Volume 57 · Issue 09 · 2021

Lots of new micro-invasive glaucoma surgeries (MIGS) are clinically available in recent two decades. The common characters of these surgeries are micro-invasive and non-filter bleb dependent. There are some problems during the promotion of the MIGS in China, like performing the MIGS with inappropriate indications. The MIGS procedures have more strict indications than traditional trabeculectomy and need more technical skills. To promote the popularization of MIGS and improve the clinical treatment of glaucoma, strictly following the indications and standardizing the surgical technique training are needed. (Chin J Ophthalmol, 2021, 57: 641-643)

The number of corneal refractive surgery in China is increasing year by year, and the quality of surgery is also improved with the trend of diversification and standardization. Dry eye is still one of the common problems associated with corneal refractive surgery. The standardized diagnosis and treatment of dry eye during the perioperative period of corneal refractive surgery is of great significance to improve the postoperative visual quality and satisfaction of patients, and it is also an important part of medical quality control and standardized management in ophthalmology. Therefore, Chinese Optometric Association of Chinese Ophthalmological Society, and the Refractive Surgery Group and the Optometry Group of Chinese Ophthalmologist Association have worked together to address the pathogenesis of dry eye, its evaluation and management before corneal refractive surgery and postoperative nursing care and treatment. The domestic and foreign research findings and the actual clinical situation in China have been considered fully to form this experts′ consensus, which could be used as a reference for medical personnel in clinical practice. (Chin J Ophthalmol, 2021, 57: 644-650)

For people receiving laser corneal refractive surgery for refractive errors combined with age-related accommodation deficiency, more attention should be given to avoid wearing reading spectacles prematurely for presbyopia after no spectacles for distant vision are needed. Cautious preoperative screening, personalized and reasonable surgical design and postoperative care should be ensured to achieve satisfactory results. This expert consensus is written by the experts from the Refractive Surgery Group of Chinese Ophthalmologist Association based on the clinical experience and research findings. Selection of indications, methods and significance of the monocular tolerance test, customized surgical design, evaluation of postoperative visual quality and specific nursing are described, with an aim to provide guidance for the clinical standardization of laser corneal refractive surgery in the correction of refractive errors with age-related accommodation deficiency. (Chin J Ophthalmol, 2021, 57: 651-657)

Orbital tumors frequently occur in the regions where the lacrimal gland is located. Lacrimal gland tumors account for about 10% of orbital space-occupying lesions. Among them, 20% to 50% were epithelial tumors, with benign tumors accounting for 55% and malignant tumors accounting for 45%. Epithelial lacrimal gland tumors usually have a special location with relatively distinctive manifestations, and the treatment principle is different from other orbital space-occupying lesions. Improper treatment often leads to recurrence and even malignant transformation, which compromise the prognosis and life quality of patients. In view of this, the Oculoplastic and Orbital Disease Group of Chinese Ophthalmological Society has put forward the expert consensus on the diagnosis and treatment of epithelial lacrimal gland tumors after serious discussion, in order to improve the level of diagnosis and treatment of this disease in China.(Chin J Ophthalmol, 2021, 57: 658-662)

Glaucoma is the world's first irreversible eye disease causing blindness. Suspected primary angle closure (PACS) is a high-incidence anatomical risk of glaucoma in the population. Whether laser peripheral iridectomy (LPI) should be used as a group intervention to prevent PACS from converting to primary angle closure (PAC) or primary angle closure glaucoma needs to be verified based on the results of randomized controlled clinical trials with long-term follow-up. The Zhongshan Chamber Angle Closure Prevention Study aims to explore the efficacy and safety of LPI in preventing the conversion of PACS into PAC (including acute and chronic). It is currently a single-center clinical randomized controlled clinical trial with the largest number of cases and the longest follow-up time. Based on the results of this study, this paper proposes and expounds that LPI should not be popularized in the preventive treatment of PACS, in order to discuss with fellow ophthalmologists.(Chinese Journal of Ophthalmology, 2021, 57:663-665)

To describe the distribution and characteristics of peripheral anterior synechiae (PAS) in patients with primary angle-closure glaucoma (PACG).

