Volume 58 · Issue 10 · 2022

The United Nations signed "Vision for Everyone-Accelerating Action to Achieve the Sustainable Development Goals (A/RES/75/310)" at the 75th UN sessions, committing to great efforts to improve eye health globally and address the increasing impact of vision loss on sustainable development. It is the first agreement designed to tackle preventable sight loss to be adopted at the United Nations and to enshrine eye health as an integral part of universal health coverage. The resolution summarized the lessons learned from previous global eye health practices, set a target of eye care for all by 2030-with countries set to ensure full access to eye care services for their populations, and, to support global efforts, to make eye care part of their nation′s journey to achieving the Sustainable Development Goals (SDG). This global initiative will also have a significant impact on eye health in China, and we should implement this United Nations General Assembly Resolution to promote the continued development of eye health in China.

Due to factors such as medical resources, public awareness, funding for general screening, or optimized screening models, community-based screening is far from meeting the demand. Artificial intelligence (AI) can replace some of the medical work and combine it with the "Internet+" model to transfer medical resources to improve accessibility and availability. However, the application of AI technology to community-based screening still faces many challenges, such as most AI products cannot be directly applied to community-based screening, the inability to integrate multimodal information such as medical history, symptoms, and images, and the lack of relevant regulations and health policies for productization and implementation. Therefore, we suggest that the relevant departments take actions: (1) to build standardized big data sets, unlock data barriers, and accelerate the development and application of AI technology; (2) to train "AI+" medical staffs as soon as possible; (3) to establish relevant laws and regulations; (4) to establish relevant R&D plans and quality standards and regulatory frameworks for AI products; (5) to encourage more investment in medical AI infrastructure in the central and western regions and remote and poor areas.

Corneal transplantation, which can be divided into therapeutic keratoplasty and optical keratoplasty, is the main method to restore vision for patients with corneal blindness. The keys to optical keratoplasty are the regular excision and preparation of donor and recipient corneas, as well as well-developed suturing skills to reduce surgically induced astigmatism. Traditional keratoplasty mainly relies on trephination to prepare the corneal graft and the recipient bed, but this procedure lacks precision, which is an important factor affecting postoperative vision recovery. In this regard, femtosecond laser-assisted keratoplasty (FLAK) can get more precise results compared with the traditional trephine-assisted keratoplasty, thereby achieving better optical keratoplasty effects. FLAK requires the cooperation between corneal refractive surgeons and corneal transplantation surgeons, and the surgical procedure also differs from that of traditional trephine-assisted keratoplasty. To promote and standardize the implementation of FLAK in China and to provide guidance on its clinical practice, the Cornea Group of Ophthalmology Branch of Chinese Medical Association has formulated this consensus on the indications, surgical design and procedures, complications and perioperative medication management of FLAK after thoroughly discussing the domestic and foreign research results collected, combined with the clinical experience of experts in this field.

To analyze the longitudinal association between hyperopia reserve and the cumulative incidence of myopia in grade 1 primary school students.

Cohort study. This study included 2 628 grade 1 primary school students (2 628 eyes) who without myopic at baseline from the Anyang Childhood Eye Study. There were 1 515 male and 1 113 female, aged(7.16±0.40) years. Every year, cycloplegic autorefraction was performed with 1% cyclopentolate eye drops to obtain data of hyperopia reserve. Students with different ranges of hyperopia reserve at baseline were analyzed. Axial length, anterior chamber depth, corneal curvature, lens thickness, and other parameters were obtained by ocular biometrics and compared by the independent sample t test. Qualitative data were described by frequency and percentage, and comparison between groups was performed by the Chi-square test or exact probability method. Linear regression was used to analyze the association between baseline hyperopia reserve and spherical equivalent at 5 years.

