Volume 56 · Issue 12 · 2020

Uveitis is one of the most common causes of blindness worldwide. Clinical and basic studies on uveitis began in the 1980s in China. With the efforts of several generations, great progress has been made in the last 30 years with a global reputation. However, there are still challenges concerning the prevention and treatment of uveitis as well as the elucidation of the mechanisms underlying this disease. Therefore, we should continuously push the uveitis subspecialty in China to a new level. The achievements obtained in the uveitis studies during the past decades are offered as a gift to the 70th anniversary of the Chinese Journal of Ophthalmology. (Chin J Ophthalmol, 2020, 56:881-890)

Neuro-ophthalmology is an interdisciplinary subspecialty that occupies an important position in ophthalmology. We review the development history and subspecialty construction of the neuro-ophthalmology in China, showing the achievements, providing reference for the clinical and scientific research of neuro-ophthalmology in the future, commemorating the predecessors and inspiring the contemporary neuro-ophthalmology profession to forge ahead. Congratulations on the 70th anniversary of the publication of the ChineseJournal of Ophthalmology.(Chin J Ophthalmol, 2020, 56:891-894)

In evidence-based medicine, randomized controlled clinical trials are considered as the gold standard to evaluate the curative effect of the anti-vascular endothelial growth factor drugs on fundus diseases. The non-inferiority design is widely used due to the existence of the "ceiling effect" if vision improvement is used as the primary outcome. It is critical to make several issues clear before non-inferiority studies are performed. For example, patients can benefit from the new therapy other than efficacy; the determination of the non-inferiority margin should be based on the comprehensive consideration of clinical and statistical meanings; the traditional significance test method is not suitable for non-inferiority tests; the superiority test could be further performed if the non-inferiority conclusion has been reached. This article aims to elaborate these hot issues and to provide guidance for clinical researchers to carry out research designs and interpret findings objectively and scientifically. (Chin J Ophthalmol, 2020, 56: 895-898)

Multifocal electroretinogram (mfERG) is an electrophysiological detection technology to reflect local retinal function. Under the condition of bright adaptation, it divides the retina into multiple regions, and simultaneously detects the local retinal electrophysiological response in each region, reflecting the function of cone cells. The International Society for Clinical Visual Electrophysiology issued a new clinical mfERG standard in 2011, replacing the 2007 edition of the guidelines. The new standard provides essential methods and report interpretation points for mfERG detection with 61 or 103 hexagonal stimulus cells.(Chinese Journal of Ophthalmology, 2020, 56:899-906)

In recent years, with the deepening of understanding of dry eye, new therapeutic drugs and treatment methods are constantly emerging, and there are more choices for clinical treatment of dry eye. In order to meet the actual needs of the development of clinical diagnosis and treatment of dry eye in China, experts from relevant academic organizations such as China Branch of Asian Dry Eye Association, on the basis of the Expert Consensus on Clinical Diagnosis and Treatment of Dry Eye (2013), combined with the practical experience of clinical treatment of dry eye in China in recent years, have formed further consensus opinions, hoping to continuously promote the development of dry eye treatment in China to a comprehensive, individualized and standardized direction.(Chinese Journal of Ophthalmology, 2020, 56:907-913)

To summarize the clinical and fundus imaging features of purified protein derivative and T-spot positive tubercular serpiginous-like choroiditis (PTP-SLC) patients.

This retrospective study consecutively enrolled 13 PTP-SLC patients (21 eyes) in Beijing Tongren Hospital from November 2015 to November 2017. There were 8 males and 5 females with an average age of (45.2±12.1) years. Medical history and results of systemic and ophthalmological examinations, such us fundus autofluorescence photography, optical coherence tomography (OCT), fluorescein fundus angiography (FFA) and indocyanine green angiography, were evaluated.

Eight patients had binocular disease with an average interval time of (8.4±7.9) years. The average visual acuity of all patients was 0.3, and 4 patients had a clear history of exposure to tuberculosis. The active lesions in the PTP-SLC patients were homogeneous and creamish-yellow with unclear boundaries. Fundus autofluorescence showed an ill-defined, diffuse hyperautofluorescent zone. OCT showed punctate hyperreflexes between the choroidal stroma, destruction of the outer retinal structure with intraretinal edema and discrete vitreal hyper-reflective spots. FFA showed hypofluorescence in the active lesion at early stage and diffuse hyperfluorescence with leakage. Indocyanine green angiography showed persistent hypofluorescence.

