Volume 55 · Issue 07 · 2019

Cataract is one of the common cause of vision decrease in diabetic patients, which occurs earlier and develops faster than in common patients, and often requires surgery for treatment. However, diabetic patients are more likely to have fundus lesions, and are more prone to have complications, such as infection, posterior capsular opacity, cystoid macular edema, etc. Diabetic patients have a higher risk of cataract surgery than ordinary cataract patients. Therefore, clinicians should be conscious about the particularity of diabetic cataract surgery, develop an appropriate and individual diagnosis and treatment plan according to its characteristics, and regulate the overall management to prevent possible risks and ensure the safety of patients.(Chin J Ophthalmol, 2019, 55: 481-484)

Cataract surgery has entered the era of refractive surgery, and patients have higher requirements for visual quality. Astigmatism correction in cataract surgery is increasingly valued, but the astigmatism correction results are not ideal, and the principles of corneal astigmatism correction are not well established. In this article, the issues including how to dialectically decide to treat the corneal astigmatism or not, how to choose the corneal astigmatism estimating method and the calculation formula for astigmatism correction, the range of corneal astigmatism suitable for applying multifocal intraocular lens, selection of intraoperative corneal astigmatism correction method, etc., were discussed based on relevant authoritative guidelines, expert consensus and literatures, and corresponding suggestions were given. (Chin J Ophthalmol, 2019, 55: 485-490)

In recent years, multifocal intraocular lens (MIOL) has been more and more used in ophthalmology clinical practice. Due to the particularity of MIOL design, patient selection, preoperative preparation, surgical operation and individual differences after operation have become important factors affecting the surgical outcome. In order to further standardize the clinical application of MIOL, the Cataract and Intraocular Lens Group of Ophthalmology Branch of Chinese Medical Association based on the current situation and actual medical situation in China, and reached a consensus opinion through discussion, which can be used by ophthalmologists in China for reference in clinical work. (Chinese Journal of Ophthalmology,2019，55：491-494）

To compare the surgical induced astigmatism(SIA) of the total, anterior and posterior cornea between eyes with 2.2-mm and 3.0-mm clear corneal incisions in phacoemulsification.

A prospective double-blind randomized controlled study was conducted on 131 patients (131 eyes) with age-related cataract from October 2017 to June 2018. They were randomized according to the random number table. Sixty-nine patients received phacoemulsification through a 2.2-mm clear corneal incision at 140 degrees; 62 patients were recruited in the control group with a 3.0-mm clear corneal incision at the same position. Lens density was graded and compared between the groups preoperatively. Total corneal refractive power (TCRP), simulated keratometry (SimK) and posterior corneal astigmatism (PCA) (Apex, 4-mm zone) were recorded through the Pentacam preoperatively and at 1 week, 1 month and 3 months postoperatively. Corneal astigmatism was decomposed to vertical/horizontal (X) and oblique changes (Y) using the power vector analysis. Independent sample t test and matched t test were used for statistical analysis.

A total of 123 patients (123 eyes) completed 3 months of follow-up including 65 in the 2.2-mm group and 58 in the control group. The age of the two groups was (69±9) and (71±10) years old, and the lens density was (2.08±0.47) and (2.12±0.46) grades, respectively. Both the age and the lens density of the two groups were not statistically significant (both P>0.05). Preoperative TCRP, SimK and PCA were not statistically significant (all P>0.05). SIA was calculated using the vector analysis. Centroid SIA conducted from TCRP, SimK and PCA in the 2.2-mm group was -0.11 D@146°, -0.11 D@151° and -0.03 D@67°, respectively, at 3 months postoperatively. In the 3.0-mm group, it was -0.25 D@158°, -0.24 D@147° and -0.04 D@47°, respectively. Statistical significance was found between the two groups in the Y polar value of SIA of the anterior surface [(-0.10±0.30) vs.(-0.22±0.37) D, t=-2.133, P=0.035] and the SIA of the posterior surface [(0.24±0.16) vs. (0.19±0.12) D, t=2.009, P=0.047] at 3 months postoperatively. In the comparison of the SIA of TCRP and anterior surface, statistical significance was found in the absolute value of SIA at all the intervals in the 2.2-mm group [(0.87±0.80) vs. (0.58±0.48) D, (0.58±0.48) vs. (0.50±0.28)D, (0.57±0.37) vs. (0.47±0.28) D, t=5.102, 4.155, 3.877, all P<0.01] and at 1 week and 1 month in the 3.0-mm group [(0.82±0.57) vs. (0.58±0.41) D, (0.59±0.36) vs. (0.50±0.28) D, t=5.034, 3.919, both P<0.01]. X components of SIA_TCRP and SIA_simk were significantly different at 3 month postoperatively in 3.0-mm group (P<0.05). Y components of SIA_TCRP and SIA_SimK were significantly different at 1 week postoperatively in the 2.2-mm group[(-0.48±0.85) vs.(-0.24±0.42) D, P<0.01] and 3.0-mm group [(-0.58±0.66) vs. (-0.37±0.42) D, P<0.01].

