Volume 57 · Issue 06 · 2021

Pathological myopia, an important blinding eye disease worldwide, has caused a heavy social burden. The patients have become younger in recent years. In general, people have limited knowledge of pathological myopia. They often confuse pathological myopia with high myopia, and do not fully realize that pathological myopia is not only an ametropia disease, but also a fundus disease. Fundus complications of pathological myopia are the main causes of visual impairment, including posterior staphyloma, macular degeneration, and secondary choroidal neovascularization. All of them are related to axial length and can progress throughout the life, while the treatment is limited. At present, myopia prevention has become a national strategy, and pathological myopia is the key and difficult point in myopia prevention. The whole society should pay attention to the prevention and treatment for fundus complications of pathological myopia, take comprehensive measures, and increase scientific researches to protect the eye health of the people. (Chin J Ophthalmol, 2021, 57: 401-405)

Day surgery is currently a rapidly developing medical service mode. Ophthalmology is more suitable for day surgery due to its disease characteristics. To promote the healthy development of ophthalmic day surgery in China, and to improve its standardized management to ensure the medical quality and patients′ safety, the Ophthalmology Committee of the Chinese Medical Education Association, the Ophthalmology Branch of the Chinese Geriatrics Society, and the Ophthalmology Professional Committee of PLA Medical Science and Technology Association developed the present expert consensus on management of ophthalmic day surgery after serious, comprehensive, and full discussions, focusing on the facility construction, organization and management model, specific implementation, quality and safety management for ophthalmic day surgery. (Chin J Ophthalmol, 2021, 57: 406-414)

Questions and suggestions on the use of tetanus immune preparations after ocular trauma in the Expert Consensus on Emergency Treatment Standards for Ocular Trauma in China (2019) formulated by the Ocular Trauma Group of Ophthalmology Branch of Chinese Medical Association were raised, and discussed with the author.(Chinese Journal of Ophthalmology, 2021, 57:415-416)

Reply to the discussion opinions on the use of tetanus immune preparations after ocular trauma in the Expert Consensus on the Standards for Emergency Treatment of Ocular Trauma in China (2019), in order to help more ophthalmologists deepen their knowledge and understanding and promote the standardization of emergency treatment of ocular trauma in China.(Chinese Journal of Ophthalmology, 2021, 57:417-418)

To study the macular choroidal volume (MCV) of patients with highly myopic foveoschisis and its clinical value.

In this cross-sectional study, 39 outpatients (39 eyes) with highly myopic foveoschisis were included from January 2016 to December 2020 in Peking University People′s Hospital, including 18 males and 21 females. Their age was (59.3±6.7) years old. Thirty-nine highly myopic patients (39 eyes) with no macular complications were enrolled as control group. The age, gender, and refractive error were matched between two groups. Medical history information and eye examination information including refractive error, axial length and best corrected visual acuity were recorded. All patients had undergone high-resolution enhanced depth imaging optical coherence tomography to measure the retinal and choroidal thickness of multiple parts of the macular zone. According to the image characteristics, myopic foveoschisis patients were divided into the inner and outer myopic foveoschisis subgroups, and the MCV characteristics were analyzed. The independent sample t test, Pearson correlation analysis and linear regression analysis were used.

The subfoveal choroidal thickness was (74.9±59.3) and (155.6±47.1) μm, and MCV was (2.3±0.8) and (5.3±1.0) mm³ in the foveoschisis group and the control group, respectively. The differences were statistically significant (t=-6.649, -15.229; P<0.01). Although no correlation was found between subfoveal choroidal thickness and central foveal thickness in both groups (r=0.103, 0.214; P>0.05), MCV was negatively correlated with macular retinal volume (MRV) in the foveoschisis group (y=-2.90x+18.48; r²=0.47, P= 0.01). In the control group, there was a positive correlation between MCV and MRV (y=0.74x+2.02; r²=0.64, P=0.01). The best corrected visual acuity was positively associated with MCV in patients with foveoschisis (r=0.677, P<0.05). The MCV of inner (19 eyes) and outer (15 eyes) foveoschisis subgroups was (2.80±0.81) and (1.92±0.27) mm³, and the difference was statistically significant (t=4.610, P<0.05).