Retrospective case study. A total of 285 PACG patients (406 eyes) diagnosed in the Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University from January 2017 to August 2019 were included. They were 102 males and 183 females, with a median age of 67 years old (range, 21 to 95 years old). The PAS range was detected by gonioscopy examination, and the frequency distribution of PAS at 12 clock points was counted by clockwise. The PAS distribution at the middle point of PAS with continuous distribution and ≤6 clock points was assessed.

In all cases, PAS of the right eye was concentrated at 11:00 to 4:00 regions [range, 62.0% (129/208) to 78.8% (164/208)]. PAS of the left eye was concentrated at 7:00 to 1:00 regions [range, 50.0% (99/198) to 75.8% (150/198)]. When the PAS range of the atrial angle was ≤6 clock regions, it was mainly at 12:00 to 3:00 [range, 58.3% (74/127) to 67.7% (86/127)] in the right eye and at 10:00 to 12:00 [range, 54.8% (68/124) to 66.1% (82/124)] in the left eye. Among 121 cases (242 eyes) with both eyes involved, the PAS region was at 11:00 to 5:00 [range, 52.1% (63/121) to 79.3% (96/121)] in the right eye and at 8:00 to 1:00 [range, 50.4% (61/121) to 76.9% (93/121)] in the left eye. When the PAS range of the atrial angle was ≤6 clock regions, it was mainly at 12:00 to 4:00 [range, 53.2% (41/77) to 71.4% (55/77)] in the right eye and at 10:00 to 12:00 [range, 50.6% (39/77) to 64.9% (50/77)] in the left eye. In all cases, there were 171 cases of right eyes and 175 cases of left eyes with continuous angle PAS. The central PAS clock position of the right eye was mainly at 11:00 to 3:00 [range, 15.2% (26/171) to 24.0% (41/171)], and that of the left eye was mainly at 8:00 to 12:00 [range, 15.4% (27/175) to 20.6% (36/175)]. Among cases with both eyes involved, there were 98 cases of right eyes and 104 cases of left eyes with continuous angle PAS. The clock distribution of the middle position of the right eye angle PAS was concentrated at 11:00 to 3:00 [range, 17.3% (17/98) to 26.5% (26/98)], and that of the left eye was concentrated at 8:00 to 12:00 [range, 13.5% (14/104) to 20.2% (21/104)].

The PAS of PACG patients is mainly located in the upper and nasal sides, and the closer to the temporal side, the smaller the PAS frequency, showing a gradual downward trend. The PAS distribution of binocular angles is of obvious mirror symmetry.(Chin J Ophthalmol, 2021, 57: 666-671)

To compare the structural differences of the anterior segment between fellow eyes of acute angle-closure glaucoma (AACG) and the eyes of chronic angle-closure glaucoma (CACG) with milder glaucomatous damage.

In this case-control study, patients with AACG (41 eyes) and CACG (46 eyes) without prior treatment in the glaucoma clinic of Peking University People′s Hospital from September 2016 to October 2018 were enrolled. Ultrasound biomicroscopy was performed under dark condition. Parameters were measured on images including lens vault (LV), anterior chamber depth (ACD), iris thickness (IT750 and IT2000), angle-opening distance (AOD500 and AOD750), and trabecular iris angle (TIA500 and TIA750). The independent t-test was used to compare the continuous variables of the fellow eyes of AACG patients and the eyes of CACG patients with milder glaucomatous damage. After adjusting for age and gender, univariate and multivariate logistic regression analyses were performed to explore the most important parameters that may distinguish AACG from CACG.

The mean age of AACG patients was (65±10) years old and the age of CACG patients was (67±12) years old (P>0.05). The ACD [(1.79±0.25) mmvs. (1.99±0.34) mm], IT750 [(0.39±0.07) mm vs. (0.43±0.05) mm], AOD500 [(0.12±0.06) mm vs. (0.15±0.07) mm], TIA500 (10.91°±5.23° vs. 13.93°±6.33°), and TIA750 (9.33°±5.02° vs. 13.93°±6.82°) were less and the LV [(0.99±0.44) mm vs. (0.72±0.30) mm] was greater in the fellow eyes of AACG as compared to the eyes of CACG with milder glaucomatous damage (all P<0.05). In the forward multivariate logistic regression analysis, every 1-degree decrease in TIA750 (odds ratio=0.872, 95%CI: 0.794 to 0.958, P<0.01) and every 1-mm increase in LV (odds ratio=14.138, 95%CI: 2.348 to 85.130, P<0.01) were significantly associated with AACG.

