Volume 57 · Issue 05 · 2021

Cerebral/central visual impairment (CVI) has a wide range of features owing to central visual pathway disorders. It is currently the most common type of visual impairment in children in developed countries and is increasing in the developing world. The major cause of CVI is hypoxic-ischemic encephalopathy in premature children. CVI occurs from the postgeniculate visual pathway to the occipital lobe and results in severe visual impairment and even blindness. CVI may also lead to visual cognitive disability, walk difficulty, delayed social interaction and autism spectrum. These children are less likely to live independently, and this will impose huge costs on families and society. Therefore, much more care and attention should be paid to CVI. (Chin J Ophthalmol, 2021, 57: 321-325)

Inherited optic neuropathy (ION), which can be characterized by isolated optic atrophy or together with systemic manifestations, is a rare optic nerve dysfunction with multiple genetic patterns. Genetic testing plays the key roles in the diagnosis, genetic counseling and treatment of ION. Currently, most ophthalmologists are unfamiliar with how to interpret the genetic testing results correctly. This article describes the genetic characteristics of ION and explains the main points on genetic reports interpretation to help ophthalmologists getting familiar with this relatively rare field and to promote the clinical application of gene testing. (Chin J Ophthalmol, 2021, 57: 326-330)

Accommodative esotropia is the most common type of esotropia in children. The patients often need to wear hyperopic glasses to correct eye positions and improve vision and binocular function. However, the course of accommodative esotropia is usually long, so it is necessary to monitor the refractive changes for a long time. Maintaining full hyperopic correction will interfere with the emmetropia development of the eyeball, and undercorrection of hyperopia will lead to the risk of esotropia decompensation. These often bring confusion when clinicians prescribe glasses. The benefits of accommodative esotropia with a high accommodation convergence/accommodation ratio from fitting bifocal lenses and the effect of prisms on residual esotropia have also been controversial topics in this field. In this article, we combine the research status and clinical practice to present some points of view for the peer reference. (Chin J Ophthalmol, 2021, 57: 331-335)

Amblyopia is caused by vision deprivation and/or abnormal binocular interaction during visual immaturity. According to different etiologies, it is divided into strabismic, ametropic, anisometropic and visual deprivation amblyopia. The key to the treatment of amblyopia is early screening and timely intervention. The managements include eliminating the factors of visual deprivation, optical correction, patching and penalization. Following the publication of the Expert Consensus on Diagnosis of Amblyopia in 2011, the Chinese Association for Pediatric Ophthalmology and Strabismus organized experts in this field again to discuss and formulate the Expert Consensus on Prevention and Treatment of Amblyopia in Children based on the research results of evidence-based medicine. The purpose is to provide clinical guidance of the diagnosis and treatment of amblyopia for ophthalmologists and to improve clinical service. (Chin J Ophthalmol, 2021, 57: 336-340)

To develop and validate the health-related quality of life (HRQOL) questionnaire for adult patients with anisometropic amblyopia.

Cross-sectional study. A total of 170 adult patients with anisometropic amblyopia, 100 adult patients with other eye diseases and 80 healthy adults with normal vision were recruited at the First Affiliated Hospital of Nanjing Medical University, and 20 healthy adults with normal vision were recruited at Qinhuai Medical District of Easter Theater General Hospital of PLA from December 2019 to February 2020. Individual interviews of 30 adult patients with anisometropic amblyopia generated 80 questionnaire items. For item reduction, 40 adult patients with anisometropic amblyopia were asked to complete the 80-item questionnaire and responses were analyzed. Then factor analyses were performed to identify prominent factors (subscales). The reliability of the questionnaire was evaluated by Cronbach′s α coefficient. The overall and sub-scale scores were the average scores of all included items, ranging from 0 (worst HRQOL) to 100 (best HRQOL). The final 20-item questionnaire was administered to additional 100 adult patients with anisometropic amblyopia, 100 adult patients with other eye diseases and 100 visually normal adults. Mean overall and subscale scores were compared across groups using one-way analysis of variance.