The average hyperopia reserve was (+1.09±0.78) diopters (D) in grade 1 non-myopic children. Axial length, anterior chamber depth, corneal radius of curvature, and lens thickness were (22.66±0.72), (2.88±0.24), (7.80±0.25) and (3.62±0.19) mm, respectively. The cumulative incidence of myopia among non-myopic grade 1 primary school students was 8.5%, 21.5%, 35.6%, 47.6% and 64.1% at 1, 2, 3, 4 and 5 years, respectively. The incidence of myopia in girls was significantly higher than that in boys at 3, 4 and 5 years. The 5-year cumulative incidence of myopia was 4.6%, 26.3%, 52.3%, 78.6%, 92.6% and 94.3%, respectively, corresponding to students with baseline hyperopia reserve of >+2.00 D,+1.50 D to +2.00 D,+1.00 D to +1.50 D,+0.50 D to +1.00 D, 0.00 D to +0.50 D and -0.50 D to 0.00 D, and the difference was statistically significant (χ²=490.59, P<0.001). The regression equation between baseline hyperopia reserve and 5-year spherical equivalent was as follows: 5-year spherical equivalent=-3.135+1.692·baseline hyperopia reserve (R²=0.454, P<0.001).

The lower the hyperopia reserve, the higher the incidence of myopia. Monitoring children′s hyperopia reserve and early protection to reduce its consumption and timely detection of children at high risk of myopia are of great significance to prevent the occurrence and development of myopia.(This article was published ahead of print on the Online-First Publishing Platform for Excellent Scientific Researches of Chinese Medical Association Publishing House on March 15, 2022)

To assess the effect of diabetic retinopathy (DR) on vision-related quality of life (VRQoL) in patients with type 2 diabetes.

In this cross-sectional study, patients with type 2 diabetes residing in 15 residency communities in Fushun, Liaoning province were enrolled from July 2012 to May 2013. We measured the VRQoL by the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). Patients were grouped according to their age, gender, presence of visual impairment, and affected eyes. NEI-VFQ-25 scores were compared between/among groups using the Wilcoxon rank-sum test or Kruskal-Wallis H test. The severity of DR in the eyes was graded into no DR, mild non-proliferative diabetic retinopathy (NPDR), moderate NPDR, severe NPDR, and proliferative diabetic retinopathy (PDR). Severity scores from both eyes were then summarized to create a single per-person grade ranging from 1 (no DR in either eye) to 7 (bilateral PDR). Generalized linear models were used to assess the linear relationship between NEI-VFQ-25 scores and DR severity. Locally weighted scatterplot smoothing plots were generated to evaluate the possible nonlinear associations between concatenated severity of DR and VRQoL.

A total of 1 537 patients were recruited, including 836 (54.4%) with no DR, 479 (31.2%) with mild NPDR, 90 (5.9%) with moderate NPDR, 72 (4.7%) with severe NPDR and 60 (3.9%) with PDR. Compared with patients with unilateral DR, bilaterally involved subjects were statistically significantly compromised in general vision [70.2 (66.5, 72.5) vs. 68.9 (63.9, 71.6), Z=90.222, P=0.038], near activities [90.5 (85.8, 94.0) vs. 88.8 (84.5, 92.5), Z=114.942, P=0.005], dependency [91.1 (85.6, 96.5) vs. 89.3 (83.8, 94.5), Z=91.934, P=0.033], mental health [80.0 (73.4, 84.9) vs. 77.5 (70.8, 82.0), Z=118.388, P=0.003], role difficulties [76.8 (70.1, 82.4) vs. 74.5 (67.6, 80.6), Z =90.791, P=0.036] and NEI-VFQ-25 composite [88.3 (84.2, 91.0) vs. 86.9 (82.8, 90.1), Z=96.207, P=0.024]. Scores on general vision (χ²=85.665), near activities (χ²=78.462), distance activities (χ²=145.489), social function (χ²=53.629), dependency (χ²=86.710), mental health (χ²=68.281), role difficulties (χ²=45.357), color vision (χ²=68.176), peripheral vision (χ²=116.179) and NEI-VFQ-25 composite (χ²=133.291) decreased gradually as DR severity increased (all P<0.001). On role difficulties, locally weighted scatterplot smoothing plots showed significant"turning points"from bilateral mild NPDR to mild NPDR/>mild NPDR (slope m=-4.7) and from moderate NPDR/≥moderate NPDR to severe NPDR/≥severe NPDR (slope m=-12.6).

Both greater severity and bilaterality of DR were associated with lower vision-specific VRQoL, particularly role difficulties and mental health.

To investigate the prevalence and risk factors of pterygium in the rural population aged 40 years and above of 12 ethnic groups in 6 regions of Yunnan Province.

