Volume 60 · Issue 12 · 2024

This issue focuses on the research progress of cataract. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Li Chaohui.

Congenital cataract is a blinding condition that presents at birth. Form-deprivation amblyopia can be developed and has become the leading cause of childhood blindness in China. For the problems and challenges in the treatment of congenital cataract, this article discusses the surgical treatment and postoperative rehabilitation strategies and emphasizes the importance of developing effective intervention strategies to improve the visual outcomes in children with congenital cataract, providing valuable guidance for clinical treatment.

The onset of congenital cataract is in the sensitive period of eyeball and visual development, and the pathogenic factors and clinical manifestations are diverse. The age of patients seeking medical treatment can range from the neonatal period to adolescence or even adulthood. However, minors are in continuous growth and development with various characteristics at different periods, which makes the diagnosis and treatment of congenital cataract complicated. In this article, the diagnosis and treatment strategies of congenital cataract are expounded according to the characteristics of the disease in infancy, early childhood, pre-school age and school age. It is pointed out that age is an important factor in the diagnosis and treatment of congenital cataract, which should be considered in related clinical work and scientific research.

With the societal aging and the excessive use of video terminals, the prevalence rate of dry eye is increasing, and the causative factors are complex and diverse. Unremitting research and discussions on the diagnosis and treatment of dry eye have been carried out. An expert consensus on this issue was released in 2013. To further standardize and promote the diagnosis and treatment of dry eye, the Cornea Group of Chinese Ophthalmological Society and the Cornea Group of Ophthalmology Branch of Chinese Ophthalmologist Association have recently summarized the latest clinical findings and experience. A new version of the expert consensus has been formed to meet the needs of clinical practice.

To compare the postoperative visual outcomes of corneal topography-guided femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) and small incision lenticule extraction (SMILE) for myopia and myopic astigmatism.

Embase and PubMed were searched for randomized controlled trials (RCTs), prospective comparative studies, observational studies and retrospective studies of patients with myopia and/or myopic astigmatism treated by corneal topography-guided FS-LASIK, the other FS-LASIKs or SMILE (inception to November 2023). The studies meeting the criteria were collected and underwent quality assessment according to the Jadad scale for RCTs and the Newcastle-Ottawa scale for non-randomized studies. RevMan4.3.0 was used for network meta-analysis.

A total of 17 studies were included for meta-analysis, including 7 RCT and 10 observational studies. For the percentage of surgical eyes with uncorrected distance visual acuity≥20/20 (≤3 months), there were no statistically significant differences among corneal topography-guided FS-LASIK, the other FS-LASIKs and SMILE. The surface under the cumulative ranking curve (SUCRA) ranking from best to worst was corneal topography-guided FS-LASIK (86.7%), the other FS-LASIKs (53.1%) and SMILE (10.2%). For the percentage of surgical eyes with postoperative manifest refraction spherical equivalent (MRSE) within ±0.50 D (combined follow-up measure timepoint), the main analyses showed no statistical differences among the 3 surgery groups. The sensitivity analyses disclosed the relative risk (RR) of corneal topography-guided FS-LASIK significantly increased by 14% (RR=1.14, 95%CI:0.78-1.59) as compared to that of the other FS-LASIKs, while there was no significant difference between SMILE and the other FS-LASIKs. The SUCRA ranking from best to worst was corneal topography-guided FS-LASIK (90.4%), SMILE (31.7%) and the other FS-LASIKs (27.9%). For the percentage of surgical eyes with postoperative MRSE within± 1.00 D (combined follow-up measure timepoint), the main analyses showed no statistical differences among the 3 surgery groups. The sensitivity analyses showed the RR of corneal topography-guided FS-LASIK significantly increased by 15% (RR=1.15, 95%CI:0.93-1.61) as compared to that of the other FS-LASIKs, while there was no significant difference between SMILE and the other FS-LASIKs. The SUCRA ranking from best to worst was corneal topography-guided FS-LASIK (94.5%), the other FS-LASIKs (53.9%) and SMILE (1.7%). For the percentage of surgical eyes with postoperative corrected distance visual acuity improved by 1 or more lines (combined follow-up measure timepoint), the main analyses showed no statistical difference between corneal topography-guided FS-LASIK and the other FS-LASIKs, while the RR of SMILE was slightly lower than that of the other FS-LASIKs (RR=0.86, 95%CI:0.65-1.14). The sensitivity analyses disclosed the RR of corneal topography-guided FS-LASIK significantly increased by 40% (RR=1.40, 95%CI:0.06-24.00) as compared to that of the other FS-LASIKs, while SMILE had a slightly lower RR as compared with the other FS-LASIKs (RR=0.77, 95%CI:0.17-2.74). The SUCRA ranking from best to worst was corneal topography-guided FS-LASIK (72.4%), the other FS-LASIKs (67.3%) and SMILE (10.3%).

