Chinese Journal of Ophthalmology
Volume 57 · Issue 08 · 2021
Chin J Ophthalmol
Drug-induced ocular surface injury often occurs in the clinical diagnosis and treatment of eye diseases. Because of concealed clinical manifestations, it is difficult to be distinguished, causing misdiagnosis and mistreatment, and leading to serious corneal and conjunctival damage, and even visual disfunction. In this article, we focus on the mechanism, active prevention and effective treatment of drug-induced ocular surface injury, and propose that the rational use of local eye drugs can effectively reduce or avoid drug-induced ocular surface injury and improve the clinical diagnosis and treatment of eye diseases. (Chin J Ophthalmol, 2021, 57: 561-563)
Dry eye is a common complication after eye surgery and one of the important factors affecting the quality of surgery. It has attracted great attention from ophthalmologists in recent years. In order to reduce the incidence of dry eye after eye surgery and improve the effect of surgical treatment, experts from the Chinese Branch of the Asian Dry Eye Society and other related academic organizations have conducted in-depth discussions on the dry eye related to eye surgery, in terms of its definition, risk factors, pathogenesis, clinical characteristics, diagnosis, treatment and prevention, to form expert consensus opinions for reference in clinical work. This consensus further standardizes and promotes the prevention and treatment of dry eye in China, and thus improves the quality of eye surgery. (Chin J Ophthalmol, 2021, 57: 564-572)
The number of contact lens wearers is ever-growing in China. In order to promote the safety of wearing contact lenses, the Society of Contact Lens Safety Monitoring & Vision Health of Chinese Health Association has conducted extensive discussions on the diagnosis and treatment of adverse reactions of contact lens wear, including the definition, classification, contact lens-related inducements, and therapeutic principles and methods, on the basis of referencing relevant literature and summarizing clinical practice experience, combined with the opinions of experts from relevant professional groups of the Ophthalmology Branch of the Chinese Medical Association. After repeated letter reviews and revisions, this expert consensus is formed for the reference and use of optometry practitioners and clinicians. (Chin J Ophthalmol, 2021, 57: 573-579)
To investigate the relationship between inflammatory cell infiltration and nerve damage in patients with fungal keratitis at different degrees of severity.
Retrospective study. A total of 44 consecutive patients (44 eyes) with fungal keratitis in Beijing Tongren Hospital Affiliated to Capital Medical University from January 2017 to December 2019 were selected as the patient group, including 30 males and 14 females, with an age of (58.3±11.5) years old. Twenty healthy people (20 eyes) were included as control group. Slit-lamp microscopy was performed to observe the corneal ulcer. According to the diameter of corneal ulcer, patients were divided into mild, moderate and severe groups. With in vivo confocal microscopic ,the images were obtained from the epithelial layer to the endothelial layer in the central cornea and superior, inferior, nasal and temporal peripheral cornea. Parameters of the maximum density of fungal hyphae, the maximum depth of hyphal infiltration, the density, area and length of dendritic cells (DCs), the nerve density, and the number and curvature of nerve trunks were collected. The Kruskal-Wallis test, Wilcoxon test, and Spearman correlation analysis were used for analyses.