The final adult anisometropic amblyopia questionnaire (AAAQ) consisted of a function subscale and a psychosocial subscale, each containing 10 items. The Cronbach′s α coefficients of the overall, function subscale and psychosocial subscale were 0.88, 0.78 and 0.78. There were 55 males and 45 females in 100 adult anisometropic amblyopia patients, with a median age of 26 years (range, 18 to 43 years). The age and gender distribution were matched with 100 adult patients with other eye diseases and 100 healthy adults with normal vision (all P>0.05). The mean overall score (28.63±9.18), function subscale score (27.69±9.88) and psychosocial subscale score (29.53±9.90) for adult patients with anisometropic amblyopia were significantly lower compared to adult patients with other eye diseases (71.28±8.14,P<0.01; 65.56±7.81,P<0.01; 76.85±10.76,P<0.01) and visually normal adults (84.54±9.13,P<0.01; 81.70±9.27,P<0.01; 87.38±10.06,P<0.01).

The AAAQ meets the requirements for validity and reliability of a HRQOL questionnaire, and can be used to assess the HRQOL of adult patients with anisometropic amblyopia. (Chin J Ophthalmol, 2021, 57: 341-347)

To investigate the clinical characteristics, possible etiology and surgical efficacy of acute acquired concomitant esotropia (AACE) with atypical etiology.

Case-control study. Twelve patients, including 7 males and 5 females, who complained of diplopia and were diagnosed with AACE in Tianjin Eye Hospital from January to December 2019 and underwent surgical treatment were included. The duration of the disease was (8.83±3.71) months. All patients underwent routine ocular examination except amblyopia and ocular organic lesions. MRI examination of the orbits and the brain was performed in all the patients in order to screen orbital and craniocerebral diseases, and patients denied that the existence of common causes of AACE (such as occlusion of one eye, mental or psychological factors, medium to high myopia, etc. during medical examination). The characteristics of the disease, the difference of deviation angle at 33 cm and 5 m, and the changes of deviation angle and stereopsis before and after surgery were analyzed. The forced duction test was performed before operation, and the distance between the sclera margin and the midpoint of the medial rectus muscle attachment was measured and compared with the patients with intermittent exotropia (10 cases) and comitant esotropia (10 cases). Paired samplet-test and one-way analysis of variance were used for statistical analysis.

The mean spherical equivalent was (1.70±0.88) D in all AACE patients, and the deviation angle was (22.42±5.82) prism diopter (PD) at 33 cm and (20.00±4.86) PD at 5 m in primary gaze, which were not statistically significant (P=0.371). The force duction test showed no obvious tension or contracture of the medial rectus and no paralysis. In patients with AACE, the horizontal distance from the midpoint of the medial rectus to the limbus was (5.20±0.27) mm, versus (5.30±0.25) mm in intermittent exotropia patients and (5.30±0.31) mm in concomitant esotropia patients. All the differences were not statistically significant (P=0.618). All the patients with AACE had residual esotropia (mean, 3.42 to 6.33 PD) at 6 weeks, 3 months, and 6 months postoperatively, and their stereopsis improved more than before, with no stereopsis in 2 patients before surgery and stereopsis in all 12 patients after surgery.

AACE patients with atypical etiology do not have high myopia and hyperopia. There is no significant difference between the distance and near angles. The occurrence of esotropia is related to decompensation of esophoria, which may result in clinical symptoms of diplopia. Conventional surgery can reduce esotropia and restore stereoscopic vision, but there is still a small amount of esophoria after surgery. There is no abnormality in the attachment point of the medial rectus muscle. (Chin J Ophthalmol, 2021, 57: 348-352)

To investigate the characteristics and associated factors of early refractive parameters in premature infants.

Case-control study. Premature infants who underwent the first fundus screening in the ophthalmic clinic of Xiamen children′s Hospital from May 2018 to February 2019 were collected. The screening time was 4 to 6 weeks after birth or corrected gestational age from 31 to 32 weeks. The premature infants who were diagnosed with mild retinopathy of prematurity (ROP) in one eye or both eyes but did not receive any treatment were divided into ROP group and divided into zone Ⅱ subgroup and zone Ⅲ subgroup according to the region of ROP; the premature infants without ROP were divided into non-ROP group. The gestational age, birth weight, spherical equivalent, anterior chamber depth, vitreous depth, axial length, lens thickness and corneal refractive power were recorded and compared. Independent sample t-test, multiple linear regression analysis and Pearson correlation analysis were used.