The MCV significantly decreased in patients with highly myopic foveoschisis. The smaller the MCV, the scarcer the blood supply of the outer retina, the more serious the foveoschisis, and the larger the MRV.(Chin J Ophthalmol, 2021, 57:419-425)

To identify factors associated with persistent subretinal fluid (SRF) after scleral buckling and to evaluate surgical outcomes of patients with primary rhegmatogenous retinal detachment (RRD).

Cross-sectional study and cohort study. This study included 104 patients (104 eyes) who underwent scleral buckling for repair of RRD between January 2016 and June 2017. Several statistically significant risk factors associated with SRF were screened out with univariate analysis. Then independent risk factors were determined with multivariate stepwise logistic regression analysis. Examinations were taken preoperatively, at 1, 3, 6, and 12 months postoperatively, and thereafter every six months. Patients were divided into two groups depending on the presence or absence of persistent SRF on optical coherence tomography at 1 month.

Persistent SRF occurred in 69.2% (72/104) of patients. In multivariate analysis, younger age (OR=32.860, 95%CI=3.636-296.986, P=0.002), high myopia (OR=7.229, 95%CI=1.217-42.94, P=0.03) and macula-involving retinal detachment (OR=357.397, 95%CI=29.761-4292.0, P=0.000) were associated with persistent SRF. Best corrected visual acuity in patients with SRF at 1 month (0.71±0.18 vs. 0.58±0.11; t=4.047, P<0.01) and 3 months (0.55±0.15vs. 0.43±0.12; t=3.914, P<0.01) was worse than that in patients with absence of SRF. Best corrected visual acuity in patients with SRF was 0.44±0.16 at 6 months, 0.37±0.12 at 12 months and 0.36±0.10 at the last follow-up, with no significant difference from patients without SRF at the three time points (0.39±0.13, 0.38±0.12 and 0.35±0.09;t=1.643, -0.202, 0.464; P>0.05).

RRD patients with younger age, high myopia and macular involvement were more likely to develop persistent SRF after scleral buckling. The presence of persistent SRF slowed visual recovery but did not influence the final visual outcomes. (Chin J Ophthalmol, 2021, 57: 426-432)

To observe the efficacy of macular buckling in the treatment of highly myopic traction maculopathy.

Retrospective case series study. The patients with high myopia who underwent macular buckling at the Zhongshan Ophthalmic Center of Sun Yat-sen University from June 2014 to June 2019 were enrolled, including 136 males and 212 females. The age was (56.68±11.59) years old. The outcomes measured included retinal reattachment rate, foveoschisis recovery rate, macular hole closure rate, postoperative best corrected visual acuity (BCVA), axial length (AL), and complications. The measurements were recorded preoperatively and at 1 month, 6 months, 1 year, 2 years, and 3 years postoperatively. The data was statistically analyzed using paired t test.