This was a cross-sectional study. According to the method of multistage stratified sampling, samples of the rural population aged 40 years and above were collected from 12 ethnic groups (Han, Yi, Tibetan, Lisu, Bai, Naxi, Zhuang, Miao, Dai, Jingpo, Hani, and Lahu) in six areas (Diqing, Lijiang, Wenshan, Dehong, and Pu′er) of Yunnan Province from March 2019 to November 2019. Anterior segment examination was carried out in the target population with a hand-held slit-lamp, according to which pterygium was diagnosed, while the posterior segment of the eye was assessed by direct ophthalmoscopy. A field questionnaire survey was also conducted. A two-level model was used to study the effects of the location, nationality, sex, age, occupation, outdoor activities, smoking, and alcohol consumption on the prevalence of pterygium, with the ethnic group as the high level and the individual as the low level.

Among 9 617 subjects, the total prevalence rate of pterygium was 22.6%, which was adjusted to 19.6% according to the age and gender data of the Statistics Bureau of Yunnan Province. There was significant difference in prevalence of pterygium among six regions after adjusting for age and sex (χ²=146.50, P<0.001). The prevalence of pterygium was the highest in Wenshan (29.4%), followed by Chuxiong (24.4%), Diqing (17.5%), Pu′er (17.5%), Dehong (15.8%), and Lijiang (15.7%) (χ²=146.50, P<0.001). The results of the single factor analysis showed that there was statistically significant difference among different groups of age, gender, nationality, location, history of smoking, drinking, eating habits, sleeping time, continuous use of eye drops, temperature, humidity, altitude, longitude, latitude, and ultraviolet ray (P<0.05). However, the results of the multivariate analysis showed that the main risk factors of pterygium were female(OR=1.357,95%CI:1.173~1.568), advanced age(OR=1.540,95%CI:1.301~1.823), location(OR=1.713,95%CI:1.000~2.667), continuous use of eye drops(OR=1.177,95%CI:1.034~1.340), and more than 40 years of alcohol drinking(OR=1.525, 95%CI: 1.108~2.099), and the protective factor was more than 40 years of smoking(OR=0.723,95%CI:0.544~0.960).

The prevalence of pterygium varies greatly among different regions in Yunnan Province. The main factors affecting the prevalence are sex, age, region, smoking history, and drinking history.

To explore the demographic distribution, clinical signs, and clinical types of herpes simplex virus keratitis (HSK).

Retrospective case series. The data of 1 015 cases of HSK (1 054 eyes) diagnosed in Beijing Tongren Eye Center, Beijing Tongren Hospital of Capital Medical University from January 2010 to June 2019 were collected. The patients included 613 males and 402 females, and the age was 47.43±16.79 years. Information of the patients such as age, sex, the season of onset, eye laterality, and clinical signs was assessed. Slit-lamp microscopy and corneal fluorescein staining were used to locate the anatomical position of lesions. HSK was classified into epithelial type, neurotrophic type, stromal type, endothelial type, and mixed type. The distribution data was compared by the Chi-square test or Fisher′s exact test.

There were 41 children (≤14 years old; 4.04%), 338 youth (15-44 years old; 33.30%), 374 middle-aged (45-59 years old; 36.85%), and 262 elderly (≥60 years old; 25.81%) patients. The type was epithelial in 246 cases (24.24%), neurotrophic in 27 cases (2.66%), stromal in 372 cases (36.65%), endothelial in 274 cases (26.99%), and mixed in 96 cases (9.46%). There was statistically significant difference in clinical typing among the different age groups (χ²=30.197, P=0.003). Epithelial HSK was found in 141 males (57.32%) and 105 females (42.68%), neurotrophic HSK in 16 males (59.26%) and 11 females (40.74%), stromal HSK in 226 males (60.75%) and 146 females (39.25%), endothelial HSK in 171 males (62.41%) and 103 females (37.59%), and mixed HSK in 59 males (61.46%) and 37 females (38.54%). There was no statistically significant difference in clinical classification of keratitis between genders (χ²=1.519, P=0.823). Among the cases of mixed type, there were 21 cases of epithelial-stromal type (21.88%), 30 cases of epithelial-endothelial type (31.25%), 37 cases of stromal-endothelial type (38.54%), 1 case of epithelial-neurotrophic type (1.04%), and 7 cases of neurotrophic-stromal type (7.29%).

