Volume 57 · Issue 03 · 2021

Glaucoma is the leading cause of irreversible blindness worldwide. The Chinese Glaucoma Guidelines (2020) formulated important references and suggestions for the treatment of glaucoma, based on the basic national condition of China and considering the latest global progress. To fulfill their guiding effect on clinical work, publicity and promotion of the Guidelines should be intensified to prompt the communication and application. The ophthalmology specialists should pay attention to the quality assessment and reevaluation of the Guidelines regarding their reliability and applicability in clinical work, and promote the evidence-based practice of glaucoma. Continuous feedbacks from clinical practice would enable timely updates and improvement of the Guidelines, thus building a better evidence ecosystem and constantly optimizing the diagnosis and treatment of glaucoma in China. (Chin J Ophthalmol, 2021, 57:161-165)

Primary glaucoma with cataract is a common eye disease in China, and surgery is the main treatment. With the continuous advance of medical technology, the choice of surgical methods is controversial, and there is still a lack of consensus with general guiding significance in China. In order to standardize the clinical treatment, Chinese Glaucoma Society has formulated this consensus after a serious discussion. This consensus is aiming at guiding clinical practice and putting forward instructive opinions on the operation methods, perioperative and follow-up management of different types and stages of primary glaucoma with cataract surgery indications.(Chin J Ophthalmol, 2021, 57:166-170)

Demyelinating optic neuritis (DON) is an inflammatory demyelinating disease of the central nervous system, which can lead to visual loss in young adults as a major factor. The key points concerned by neuro-ophthalmologists are to reduce the rate of recurrence and improve the prognosis in the course of diagnosis and treatment of DON. Companied with the deep research of diagnostic markers, different classifications and therapies, and evidence-based medicine, there are more and more clinical evidences for the development and standardization of evidence-based guidelines for diagnosis and treatment. According to the routine procedures, the expert steering committee, the guideline development group, the external review expert group and the working group were established. The clinical concerns were collected directly from neuro-ophthalmologists, ophthalmologists of other subspecialties and neurologists. The guideline development group comprehensively searched and systematically evaluated the relevant research evidence at home and abroad, analyzed the preferences and values of patients, and organized the expert consensus meeting. Sixteen recommendations for the diagnosis and treatment of DON were formulated, including classification and diagnosis, therapies in acute and chronic phases, and the follow-up management, which has important guiding significance for the improvement of clinical treatment and reduction of the recurrence rate. (Chin J Ophthalmol, 2021, 57:171-186)

Glaucoma is the world's first irreversible blinding eye disease. Since glaucomatous visual impairment is irreversible, accurate assessment of the condition of glaucoma patients is of great significance for the long-term control of glaucoma patients. Previous studies have shown that the accuracy of artificial intelligence algorithms based on color fundus photography and coherent light tomography for early diagnosis of glaucoma is close to or better than that of ophthalmologists; At the same time, the algorithm can also predict future disease changes such as the degree of visual field defect and the change of nerve fiber layer thickness based on the baseline examination results. Based on high-quality multimodal image data and advanced artificial intelligence algorithms, it is expected to realize the prediction of the condition changes of glaucoma patients, which will be an important link to realize the individualization of treatment plans. The combination of artificial intelligence and imaging will bring breakthrough innovation to the clinical diagnosis and treatment of glaucoma.(Chinese Journal of Ophthalmology, 2021, 57:187-190)

With the application of new screening methods such as telemedicine consultation and artificial intelligence technology, the adoption of artificial intelligence-assisted diagnostic technology has proven to have the potential to provide an effective and quick way for glaucoma screening. Artificial intelligence algorithms have also achieved preliminary results in predicting future disease changes such as visual field and nerve fiber layer thickness changes based on baseline examination results. However, combined with the actual situation in China, this paper proposes that the current popularization of artificial intelligence in the field of glaucoma should focus on screening rather than prediction.(Chinese Journal of Ophthalmology, 2021, 57:191-193)

To investigate and compare the sub-foveal choroidal thickness (SFCT) in both eyes of patients with unilateral primary open-angle glaucoma (POAG) and healthy controls.

Cross-sectional study. Patients with unilateral POAG and healthy controls were recruited from September 2018 to September 2019 in the Beijing Tongren Hospital. All subjects underwent enhanced depth imaging optical coherence tomography. The SFCT was measured at the fovea, and at 500 μm, 1 000 μm and 2 000 μm nasal and temporal to the fovea. Paired t test was conducted to compare the choroidal thickness between affected POAG eyes and unaffected fellow eyes. Analysis of covariance was conducted to compare the choroidal thicknesses between POAG eyes and controls. Multiple regression analysis determined the association between choroidal thickness and age, gender, spherical equivalent and mean deviation.