On confocal microscopy, many uniform, highly reflective, segment-like structures in parallel or staggered rows were detected in the cornea, with a certain degree of physiological curvature and branching. Quantitative analysis of hyphal density found that the median rating of hyphal density was 2.6 (2.0, 3.0), mainly with medium to large amounts of hyphae. Most hyphae were 100-150 μm in depth (18 cases, 40.9%), and the maximum depth of hyphae in 95.5% (42 cases) of patients was within 300 μm. The hyphal invasion depth in the mild group was 89.4 (50.5, 106.8) μm, in the moderate group was 133 (122, 203) μm, and in the severe group was 135 (74, 151) μm. As the severity of the disease increased, the depth of hyphal invasion increased (F=4.248, P=0.001). Compared with the control group, the DC density [166 (81.3, 212.5) vs. 24.0 (20.8, 32.3) cells/μm2], area [441.3 (291.9, 529.5) vs. 63.7 (47.7, 70.3) μm2] and length [68.3 (39.4, 91.0)vs. 9.2 (7.0, 11.3) μm] increased in patients (W=493.5, 500.0, 500.0; P<0.01). The nerve density [5 398.3 (3 202.7, 6 828.3)vs. 19 171.8 (17 558.8, 21 550.4) μm/mm2; t=-14.448, P<0.01] and the length [692.7 (402.0, 925.1)vs.2 138.4 (1 940.4, 2 597.2) μm; t=-11.930, P<0.01] and number [2.9 (2.0,3.0)vs. 6.0 (5.5,7.0); t=-8.282, P<0.01] of nerve trunks in patients decreased. There were strong negative correlations between the nerve density, the number of nerve trunks, and the DC density (r=-0.555, -0.466; P<0.01).
The depth of fungal hypha invasion in patients with fungal keratitis is mainly concentrated in the epithelial layer and superficial stroma layer. The density of mature dendritic cells in the lesion area was negatively correlated with the density and number of subbasal nerves. The density of subbasal nerves decreased as the increase of the severity of the lesion.(Chin J Ophthalmol, 2021, 57: 580-588)
To analyze the clinical features and evaluate the prognoses of Pythium keratitis.
It was a retrospective study. The clinical characteristics, confocal microscopic image characteristics, treatment and curative effect of 6 cases of Pythium keratitis identified by DNA sequencing from June 2017 to June 2019 were reviewed retrospectively.
Among the 6 patients, there were 4 males and 2 females. All cases were monocular. The age was (58.7±11.3) years (range, 52 to 72 years). Keratopathy under a slit lamp was characterized by a dry ulcer surface, burr signs, satellite foci and pseudopodia around the ulcer. An elevated lesion was observed in 2 patients, and no obvious immune ring structure was observed in all patients. Confocal microscopy did not reveal any specific characteristics of Pythium infection. All patients did not respond well to antifungal drugs and received keratoplasty. Three patients had postoperative recurrence. The recurrence time was 4-6 days after the first operation and 2-3 days after the second operation. Two patients underwent two and three corneal transplants, respectively, after recurrence, but evisceration was required finally.
Pythium keratitis is rare and can hardly be distinguished from common fungal infections in clinical manifestations and auxiliary examinations. The disease progresses rapidly, the rates of recurrence and evisceration after keratoplasty are both high, and DNA sequencing is the key to identifying the etiology, which should be paid more attention. (Chin J Ophthalmol, 2021, 57: 589-594)
To investigate causes and management of surgical complications of Descemet membrane endothelial keratoplasty (DMEK) in initial cases.
A retrospective study. A total of 52 eyes of 52 patients underwent DMEK by one surgeon in Peking University Third Hospital from February 2017 to December 2019, including 17 males and 35 females, aged (66±12) years. All patients′ demographic characteristics, previous surgical history, intraoperative and postoperative complications were recorded.
Intraoperative complications included difficulties in unfolding the graft in 6 cases (11.5%), inverted grafts in 5 cases (9.6%), grafts rushing out of the anterior chamber in 2 cases (3.8%), grafts injected behind the iris in 3 cases (5.8%) and hemorrhage in 1 case. Partial graft detachment that occurred in 28 cases (53.8%) was the most frequent postoperative complication. Rebubbling was performed in 25 cases (48.1%). Pupillary block occurred in 9 cases (17.3%) and was managed by reducing air under a slit lamp. Primary graft failure occurred in 3 cases (5.8%) and viral infection occurred in 2 cases (3.8%).