A total of 378 eyes were included, including 216 eyes with foveoschisis and macular detachment and 162 eyes with macular holes and macular detachment. Among them, 296 eyes underwent macular buckling, and the other 82 eyes underwent macular buckling combined with pars plana vitrectomy. During the follow-up period, 373 eyes (98.68%) achieved retinal reattachment; in patients with foveoschisis, 204 eyes (94.44%) were recovered; in patients with macular holes, 89 eyes (54.09%) achieved closure. All the postoperative results of BCVA were better than the preoperative value (1.459±0.841). BCVA continued to increase from postoperative month 1, remained stable at 1 year, and reached 0.908±0.606 at 3 years (t=6.896, P<0.01). All the postoperative results of AL were shorter than the preoperative value. The AL shortened by (4.423±1.740)mm at one month (t=33.144, P<0.01), increased gradually thereafter, remained stable at 1 year, and shortened by (2.101±1.643) mm at three years (t=6.392, P<0.01). The common complications included transient high intraocular pressure in 98 eyes (25.92%), epiretinal hemorrhage in 67 eyes (17.72%), and vitreous hemorrhage in 9 eyes (2.38%), which all resolved spontaneously within 1 month. In the early postoperative period, all patients had a certain degree of eye movement limitation, and 39 eyes (10.31%) had diplopia which resolved within 6 months without treatment. The strabismus surgery was arranged to treat esotropia in 6 eyes (1.58%). The macular buckle was removed from 1 eye (0.26%) because of the inability to tolerate diplopia. There were 8 eyes (2.11%) requiring a second operation to adjust the position of the buckle. The macular buckle was also removed from 4 eyes (1.05%) due to the implant rejection.

Macular buckling can effectively shorten the AL, resolve posterior scleral staphyloma, and improve vision in the treatment of highly myopic traction maculopathy. (Chin J Ophthalmol, 2021, 57: 433-439)

To report the efficacy and safety of minimally invasive vitrectomy for the treatment of severe proliferative diabetic retinopathy (PDR) and the effect of preoperative retinal photocoagulation on prognosis.

Case-series study and cohort study. This study included 48 severe PDR patients (53 eyes). There are 28 males and 20 females. The average age was 53.5 (range, 40.0 to 59.0) years old. Patients were divided into two groups according to whether preoperative retinal photocoagulation was performed. Under the guidance of the concept of minimally invasive vitrectomy, all patients received intravitreal injection of conbercept 3 days before standard pars plana vitrectomy with a 27G+ vitrectomy system. To relieve traction, the proliferative fibrovascular membrane was divided into islands as small as possible. It was not necessary to pursue a complete removal of the proliferative membrane. The 27G+ vitrector was flexibly applied as a multifunctional tool for membrane removal by reducing frequencies at which the device entered and left the eye. Intraocular retinal photocoagulation was performed in the main area. The primary outcome measures were best corrected visual acuity (BCVA) and retinal reattachment rate, and the secondary outcome measures were intraoperative and postoperative complications. Statistical analysis was performed using t test, rank sum test and χ² test.

All patients tolerated intravitreal conbercept, with no serious intraoperative or postoperative adverse events. Postoperative BCVA values were improved significantly compared with preoperative values (χ²=125.11, P<0.01). The mean logMAR BCVA improved from 1.90 (1.30, 2.30) preoperatively to 1.00 (0.70, 1.90) at 1 week postoperatively, 0.8 (0.5, 1.3) at 1 month postoperatively, 0.7 (0.40, 1.20) at 3 months postoperatively, and 0.70 (0.40, 1.20) at 6 months postoperatively. The visual function increased progressively with time. Postoperatively, the primary and final reattachment rates were 92.5% (50/53) and 96.2% (51/53), respectively. Abnormal intraocular pressure lasted for more than one week occurred in 2 eyes; Vitreous hemorrhage recurred in 5 eyes; Retinal detachment occurred in 4 eyes (7.5%); No postoperative endophthalmitis, choroidal detachment or incision related retinal hole occurred. The intraoperative and postoperative parameters in the preoperative retinal photocoagulation group were better than the preoperative non-photocoagulation group, but the difference was not significant (P>0.05).

Minimally invasive vitrectomy is fully qualified for the management of severe PDR, with maximized benefits. (Chin J Ophthalmol, 2021, 57:440-446)

To developed an image analysis system of anterior segment optical coherence tomography (AS-OCT) examination results based on deep learning technology, and to evaluate its effect in identifying various types of corneal pathologies and quantified indices.