Seventy-five patients with unilateral POAG (mean age, 46 years; 48 males, 27 females) and 61 healthy controls (mean age, 44 years; 34 males, 27 females) were included in this study. The SFCT of POAG eyes was (244.41±83.18) μm, which was not significantly different from their unaffected fellow eyes [(254.28±88.92) μm, P>0.05] and controls (right eyes) [(272.98±55.87) μm,P>0.05]. Choroidal thickness at 2 000 μm nasal to the fovea was significantly decreased in the glaucomatous eyes compared with the unaffected fellow eyes [(167.84±70.44)vs. (188.84±89.06) μm, t=-3.55; P<0.01]. There were no significant differences among the glaucomatous eyes, unaffected fellow eyes and healthy controls in choroidal thickness at 500 μm and 1 000 μm nasal and temporal to the fovea, as well as at 2 000 μm temporal to the fovea (allP>0.05). The SFCT of POAG eyes was associated with mean deviation (β=14.66,P<0.05) and spherical equivalent (β=14.95,P<0.01) but not with age and gender (bothP>0.05).

The SFCT of affected eyes in patients with unilateral POAG has no significant difference from unaffected fellow eyes and healthy controls. However, the choroidal thickness at 2 000 μm nasal to the fovea is thinner in the POAG eyes as compared with the fellow eyes. A thinner SFCT is correlated with the loss of visual field and a higher spherical equivalent in myopia. This may suggest a contributing role of the perfusion of the choroid in the pathogenesis of glaucoma. (Chin J Ophthalmol, 2021, 57: 194-200)

To evaluate the retinal vessel density in eyes with primary open-angle glaucoma (POAG) with single-hemifield visual field (VF) defects and its relationship to retinal nerve fiber layer (RNFL) thickness and visual field indices.

Cross-sectional study. Twenty-eight POAG patients with single-hemifield VF defects and 31 normal controls were recruited from October 2015 to October 2018 in the Eye, Ear, Nose and Throat Hospital of Fudan University. All subjects underwent complete ophthalmological examinations, including RNFL, retinal ganglion cell complex (GCC) thickness and visual field tests, and the general information was collected. The peripapillary radial peripapillary capillaries (RPC) and macular superifical retinal capillary plexus (SCP) were derived from optical coherence tomography angiography. The retinal vessel density, structural values, and VF values were compared among the corresponding hemifields of POAG and healthy eyes using the Rank Sum test.

There were 16 males and 12 females in POAG patients, with the age of (47±12) years; there were no significant differences in gender distribution, age, intraocular pressure, central corneal thickness, axial length and intraocular perfusion pressure between POAG patients and the normal controls (all P>0.05). Among POAG patients, there were 19 cases with upper and 9 cases with lower visual field defect. In the POAG eyes, the vascular density of peripapillary RPC and macular SCP were 45.86% (34.92%-52.78%) and 39.31% (32.55%-46.79%), respectively. In the normal eyes, the vascular density of peripapillary RPC and macular SCP were 56.90% (51.69%-60.84%) and 47.48% (37.95%-52.25%), respectively. The difference was statistically significant (Z=-6.56, -5.86; both P<0.01). The RNFL and GCC thicknesses in the POAG group were 84.4 (62.1-97.1), 76.4 (60.3-92.5) μ m, respectively, which were smaller than those in normal controls [110.6 (95.7-131.6), 98.1 (84.0-109.2) μm;Z=-6.57, -6.36; both P<0.01]. In the POAG eyes, the peripapillary RPC [44.12% (34.73%-53.20%)vs. 51.85% (38.64%-61.02%); Z=-4.62; P<0.01] and macular SCP [36.81% (29.73%-47.82%)vs. 41.78% (33.93%-49.22%);Z=-4.12; P<0.01] vessel densities were reduced in the abnormal hemisphere compared with the opposite hemisphere. Compared with the normal eyes, the normal hemisphere of the POAG eyes had lower peripapillary RPC and macular SCP vessel densities (Z=-5.08, -4.95; both P<0.01), a thinner RNFL and a thinner retinal GCC [93.0 (61.9-116.5) μmvs. 110.6 (95.7-131.6) μm, Z=-5.15; 86.3 (67.2-98.2) μm vs. 98.1 (84.0-109.2) μm, Z=-5.35; bothP<0.01]. But the mean deviation and pattern standard deviation values of the VF were not significantly different between them (bothP>0.05).

The retinal vessel density reduce in eyes with POAG with single-hemifield VF defects. The normal hemisphere of POAG eyes have a reduced retinal microcirculation along with the thinning of the RNFL and GCC, suggesting that vascular dysfunction and structural changes preceded VF loss in POAG. (Chin J Ophthalmol, 2021, 57: 201-206)

To evaluate the quality of life of patients with primary open-angle glaucoma (POAG) and its related factors in Wenzhou.