The rate of complications of DMEK in initial cases is higher than that of Descemet stripping automated endothelial keratoplasty. Intraoperative graft inversion and postoperative graft detachment are the most common complications. It is important to select appropriate indications and discover or manage intraoperative and postoperative complications in time to reduce the incidence of complications. (Chin J Ophthalmol, 2021, 57:595-600)
To investigate the clinical efficacy and safety of compound wild chrysanthemum eye masks for mild and moderate dry eye.
In this double-masked, multicenter, placebo-controlled, randomized trial, middle-aged and elderly patients with mild and moderate dry eye were enrolled from six hospitals (Xiamen Eye Center of Xiamen University, China-Japan Friendship Hospital, Peking Union Medical College Hospital, Wangjing Hospital of China Academy of Chinese Medical Sciences, Affiliated Eye Hospital of Shandong University of Traditional Chinese Medicine and Hebei Eye Hospital). The patients were assigned to the compound wild chrysanthemum eye mask group and the eye mask simulator group based on the random number table. Subjective symptoms of dry eye, visual acuity, break-up time (BUT), Schirmer Ⅰ test, and corneal fluorescent staining were evaluated in all patients before treatment and at 1 and 2 weeks after treatment. All adverse reactions during the treatment and follow-up were recorded.
A total of 120 patients were enrolled. Among them, 112 subjects were included for statistical analyses after the exclusion of 8 subjects who were lost for follow-up or had an adverse event, with an age of (54.26±7.44) years. All the indicators were equally comparable between the two groups. Before treatment and at 1 and 2 weeks after treatment, the median (lower quartile, upper quartile) of total score of questionnaires in the eye mask group was 14.50 (10.00, 19.00), 9.00 (5.00, 14.00) and 7.00 (4.00, 10.00), respectively, and that in the control group was 14.00 (9.00, 22.50), 12.00 (6.00, 20.00) and 10.00 (3.50, 17.00), respectively. The score decreased significantly in both groups after 1 week (t=9.1604, S=398.00; P<0.01) and 2 weeks (S=681.00, 575.50; P<0.05) of treatment. The total score of questionnaires in the eye mask group was significantly lower than that in the control group (Z=3.27, 2.81; P<0.05) after treatment. After 1 week of treatment, the average BUT of the eye mask group was (5.71±2.31) s, which was significantly longer than that before treatment (5.06±2.00) s (S =208.50, P<0.05). But there was no significant difference in the control group (S=150.00, P>0.05). After 2 weeks of treatment, there was statistically significant difference in BUT between the two groups (S=407.00, t=3.07; P<0.01). After 1 week of the treatment, the amount of tear secretion in the eye mask group [(6.88±4.78) mm] was significantly larger than that before treatment (S=196.50, P<0.05), while the control group [(6.80±5.85) mm] showed no significant difference (S=55.00, P<0.05). After 2 weeks of the treatment, the amount increased significantly to (7.43±4.86) mm and (7.29±4.56) mm, respectively, in both groups (t=-3.29, -2.26; P<0.05). The difference in the average BUT, Schirmer Ⅰ test result and corneal fluorescent staining between both groups was not statistically significant at each time point. Five mild adverse events occurred, including 2 adverse events (2 times, 3.51%) in the eye mask group and 3 adverse events (4 times, 5.36%) in the control group.
Compound wild chrysanthemum eye masks can effectively improve the symptoms and physical signs of mild and moderate dry eye and can be used as an auxiliary treatment. (Chin J Ophthalmol, 2021, 57: 601-607)
To study the ultrastructural features of the corneal epithelium in the corneal allograft of rats with micromolecular compound J2.
An experimental study. Primarily cultured corneal epithelial cells of rats were used. Mononuclear cells (MNCs) by density gradient centrifugation were assigned into the experimental group [MNCs (2 ml)+corneal epithelial cells+J2], control group [MNCs (2 ml)+corneal epithelial cells] and blank group (corneal epithelial cells). Quantity of CD80 expression was obtained by flow cytometry after coculture. Amplitude and height images were obtained by tapping mode atomic force microscopy (AFM) with a scan rate of 2 Hz and an integral gain of 0.3 to 0.5. Statistical analysis of Ra, Rq, Rvm and Rt was performed using the single-factor analysis of variance, andP value was calculated.