A total of 180 premature infants, 101 males and 79 females, with gestational age of (30.82±3.10) weeks, corrected gestational age of (37.21±1.44) weeks and birth weight of (1 577.85±572.12) g were included in this study. Ninety premature infants were included in the ROP group (162 eyes, of which 85 right eyes were included in the analysis) and 90 in the non-ROP group (90 right eyes). There was no significant difference in the distribution of gestational age, birth weight and corrected gestational age between the ROP group and non-ROP group (all P>0.05), but there was significant difference in the spherical equivalent between the two groups [(1.90±1.39) Dvs. (3.04±1.88) D, t=-4.653, P<0.01], and ROP group was relatively smaller. In the ROP group, the anterior chamber depth was (1.82±0.23) mm, the lens thickness was (4.54±0.18) mm, and the corneal refractive power was (43.99±0.99) D. In the non-ROP group, the anterior chamber depth was (1.91±0.94) mm, the lens thickness was (4.23±0.50) mm, and the corneal refractive power was (43.72±0.92) D. The difference between the two groups was statistically significant (allP<0.01). In ROP group, the anterior chamber depth was shallower, the lens was thicker, and the corneal refractive power was higher. In ROP group, the corneal refractive power of 48 right eyes in zone Ⅱ subgroup and 37 right eyes in Zone Ⅲ subgroup were (43.92±0.78) D and (43.39±1.05) D respectively, and the spherical equivalent were (2.08±0.95) D and (2.52±1.12) D respectively. The corneal refractive power of zone Ⅱ subgroup was higher and the spherical equivalent was smaller, and the differences were statistically significant (allP<0.05). Multiple regression analysis showed that birth weight, gestational age and corneal refractive power were the influencing factors of spherical equivalent (P<0.01). The results of Pearson correlation analysis showed that the gestational age (r=0.182), birth weight (r=0.223) and corneal refractive power (r=-0.125) of premature infants were closely related to the spherical equivalent (all P<0.05).

In premature infants, the larger spherical equivalent is related to greater gestational age and heavier birth weight. The refractive parameters of mild ROP are characterized by shallow anterior chamber, thick lens, high corneal refractive power and small spherical equivalent. The spherical equivalent is closely related to the development of ROP.(Chin J Ophthalmol, 2021, 57: 353-357)

To evaluate the visual quality after phacoemulsification and implantation of a rotational asymmetric refractive intraocular lens in patients with high myopia and cataract.

A retrospective cohort study. Sixty-two patients (92 eyes) of the First Affiliated Hospital of Zhengzhou University from June 2017 to December 2019 were evaluated after phacoemulsification and implantation of a rotational asymmetric refractive intraocular lens (LS-313 MF30). According to the axial length, the participants were allocated to either a control group or a high myopia group. Among the 33 patients (46 eyes) in the control group, the axial length was shorter than 26 mm; among the 29 patients (46 eyes) in the high myopia group, the axial length was more than 26 mm. The high myopia group was further divided into two subgroups. The super high myopia subgroup included 12 patients (18 eyes), and the axial length was ≥30 mm; the high myopia subgroup consisted of 17 patients (28 eyes), and the axial length was<30 mm and ≥26 mm. Uncorrected distance visual acuity, uncorrected intermediate visual acuity and uncorrected near visual acuity were recorded after surgery. The follow-up time was more than 6 months. At the end of the follow-up, patients′ contrast sensitivity (CS), reading acuity, reading speed and visual quality questionnaire results were assessed. The main statistical methods were two-way repeated measures analysis of variance, independent samplet-test, one-way analysis of variance and Kruskal-Wallis test.

There were no significant differences in gender distribution, age, or follow-up time between the control and high myopia groups, the control and high myopia subgroup, or the super high myopia subgroup (all P>0.05). At the end of the follow-up, the uncorrected distance, intermediate and near visual acuity of the super high myopia subgroup was 0.07±0.11, 0.34±0.08 and 0.20±0.09, respectively. The difference in postoperative visual acuity was not statistically significant (allP>0.05). The CS and CS with glare of the high myopia group (3 cpd: 1.48±0.18, 1.42±0.16; 6 cpd: 1.75±0.18, 1.76±0.15; 12 cpd: 1.44±0.24, 1.43±0.19; 18 cpd: 0.90±0.23, 0.85±0.20) were significantly different from the control group (3 cpd: 1.66±0.18, 1.62±0.16; 6 cpd: 1.88±0.14, 1.85±0.11; 12 cpd: 1.54±0.18, 1.53±0.14; 18 cpd: 1.06±0.18, 1.01±0.15) (P<0.05), except at 12 cpd (P=0.05). The CS and CS with glare of the super high myopia subgroup (3 cpd: 1.39±0.21, 1.31±0.13; 6 cpd: 1.66±0.16, 1.64±0.12; 12 cpd: 1.32±0.23, 1.31±0.18; 18 cpd: 0.75±0.16, 0.73±0.15) were worst (all P<0.05). A significant difference between the high myopia subgroup and the control group was only found at 3 cpd (1.53±0.13vs. 1.66±0.18, 1.50±0.13 vs. 1.62±0.16; both P<0.05). The reading acuity and reading speed of the super high myopia subgroup were lower than the high myopia subgroup and the control group, while the differences were not statistically significant (allP>0.05). The questionnaire survey showed that there was no significant difference in the proportion of glare and halo between the two subgroups and the control group (bothP>0.05). No patients reported dissatisfaction. The rate of glasses independents was 11/12 in the super high myopia subgroup, 15/17 in the high myopia subgroup and 31/33 in the control group, with no significant difference (P>0.05).