Compared with SMILE, FS-LASIK showed a similar postoperative visual acuity improvement. The corneal topography-guided FS-LASIK had better predictability with a higher rate of MRSE within ±0.50 D/1.00 D.

To explore the corrective effect of cataract extraction surgery combined with a 2.8 mm steep-axis corneal incision under ophthalmic surgical navigation on low-to-moderate corneal astigmatism and different types of corneal astigmatism.

A prospective cohort study was conducted. Patients with age-related cataract who underwent cataract extraction combined with single-focus intraocular lens implantation in the Department of Ophthalmology at the Sixth People′s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from June to October 2023 and had a total corneal regular astigmatism degree of ≥0.50 D and <1.50 D were continuously collected. Patients were divided into a low-degree group (<1.00 D) and a moderate-degree group (≥1.00 D) according to corneal astigmatism degree. Simultaneously, they were classified into with-the-rule (WTR), against-the-rule (ATR), and oblique astigmatism based on preoperative corneal astigmatism axis position. Subjective refraction and anterior segment biometer examination were performed before and 3 months after surgery, respectively. Vector analysis of corneal astigmatism was conducted using the Alpins vector analysis method. The main observational indicators included target induced astigmatism, surgically induced astigmatism, and the correction index.

A total of 95 patients (110 eyes) were collected in this study. Thirteen patients (18 eyes) were lost to follow-up, and finally 82 patients (92 eyes) were included. In the low-degree group, there were 14 males (16 eyes) and 26 females (23 eyes), with an age of (69.62±12.22) years. In the moderate-degree group, there were 13 males (15 eyes) and 33 females (35 eyes), with an age of (72.98±8.28) years. The target astigmatism correction amount, surgically induced astigmatism, and deviation vector in the low-degree group were all smaller than those in the moderate-degree group (all P<0.05). Postoperative corneal astigmatism in both groups was undercorrected. The correction index in the low-degree group (0.88±0.44) was greater than that in the moderate-degree group (0.59±0.34) (P=0.001), and the undercorrection proportion in the moderate-degree group (90.00%, 45/50) was much higher than that in the low-degree group (57.14%, 24/42). In the low-degree group, the correction index from high to low was WTR (1.07±0.41), oblique (0.90±0.58), and ATR astigmatism eyes (0.69±0.37). After multiple comparison analysis, the correction index of WTR astigmatism eyes was significantly higher than that of ATR astigmatism eyes (P<0.05). The success index from high to low was oblique (0.82±0.57), ATR (0.74±0.39), and WTR astigmatism eyes (0.68±0.43). In the moderate-degree group, the order of the correction index from high to low was the same as that in the low-degree group, also WTR (0.79±0.33), oblique (0.71±0.50), and ATR astigmatism eyes (0.53±0.30), but there was no statistical significance among the three (P>0.05). In the low-degree group, there were 6 WTR astigmatism eyes undercorrected, fewer than 12 overcorrected eyes; there were 16 ATR astigmatism eyes undercorrected, more than 3 overcorrected eyes. In the moderate-degree group, there were 6 WTR astigmatism eyes undercorrected, more than 2 overcorrected eyes, but there were 2 ATR astigmatism eyes overcorrected, fewer than 34 undercorrected eyes.