PTP-SLC fundus lesions are mainly manifested as homogeneous creamish-yellow lesions with unclear boundaries and high in autofluorescence. The involvement of the choroid and the outer layer of the retina can be observed on OCT. FFA can find more retinal vascular inflammatory changes. It is difficult to distinguish PTP-SLC from serpiginous choroiditis simply based on clinical and epidemiological characteristics. The pathogenic examination of tuberculosis is still the key to differential diagnosis (Chin J Ophthalmol, 2020, 56: 914-919)

To develop a fundus image quality assessment system based on computer vision technology and to verify its accuracy by comparing the results of artificial discrimination and using this system.

The process of image evaluation was divided into four modules: fundus image preprocessing, fundus image quality evaluation, fundus image content detection and evaluation result output. The system was designed to automatically evaluate the image quality of each fundus image, identify the optic disc and macula, and judge whether the image was qualified or not according to the image quality discrimination rules. A total of 2 397 fundus images of 787 type 2 diabetes patients were selected as the test data set. The average age of the patients, including 384 males and 403 females, was (69.65±19.09) years old. The images were taken by the staff of community health service centers in Shanghai with a fundus camera. The fundus image quality assessment system was used to conduct quality control and classification of the data set. At the same time, 12 professional fundus picture readers were employed to conduct manual quality control and classification of this data set. The system quality control results and artificial quality discrimination results were compared and analyzed.

The fundus image quality assessment system automatically recognized left and right eyes and eye positions on the input fundus images. The quality control interface included four indicator lights, which respectively corresponded to the images with the optic disc or macula as the center of the left or right eye. Evaluation of each fundus image was completed within 1 second, and the results were automatically displayed on the user interface. The 2 397 fundus photos were identified manually as 1 846 qualified photos and 551 unqualified photos. Among the unqualified images, 62 (11.27%) were too dark, 51 (9.27%) were too bright, 59 (10.73%) were not clear in the macular area, 36 (6.54%) showed no macula or optic disc, 125 (22.73%) could not present the fundus structure, 175 (31.82%) were blurred, and 42 (7.64%) were blocked. The results of the system and manual assessment were consistent in 1 788 qualified images (96.86%) and 550 unqualified images (99.82%), with an overall consistency rate of 97.54%.

The fundus image quality assessment system can achieve highly consistent results with the professional judgment of ophthalmologists and has the characteristics of objectivity. (Chin J Ophthalmol, 2020, 56:920-927)

To observe the clinical efficacy of vitrectomy combined with foveal-sparing circular internal limiting membrane peeling with the central fovea reserved in patients with high myopic foveoschisis.

Case-control study. A total of 72 patients (86 eyes) with foveoschisis due to high myopia who underwent vitrectomy combined with internal limiting membrane peeling in Lishui Municipal Central Hospital of Zhejiang Province from June 2016 to May 2017 were enrolled, including 18 males (18 eyes) and 54 females (68 eyes), aged (50.5±8.9) years. The patients were randomly divided into the observation group (34 cases, 43 eyes) and the control group (38 cases, 43 eyes) using a random number table and random number residual grouping method. Vitrectomy was performed in all patients. In the control group, the limiting membrane in the macular area was removed during surgery. In the observation group, the foveal annular internal limiting membrane was preserved during surgery. In severe cases, cataract extraction was performed.

In the observation group, the mean central foveal thickness (CFT) on optical coherence tomography was (723.49±130.95) μm preoperatively and decreased to (286.33±210.73) μm postoperatively, and the difference had statistical significance (t=17.059, P=0.000). In 39 eyes with complete or partial healing of the foveal split, the best corrected visual acuity (BCVA) was (0.99±0.40) logMAR before the treatment and increased to 0.68±0.24 after the treatment, and the difference had statistical significance (t=7.585, P=0.000). In the control group, the mean CFT was (726.98±140.62) μm and (297.88±241.56.) μm before and after the treatment, respectively, and the difference had statistical significance (t=16.271, P=0.000). In 38 eyes with complete or partial healing of the foveal split, the BCVA increased from preoperative 1.04±0.47 to postoperative 0.69±0.21, and the difference had statistical significance (t=6.707, P=0.00). With the follow-up time as the efficacy determination time, there was no significant difference in BCVA (t=0.22, P=0.983) and CFT (t=0.236, P=0.814) between the observation group and the control group (P>0.05); there was significant difference in the incidence rate of macular holes (P=0.026). There was no statistically significant difference in the rate of complete macular morphology healing between the two groups (P=0.816).