The rotational asymmetric refractive intraocular lens is suitable for patients with high myopia and cataract, and has good far and near vision after operation. However, it could result in relatively low CS for super high myopia patients, so rigorous preoperative examination must be done. (Chin J Ophthalmol, 2021, 57: 358-365)

To summarize the clinical and pathological characteristics of diffuse large B-cell lymphoma of ocular adnexal (OA-DLBCL).

A retrospective case series study. Twenty-three cases of OA-DLBCL were collected in Tianjin Eye Hospital from January 2005 to December 2018. The clinical manifestations and imaging examination results were analyzed. The pathological characteristics and immune subtypes were analyzed with hematoxylin and eosin staining and immunohistochemistry. Eighteen patients completed the follow-up. Overall survival (OS) time was from the date of diagnosis to the date of death or the final follow-up (April 30, 2020). Clinical stages were analyzed by the Ann Arbor classification; Kaplan-Meier plots were used to visualize survival outcomes. The different risk groups were compared using Log-rank test.

There were 13 males and 10 females. The median age was 65 years (range, 43 to 82 years). Twenty-two patients had unilateral lymphoma (14 left eyes, 8 right eyes), and one patient had bilateral lymphoma. The OA-DLBCL was in the orbit in 14 patients, in the lacrimal gland in two patients, in both the lacrimal gland and the orbit in three patients, in both the lacrimal sac and the orbit in one patient, in the conjunctiva in one patient, in both the conjunctiva and the orbit in one patient, and in the skin of eyelids in one patient. Imaging examinations showed the tumors were of irregular soft tissue density. MRI showed the tumors were close to the extraocular muscles or ectocinerea. Centroblastic morphology was present in 21 specimens, and 2 specimens had immunoblastic morphology. Six patients were of germinal center B cell-like (GCB) type, and 17 were of non-GCB type. There were 2 patients with double expression of cellular-myelocytomatosis viral oncogene and B-cell lymphoma 2. The follow-up time ranged from 25 to 156 months, and the median follow-up time was 48 months. Five of them had primary OA-DLBCL, and 13 patients had secondary OA-DLBCL. Five patients were at the Ann Arbor clinical stage ⅠE, one was at stage ⅢE, and 12 were at stage ⅣE. During the follow-up, 8 patients survived, and 10 died. The 1-, 3-, and 5-year OS rates were 88.9%, 71.4% and 41.7%, respectively. Log-rank analysis indicated that the Ann Arbor clinical stage and age were related to the OS of OA-DLBCL (χ²=7.448, 8.804; both P<0.01). The gender, tumor size, molecular typing, Ki-67 index, and bone invasion were not related to the OS of OA-DLBCL (allP>0.05).

OA-DLBCL mainly occurrs in the elderly population, unilaterally, and in the orbit. Most molecular types are non-GCB subtypes. The Ann Arbor clinical stage and age are associated with prognosis.(Chin J Ophthalmol, 2021, 57: 366-371)

A 3-month-old infant patient presented with a 1-week history of a quickly progressive mass in the left eye. A hard, irregularly shaped tumor was found in the superolateral orbit. B-scan showed an uneven hypoecho and an undefined lesion. On the orbital CT, a soft tissue mass was located around the left zygomatic tubercle, involving part of the bone and lacrimal gland. The left orbital mass was removed under general anesthesia after admission. The histological and immunohistochemical examination revealed it was a melanotic neuroectodermal tumor. The infant patient was followed up for 6 months after the operation, and no recurrence was found. (Chin J Ophthalmol, 2021, 57: 372-374)

