Volume 56 · Issue 11 · 2020

With the unremitting efforts of several generations of experts in ocular trauma, great progresses have been achieved in the field of ocular trauma in terms of the treatment, scientific research, international communication, talent team construction and cultural inheritance. The purpose of looking back on the development history of the past 70 years is to commemorate our predecessors and inspire the followers to continue to strive for the progress of this subspecialty in China. We would like to send congratulations on the 70th anniversary of Chinese Journal of Ophthalmology with this article. (Chin J Ophthalmol, 2020, 56: 801-804)

Oculoplastic and orbital surgery is concerned with the occurrence, manifestation, diagnosis, treatment and prevention of the eyelid, orbit and lacrimal diseases, as well as the repair and reconstruction of the related deformities and defects. Since the beginning of the new century, the number of patients with eyelid and orbital diseases has increased continuously, and the team of specialists has expanded rapidly. The development of oculoplastic and orbital surgery in China has entered an all-round new stage, especially with the establishment of Chinese Society of Oculoplastic Surgery and Orbital Disease in 2013. Oculoplastic and orbital surgery in China has made outstanding achievements in strengthening the training of professional talents, promoting interdisciplinary and international exchanges, improving the academic level of basic research, and emphasizing on the research of translational medicine. The technique of ocular plastic surgery has been progressing continuously. Cosmetic surgery of the eye has gained widespread popularity and standardization. Orbital surgery has recorded an innovative, interdisciplinary and rapid growth. International exchanges have helped to expand the international influence and competitiveness. This article is written to celebrate the 70th anniversary of Chinese Journal of Ophthalmology.(Chin J Ophthalmol, 2020, 56: 805-810)

Visual electrophysiological examination, which features the advantage of being objective, noninvasive and quantitative, is an important method for visual function assessment. The problem yet to be resolved in clinical and medical authentication, is the standardization of application, particularly in terms of test procedure and results interpretation. Visual electrophysiology examination includes many tests. Each kind of test has its own clinical significance. There are many factors that may affect results. Therefore, the standardization in the examination procedure can ensure the accuracy and repeatability of the result. The interpretation of the report, which relies upon both clinical operation guidance and clinical experiences, also needs to be standardized. Focus should be put on the issues above in an effort to realize the reasonable application of visual electrophysiology in clinic diagnosis and medical authentication, and to avoid the misjudgment or misdiagnosis.(Chin J Ophthalmol, 2020, 56: 811-814)

With the progress of ocular trauma treatment technology and the continuous accumulation of experience, the treatment level of endangered ocular trauma in China has been greatly improved. About 30% of eyes without light sensitivity with ocular trauma that needed to be removed in the past can be anatomically repaired and their vision above light sensitivity can be restored. The concept of intraocular anatomical repair in exploratory vitreoretinal surgery has been put forward, formed and popularized, which has saved a considerable number of ocular trauma without photosensitive eyes. However, due to various factors, it is still necessary to standardize the reasonable treatment of stage I and timely intraocular anatomical repair of stage II in the treatment of ocular trauma without light sensitivity. In order to further clarify and standardize the treatment principles and methods of complex ocular trauma without light sensitivity, the ocular trauma group of Ophthalmology Branch of Chinese Medical Association reached a consensus opinion after repeated and careful discussion, which can be used by ophthalmologists for reference in clinical work.(Chinese Journal of Ophthalmology, 2020, 56:815-819)

Chronic dacryocystitis is a common disease in ophthalmology, and persistent epiphora and pus are the main clinical manifestations. With the widespread application of endoscopic technique in ophthalmology, endoscopic dacryocystorhinostomy (En-DCR) has become the main surgical method for the treatment of chronic dacryocystitis. However, in the process of its popularization and popularization, there are problems such as inaccurate surgical indications, irregular surgical operations, and many surgical complications, so it is urgent to form a treatment consensus. Therefore, the Ophthalmology and Orbitology Group of the Ophthalmology Branch of the Chinese Medical Association formulated this consensus after full discussion, with a view to improving the clinical effect of En-DCR in the treatment of chronic dacryocystitis.(Chinese Journal of Ophthalmology, 2020, 56:820-823)

To analyze the characteristics of vessel density in the optic disc and macular area of patients with different phases of thyroid-associated ophthalmopathy (TAO) and their correlation with visual function.