A total of 4 026 patients (5 617 eyes), including 1 977 males and 2 049 females, aged (45±23) years, were enrolled in Qingdao Eye Hospital from January 2011 to August 2019. The AS-OCT images were used as a training dataset, which were labeled with location information of 16 corneal pathologies (including corneal epithelial defect, corneal epithelial thickening, corneal thinning and so on) by clinical experts, as well as the tissue stratification of the corneal epithelium and stroma. The labeled AS-OCT images were used to train the corneal pathology detection model and corneal stratification model based on deep convolutional neural network algorithm. Then 1 709 AS-OCT images of the affected eyes were collected as a validation dataset. Compared with the artificial labeling results, the accuracy, sensitivity and specificity were evaluated in the corneal pathology detection model, and the overlapping rate (Dice coefficient) between the labeled area of the model and the artificial labeling area was used to evaluate the corneal stratification model.

The results of 5 617 training sets showed that there were 1 472 cases of corneal epithelial defect, 2 416 cases of corneal epithelial thickening, 2 001 cases of corneal thinning, 780 cases of corneal lordosis, 2 064 cases of corneal thickening, 358 cases of subepithelial blisters, 486 cases of subepithelial opacity, 1 010 cases of corneal ulcer, 3 635 cases of stromal opacity, 1 060 cases of posterior elastic layer fold, 137 cases of posterior elastic layer detachment, 665 cases of keratic precipitate, 176 cases of corneal perforation, 127 cases of corneal foreign body, 299 cases of after lamellar keratoplasty (LKP) and 234 cases of after penetrating keratoplasty (PKP). Among 1 709 images, 1 596 were manually labeled. The average sensitivity and specificity of the corneal pathology detection model were 96.5% and 96.1% compared with the results of manual labeling. Fifteen samples were missed for detection, and the rate was 0.93%. The average Dice coefficients of the corneal stratification model for the corneal epithelium and stroma were 0.985 and 0.917, respectively.

Our artificial intelligence-based diagnosis system with AS-OCT is able to give quantified information and location information of corneal lesions with high accuracy, which can help ophthalmologists improve the efficiency and accuracy of diagnosis. (Chin J Ophthalmol, 2021, 57: 447-453)

The proband was a 5-year-old boy with binocular esotropia since childhood. Ocular examination showed the binocular optic cup was wide and deep excavated with radial emergence of the retinal vessels and retinal detachment was seen in the left eye. The father of the proband with worse vision of the right eye from a child and received a kidney transplant 10 years ago. Ocular examination showed large optic nerves with large optic cups of the right eye accompanied by retinal detachment in macular area. The left eye showed normal size of the optic disc and etinoschisis. Both nerves had anomalous vascular patterns. The sister of the proband showed binocular wide and deep optic cups, and the vascular course was normal. Renal color Doppler ultrasound and urine routine examination showed that the proband and his sister had bilateral renal calcification, pyelic separation and mild proteinuria. The results of gene detection showed heterozygous mutation (c.419_421delGGA) of the PAX2 gene in this family. Combined with the above examination results, the diagnosis was renal coloboma syndrome.(Chin J Ophthalmol, 2021, 57: 454-457)

Surgeon IntroductionTian Bei, MD, Chief Physician, Associate Professor. Member of the Standing Committee of the Chinese Institute of Sports Rehabilitation Education of the Chinese Medical Association, Member of the Sports Medicine Branch of the Chinese Medical Association, Member of the Optometry Group of the Ophthalmologist Branch of the Chinese Medical Doctor Association, Member of the Standing Committee of the Diabetes Professional Committee of the Chinese Geriatric Health Care Association, Member of the Ophthalmology Professional Committee of the Chinese Medical Equipment Association, Member of the Diabetes Ophthalmology Group of the Diabetes Professional Committee of the Chinese Research Hospital Association, and Member of the 12th Health and Wellness Committee of the China Democratic League. Senior visiting scholar of China Study Abroad Fund (State Administration of Foreign Experts), corresponding editorial board of Chinese Journal of Ophthalmology. Honorary research fellow, Royal Eye Hospital, Murphy, UK, and a member of the Vitreoretinal Surgery Association, UK and Ireland. He has been engaged in the first-line clinical work of ophthalmology in Beijing Tongren Ophthalmology Center, Beijing Tongren Hospital affiliated to Capital Medical University for more than 20 years. He is good at vitrectomy, phacoemulsification cataract aspiration, fundus laser surgery, etc. So far, he has more than 10,000 surgical experiences.