Compared with the eyes of CACG with milder glaucomatous damage, fellow eyes of AACG have thinner peripheral iris thickness, narrower angle width, shallower ACD, and greater LV. LV and TIA750 may play important roles in distinguishing eyes predisposed to AACG or CACG.(Chin J Ophthalmol, 2021, 57: 672-678)

To evaluate the efficacy and safety of the XEN gel implant in the treatment of glaucoma.

It was a retrospective case series study. Eight patients (8 eyes) in the First Affiliated Hospital of Fujian Medical University from January 2020 to September 2020 were included, including six males and two females, aged 29 to 74 years. The patients treated with the XEN gel implanting for glaucoma. After detailed ophthalmic examination, all the patients met the surgical indications for the XEN gel implanting. Preoperative and postoperative intraocular pressure (IOP), anterior segment and fundus examination results, medication, and surgical complications were evaluated.

There were seven patients with primary open-angle glaucoma and one patient with glaucomatocyclitic syndrome. Five patients had received anti-glaucoma surgeries, and the remaining three patients had not received surgical treatment. All XEN gel stents were implanted successfully. All patients were followed up for 4 to 12 months. The preoperative maximum IOP ranged from 11 to 44 mmHg (median, 28 mmHg, 1 mmHg=0.133 kPa), and the IOP was 10 to 18 mmHg (median, 13 mmHg) at the last follow-up. Two to 4 types of medication were used for glaucoma preoperatively (median, 3), while 0 to 2 types (median, 0) were used at the last follow-up. During the follow-up, 7 cases were completely successful and only one case failed. Intraoperative hemorrhage occurred in two patients, and after effective treatment, the IOP decreased to below 20 mmHg. One patient was found to have an increased IOP with the XEN luminal obstruction, and the XEN drainage tube was recanalized. The IOP was about 10 mmHg at the last follow-up, and no anti-glaucoma drugs were used, but the surgery was assessed as failure by standard. The remaining patients had no other serious complications.

This preliminary study shows that the XEN gel drainage may be a safe and effective treatment for patients with glaucoma. (Chin J Ophthalmol, 2021, 57: 679-684)

To investigate the clinical effect of anterior 1/3 superior oblique tendon tucking in acquired symptomatic excyclotropia adults.

Retrospective case series. Seven patients (7 eyes) with acquired symptomatic excyclotropia who underwent an anterior 1/3 superior oblique tendon tuck procedure in Tianjin Eye Hospital from January 2019 to December 2019 were included. There were 5 male patients and 2 female patients, with an average age of (49±12) years old. All the patients had a history of a closed head injury. There was torsional diplopia in primary position, and eye movement examination showed paralysis of the superior oblique muscle in the affected eye, without obvious hyperactivity of the inferior oblique muscle. The anterior 1/3 tendon of the superior oblique muscle was tucked during surgery according to the relaxation of the superior oblique tendon in the forced duction test. The paired-sample nonparametric rank sum test was used to analyze the preoperative and postoperative (at 1 day after surgery and the last follow-up) excyclotropia angle.

The mean tuck amount was (7.7±1.8) mm (range, 6.0 to 10.0 mm). During operation, patients complained that excyclotropia improved markedly. The excyclotropia angle with the double Maddox rod test improved significantly from preoperative 10° (8°, 15°) to 2° (0°, 3°) at 1 day (Z=-2.379; P<0.05) and 2° (2°, 5°) at the last follow-up (Z=-2.375; P<0.05). The follow-up period was (112+38) days. All patients had no complaints of excyclotropia at the last follow-up.