This case-control study was conducted at the Department of Ophthalmology of Peking Union Medical College Hospital between June 2019 and September 2019. TAO patients and healthy volunteers were included in the study. Patients with a clinical activity score greater than or equal to 3 points were categorized as active TAO. Dysthyroid optic neuropathy (DON) patients with a course less than 6 months were categorized as acute phase of DON, and those more than 6 months were in the chronic group. Healthy volunteers were in the control group. Each group included 12 subjects, with right eyes for analysis. There were 6 males and 6 females in each group. All participants underwent comprehensive ophthalmic examination including best corrected visual acuity and visual field examination for the mean defect (MD). Best corrected visual acuity was subsequently converted to logarithm of minimum angle of resolution (logMAR). Optical coherence tomography was used to measure the thickness of the retinal nerve fiber layer (RNFL) and retinal ganglion cell complex (GCC). Optical coherence tomography angiography was used to the peripapillary and macular vessel density. The differences in the vessel densities in the optic disc and macular area between groups and their correlation with different factors were analyzed. Analysis of variance, non-parametric Mann-Whitney U test and Spearman coefficient were conducted for statistical analysis.

There was no significant difference in age among the four groups (P>0.05). The logMAR of the acute DON group was 0.1 (0.0, 0.2), worse than the control group, which was 0.0 (0.0, 0.0) (U=114.000, P<0.05). The overall vessel densities of the optic disc in acute DON and chronic DON were significantly lower than the control group (54.70%±2.31% and 54.31%±3.65%vs. 57.54%±2.17%; t=3.104, 2.636; both P<0.05). The overall superficial vessel densities of the macular area in active TAO, acute DON and chronic DON were significantly lower than the control group (46.07%±3.06% and 42.26%±5.05% and 45.63%±3.87%vs. 49.34%±3.08%), and the differences were statistically significant (t=2.614, 4.147, 2.603; all P<0.05). There was no statistically significant difference in the size of the foveal avascular zone or the density of deep blood vessels in the macular area among the four groups (allP>0.05). In the active TAO period, there was no correlation between the MD value, RNFL thickness, GCC thickness and the vessel densities of the optic disc and macular area (allP>0.05). The vascular density of the whole layer of the optic disc in acute DON was negatively correlated with the MD value (r=-0.591, P<0.05) and positively correlated with the RNFL thickness and GCC thickness (r=0.595, 0.693; both P<0.05). In chronic DON, the overall capillary density of the optic disc was negatively correlated with the MD value (r=-0.673, P<0.05); the superficial overall blood vessel density of the macular area was positively correlated with the thickness of RNFL and GCC (r=0.732, 0.712;both P<0.01).

In active TAO, only the blood supply to the superficial layer of the macular area is decreased. In the acute and chronic phases of DON, the blood supply to the superficial layer of the macular area and the optic disc is both reduced; the smaller the blood vessel density, the more severe the visual field defect, and the thinner the RNFL and GCC. (Chin J Ophthalmol, 2020, 56:824-831)

To describe imaging signs of infraorbital nerve enlargement (IONE) and frontal nerve enlargement (FNE) in orbital lymphoproliferative diseases (LPDs), and to explore the diagnostic value and differential diagnostic role of the signs.

A retrospective case series study. The data of 222 cases (262 eyes) of LPDs and 95 cases (134 eyes) of inflammatory pseudotumors (IPs) pathologically confirmed by the Peking University People′s Hospital and the Third Medical Center of the Chinese PLA General Hospital from January 2013 to December 2018 were analyzed. The LPDs were lymphoma (including atypical lymphoid hyperplasia) in 91 cases (110 eyes) and reactive lymphoid hyperplasia (RLH) in 131 cases (152 eyes). The patients with LPD included 101 males and 121 females, aged (58±17) years, and the patients with IP included 44 males and 51 females, aged (49±21) years. All patients underwent orbital CT or MRI with T₁ weighted imaging, T₂ weighted imaging and enhanced T₁ weighted imaging scanning. Slice thickness was 3 mm. In the coronal CT or MRI, the criterion for determining IONE was the inferior orbital nerve diameter greater than the optic nerve, and the criterion for determining FNE was the forehead nerve diameter equal to or greater than the optic nerve. The pathological types and imaging features of nerve enlargement were recorded. The incidence rates of different pathological types were compared using chi-square test.