The first patient complained visual loss of left eye for 1 week. The second patient complained visual loss of right eye for 2 months with conjunctival edema for more than 10 days. The third patient complained redness and swelling of both eyes for 1 year, poor appetite and fatigue for 4 months. All three patients were male with binocular involvement. Enlargement of lacrimal glands in both eyes with bulbar conjunctival edema were observed in 2 patients and binocular eyelid swelling in 1 patient, all 3 patients were associated with external orbital tissue involvement, which were diagnosed as IgG4-related ophthalmic diseases. After treatment with glucocorticoid, the symptoms of the patients were improved, and the patients were followed up for 58, 54, and 60 months, respectively. Among the 3 patients, 2 had recurrence for once, and 1 had recurrence 3 for times. (Chin J Ophthalmol, 2021, 57: 375-378)

The patient was a 36-year-old male. Because of repeated redness and photophobia in his right eye for more than 3 years, he went to the ophthalmology clinic of the First Affiliated Hospital of Suzhou University. A whole body examination a few months ago showed no abnormalities. Eye examination: corrected visual acuity was 0.8 for the right eye and 1.0 for the left eye; Intraocular pressure was normal in the right eye and normal in the left eye 14.0 mmHg (1 mmHg =0.133 kPa); Superficial corneal infiltration in the right eye, pannus with neovascularization, clear cornea in the left eye; The pupils of both eyes are equal in size and respond normally to light. Thick iris blood vessels can be seen in the left eye at the iris collar (Quintessence Picture 1）。 Fluorescein fundus angiography in both eyes showed no abnormalities. Clinical diagnosis: recurrent keratitis of right eye; Thick iris vessels in the left eye.

With improved neonatal care, the survival rate of premature infants has been greatly increased, and retinopathy of prematurity (ROP) has already been the leading cause of blindness in children. Thereupon screening and treatment of ROP have been deeply performed in China. However, the implementation and the detection rate vary greatly in different regions. In this article, based on the 20-year prevalence data of ROP in all parts of the country before 2010, we review and summarize the literatures from 2008 to 2018, in order to track and update the screening data of ROP in the mainland of China and to find the incidence trend during the decade. The evidence of the changing prevalence of ROP would benefit further prevention of this serious eye disease. (Chin J Ophthalmol, 2021, 57: 379-385)

Mitochondrial optic neuropathy (MON) describes a group of optic neuropathies that exhibit mitochondrial dysfunction in retinal ganglion cells. Pathogenesis of MON includes genetic factors, such as Leber hereditary optic neuropathy and dominant optic atrophy, or acquired factors, such as drug intoxication and nutritional deficiencies, or the combination of both genetic factors and acquired factors. Regardless of different causes, MON shares similar features including bilateral central visual acuity loss, equally normal or slightly sluggish reaction of pupils to light and so on. Many novel therapies, such as pharmacological strategies, genetic therapy and stem cell therapy, are being widely studied in order to limit or reverse the damage of retinal ganglion cells. This article review the pathogenesis, clinical manifestations, ancillary testing, differential diagnosis and treatment progress of MON. (Chin J Ophthalmol, 2021, 57: 386-390)

Facial cosmetic injections refer to a medical cosmetology approach that applies percutaneous injection method to inject filler materials or drugs into the target position of the face to repair and remodel the face. Common facial cosmetic injections include facial filler injection and botulinum toxin injection. A number of iatrogenic eye complications following facial cosmetic injections have been reported, such as ptosis, ophthalmoplegia, vision loss. This article reviews the cosmetic iatrogenic eye complications of the two selected common facial cosmetic injections techniques, i.e. facial filler injection and botulinum toxin injection.(Chin J Ophthalmol, 2021, 57: 391-395)

Infants and young children are the critical period of visual development. The visual abnormalities at this stage may be caused by a variety of eye diseases. If not diagnosed in time and intervened in time, it is likely to bring lifelong visual damage. Therefore, it is of great clinical significance to conduct visual evaluation for infants and young children with suspected visual abnormalities. However, because infants and young children cannot express their discomfort in words and respond clearly to visual stimuli, clinical visual assessment for infants and young children is not popular. This paper focuses on the characteristics of visual development and visual examination methods of infants and young children, in order to further promote the clinical visual evaluation of infants and young children.(Chinese Journal of Ophthalmology, 2021, 57:396-400)