Compared with the 3.0-mm incision, the 2.2-mm coaxial micro-incision cataract surgery has a lower and more stable SIA. The effect of a clear corneal incision in cataract surgery on the total cornea is more obvious than that on the anterior surface of the cornea. The difference is significant in the early stage and gradually decrease with time. (Chin J Ophthalmol, 2019, 55: 495-501)

To research the change of cornea astigmatism after combined cataract phacoemulsification and Callisto Eye-assisted arcuate keratotomy and to assess the effectiveness and safety of this surgery for improving patients′ uncorrected visual acuity.

Prospective interventional non-randomized controlled study. Consecutive cataract patients with cornea astigmatism greater than 0.75 D were recruited at the southern part of Beijing Tongren Hospital, Capital Medical University and Beijing Tongren Eye Center, between October 2017 and March 2018, and were divided into the experimental group and the controlled group. In the experimental group the patients are further divided into three subgroups of A(0.75-1.24 D), B(1.25-1.74 D) and C(≥1.75 D) according to the degrees of their cornea astigmatism before surgery. The combined cataract phacoemulsification and Callisto Eye-assisted arcuate keratotomy were performed for the experimental group with the depth and length of the corneal arcuate incision differing in subgroups, while only cataract phacoemulsification was performed for the control group. The complications on and after the surgery were observed and the change of cornea astigmatism and uncorrected visual acuity in three months after surgery were recorded. Independent sample t test was used for statistical analysis.

A total of 108 patients (108 eyes) were enrolled, including 46 males and 62 females, the age was (68±11) years old.The experimental group included 76 eyes of 76 patients (subgroup A 38 eyes, subgroup B 18 eyes, subgroup C 20 eyes). The controlled group included 32 eyes of 32 patients. The preoperative cornea astigmatism and postoperative cornea astigmatism of the experimental group are (1.54±0.90) D and 0.62 (0.36-0.95) D. The change of cornea astigmatism of the experimental group is (1.15±0.58) D. The index of correction and flattening are 0.97±0.20 and 0.61±0.31 respectively, the error of axial deviation is 9.55°±5.22°. The index of success is 0.51±0.36. In the experimental group, subgroup C has the highest correction efficiency of corneal astigmatism (axial deviation error 8.07°±3.13°, flattening index 0.72±0.31) which is followed by subgroup B, and subgroup A ranked the last one (axial deviation error 10.27°±6.47°, flattening index 0.42±0.30).The uncorrected distance visual acuity (logarithm of the minimum angle of resolution) of the experimental group and the control group are significantly different (0.15±0.12 vs. 0.24±0.17, t=-4.129, P<0.01). None of the patients recruited have complications including poor wound healing and cornea penetration and cornea edema and cystoid macular edema on or after the surgery.

Combined cataract phacoemulsification and Callisto Eye-assisted arcuate keratotomy are of favorable effect on improving the uncorrected visual acuity and have relatively good accuracy and predictability on the correction of cornea astigmatism. It is a safe surgery with considerable efficency. (Chin J Ophthalmol, 2019, 55: 502-508)

To investigate the efficacy and adverse reactions of 5% povidone-iodine in removing bacteria from the conjunctival sac with different durations.