The patient was a 59-year-old male. He went to the Affiliated Optometry Hospital of Wenzhou Medical University due to decreased visual acuity in both eyes and dark shadows fluttering in front of his eyes for 1 week. He has a history of diabetes for more than 10 years and a history of hypertension for 8 years, and is well controlled by taking medication. Eye examination: visual acuity was 0.6 for the right eye and 0.5 for the left eye; IOP was 13.8 mmHg (1 mmHg =0.133 kPa) in the right eye and 13.2 mmHg in the left eye. Coherence light tomography examination showed that there was no obvious abnormality in the retinal structure of all layers in the macular area of the right eye; Hyporeflective small cystic cavity can be seen in the nasal retina of the macular area of the left eye. Autofluorescence: In the absence of red light mode, neovascularization of different shapes can be seen in multiple places of the retina of both eyes (Quintessence Picture 1）。 Clinical diagnosis: proliferative diabetic retinopathy in both eyes.

Choroidal thinning is an important feature of high myopia and has a negative correlation with the degree of myopia. However, due to the limitations of choroidal imaging, specific changes in choroidal thickness and vasculature are unclear. In recent years, the development of optical coherence tomography technology and optical coherence tomography angiography technology has made it possible to solve the problem. Emergence of biomarkers that objectively quantify choroidal thickness and vascular changes will help us understand the pathogenesis of high myopia and provide new ideas for the prognosis and treatment of myopia. In this review, in order to provide reference for clinical work, we summarize recent advances in the application of the two technologies in observing morphological changes of the choroid in high myopia and discuss the problems and prospects when they are combined with artificial intelligence for choroidal imaging. (Chin J Ophthalmol, 2021, 57: 459-464)

The application of artificial intelligence (AI) in ophthalmology will greatly reduce the workload of ophthalmologists. Machine learning is an important branch of AI, and deep learning is the most important algorithm in machine learning. At present, AI is well applied in the ophthalmic field. This article summarizes the use of AI in ophthalmology and discusses its inadequacy and future to provide reference for clinical practice. (Chin J Ophthalmol, 2021, 57: 465-469)

Myopia has become an important global public health problem, especially in East Asia. Due to its high prevalence and multiple ocular complications, it is imperative to take effective measures against the development of myopia. Recent studies have shown that outdoor activity is one of the protective factors for myopia and sunlight can delay the progression of myopia. As a possible mediator between sunlight and myopia, vitamin D gradually comes into public view. Vitamin D refers to a kind of secosteroids responsible for regulating calcium and phosphate metabolism. In addition to this main function, it is also correlated with many eye diseases like diabetic retinopathy, age-related macular degeneration, glaucoma etc. This review summarizes relevant epidemiologic and genetic studies as well as possible biological mechanisms to provide theoretical reference for the plausible application of vitamin D in the prevention and therapy of myopia. (Chin J Ophthalmol, 2021, 57: 470-476)

The prevalence of macular neovascularization (MNV) in highly myopic eyes is as high as 10%. The early stage of visual decline is due to MNV formation, and the main cause in the long term is the appearance of MNV-related macular atrophy, which ultimately leads to the loss of central vision in pathological myopia. In this paper, the natural course of MNV, the diagnostic mode of multimodal imaging, the therapeutic basis and methods were introduced, in order to provide a reference for the early diagnosis and treatment of MNV and its related macular atrophy in pathological myopia.(Chinese Journal of Ophthalmology, 2021, 57:477-480)