There were obvious differences in the ultrastructure measured by AFM among groups. Ra was 86.75±12.60 in the experimental group, 120.23±12.11 in the control group, and 61.94±10.62 in the blank group (F=306.92, P<0.01). Rq was 102.53±9.45, 138.30±10.13, and 91.96±7.25, respectively, in the three groups (F=361.85, P<0.01). Rvm was -42.21±14.22, -67.36±10.89, and -32.18±19.01, respectively (F=72.22, P<0.01). Rt was 437.32±15.66, 495.32±13.96, and 339.92±11.22, respectively (F=1634.26, P<0.01). The one way analysis of variance showed significant differences in these parameters among groups.
Corneal epithelial cells of rats activated by MNCs had higher CD80 expression, but the expression became decreased with micromolecular compound J2. The ultrastructure of the corneal epithelium became coarser after MNCs activation, and the number of protrusions increased significantly. The ultrastructural changes were alleviated by J2.(Chin J Ophthalmol, 2021, 57: 608-613)
Nowadays, myopia morbidity keeps increasing in China. As the improvements of technique and safety in corneal refractive surgeries, an increasing number of patients with refractive error tend to choose these treatments. The 26-year-old woman with myopia in this case, whose UCVA was 0.1 in OD and 0.2 in OS, had corneal macula in the nasal side of the left eye owing to a corneal trauma occurred more than 10 years ago. After sufficient preoperative examinations, FS-LASIK was performed on the right eye and PTK combined with PRK was performed on the left eye. The UCVA was 1.2 in both eyes 3 months postoperatively, and the corneal macula was mostly cleared in the left eye. It is demonstrated that PTK combined with PRK is an effective and safe way to correct the diopter as well as remove the lesions for the lowly or moderately myopic patients accompanied with superficial corneal opacity. (Chin J Ophthalmol, 2021, 57: 614-617)
A 31-month-old female patient presented to our department of Ophthalmology in Xijing Hospital with insufficiency closed eyelid in left eye and photophobia for one month. Unsteady gait with asymmetrical face, bilateral auricle deformity and deafness could be observed on the pediatric patient. Esotropia in left eye combined, left facial nerve palsy, with binocular anisometropia was checked out after general eye examination. Echocardiography revealed that she was treated with ligation of the ductus arteriosus. A de novo pathogenic variant, c.3392T>C, was identified in CHD7 gene, which supported the diagnosis of CHARGE syndrome.(Chin J Ophthalmol, 2021, 57: 618-620)
A six-and-a-half-year-old girl with white secretions in her eyes for 2 weeks was treated in the Ophthalmology Department of the First Affiliated Hospital of Xi′an Jiaotong University after ineffective treatment in several hospitals. The patient refused to communicate with the doctor and receive detailed examination. Only conjunctival congestion was found in both eyes. According to the photos and specimens of white secretions from both eyes provided by the parents of the patient, the diagnosis was conjunctivitis and conjunctival foreign bodies. With the doctor′s reminding, the parents did close observation and good communication. The child finally admitted that she had put tissue fragments into her eyes in order to attract the parents′ attention. Munchausen syndrome was diagnosed by a psychiatrist. After symptomatic treatment and improvement of family environment, the patient′s condition improved. (Chin J Ophthalmol, 2021, 57: 621-623)
The operator introduces Hong Jing, professor, doctoral supervisor, director of ophthalmology, director of corneal and ocular surface diseases and director of eye bank of Peking University Third Hospital. Head of Infectious Disease Group of Ophthalmologist Branch of Chinese Medical Doctors Association, Vice Chairman of Ophthalmology Professional Committee of Chinese Women Doctors Association, Standing Committee of Ophthalmology Professional Committee of Cross-Strait Medical and Health Exchange Association, and Deputy Head of Ocular Surface and Lacrimal Disease Group. He has been engaged in clinical and basic research of corneal and ocular surface diseases for a long time, and has taken the lead in carrying out corneal endothelial transplantation in China. It has undertaken 7 projects of the National Natural Science Foundation of China and more than 10 other provincial and ministerial projects. He wrote 6 books such as Corneal Endotheliopathy, and published more than 100 academic papers in authoritative journals at home and abroad. In 2018, he won the second prize of Scientific and Technological Progress Award for Outstanding Achievements in Scientific Research in Colleges and Universities.