The anterior 1/3 superior oblique tendon tucking can effectively improve clinical symptoms in the primary position in adults with acquired excyclotropia and diplopia. The short-term postoperative results seem to be stable, without significant regression. (Chin J Ophthalmol, 2021, 57: 685-688)

To investigate the clinicopathologic features and differential diagnosis of ocular Kimura disease (KD) and epithelioid hemangioma.

It was a retrospective case series study. The data of 10 patients with ocular KD and 3 patients with ocular epithelioid hemangioma from the Pathology Department of Eye & ENT Hospital of Fudan University from January 2010 to December 2019 were retrospectively analyzed, including clinical manifestations, morphology and immunophenotypes.

Among patients with ocular KD, there were 9 males and 1 female with an age from 7 to 75 years (mean, 30 years). There were 6 unilateral cases and 4 bilateral cases. The disease mainly involved the orbit in 3 patients, the lacrimal gland in 5 patients and the eyelid in 2 patients. The ophthalmic presentation included a palpable periorbital or eyelid mass with eyelid swelling and ptosis, proptosis and displacement of the eyeball, and ocular dysmotility. Three patients had a history of lymphadenopathy. The disease course ranged from 6 months to 7 years (mean, 34 months). All the patients had elevated peripheral blood eosinophilia. Three patients of ocular epithelioid hemangioma were all males with age from 25 to 60 years old. They were all unilateral cases with 1 right eye and 2 left eyes. The disease respectively involved eyelid and orbit, the eyebrow skin and the inner canthus skin. They presented with eyelid swelling, orbital mass or subcutaneous nodule for 5 months to 2 years. All patients (11 eyes) with KD underwent incisional or excisional biopsy. The histopathology revealed follicular hyperplasia of lymphoid tissue with active germinal centers in orbital fibroadipose tissue. There were massive interfollicular eosinophils with eosinophilic microabscesses. Some swelling endothelial cells of proliferating vessels were seen. All the 3 patients (3 eyes) with ocular epithelioid hemangioma underwent excision of the lesions. Histopathological examination showed proliferation of small and medium blood vessels. The vessels were lined by endothelial cells with abundant eosinophilic cytoplasm which protruded into the lumen. The endothelial cells were positive for CD31, factor Ⅷ-related antigen and E26 transformation-specific related gene immunohistochemically. There was a moderate amount of lymphocytes, plasma cells and eosinophils surrounding blood vessels without eosinophilic microabscess.

Both ocular KD and epithelioid hemangioma are more commonly seen in males and share the common histopathological features of vascular proliferation, swelling endothelial cells and eosinophilic infiltration. KD is an allergic benign lymphoid tissue proliferation characteristic of massive eosinophilic infiltration, whereas epithelioid hemangioma is a benign neoplasm of blood vessels with plump and epithelioid endothelial cells. (Chin J Ophthalmol, 2021, 57: 689-695)

A 70-year-old male patient, who had a right upper eyelid tumor excision 4 years ago, complained of eyelid swelling and ptosis for 3 months. Orbital CT and MRI showed an orbital cystic lesion with hemorrhage in the right eye. The tumor was resected under general anesthesia. The pathological diagnosis was epithelioid hemangioendothelioma.(Chin J Ophthalmol, 2021, 57:696-698)

Introduction Lin Ding, professor, chief physician, president of Changsha Aier Eye Hospital, doctoral supervisor of Central South University. Member of Glaucoma Group of Ophthalmology Branch of Chinese Medical Association, member of Ophthalmologist Branch of Chinese Medical Doctors Association, standing member of Ophthalmology Professional Committee of China Association of Non-public Medical Institutions and deputy director of Glaucoma Sub-Committee.

The patient was a 56-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. Previous history of hypertension for 10 years, controlled with medication (specificity unknown). Eye examination: visual acuity was 1.0 for the right eye and 0.1 for the left eye; IOP was 17.7 mmHg (1 mmHg =0.133 kPa) in the right eye and 15.7 mmHg in the left eye; The conjunctiva of both eyes is not congested, the cornea is transparent, the anterior chamber is clear and deep, the pupil is round, and the lens is mildly opaque; No obvious abnormalities were observed in the right eye; Vitreous hemorrhage in the left eye, neovascularization in the optic disc and retina, and laser photocoagulation plaque above the retina (Quintessence Picture 1In a). The results of fluorescein fundus angiography in the left eye are shown in B in Essence Picture 1. Clinical diagnosis: branch retinal vein occlusion in the left eye.