HSK occurs mainly in middle-aged and young adults, but rarely in children. The proportion of males is higher than that of females. The proportion of stromal HSK is highest, and 9.46% of patients present mixed HSK.

To investigate the clinical efficacy of modified partially penetrating deep lamellar keratoplasty in the treatment of severe infected corneal ulcers (full-thickness involvement of corneal infection) and perforation in emergency situations without penetrating keratoplasty materials and the effects of different corneal donors.

Retrospective cohort study. Twenty-three patients (23 eyes) with severe infected corneal ulcer who attended the Department of Ophthalmology of the General Hospital of the Northern Theater of the People's Liberation Army from January to December 2020 were collected, including 14 males and 9 females; They were aged (58.4±15.0) years, and were divided into biological cornea group (11 cases) and glycerol cornea group (12 cases) according to the type of corneal graft used. A modified, emergency lamellar keratoplasty, i.e., partially penetrating deep lamellar keratoplasty, was used for surgical treatment and retrospective analysis. The cure rate of infection, the best corrected visual acuity after operation, the healing time of graft epithelium, the central thickness of graft, the transparency of graft, the neovascularization of graft and the complications were observed in the two groups. Nonparametric rank sum test orχ² Test Statistical analysis of data was performed.

The cure rate of postoperative primary infection was 91.3% (21/23). 10/11 and 11/12 in the biological and glycerol corneal groups, respectively, with no statistically significant differences (χ²=0.004，P=0.949）。 At the last follow-up, there was no statistically significant difference in best corrected visual acuity between the biological and glycerol corneal groups (Z=-1.961，P=0.061）； The best corrected visual acuity in the glycerol cornea group was improved after operation compared with that before operation. Postoperative central graft thickness was (1 029 ± 64) and (1 026 ± 53) μ m in the biological and glycerol corneal groups at 3 months postoperatively (Z=-0.741，P=0.468）； At 6 months postoperatively, (973 ± 62) and (921 ± 49) μ m (Z=-1.799，P=0.072）； None of the differences were statistically significant. The graft transparency score of glycerol cornea group was better than that of biological cornea group after 1 week postoperatively. The graft neovascularization score of the two groups was similar at 3 months postoperatively, and there was no significant difference in the incidence of postoperative complications between the two groups.

In the absence of fresh donor cornea, using bioengineered cornea and glycerol cryopreservation of corneal material, and using partially penetrating deep lamellar keratoplasty can effectively control the primary infection and prolong the survival time of temporary graft for severe infectious corneal ulcer with infection that has involved the whole thickness of the cornea or has been perforated. Glycerol cryopreservation of human cornea is slightly superior to biological cornea only in improvement of corneal transparency and degree of neovascularization.

A 5-year-old female patient, presented with"night blindness and poor hearing for 1 year"whose first diagnosis was Usher syndrome due to retinitis pigmentosa accompanied by sensorineural deafness. Compound heterozygous variants (c.5G>A, p.W2*/c.3022C>T, p.P1008S) of PEX1, the causative gene for Zellweger spectrum disorder was confirmed by targeted exome sequencing analysis. Permanent tooth enamel dysplasia, nail leukoplakia, and biochemical abnormalities of peroxisome which is consistent with mild Zellweger spectrum disorder were found when she followed up.

This article describes a case which seek medical advice for 2 months due to retrogressive development, The discovery of the characteristic fundus of the macular cherry-red spot is a key clue for further genetic analysis, GLB compound heterozygous mutations is detected, and enzymology results show that the acid B-galactose glucoside enzyme significantly decrease, fundus inspection help diagnosis GM1 gangliosidoses.

A 4-month-old boy was admitted to the hospital after his parents noticed fog in his right eye for 27 days. Physical examination revealed multiple light brown macules on the skin. The intraocular pressure (IOP) of the right eye was 34.4 mmHg (1 mmHg=0.133kPa) and the corneal was enlarged and edema while the aqueous humor was cloudy with blood in the right eye. Yellow peripheral anterior synechia was seen on the temporal and inferior iris. Ultrasound biomicroscopy (UBM) showed extensive adhesion closure of the anterior chamber angle and the local thicken iris with the nodule. No obvious abnormality was observed in the left eye. It was confirmed as juvenile xanthogranuloma by skin lesion biopsy. IOP was normal after systemic and local therapy with corticosteroids and local IOP lowering medication. Follow up 35 months, IOP is normal without medication.