Cross-sectional analysis. A total of 339 POAG patients diagnosed in the Wenzhou glaucoma progression study conducted in the Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University from March 2014 to October 2019 were included. Quality of life of POAG patients was assessed by EQ-5D including the visual analogue scale (VAS). The effects of gender, age, visual field loss (VFL), family history of glaucoma, hypertension, diabetes, migraine, sleep quality, and amateur exercise on the quality of life were analyzed. The utility value (UV) and VAS score were expressed as the median (P₂₅, P₇₅), and Mann-Whitney U was used for the comparison between two groups. Kruskal-Wallis H was performed to compare the differences among multiple groups.

A total of 339 POAG patients were included in the study; 164 were males (48.4%), and 175 were females (51.6%). The mean age was (63±10) years. Thirty-four patients (10.0%) had received medication (including one with combined surgical treatment), while the remaining 305 patients (90.0%) had received no anti-glaucoma treatment. Among the patients, 10.5% (32/305) had no VFL, 68.9% (210/305) had mild VFL, 17.0% (52/305) had moderate VFL, and 3.6% (11/305) had severe VFL. In all patients, the median of UV was 1.000 (1.000, 1.000), the mean of UV was 0.964, and the median of VAS score was 80 (75, 90), the mean of VAS score was 81.58. Anxiety or depression and pain or discomfort occurred in 45.7% (43/94) and 34.1% (32/94), respectively, of POAG patients with decreased UVs, as well as mobility constraints in 13.8 % (13/94) and usual activity constraints in 6.4% (6/94). The median of UV of the eye with a better visual field in the group without VFL or with mild or moderate VFL was 1.000 (1.000, 1.000), and in the group with severe VFL was 1.000 (0.862, 1.000), but there was no significant difference in the UV and the VAS score of the eye with a better visual field among groups with different degrees of VFL (bothP>0.05). There was statistically significant difference in the UV among groups with different sleep qualities (H=17.465; P<0.01). Using pairwise comparison, the median of UV of the very good sleep group was 1.000 (1.000, 1.000), significantly different to the slightly poor sleep group 1.000 (0.866, 1.000) (z=3.613; P<0.05). The median of UV in patients with migraine was 1.000 (0.875, 1.000), without migraine 1.000 (1.000, 1.000), and in patients with hypertension was 1.000 (0.875, 1.000), without hypertension 1.000 (1.000, 1.000), and in patients with diabetes was 1.000 (0.875, 1.000), without diabetes was 1.000 (1.000, 1.000), the difference was statistically significant (Z=-2.189, -3.864, -2.417; all P<0.05). The UV was not related to age, gender, family history of glaucoma, amateur exercise, alcohol and tobacco, and history of anti-glaucoma medication (allP>0.05).

VFL is related to the UV of POAG patients in Wenzhou. Quality of life in mild POAG patients is good but decrease in advanced POAG patients. Sleep quality, systemic complications and physical or psychological discomfort impact on quality of life in POAG patients. (Chin J Ophthalmol, 2021, 57: 207-214)

To explore the possible mechanism of silent information regulator 1 (SIRT1) in regulating the function of human trabecular meshwork cells (HTMCs).

Experimental study. HTMCs were transfected with SIRT1-overexpressed lentivirus and control lentivirus at the optimal multiplicity of infection, respectively. The total RNA was extracted, and the long non-coding RNA (lncRNA) microarray was used to detect the expression of lncRNAs. The differentially expressed lncRNAs were analyzed by bioinformatics. Real-time PCR was used to verify the microarray results. Student′s t-test was used for comparison between groups.

Compared with the control group, there were 636 up-regulated lncRNAs and 2 246 down-regulated lncRNAs in the SIRT1 overexpressed group (all P<0.05). Gene ontology analysis showed that SIRT1 regulated extracellular matrix, cell metabolism, proliferation and apoptosis of HTMCs. Kyoto encyclopedia of genes and genomics pathway analysis indicated that differential lncRNAs induced by SIRT1 were involved in 19 signal pathways, including Notch signaling pathway, mitogen-activated protein kinase signaling pathway, inflammatory mediator regulation of tyrosinase-associated protein channels and extracellular matrix-receptor interaction.

SIRT1 could have effects on the function of HTMCs through regulating lncRNAs in multiple signaling pathways, including Notch signaling pathway, mitogen-activated protein kinase signaling pathway, etc. (Chin J Ophthalmol, 2021, 57: 215-222)

To observe the changes of four pulley locations of extraocular rectus muscles and rectus muscle volumes, as well as superior and inferior part ratio of horizontal rectus muscles, in concomitant exotropia with small-angle vertical deviation in primary gaze.

