of Ophthalmology Branch of Chinese Medical Association and leader of glaucoma group, president of Ophthalmologist Branch of Chinese Medical Doctors Association, chairman of Public Health Ophthalmology Branch of Chinese Preventive Medicine Association, and leader of National Blindness Prevention Technical Guidance Group; Honorary Editor-in-Chief of the Editorial Board of Chinese Journal of Ophthalmology; Fellow of the International Academy of Ophthalmology, President of the Asia-Pacific Ophthalmology Society, Member of the Board of Directors of the World Glaucoma Association, and Member of the Board of Directors of the Asia-Pacific Glaucoma Association.

The patient was a 32-year-old Tibetan female. Because of the progressive decline of visual acuity in both eyes for more than 10 years and the aggravation of his left eye for 2 months, he went to the Department of Ophthalmology, West China Hospital, Sichuan University. There were no symptoms of red eyes, eye pain, photophobia and tearing. Ophthalmological examination: naked eye visual acuity was 0.2 in the right eye and 0.01 in the left eye; IOP was 11.9 mmHg (1 mmHg =0.133 kPa) in the right eye and 9.5 mmHg in the left eye; There were no abnormalities in the outer eyes of both eyes; The bulbar conjunctiva is not congested or edematous, the cornea is transparent, the retrocorneal deposition (-), the anterior chamber depth is normal, the pupil is round, about 3 mm in diameter, and it is sensitive to light. The intraocular lens of the right eye is in place, and the central anterior capsule and cortex of the lens of the left eye are bulging towards the anterior chamber. The bulging lens capsule is folded, and the cortex is mildly opaque (Quintessence Picture 1), the fundus of the eye is not clear. Ultrasound biomicroscopy is shown inQuintessence Picture 2。 Coherence light tomography revealed thinning of the temporal retina in both eyes with speckle-like changes. Clinical diagnosis: Left anterior conical lens; Cataract in both eyes (after cataract extraction and intraocular lens implantation in the right eye). (The picture in this article won the Excellence Award of TOPCON Cup Photo Exhibition of the 23rd National Ophthalmology Academic Conference in 2018)

Multiple sclerosis (MS) is a demyelinating disease of central nervous system, which often affects ocular region and causes structural and functional changes of eyes. Therefore, there have been plenty of researches on the alteration of motor and structures of eyes by MS. This paper reviews and summarizes the progress of MS-related changes of ocular motor, cornea, structure and blood flow of retina, and optic nerve, and may provide a new insight for related clinical researches. (Chin J Ophthalmol, 2020, 56: 711-715)

Extranodal marginal zone lymphoma of ocular adnexal mucosa-associated lymphoid tissue (MALT lymphoma) is a non-Hodgkin's B-cell lymphoma that occurs in mucosa-associated lymphoid tissue. It is the most common histopathological type of ocular adnexal lymphoma, with low malignancy and good prognosis. The occurrence of MALT lymphoma is related to infection and autoimmune abnormalities, and its clinical manifestations are complex and diverse, lack of characteristics, and difficult to diagnose. This article focuses on the clinical characteristics, histopathological characteristics, diagnosis and differential diagnosis, and treatment methods of ocular adnexal MALT lymphoma, in order to help clinicians to deeply understand ocular adnexal MALT lymphoma, so as to diagnose and treat the disease more accurately and effectively.(Chinese Journal of Ophthalmology, 2020, 56:716-720)