Two adolescents with T1DM participated in the Shanghai Children and Adolescent DM Eye study (SCADE) 2017-2018. The previous T1DM history of the 2 children were 12 years and 4 years respectively. The history of optic atrophy were 8 years and 4 years respectively. The ophthalmic examination showed that there were slight posterior capsule cataract and atrophy of optic atrophy in both patients. Optical Coherance Tomographic examination showed that the choroidal thickness of the inferior inner ring of the optic nerve and RNFL layer thickness decreased markedly, perfusion density and vascular density of the optic disc area and macular decreased markedly, electrophysiological examination showed that amplitude decreased markedly, and visual field examination showed binocular extinction or tubular vision field. Now the 2 adolescents were in closely followed-up. We suggest that children with T1DM whose best corrected visual acuity decreased recently to 0.6 or lower, in addition to routine ophthalmic examination, choroidal thickness, retinal nerve fiber layer thickness, retinal blood flow, ERG and visual field examination are recommended to distinguish wolfram syndrome from T1DM. Genetic sequencing examination of WFS-1 is also recommended if possible.

A 48-year-old man presented to Beijing Tongren Hospital Ophthalmology Department with redness, increased secretions and vision loss in his right eye. He had been treated with pterygium excision and lamellar keratoplasty due to recurrent pterygium in the right eye. After corneal scraping and microbial culture, he was diagnosed as bacterial keratitis after pterygium lamellar keratoplasty in the right eye. After applying topical antibiotic eye drops, removing corneal graft and conducting amniotic membrane transplantation, corneal infection was controlled and his vision was recovered.

Hypermetropic anisometropia is often accompanied by visual fatigue, and the higher hyperopia is prone to form amblyopia. To avoid Wear glasses fatigue, the higher hyperopia is often under corrected and regulative spasm. Pseudomyopia may occur in the early stage after refractive surgery. In this case, autologous corneal stromal lenticule transplantation was used to correct hyperopia. After standard visual cognitive training, the Uncorrected Distance Visual Acuity was rapidly improved, and the binocular vision was normal.

A 24-year-old male was treated with transepithelial photorefractive keratectomy for myopia in both eyes 5 years ago. He had allergic conjunctivitis for 3 years. The night vision of both eyes was decreased for 2 years. The clinical diagnosis was keratoconus binoculus. Therefore, corneal collagen cross-linking was performed in both eyes, and the follow-up was 6 months. Confocal microscopy showed that the cross-linking of riboflavin and fiber amino was successful, and the keratoconus did not progress during the follow-up. Although there have been few case reports of keratoconus after transepithelial photorefractive keratectomy at home and abroad, great importance should be attached to the early and comprehensive screening of keratoconus in the candidates of refractive surgery in order to improve the long-term safety.

A myopic patient with self-reported photorefractive keratectomy 9 years ago requested small incision lenticule extraction (SMILE) as retreatment. The presence of interface bubbles while creating a corneal cap of the right eye revealed that the previous refractive surgery was laser in situ keratomileusis (LASIK). Therefore, the SMILE procedure was resumed in the right eye, but flap-lift LASIK was performed in the left eye. Postoperative follow-up showed that the vision in both eyes reached the preoperative best corrected level. SMILE may be a potential option for refractive regression after LASIK.

Human corneal endothelial cells (HCECs) are the prerequisite for maintaining corneal transparency, but HCECs remain arrested at the G1 phase after embryonic development and can not proliferate and regenerate. Thus, the density of HCECs decreases spontaneously with corneal development. Systemic factors, primary corneal disease, refractive factors, glaucoma, inflammation, and trauma all can cause a massive loss of HCECs, lead to corneal edema and turbidity, and ultimately induce blindness. Currently, keratoplasty is the only effective treatment, but the scarcity of donor corneas and the limitation of corneal preservation technology restrict the availability of keratoplasty. Therefore, the most appealing way to tackle the tissue shortage problem is corneal endothelial cell regeneration. In recent years, not only the endogenous regeneration of HCECs mediated by surgery, drugs and gene therapy but also the exogenous regeneration of HCECs mediated by cell therapy have made fruitful progress. Although a number of regeneration strategies have entered the clinical trial stage, the wide clinical application of corneal endothelial regeneration is still far away. This review elaborates the basic research, clinical application and limitation of current strategies of corneal endothelial cell regeneration.