Cross-sectional study. Data was collected from January 2018 to December 2019 in Tianjin Eye Hospital. The pulley position changes and volumes of four extraocular rectus muscles in the coronal position of patients who had concomitant exotropia without vertical deviation (group A) or with small-angle vertical deviation in primary gaze (<5 prism diopter; group B) and normal controls (group C) were observed using MRI, and the changes of the volume ratio of the superior and inferior parts of the horizontal rectus muscle were calculated. One way analysis of variance and Kruskal-Wallis test were used for statistical analysis.

There were 19 patients (38 eyes; 10 males, 9 females) aged (30±7) years in group A, ten patients (20 eyes; 4 males, 6 females) aged (27±6) years in group B, and 20 healthy volunteers (40 eyes) in group C. Age and gender distribution were matched among the three groups (all P>0.05). Among the three groups, the pulley locations of the four extraocular rectus muscles were not significantly different (allP>0.05). The medial rectus muscle volume in groups A [(358.6±44.9) mm³; t=6.405, P<0.01] and B [(334.7±35.6) mm³; t=6.025, P<0.01] was significantly smaller than group C [(437.5±49.3) mm³]. There was no statistically significant difference in the superior and inferior muscle volume ratio of the lateral rectus in three groups (all P>0.05), while the ratio in group B was more dispersive.

The pulley location changes of four extraocular rectus muscles of patients with concomitant exotropia and small-angle vertical deviation in primary gaze are not significant, but the medial rectus volume in patients who had concomitant exotropia with vertical deviation or not is significantly smaller. The dispersive superior and inferior muscle volume ratio of the horizontal rectus muscles may be related to the small angle of vertical deviation in clinical examinations. (Chin J Ophthalmol, 2021, 57: 223-227)

The study aimed to introduce a new analysis method of 24-hour intraocular pressure (IOP) and to propose the concept of overall IOP. Data of 24-hour IOP of a patient with a confirmed diagnosis of normal tension glaucoma was selected. Based on the present indexes including peak IOP, trough IOP, maximum difference, and mean IOP, new indexes were proposed, which included main IOP, duration of main IOP, and rate of IOP increase. A radar chart was drawn, and overall IOP was calculated. Overall IOP value = IOP distribution (sum of IOP value multiplied by the corresponding duration) × IOP fluctuation (standard deviation) × rate of IOP increase/100. By comparing two series of IOP data, the advantages of the new IOP indexes were demonstrated. The introduction of the concept of overall IOP expands the description of IOP from a single static state to a comprehensive dynamic state, which enables us to analyze the results of 24-hour IOP monitoring more thoroughly. (Chin J Ophthalmol, 2021, 57: 228-231)

The patient was a 29-year-old male. Because of repeated redness and pain in his left eye for 1 month, he went to Xiamen Ophthalmology Center affiliated to Xiamen University. Six months ago, the left eye underwent vitrectomy and intraocular foreign body removal combined with silicone oil filling in a local hospital due to intraocular metal foreign body. Intraoperative heavy water and laser were used, and postoperative retinal repositioning was performed. One month ago, cataract cortical aspiration combined with posterior silicone oil removal was performed in a local hospital. Ocular examination: visual acuity in the left eye was 0.02 (+10.00 DS =0.5) and intraocular pressure was 12 mmHg (1 mmHg =0.133 kPa); The conjunctiva is mixed and congested, the cornea is transparent, the anterior chamber is deep, and transparent particles of different sizes are visible below, and the particles contain fine particles (Quintessence Picture 1), the lens is absent, the posterior capsule is intact, the fluid in the vitreous cavity is clear, the retina is flat in the fundus of the eye, and the scar is visible in the nasal equator. Clinical diagnosis: After vitrectomy for removal of foreign body in left eyeball; Heavy water and silicone oil residue in the anterior chamber of the left eye; Left eye aphakia.

By reviewing the recent articles regarding the ocular side effect of tamoxifen when treating breast cancer and glioma, this article summarized the incidence and the potential mechanism of the side effects of tamoxifen, and the specific ocular toxicity including keratopathy, cataract, retinopathy, optic neuropathy. This review would provide guidance for clinical ophthalmologists to early identify and appropriately manage tamoxifen induced ocular diseases.(Chin J Ophthalmol, 2021, 57: 232-236)

Fundus image registration is to superimpose and overlap fundus images taken at intervals of time and display them alternately after searching for features through software, so that the observer can clearly observe the subtle changes of fundus images due to different times. The Chinese Glaucoma Guidelines (2020) have listed fundus image registration as a recommended method for observing the anatomical changes and injury progression of glaucoma fundus. This paper introduces the advantages and disadvantages of the method of follow-up examination of optic nerve morphology and the principle and performance of fundus image registration to detect the changes of optic nerve injury in glaucoma, so as to explain that fundus image registration is a sensitive method to detect the progression and changes of optic nerve injury in early and middle stages of glaucoma, so as to promote the use of this method in qualified ophthalmology institutions in China as soon as possible.(Chinese Journal of Ophthalmology, 2021, 57:237-240)