Cataract extraction surgery combined with a steep-axis corneal incision can achieve a certain astigmatism correction effect in patients with preoperative low-to-moderate corneal astigmatism. Patients with a preoperative corneal astigmatism degree of mild can achieve a better astigmatism correction effect than those with moderate, especially in the WTR astigmatism population. However, for cataract patients with preoperative corneal astigmatism of moderate and WTR astigmatism, a steep-axis corneal incision can also be combined to correct astigmatism as it can achieve the expected postoperative "with-the-rule undercorrection".

To assess the surgical outcomes of cataract surgery combined with phakic posterior chamber intraocular lens (ICL) implantation in the contralateral eye for patients with high myopia and monocular cataract.

This is a retrospective case series study. Clinical data were collected from 10 patients (20 eyes) with high myopia and monocular cataract who underwent phacoemulsification cataract extraction and intraocular lens implantation in the cataract eye (cataract surgery eye), and implantable Collamer lens (ICL) implantation in the contralateral eye (ICL implantation eye) at the Ophthalmology Department of the Army Characteristic Medical Center from June 2021 to December 2023. Among them, there were 4 males and 6 females, with an average age of (35.60±7.62) years. Uncorrected visual acuity was measured using the international standard visual acuity chart, and spherical equivalent (SE) and best corrected visual acuity (BCVA) were obtained through comprehensive optometry. Visual acuity was recorded in the form of logarithm of the minimum angle of resolution (logMAR). Objective visual quality parameters were obtained using a visual quality analysis system, and subjective visual quality was obtained through questionnaire surveys. Postoperative accommodative function and defocus curve were also examined. Various indicators before and 5 months after surgery were compared between the two eyes.

The BCVA in the cataract surgery eye significantly improved postoperatively (P<0.05), while no significant change was observed in the ICL implantation eye (P>0.05). Postoperative UCVA for the cataract surgery eye was 0.12±0.12 for distance, 0.18±0.18 for intermediate, and 0.28±0.20 for near vision. For the ICL implantation eye, these values were 0.10±0.11, 0.00 (0.00, 0.03), and 0.01 (0.00, 0.06), respectively. Objective scatter indices postoperatively were 2.20±1.82 for the cataract surgery eye and 0.90 (0.48, 1.90) for the ICL implantation eye. All patients became spectacle-independent postoperatively, with 6 experiencing halo phenomena that did not affect their daily life. The average patient satisfaction score was 9.5. The ICL implantation eye showed better accommodative amplitude and facility than the cataract surgery eye, with statistically significant differences (both P<0.05). The defocus curve indicated good binocular visual acuity, and no severe intraoperative or postoperative complications were reported.

For patients with high myopia and monocular cataract, the combination of cataract surgery and ICL implantation in the contralateral eye effectively enhances postoperative visual acuity and quality, preserves natural accommodation, establishes binocular vision balance, and facilitates spectacle independence. The procedure is safe, reliable, and improves the quality of life and work.

To determine the causal relationship between cataracts and type 2 diabetes mellitus (T2D) by the Mendelian randomization (MR) analysis using the genome-wide association study (GWAS) data.

Data on T2D and cataracts in the European population were obtained from the OpenGWAS database. The single nucleotide polymorphisms (SNPs) that met the genome-wide significance criteria (P<5×10⁻⁸) of T2D (48 286 cases, 250 671 controls) and cataracts (5 045 cases, 356 096 controls) were selected. The main method was random effects inverse variance weighting (IVW), and four other two-sample MR methods were also used, including MR Egger, Simple median, Weighted median, and Weighted mode, to assess the causal relationship using odds ratios (OR). Sensitivity analyses were conducted using the leave-one-out approach to evaluate the robustness of the results.