The enlarged nerves showed homogeneous soft tissue density on CT images, accompanied with enlarged bony infraorbital nerve grooves (foramina). MRI showed moderate signals of T₁ and T₂ weighted imaging, with clear boundaries and obvious enhancement, which could spread to the pterygopalatine fossa and the cranial cavity. The accompanying images included the enlargement of lacrimal glands or extraocular muscles, intraorbital mass or sinuses opacity. The IONE and/or FNE were found in 12 patients with LPD, but were not found in any patients with IP. The difference was statistically significant (12/222 vs. 0/95, χ²=5.337, P=0.021). Among the cases with nerve enlargement, there were 2 cases of diffuse large B cell lymphoma and 10 cases of RLH (2/91 vs. 10/131, χ²=3.103, P=0.078), as well as 7 cases of IgG4-related ophthalmic disease (IgG4-ROD) and 3 cases of non-IgG4-ROD (7/28 vs. 3/103, χ²=15.232, P=0.000).

Lymphoma and RLH can express IONE and/or FNE, in which the IgG4-ROD is the most common and specific type. CT and MRI scans can show enlarged nerves and accompanying signs. Neural thickening can also be applied as a discrimination marker of LPDs and IPs.(Chin J Ophthalmol, 2020, 56: 832-838)

To observe the efficacy of intralesional rituximab administration in primary ocular adnexal mucosa-associated lymphoid tissue lymphoma (POAML).

Retrospective case series study. The clinical and follow-up data of eight patients with POAML in the treatment group from September 2017 to December 2018 at the First Affiliated Hospital of Zhengzhou University were collected and analyzed retrospectively. The patients (3 males and 5 females) were 35 to 83 years old, with a median of 58 years. All patients received surgical treatment (most of the tumor were removed). The diagnosis of mucosa-associated lymphoid tissue lymphoma was confirmed by histopathology and immunohistochemical staining showed CD20⁺. Examinations such as chest CT, abdominal CT, bone marrow biopsy or positron emission tomography-CT to exclude lymphoma with systemic lesions. Patients with conjunctival POAML were injected through the subconjunctival infiltration. For the lacrimal gland POAML and the orbital POAML, the injection was performed through the periocular space by using a post-bulb syringe needle at multi-points with an interval of 1 cm, before the pressure dressing. All patients were injected 1.5 to 5.0 ml (15 to 50 mg) once every three weeks, 4 to 6 times as a treatment cycle. The injection range included or exceeded the lesion area. Then consider whether to supplement the number of treatments based on the remaining tumor. The patients' treatment doses, drug onset time, tumor regression, local reactions (local pain and swelling), systemic reaction indicators (fever, gastrointestinal reactions, complete blood count and the lymphocyte subsets), and systemic recurrence indicators (serum β₂ microglobulin and lactate dehydrogenase detecting) were recorded.

Two patients, including one patient with bilateral lesions, had conjunctival POAML, one patient had lacrimal gland POAML, and five patients had orbital POAML. They received 2 to 7 injections, and the total dose was 45 mg to 280 mg. There were tolerable local pain upon injections in all patients, local redness and swelling in one patient, fever in two patients, mild gastrointestinal reactions in one patient, fatigue in one patient, and palpitation and discomfort in one patient. After close observation or corresponding symptomatic treatment, the symptoms subsided. No special treatment was given. The follow-up time was 9 to 30 months, and the median was 20 months. The lymphomas in all patients were controlled without recurrence. The MRI showed that local lesions disappeared completely in five patients, and the conjunctiva and the extraocular muscle became thickened in three patients. There was no abnormity in complete blood count, serum β₂ microglobulin and lactate dehydrogenase.

The intralesional rituximab administration is a simple, effective therapy for localized POAML with no systemic invasion. (Chin J Ophthalmol, 2020, 56: 839-845)

To report the clinical and pathological features and surgical treatment of the linear nevus sebaceous syndrome.

It was a retrospective case series study. The clinical records of 11 patients (14 eyes) who were diagnosed as linear nevus sebaceous syndrome between April 2009 and February 2018 at Beijing Tongren Hospital were analyzed. Data collected included sex, age, clinical manifestations, disease site, pathological features, surgical treatment and therapeutic effects.