Randomized controlled study. A total of 420 patients who underwent cataract surgery in Daping Hospital, Army Medical University from December 2017 to June 2018 were selected. Non-surgical eyes (420 eyes) were selected as the study subjects and divided into 4 groups randomly: 30-second group, 1.0-min group, 2.0-min group and 3.5-min group. On the day of surgery, domestic 5% povidone-iodine was used to flush the conjunctival sac for 30 seconds, 1.0 min, 2.0 min and 3.5 min, respectively. The conjunctival sac specimens were collected for bacterial culture and bacterial identification before and after flushing the conjunctival sac with povidone-iodine. The positive rates of bacterial culture and bacterial growth were compared. The patients′ ocular surface was observed and the incidence of corneal epithelial injury was recorded at 1 hour and 1 day after surgery. The positive rates of bacterial culture and corneal epithelial injury between groups were compared by Pearson chi-square test.

After excluding 20 patients with suspected specimens contamination, 400 patients (400 non-surgical eyes) were enrolled, including 191 males and 209 females, with an average age of 66.8 years. Before flushing the conjunctival sac, the positive rates of bacterial culture in the 30-second group, 1.0-min group, 2.0-min group and 3.5-min group were 44.8% (43/96), 43.3% (39/90), 43.1% (47/109) and 43.8% (46/105), respectively, with no statistically significant difference (χ²=0.066, P=0.996). After flushing, the positive rates of conjunctival sac bacterial culture in the 4 groups were 29.2% (28/96), 31.1% (28/90), 13.8% (15/109) and 13.3% (14/105), respectively. The differences between the 30-second group and 2.0-min group (χ²=7.308, P=0.007), between the 1.0-min group and 2.0-min group (χ²=8.760, P=0.003), between the 30-second group and 3.5-min group (χ²=7.606, P=0.006), and between the 1.0-min group and 3.5-min group (χ²=9.063, P=0.003) were statistically significant. At 1 hour after surgery, mild corneal epithelial injury occurred in each group, with a rate of 16.7% (16/96), 18.9% (17/90), 20.2% (22/109) and 34.3% (36/105), respectively. The differences between the 30-second group and 3.5-min group (χ²=8.118, P=0.004), between the 1.0-min group and 3.5-min group (χ²=5.804, P=0.016), and between the 2.0-min group and 3.5-min group (χ²=5.383, P=0.020) were statistically significant. At 1 day after surgery, there was no occurrence of new injury, and the incidence of mild corneal injury in each group was 3.1% (3/96), 5.6% (5/90), 9.2% (10/109) and 15.2% (16/105), respectively. There was statistically significant difference between the 30-second group and 3.5-min group (χ²=8.597, P=0.003), and between the 1.0-min group and 3.5-min group (χ²=4.728, P=0.030). The corneal epithelial injury healed completely at 1 week after surgery.

The preoperative bacterial load of the conjunctival sac is more effectively reduced with 5% povidone-iodine in the 2.0-min and 3.5-min than in the 30-second and 1.0-min, and the 2-min is superior to the 3.5-min in the occurrence of corneal epithelial injury at 1 hour after surgery. Irrigation of the conjunctival sac with 5% povidone-iodine for 2 min is effective and safe, which can be an alternative measure. (Chin J Ophthalmol, 2019, 55: 509-514)

To compare biometry with new biometers of Pentacam AXL and IOLMaster 700 and the widely used biometer of IOLMaster 500 in cataract patients.

Cross-sectional study. A total of 223 eyes of 147 cataract patients from Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University during 4-8 December 2017 were recruited. There were 67 males and 80 females with an age of (64±11) years.The axial length (AL), mean keratometry (Km), anterior chamber depth (ACD) and white-to-white corneal diameter (WTW) from each device were recorded. The difference and agreement between the measurements were evaluated by ANOVA, LSD test, intraclass correlation coefficient and Bland-Altman analysis.