The MR Egger analysis showed a significant risk association between T2D and cataracts (OR=1.003, 95%CI=1.001-1.006; P=0.013). Using the methods of Weighted median (OR=1.002, 95%CI=1.000-1.004; P=0.029) and Weighted mode (OR=1.002, 95%CI=1.000-1.005; P=0.046), similar results were obtained. However, the IVW test failed to confirm the causality (P=0.149). The sensitivity analyses using the MR Egger and IVW tests did not show significant heterogeneity between T2D and cataracts (all P>0.05). With the leave-one-out analysis, the SNPs with significant effects were not identified, indicating the robustness of the MR results in this study. The MR Egger interception of the SNPs showed significant directional pleiotropy (P=0.038), suggesting a directional pleiotropy between T2D and cataracts.

The results of the MR analysis suggest there is a causal relationship between T2D and cataracts, and T2D increases the risk of cataracts.

To investigate the clinical efficacy of wound exclusion combined with silicone tube bicanalicular intubation for treatment of pigmented nevi of the lacrimal punctum.

A retrospective case series analysis was conducted. Clinical data were collected from patients with pigmented nevi of the lacrimal punctum who underwent wound exclusion combined with silicone tube bicanalicular intubation at the Ophthalmology Center of Zhejiang Provincial People′s Hospital from April 2020 to February 2023. During the surgery, a linear silicone tube was annularly placed to support the punctum and lacrimal canaliculus under local anesthesia, followed by the pigmented nevus excision under a surgical microscope. The linear silicone tube was removed at 4 to 6 weeks postoperatively. The duration of surgery and postoperative recovery status were recorded and summarized, including the recurrence of the pigmented nevus, epiphora, shape and position of the punctum, medial canthal morphology, and local scar condition.

This study included a total of 15 patients, 5 males and 10 females, with an average age of (47.7±13.5) years (range, 19 to 65 years). Two patients had pigmented nevi of the upper punctum, and 13 had pigmented nevi of the lower punctum. All nevi grew around the punctum and were completely excised during the surgery, which lasted (21.8±2.4) minutes on average. By 2 weeks postoperatively, all wounds healed with conjunctivalization, and new punctum openings formed. By 4 to 6 weeks postoperatively, the eyelid margin morphology was almost normal, when the linear silicone tube was removed. The follow-up ranged from 6 months to 2 years. No recurrence of the pigmented nevus was observed during the follow-up. The puncta were well formed without the symptom of epiphora, the medial canthal morphology was basically symmetrical to the healthy side, and the eyelid margin scars were inconspicuous, with a satisfactory appearance. No complications such as punctal occlusion, trichiasis, entropion, and ectropion occurred.

For exophytic pigmented nevi of the punctum that do not deeply involve the lacrimal canaliculus, using the wound exclusion combined with silicone tube bicanalicular intubation during the nevus excision may reduce surgical trauma. This simple and feasible method can achieve good therapeutic effects and cosmetic outcomes.

A 58-year-old male patient presented with a 2-year history of blurred vision and eye discomfort in the right eye. The patient had a history of cataract surgery and glaucoma surgery. Upon admission, the unaided visual acuity of the right eye was 0.4, and the intraocular pressure was 33.4 mmHg (1 mmHg=0.133 kPa). The intraocular lens was decentered towards the nasal inferior direction, with a transparent capsular bag, no fibrous degeneration, or opacification observed. The patient underwent vitrectomy, intraocular lens suspension, and glaucoma valve implantation. During surgery, the capsular bag was found to be transparent and soft, and pathological examination revealed thinning of the capsular bag with very few epithelial cells. Postoperatively, the patient′s unaided visual acuity in the right eye recovered to 0.8, and the intraocular pressure was controlled. Capsular bag necrosis syndrome is a recently proposed concept, characterized by an average age of onset of about 65.7 years, displacement of the intraocular lens years after IOL implantation, a transparent and soft capsular bag without fibrous proliferation, thinning and splitting/layering of the capsular bag, and no abnormalities in the zonules during the initial cataract surgery. The clinical and pathological features of this case are consistent with this syndrome, suggesting that this syndrome may be a new cause of intraocular lens displacement, and further research is needed on its pathogenesis and treatment measures.