Nanomaterials have been used in many aspects of ophthalmic treatment. By emphasizing the ubiquitous characteristics of nanoparticles and composites, we first explained their relatively mature applications in drug delivery. Then we reviewed the research on nanomaterials in regenerative medicine and gene therapy in recent years. We also discussed the main limitations of the wider application of nanomaterials in ophthalmology: stability, biotoxicity and preclinical-clinical differences. The development of efficient and non-toxic nanomaterials, combined with appropriate transportation systems and application occasions, will provide more possibilities for the future application of nanomaterials in ophthalmic treatments.

A large number of commensal bacteria settle in the intestine and play an important role in maintaining normal functions of the intestine, regulating host immunity and metabolism. In recent years, researches have found that intestinal flora can be involved in the occurrence and deterioration of various extraintestinal diseases. Ophthalmic diseases such as uveitis, age-related macular degeneration, and glaucoma are also affected by the intestinal flora. The intestinal flora and its metabolites, under different circumstances, can change the body′s immune homeostasis or regulate multiple metabolic pathways, induce autoimmune responses in the eyes and promote chronic inflammation. This article reviews the relationship between intestinal flora and ophthalmic diseases to provide new research ideas for the pathogenesis and intervention of various ophthalmic diseases.

High myopia is an important cause of low vision and blindness in the world, most of which are characterized by the prolongation of the axial length, accompanied by various degenerative changes of fundus posterior pole, especially in the optic disc area and peripapillary structures, such as optic disc tilt, optic cup and rim changes, chorioretinal atrophy, posterior staphyloma and intrachoroidal cavitation, and so on. This article reviews the optic disc morphological features and peripapillary structure changes of high myopia, in order to reveal the pathogenesis of high myopia and provide new ideas for finding more effective prevention and treatment methods.

The cornea is a transparent tissue with significant refractive and barrier functions. Corneal epithelium constitutes the first line of defense against foreign pathogens. Corneal epithelial cells interact to form a functionally selective permeability barrier. Dysfunction of this barrier leads to corneal impairment followed by a series of ocular surface diseases and even blindness. Tight junctions (TJ), located at the top of the intercellular space of corneal epithelial superficial cells, play a critical role in establishing and maintaining the barrier function. Previous studies have shown that destruction of the TJ acts as a crucial step of the occurrence and progression of multiple ocular surface diseases. Understanding the fundamental features and functions of the TJ, noticing the risk factors of TJ disruption, and clarifying the key role of TJ in the pathogenesis of various ocular surface diseases will help to better understand and treat ocular surface diseases.

The diagnosis of keratoconus is closely related to artificial intelligence. Machine learning is the core of artificial intelligence, machine learning models combined with corneal information are effective supplements in keratoconus diagnosis and provide decision support. These artificial intelligence systems can bring efficiency, reduce artificial misjudgment and effectively reduce manpower costs. In this paper, by summarizing the previous machine learning models that assisted the diagnosis of keratoconus, we may help researchers understand the relevant knowledge in the field of intelligent diagnosis of keratoconus, which is of great significance for further machine learning research.

Achieving universal health coverage is a strategic priority for the World Health Organization. Eye health is an important part of health for all. Assessing the use and quality of eye health services worldwide can help better monitor overall progress in universal health coverage. The World Health Organization recommended population-based effective cataract surgery coverage (eCSC) and effective refractive error correction coverage (eREC) as new eye health indicators at the 74th World Health Assembly, and adopted a resolution to set the target of the indicators as a 30% increase in eCSC and a 40% increase in eREC for countries by 2030. China's National Health Commission officially included these two indicators in the 14th Five-Year National Eye Health Plan (2021-2025). This article will interpret the definition, calculation, consideration factors of these two indicators, as well as the problems that need attention in actual collection and reporting, in order to help the high-quality monitoring of eye health services.