The success rate of AL measurement was 85.2% (190/223) with the Pentacam AXL, 96.9% (216/223) with the IOLMaster 700 and 90.6% (202/223) with the IOLMaster 500. There was no difference among devices in measuring the AL, Km and ACD (all P>0.05). Significant difference was found in WTW [(11.36±0.42) vs. (11.69±0.45) vs. (11.45±0.42) mm; F=34.696, P=0.000]. Intraclass correlation coefficient was 0.859-1.000, and Bland-Altman analysis showed good agreement among three devices.

The new biometers of Pentacam AXL and IOLMaster 700 and the widely used IOLMaster 500 show no difference in measuring AL, Km and ACD. All three devices show good agreement in biometry of cataract patients. (Chin J Ophthalmol, 2019, 55: 515-521)

To systematically compare the effects of Toric intraocular lens (IOL) implantation and corneal incisional procedures on the correction of astigmatism during cataract surgery.

A peer-reviewed literature search was implemented in MEDLINE, EMBASE, EBSCO, ScienceDirect, Trip Database, Ovid, and the Chinese databases including CNKI and Wanfang Data. The inclusion criteria were randomized controlled trials (RCTs) that compared the Toric IOL implantation and the corneal incisional procedures to correct low and moderate astigmatism during cataract surgery. The mean difference (MD) and the relative risk were respectively used to describe the effect sizes of continuous data and nominal data with a confidence interval (CI) of 95%. The random effects model was applied to pool the data including postoperative uncorrected visual acuity, residual astigmatism and surgical complications by Review Manager 5.3.

A total of 12 RCTs were included in this study, including 330 eyes implanted with Toric IOLs and 336 eyes with non-Toric IOLs combined with corneal incisional procedures to correct astigmatism. According to the types of corneal incisions, the included RCTs were divided into three groups: limbal relaxing incision group, opposite clear corneal incision group, and astigmatic keratotomy group. Meta-analysis showed that postoperative logarithm of the minimum angle of resolution uncorrected visual acuity was significantly better in eyes implanted with Toric IOLs than those with corneal incisional procedures (MD, -0.05; 95% CI, -0.08 to -0.02; P<0.01), and the residual astigmatism was significantly lower in eyes implanted with Toric IOLs (MD, -0.33 D; 95% CI, -0.48 to -0.18 D; P<0.01). There was no significant difference in the risk of surgical complications between the Toric IOL implantation and the corneal incision correction for astigmatism (relative risk, 0.45; 95% CI, 0.07 to 2.95; P=0.40).

The current evidence suggests that Toric IOL implantation is more effective in correcting astigmatism than corneal incisional procedures during cataract surgery and shows better postoperative visual acuity. However, they are similar in the risk of postoperative complications. (Chin J Ophthalmol, 2019, 55: 522-530)

To describe the clinicopathological features of conjunctival actinic keratosis (AK) and relation to the infection of human papillomavirus (HPV).

Retrospective case series study. Eighteen cases (18 eyes) of conjunctival AK were obtained in Tianjin Eye Hospital and Institute (2005-2018). The clinical and histopathological features were studied. HPV was detected by a modified general primer HPV polymerase chain reaction (PCR) system in all formalin-fixed, paraffin-embedded specimens.

The male to female ratio was 5∶1. The mean age at diagnosis was 60 years (range: 43-79 years). Sixteen cases were located in the nasal interpalpebral region, and two cases were located in the temporal interpalpebral region. All cases were located in corneal limbus, and the mean distance of corneal invasion was 2 mm (range, 1-4 mm). The mean diameter was 4.6 mm (range, 2.0-8.0 mm). Clinically, most lesions (16 cases) appeared as a white or milky, flat plaque with clear borderline and conjunctival hyperemia; a few lesions (2 cases) showed a brown-black mass, partially white. Pathologically, conjunctival AK was a proliferation of epithelium with prominent parakeratosis or hyperkeratosis, stratum spinosm thickening and basal cell proliferation. Many AKs show solar elastosis and a mild inflammatory infiltrate of lymphocytes and plasma cells in the stroma. Most lesions (15 cases) were hypertrophic type, two cases were pigmented type, and one case was acantholytic type. HPV was negative in 18 cases. All case were removed by complete surgical excision. The rage of follow-up period was 1.0-10.4 years, ten cases were recorded, and no case recurred after surgical excision.