Vitrectomy combined with foveal-sparing circular internal limiting membrane peeling can effectively treat high myopic macular holes and reduce the formation of postoperative macular holes. (Chin J Ophthalmol, 2020, 56: 928-932)

To study the expression levels of secretogranin Ⅲ (SCG3) in the peripheral blood and vitreous of patients with diabetic retinopathy (DR).

Cross-sectional research. A total of 77 patients (41 men and 36 women, 77 eyes) received vitrectomy in Tianjin Medical University Eye Hospital from May to December 2018, with an average age of (60.75±11.34) years. According to the blood glucose level, diabetes history and fundus status, all the patients were divided into the DR group and the non-diabetic group. According to the patients′ blood lipids and body mass index (BMI), patients were further divided into subgroups of high blood lipids, normal blood lipids, high BMI and normal BMI. All patients were tested with eye examinations, height and weight to calculate the BMI, and blood lipid levels in the peripheral blood. The vitreous was collected during the vitrectomy surgery, and the levels of SCG3 in the vitreous and peripheral blood were analyzed by ELISA. All the data were analyzed statistically with Wilcoxon rank sum test.

There were 43 patients in the DR group, among whom 25 had hyperlipidemia, 18 had normal blood lipids, 22 had a high BMI, and 21 had a normal BMI. There were 34 patients in the non-diabetic group, among whom 13 had hyperlipidemia, 21 had normal blood lipids, 17 had a high BMI, and 17 had a normal BMI. The level of SCG3 in the DR group [6.02 (4.34, 11.76) ng/ml] was higher than that in the non-diabetic group [4.30 (3.20, 10.78) ng/ml] (Z=-2.339, P =0.019). The level of SCG3 in the hyperlipidemia subgroup of the DR patients [7.94 (5.33, 13.51) ng/ml] was higher than that in the normal blood lipid subgroup of the non-diabetic patients [4.04 (3.12, 7.77) ng/ml] (Z=-3.473, P=0.001), and higher than that in the DR patients without hyperlipidemia [4.45 (3.71, 9.14) ng/ml] (Z=-2.511, P=0.012). The level of SCG3 in the DR patients with a high BMI [7.12 (4.56, 13.12) ng/ml] was higher than that in the non-diabetic patients with a normal BMI [3.53 (3.16, 4.38) ng/ml] (Z=-3.767, P =0.000). The level of SCG3 in the DR patients with a normal BMI [5.72 (4.10, 11.60) ng/ml] was higher than that in the non-diabetic patients with a normal BMI (Z=-2.862, P = 0.004). SCG3 in the plasma was rare or can not be detected.

The concentration of SCG3 in the vitreous increase in DR patients. However, SCG3 can not be detected in the healthy vascular system.(Chin J Ophthalmol, 2020, 56: 933-937)

To investigate the imaging features of Fuchs endothelial corneal dystrophy (FECD) and to provide imaging evidence for the diagnosis of this disease.

Retrospective case series study. A total of 128 eyes (64 patients, including 19 males and 45 females) diagnosed with FECD at the Beijing Tongren Eye Center of Capital Medical University from January 2014 to December 2016 were enrolled. The average age was 57.8±12.9 years. There were 25 eyes of stage Ⅰ (19.5%), 81 eyes of stage Ⅱ (63.3%), 16 eyes of stage Ⅲ (12.5%) and 6 eyes of stage Ⅳ (4.7%).All patients underwent specular microscopy, and 41 patients (82 eyes) had in vivo confocal microscopy (IVCM). The patients′ general data, clinical stage, and image features of specular microscopy and IVCM were analyzed. The enumeration data was compared by chi-square test. Differences of measurement data were compared by ANOVA. Data which cannot be accurately measured was compared by rank sum test.

As the disease progressed, the number, incidence rate, and fusing rate of dark“holes”on specular microscopy increased. The number of guttata on IVCM increased, and the fusing pattern of guttata developed from pair-like, chain-like to group-like. On specular microscopy, the mean rank of stage Ⅰ (78.2), stage Ⅱ (228.4), stage Ⅲ (284.5) and stage Ⅳ (288.5) was statistically different (χ²=84.183, P=0.000). All positions of all eyes of stage I had no fusion of the dark “holes”. The incidence of fusion on the peripheral cornea gradually increased significantly (χ²=27.167, P=0.000) from stage Ⅱ (45.1%, 146/324), stage Ⅲ (76.3%, 45/59) to stage Ⅳ (83.3%, 15/18).