The patient was a 70-year-old female. Because of the fluttering black shadow in front of his left eye for 1 d, he went to Weifang Eye Hospital. Eye examination: visual acuity was 1.0 in both eyes; IOP was 15 mmHg (1 mmHg =0.133 kPa) in the right eye and 14 mmHg in the left eye; The cornea of both eyes is transparent, the anterior chamber is medium-deep, the aqueous humor is clear, the pupil is round, about 3 mm in diameter, and it is sensitive to light. The intraocular lens is transparent and the vitreous body is mildly opaque. No obvious abnormalities were observed in the fundus of the right eye; The optic disc of the left eye has clear boundaries and normal color, the ratio of optic cup to optic disc diameter is about 0.3, and local retinal edema from the temporal side of the optic disc to the macular area, with an area of about 2.5 mm ×1.5 mm, and no fovea is involved. The results of ultra-wide-angle laser scanning ophthalmoscopy and coherent light tomography angiography are shown in
Cytomegalovirus(CMV) corneal endotheliitis is an inflammatory disease of corneal endothelium caused by CMV infection. It mainly occurs in middle-aged and elderly immunocompetent people and has a relatively high incidence in Asia. It is characterized by localized corneal edema, coin-shaped or linear keratic precipitates and mild anterior chamber reaction, possibly with raised intraocular pressure or a history of recurrent anterior uveitis. The pathogenesis of this disease is not yet clear. Previous studies suggested it was related to viral infection and immune response; Therefore, the current treatment is empirically using antiviral agents combined with topical corticosteroids. Making an accurate early diagnosis and continuous antiviral therapy are crucial in controlling disease progression and preserving corneal endothelial function. (Chin J Ophthalmol, 2021, 57: 624-629)
Diabetic neuropathy is a common complication of diabetes. Its incidence among diabetic patients is more than 50%, and its ocular manifestations include diabetic retinopathy and diabetic corneal neuropathy. By using confocal microscopy, diabetic neuropathy in the cornea has been found to occur earlier than other parts of the body, which helps for early diagnosis, risk assessment and treatment options for diabetic peripheral neuropathy. The repair and treatment of nerve damage in diabetic corneal neuropathy has been frequently studied. This review focuses on the research progress of diabetic corneal neuropathy in recent years, and discusses the research findings on corneal nerve injury, anatomical and functional changes, and mechanism of injury and repair. (Chin J Ophthalmol, 2021, 57: 630-636)
In recent years, the number of myopic patients over 40 years old undergoing corneal refractive surgery has increased year by year. How to balance the distance and near vision of naked eye has become an urgent clinical problem to be solved. At present, a variety of surgical methods have adopted special design schemes to compensate presbyopia. Among them, the improved monocular vision scheme with Q value adjustment can effectively improve the near vision while improving the distance vision of the naked eye after operation, so as to meet the daily life and work needs of people over 40 years old. This paper summarizes and analyzes the existing surgical methods of presbyopia compensation, and emphasizes the common clinical Q-value adjustment and improved monocular vision scheme, in order to provide reference for the related work of ophthalmology.(Chinese Journal of Ophthalmology, 2021, 57:637-640)
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