Conjunctival AK is epithelial precancerous lesion that occurs in the keratoconjunctival margin. HPV infection might not be a causative factor in conjunctival AK. (Chin J Ophthalmol, 2019, 55: 531-535)

To investigate the surgical effect of repairing leakage of filter vesicles with autologous Tenon tissue.

Retrospective serial case study. From January 2010 to August 2018, the clinical and follow-up data of 16 patients (16 eyes) with leakage of filter vesicles after trabeculectomy for glaucoma were collected. All patients underwent autologous Tenon tissue packing under the scleral flap and suture fixation combined with conjunctival flap repair (with surgical video). Under the anesthesia of infraorbital nerve combined with ciliary ganglion block, the bulbar conjunctiva at the edge of the filter vesicle was cut and the cystic degenerative filter vesicle was peeled off, the upper bulbar conjunctiva flap was bluntly separated, the scleral flap was exposed and re-peeled according to the original scleral lamella, the healthy Tenon tissue of the corresponding size of the original scleral flap was taken for spare use, the scleral flap was fixed and sutured with 10-0 nylon thread, the spare Tenon tissue was packed under the scleral flap, sutured and fixed to form an anterior chamber, the intraocular pressure and filtration were explored, and the upper bulbar conjunctiva flap was aligned and sutured to the corneoscleral margin. The evaluation indexes mainly included preoperative and postoperative intraocular pressure, visual acuity, postoperative complications, etc. Comparison of measurement information is mainly matchedtInspection.

Of the 16 patients (16 eyes), 11 were males and 5 were females; The age ranged from 46 to 80 years, with a median of 57 years. The postoperative follow-up time was 2.0 to 96.0 months, with a median of 10.0 months. IOP increased from (9.7 ± 1.2) mmHg (6.0~15.0 mmHg) (1 mmHg =0.133 kPa) before surgery to (15.5 ± 2.7) mmHg (10.0~20.0 mmHg) 3 months after surgery, and the difference was statistically significant (t =2.63，P =0.02), the intraocular pressure was normal with or without medication at the last follow-up visit. The best corrected visual acuity (logarithmic visual acuity of minimum resolution angle) was 0.32 ± 0.08 at 3 months after operation, which was significantly improved compared with that of 0.59 ± 0.25 before operation (t =3.04，P =0.02）； The best corrected visual acuity at the last follow-up was 0.24 ± 0.06, and there was no significant difference from the best corrected visual acuity at 3 months after surgery (t =0.81，P =0.42）。 Transient shallow anterior chamber occurred in 3 eyes, 2 of which were complicated with choroidal detachment, which recovered within 1 week of medical treatment without other serious complications.

Application of autologous Tenon tissue combined with advanced conjunctival flap to repair the leakage of filter vesicles is simple, safe and effective. (Chinese Journal of Ophthalmology,2019，55：536-540）

One patient with a complaint of blurred vision in both eyes for 2 years was seen in the ophthalmology department. 12 years of previous history of type 1 diabetes. Ocular examination showed opacity of both eyes, optic nerve atrophy in both eyes, and visual acuity improved after phacoemulsification and cataract aspiration plus intraocular lens implantation. Four years later, the patient developed hearing loss, and genetic testing revealed a mutation in the WFS1 gene, confirming the diagnosis of Wolfram syndrome. (Chinese Journal of Ophthalmology,2019，55：541-542）

A child with 2 years of red eyes and 1 month of elevated intraocular pressure in his right eye was diagnosed as binocular uveitis, secondary glaucoma in his right eye and Blau syndrome by laboratory examination and genetic testing. He was given peripheral iridectomy in his right eye and systemic glucocorticoid and immunosuppressant therapy. One month after operation, the intraocular pressure in his right eye was normal, the anterior chamber formed well, the iris root incision was unobstructed, and the rash and joint swelling subsided. (Chinese Journal of Ophthalmology,2019，55：543-545）