Pyroptosis, which is put forward after apoptosis, necrosis and autophagy, is a programmed pro-inflammatory cell death mode mainly mediated by inflammasomes. The main signaling pathways include the classic caspase-1-dependent pyroptosis pathway and the non-classical caspase-4, caspase-5 and caspase-11-dependent pyroptosis pathway. Pyroptosis is involved in the normal physiological function and plays an important role in the pathogenesis of many diseases, especially in neurodegenerative diseases such as Alzheimer′s disease and glaucoma. Glaucoma, which is mainly related to pathological intraocular pressure elevation, is a kind of eye diseases that threaten and damage the optic nerve and its visual pathway and eventually lead to visual function impairment. With more attention paid to pyroptosis involved in the mechanism of eye diseases and the pathogenesis and treatment of glaucoma, studies have found that pyroptosis is tightly correlated with glaucoma. Pyroptosis of retinal ganglion cells and microglia-mediated pyroptosis possess a significant position in the development of glaucoma. Further understanding of the relationship between pyroptosis and glaucoma might bring a new dawn for glaucoma treatment. The mechanism of pyroptosis may provide a new strategy for the pathogenesis and treatment of glaucoma. (Chin J Ophthalmol, 2021, 57: 702-706)

Glaucoma is a serious irreversible blinding disease. The pathogenesis is still unknown, and the diagnosis and treatment effect is not good. An effective early diagnosis method is urgently needed. In recent years, a number of glaucoma-related biomarkers have been discovered. In order to promote clinical application of these biomarkers, a series of studies are actively carried out to clarify specificity and sensitivity of these molecules, to verify the criteria by clinical randomized controlled trials, and to provide large sample data by multi-center clinical trials. However, the samples of these biomarkers are provided by patients who have been diagnosed with glaucoma by clinical examinations. The differences may represent the molecular features of middle-stage and advanced glaucoma. Whether they are helpful for early diagnosis and the exploration of pathological mechanisms should be further investigated. This article describes the potential molecular targets that can help in diagnosis of glaucoma from the aspects of DNA, RNA and protein, and discusses further research pathways and clinical application prospects. It is hoped to explore the effective molecular marker for early diagnosis of glaucoma. (Chin J Ophthalmol, 2021, 57: 707-711)

Human induced pluripotent stem cells have the ability to differentiate into specific cell types or tissues of the eye in humans and have application prospects in retinal cell transplantation, corneal transplantation, and lens regeneration. Gene editing technology of clustered regularly interspaced short palindromic repeats/crispr-associated protein-9 nuclease (CRISPR/Cas9) can introduce causative mutations of inherited ocular diseases into human induced pluripotent stem cells effectively. Then they can be further differentiated into specific somatic cells maintaining a genetic disease background, which can mimic the occurrence of inherited ocular diseases in vitro. The cell model may help scientists study the mechanism of human disease development, establish an in vitro screening platform to find therapeutic drugs, and correct genetic mutations in the human genome for cell therapy. The combination of stem cells and gene editing technology is revolutionizing the regenerative medicine in ophthalmology and gene therapy of inherited ocular diseases. This review summarizes the current application of human induced pluripotent stem cells and its combination with gene editing technology in the study of inherited ocular diseases.(Chin J Ophthalmol, 2021, 57: 712-716)

The core problem of glaucoma is glaucomatous optic neuropathy caused by retinal ganglion cell damage and death. Its etiology and pathological mechanism are complex. So far, there are few clinical repair (protection, salvage and reversal) strategies with sufficient evidence and definite efficacy. In order to realize the clinical translation and application of the research results of glaucomatous optic nerve injury repair, it is necessary to comprehensively understand the complexity of glaucoma pathogenesis, follow the basic research and clinical application transformation process, and always take the retina and visual center as a whole to determine the visual function repair strategy. This article expounds the above problems in order to provide reference for ophthalmologists to carry out related work.(Chinese Journal of Ophthalmology, 2021, 57:717-720)