The imaging features of specular microscopy and IVCM can be applied as an important basis for early diagnosis of FECD. Specular microscopy is a practical method for rapid screening of FECD. IVCM is an important imaging basis for clarifying the appearance of guttata and analyzing fusion features, so as to guide the differentiation of stages. (Chin J Ophthalmol, 2020, 56:938-943)

A 57-year-old male patient was seen for 1 month due to painless visual loss in his right eye. After perfect eye examination, he was initially diagnosed with central retinal vein occlusion in both eyes, and was diagnosed with immunoglobulin G type multiple myeloma by hematology evaluation. After BCD regimen chemotherapy and intravitreal injection of anti-vascular endothelial growth factor drugs in both eyes, the patients' ocular symptoms improved significantly after 1 month.(Chinese Journal of Ophthalmology, 2020, 56:944-946)

The patient was a 62-year-old female. The left eye was repeatedly red and painful, and the discharge increased for 5 months. The initial diagnosis was acute keratoconjunctivitis (bacterial possibility), and glaucoma was suspected. A large amount of white exudate covered the whole cornea 1 week after the administration of ofloxacin eye drops and intraocular pressure lowering drugs, and the laboratory smear cytology results showed occasional paired cocci. After retrospective medical history, it was found that the patient's right eye had been proposed to be diagnosed as ocular mucosal pemphigoid, and the clinical diagnosis was revised as binocular mucosal pemphigoid after diagnostic treatment.(Chinese Journal of Ophthalmology, 2020, 56:947-948)

The patient was a 45-year-old male. Because of blurred vision in his left eye for 3 days, he went to the Affiliated Optometry Hospital of Wenzhou Medical University. Has a history of diabetes for more than 15 years, a history of hypertension for 10 years, and is controlled by oral medication (details unknown). Eye examination: visual acuity was 0.6 for the right eye and 0.12 for the left eye; IOP was 18.3 mmHg (1 mmHg =0.133 kPa) in the right eye and 16.1 mmHg in the left eye; The conjunctiva of both eyes was not congested, the cornea was transparent, the anterior chamber was deep, the pupil was round, the iris was not obviously neovascularized, and the lens was still transparent; Neovascular membrane was seen in the optic disc of the right eye, and the retina was scattered with bleeding, including hard exudation, cotton lint and macular edema. Vitreous hemorrhage in the left eye, unclear peeping in the fundus. Autofluorescence fundus examination without red light and fluorescein fundus angiography are shown inQuintessence Picture 1。 Clinical diagnosis: Proliferative diabetic retinopathy in both eyes; Vitreous hemorrhage in the left eye.

Optical coherence tomography angiography (OCTA) is a novel, non-invasive imaging technology, which could acquire volumetric angiographic information. Numerous studies have reported the potential clinical use of OCTA in a variety of common retinal disorders. Polypoidal choroidal vasculopathy (PCV) is characterized by the formation of branching choroidal vascular networks (BVN) with terminal dilatations (polyps). Indocyanine green angiography (ICGA) remains the golden diagnostic standard for PCV. The clinical application of OCTA in PCV is also widely investigated recent years. But the results are controversially interpreted. In addition to various diagnostic accuracy of PCV from different studies, the clinical application of OCTA in PCV is limited. With the constant innovation of fundus imaging techniques, OCTA is reaching greater investigation depth and become more accurate at picking up blood flow signals, which also improves the diagnostic accuracy of PCV. In this paper, we reviewed the clinical application and research progress of OCTA in PCV, in order to provide some assistant for clinical practice and correct interpretation of the reports. (Chin J Ophthalmol, 2020, 56:950-955)

Limbal Stem Cell Deficiency (LSCD) is an ocular surface disease caused by the decrease of the quantity and dysfunction of limbal stem cell, which is characterized by conjunctivalization and other signs of epithelial dysfunction. For sever LSCD, surgery is the main treatment way. Recently, plenty of researches published the outcomes of different operation methods. This article summarized five major operations, including conjunctival limbal autograft (CLAU), simple limbal epithelial transplantation (SLET), limbal allograft, cultivated limbal stem cell transplantation (CLET) and cultivated oral mucosal epithelial transplantation (COMET). (Chin J Ophthalmol, 2020, 56:956-960)