One patient who complained of redness and swelling of the lower eyelids of both eyes for more than 10 years went to the ophthalmology department. According to the clinical characteristics, imaging examination and histopathological findings after mass resection, the diagnosis of Madelon's syndrome with redness and swelling of both eyes was made. After double eyelid mass resection, the skin swelling of lower eyelid of both eyes improved compared with before, the appearance of the periocular area was improved, and the discomfort caused by the mass compressing the periorbital area was alleviated. (Chinese Journal of Ophthalmology,2019，55：546-547）

Yao Ke, Chief Physician, Prof. Chairman of Ophthalmology Branch of Chinese Medical Association, Head of Cataract and Intraocular Lens Group, Editor-in-Chief of Editorial Committee of Chinese Journal of Ophthalmology. Member of the International Council of Ophthalmology, Academician of the International Academy of Ophthalmology, Vice President of the Asia-Pacific Society of Cataract and Refractive Surgery, and Head of the Asia-Pacific Society of Ophthalmology in China. He has obtained six national invention patents, and has successively obtained more than 30 national, provincial and ministerial major projects, such as key projects of the National Natural Science Foundation of China, national support projects of the 11th Five-Year Plan and the 12th Five-Year Plan, and key and general projects of national funds. The first winner won two second prizes of national scientific and technological progress awards, more than 10 provincial and ministerial scientific and technological major contribution awards and the Alfred-Vogt Award of Swiss Ophthalmology.

The patient was a 34-year-old male. The right eye was blurred for 2 months, and he went to Chaoju Eye Hospital in Baotou, Inner Mongolia Autonomous Region. Deny history of trauma and family genetic disease. There were no obvious abnormalities in the whole body examination. Eye examination: visual acuity in the right eye was 0.05, intraocular pressure was 16 mmHg (1 mmHg =0.133 kPa); The conjunctiva is not congested, the cornea is transparent, the depth of the anterior chamber axis is normal, the pupil is round, and it is sensitive to light, the lens is transparent, part of the lens is absent, and the edges are rounded (Quintessence Picture 1）； No abnormalities were observed in the fundus of the eye. Ultrasound biomicroscopy showed the absence of the suspensory ligament of the lens from 6:00 to 12:00 (Quintessence Picture 2）。 Clinical diagnosis: congenital absence of lens and suspensory ligament in right eye.

Regeneration of the lens is an ideal strategy for cataract patients to restore their adjustable vision and to acquire excellent visual quality. However, mammalian lens regeneration is slow and incomplete, and functional lens regeneration cannot be achieved. The ability of lower amphibians (such as newts) to regenerate the lens provides the impetus for research on the regeneration of the lens of mammal. At present, the main form of mammalian lens regeneration is the differentiation of lens epithelial cells by capsular bag as a scaffold. In recent years, the continuous development of stem cell technology, tissue engineering and biological materials have made great progress in lens regeneration. This article describes the processes in the normal development of the lens, and reviews the research results of lens regeneration at home and abroad, and discusses the possibility of the new techniques and methods related to regenerative medicine applied to lens regeneration. It is hoped to help in the realization of rapid and complete regeneration of functional lens.(Chin J Ophthalmol, 2019, 55: 549-553)

In order to further standardize the use of Toric intraocular lens (IOL), the Cataract and Intraocular Lens Group of Ophthalmology Branch of Chinese Medical Association released the "Expert Consensus on Clinical Application of Astigmatism Correction Intraocular Lens in China (2017)" in 2017, which provided comprehensive guidance on Toric IOL implantation in a series of links such as patient selection, preoperative preparation, surgical operation and postoperative follow-up. In order to help ophthalmologists understand and master its contents more deeply, the relevant issues are interpreted and supplemented. (Chinese Journal of Ophthalmology,2019，55：554-556）