There were six males and five females, aged 6 months to 7 years (mean, 2.8 years). The nevus sebaceous was located at the head (9 patients), face (5 patients) and neck (3 patients). The most common ocular manifestations were blepharocoloboma (13 eyes) and external ocular mass (9 eyes). Surgical treatment was performed in 9 patients (11 eyes), including lid reconstruction in all these eyes, corneal and conjunctival mass resection in four patients (4 eyes), eyelid tumor resection in 5 patients (5 eyes), and symblepharon separation and conjunctival sac reconstruction in 3 patients (5 eyes). Pathological examinations of the external ocular, corneal and conjunctival masses (6 eyes) confirmed the diagnosis of complex choristoma. All operated patients had improved appearance.

Linear nevus sebaceous syndrome has characteristic cutaneous lesions and ocular manifestations. Histopathologically, all epibulbar lesions prove to be complex choristomas. The appearance of patients with linear nevus sebaceous syndrome can be significantly improved by oculoplastic surgery. (Chin J Ophthalmol, 2020, 56: 846-852)

To investigate the long-term clinical efficacy and safety of the bilateral superior oblique tendon suture spacer in treatment of A-pattern strabismus with superior oblique overaction (SOOA).

Retrospective case series study. Twenty-one A-pattern strabismus patients who received the quantitative bilateral superior oblique tendon suture spacer with a complete follow-up from January 2009 to August 2017 were enrolled. Among these patients, 19 were exotropic and 2 were esotropic, including 11 males and 10 females, aged (14±9) years. Patients with unilateral superior oblique overaction, Broun syndrome or Helveston syndrome were excluded. The A-pattern strabismus, objective torsion, function of the superior oblique muscle and binocular vision were examined pre-and post-operatively. Paired t-test was used for normal distribution data, Wilcoxon rank-sum test was used for non-normal distribution data, Spearman rank correlation test and simple linear regression were used to analyze the correlation between the two variables.

The follow-up was 12 to 109 months (mean, 26±17 months). Twenty patients showed good alignment in the primary position with a deviation angle less than 10 prism diopter (PD), and 1 patient with esotropia had an angle greater than 15 PD. All the patients had no A pattern after surgery. The average pre-and post-operative A-patterns were (23.81±9.47) PD and (0.90±3.59) PD (t=11.29, P<0.01), respectively, and the average corrected A pattern was (23.52±9.68) PD.The average pre-and post-operative torsion was 3.18°±3.26° and -4.81°±4.13° (t=8.87, P<0.01), espectively, and the average corrected torsion was 7.95°±3.88°. No patient complained of torsional diplopia after surgery. The average amount of pre-and post-operative SOOA was 3.0 (2.0) and 0.0 (1.0) in 42 eyes (Z=-5.78, P<0.01), respectively. Suture extension of the superior oblique tendon was related with the pre-operative SOOA (r=0.47, P<0.01), but was not related with the pre-operative torsion (r=0.02, P=0.88). The linear regression results was suture extension=2.71× the grade of pre-operative SOOA (t=27.93, P<0.01).

The bilateral superior oblique tendon suture spacer can improve the A-pattern, objective torsion and SOOA, with no torsional diplopia or V pattern after the long-term follow-up. It is a safe and effective superior oblique muscle weakening procedure.(Chin J Ophthalmol, 2020, 56: 853-858)

Three patients with exophthalmos were seen in the ophthalmology department, and two cases were juvenile trabecular ossifying fibroma, all of which showed gradual aggravation of exophthalmos and normal eye movement. The imaging examination showed that the bone wall surrounded the soft tissue density occupying space lesion, and the trabecular bone structure could be seen in the tumor tissue under the microscope. One case was saratoma-like ossifying fibroma, which showed exophthalmos, eyelid swelling, and restricted external and upward turning of the eyeball. Imaging examination showed that the bone in the upper wall of the left orbit was thinned and swollen, and the bone shell was formed, surrounding the irregular soft tissue shadow. Under the microscope, a small bone fragment structure similar to an osseous body was seen. All 3 cases underwent surgical resection.(Chinese Journal of Ophthalmology, 2020, 56:859-861)