The patient was a 19-year-old male. Surgical treatment was planned for refractive error, and he went to the Ophthalmology Center of the Second Affiliated Hospital of Zhejiang University School of Medicine. Consciously occasionally feel the black shadow fluttering in front of my eyes, denying the history of eye trauma, surgery and infection. Eye examination: binocular corrected visual acuity was 1.0; There were no structural abnormalities in the anterior segment of both eyes; A floating brown "sphere" can be seen in the vitreous cavity of the right eye, pulled by a white cord-like object at the top, and suspended in the vitreous cavity (Quintessential Picture 1); Fundus examination revealed an oval mass with a diameter of about 4 optic disc diameter, with an uneven surface and pigmentation (Quintessential Picture 2). Ocular B-ultrasound examination: 1 round cystic strong echo in the vitreous cavity of the right eye (Quintessential Picture 3). Routine laboratory tests and imaging examinations of brain, chest and abdomen showed no obvious abnormalities, and serological parasite tests and Toxoplasma gondii antibody tests were negative. Clinical diagnosis: Pigmented vitreous cyst in the right eye.

Refractive error is a key determinant of visual acuity post-cataract surgery. Traditional methods for addressing refractive errors have been invasive, posing the risk of permanent surgical complications. Thus, the pursuit of non-invasive techniques for correcting refractive errors after cataract surgery is of significant clinical importance. Recently, a novel class of intraocular lenses (IOL), termed light-adjustable IOL, has emerged as a potential solution for refining refractive outcomes. These IOL possess the unique ability to alter their dioptric power in vitro through exposure to specific wavelengths of light, facilitating a non-invasive approach to refractive error correction. The landscape of light-adjustable IOL is diverse, encompassing ultraviolet light-adjustable IOL, novel nitinol-based thermomechanically adjustable IOL, IOL with refractive index changes induced by femtosecond lasers, and IOL utilizing two-photon effects for dioptric adjustment. This review article aims to summarize the advancements in light-adjustable lenses, providing insights and references for ongoing research and clinical practice in this field.

Glaucoma is the leading cause of blindness worldwide, and reducing intraocular pressure is crucial to delaying its progression. This review aims to explore the application progress of micropulse wave transscleral laser treatment (mTLT) in the treatment of glaucoma. This article introduces the evolution of ciliary body destructive surgical methods, and focuses on the mechanism of mTLT in the treatment of glaucoma, including reducing aqueous humor production, increasing the uveoscleral pathway and trabecular meshwork pathway for aqueous humor outflow. At the same time, the indications, contraindications, procedures and parameter settings of mTLT, its application effects in different types of glaucoma, possible complications, repeatability, and factors affecting the effect are discussed, and a comparison is made with the traditional TSCPC. However, the exact mechanism of mTLT in reducing intraocular pressure still needs to be further explored and clarified, and its related parameter settings still require a large number of clinical observations and studies.

Single-cell RNA sequencing is a cutting-edge genomic analysis technique performed at the individual cell level, offering researchers a powerful tool to investigate intercellular differences in gene expression and functional characteristics. In recent years, its application in ophthalmology has expanded rapidly, leading to numerous significant research outcomes. This review focuses on the latest advancements in single-cell RNA sequencing within the field of ophthalmology, summarizing its development, methodologies, advantages, limitations, and clinical relevance. The aim is to provide new insights into the pathogenesis of ocular diseases and the improvement of diagnostic and therapeutic strategies.

In the article "Expert Consensus on Perioperative Medication of Laser Corneal Refractive Surgery in China (2024)" published on page 648 of Volume 60, Issue 8, 2024, this journal, the members of the expert group who formed a consensus opinion were supplemented by "Zhao Xiangyang Zhijiang Campus of Optometry Hospital affiliated to Wenzhou Medical University", a member of the Ocular Microcirculation Refraction Professional Committee of China Microcirculation Committee. Corrections are hereby made.