An elderly woman presented to the ophthalmology department due to double vision for 5 months. Ocular examination showed limited external turnover of the right eye. The visual field showed non-consistent local visual field defects in the same direction in the upper quadrants of both eyes. The plain MRI scan of the head showed an aneurysm of the cavernous sinus segment of the right internal carotid artery and abnormal signals in the posterior part of the right hippocampus. The diagnosis was a large aneurysm of the cavernous sinus segment of the right internal carotid artery and paralysis of the right abducens nerve. The aneurysm was completely embolized after stent-assisted aneurysm embolization. After detailed localization diagnosis, it was found that the visual field defect of the patient was caused by the damage of Meyer haptics of optical radiation.(Chinese Journal of Ophthalmology, 2020, 56:862-864)

A child with partial whitening of the pupil area of the left eye for 2 months after birth was seen to the ophthalmology department. At 10: 00 in the left eye, the white fiber organized cord on the iris surface extends from the pupil edge to the nasal side to the iris root, with a slight bulge locally, and the pupil is needle-shaped. After dilated pupil, the pupil is slightly widened, oblique oval, and the long axis is located in the axial direction of 10: 00 to 4: 00, about 0.3 mm ×1.0 mm. It is diagnosed as congenital fibrovascular pupil membrane in the left eye. The left eye was treated with dilated pupil combined with right eye covering, but no surgical treatment was given. During the treatment, the visual acuity of the affected eye gradually improved, and regular follow-up observation was performed.(Chinese Journal of Ophthalmology, 2020, 56:865-867)

A patient with sudden painless visual loss in his right eye for 2 months when autologous fat was filled under the skin of his right forehead in a beauty salon went to the ophthalmology department. After CT and MRI examination in neurology department, autofluorescence fundus examination in ophthalmology, coherence light tomography, B-ultrasound examination and coherence light tomography angiography examination, he was diagnosed with right ophthalmic artery obstruction. Although thrombolysis, anti-inflammatory treatment, massage and vasodilatation treatment, his right eye visual acuity was still without light sensing.(Chinese Journal of Ophthalmology, 2020, 56:868-870)

In recent years, China's optometry industry has developed from simple optometry and glasses to grass-roots eye health care, and the professional technical demand for practitioners has also increased. Through the investigation of the optometry industry employees in optometry centers in different cities in China, it is found that the employees of optometry industry in China have the characteristics of involving a wide range of personnel, uneven professional level and obvious regional differences. In order to solve the shortage of optometrists in our country, it is proposed that we should combine the characteristics of the existing optometry education system in our country, take the mode and content of standardizing the development of optometry continuing education as the core, improve the professional skills of optometry practitioners in our country, increase the number of professionals with optometrists skill level, and thus improve the professional level of optometry industry in our country.(Chinese Journal of Ophthalmology, 2020, 56:871-874)

The patient was a 55-year-old male. He went to the Department of Ophthalmology, Baodi District People's Hospital, Tianjin because of visual loss and visual deformation of his left eye for 3 months. He had night blindness and color vision disorder at an early age, and denied his family history of disease and his parents' history of close marriage. Eye examination: the visual acuity was 0.5 in the right eye and 0.1 in the left eye, and there was no improvement in correction; IOP normal; No obvious abnormalities were observed in the anterior segment of both eyes; For both fundus, seeQuintessence Picture 1。 Coherence light tomography examination is shown inQuintessence Picture 2。 Electroretinogram showed that the amplitude of A and b waves in both eyes decreased. Clinical diagnosis: White dot retinal degeneration combined with wet age-related macular degeneration in both eyes; Choroidal neovascularization in the macular region of the left eye.

Behcet′s syndrome (BS) is characterized by systemic vasculitis with unknown etiology. There is evidence that more than one mechanism underlies the pathogenesis of BS, involving genetic factors and environmental stimuli. Although human leucocyte antigen-B51 is by far the most strongly associated genetic factor to BS, it accounts for less than 20% of the genetic risk, which indicates that other genetic factors remain to be discovered. Cytokines are signal molecules of the immune system which modulate the inflammatory process of nearly all immune response. The single nucleotide polymorphism (SNP) of cytokine gene have been associated with BS in many studies, involving T helper cell 1-type cytokines, interleukin 1 cytokine, interleukin 17 and chemotactic cytokine. The impact of different SNPs on BS varies, most of which affect the risk of disease, while the remaining affect the phenotype, the cumulative effect of these minor genes (SNPs) might be the genetic mechanisms of BS pathogenesis. (Chin J Ophthalmol, 2020, 56: 876-880)