Volume 55 · Issue 08 · 2019

This issue focuses on the research progress of ophthalmic epidemiology investigation. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Wang Ningli.

The prevalence of myopia in China is extraordinarily high, and much attention has been paid to the epidemiological studies related to myopia. Epidemiological investigations can be used to understand the incidence and prevalence of myopia, its epidemiological characteristics and the related risk factors. At present, there are many articlespublished in China on epidemiological surveys of myopia. However, the criteria for cycloplegic regimes are not uniform, the age limit is not definite, and cycloplegics are even not used in some researches. Lack of or insufficient cycloplegia is associated with overestimation of the prevalence of myopia and underestimation of hyperopia and leads to inaccurate assessment of risk factors. In this article, we propose standardized methods for cycloplegia in the epidemiological investigations of myopia in China by reviewing different types of cycloplegic regimes commonly used and the effects on different age groups. This will help to obtain the accurate incidence and prevalence of myopia, promote the interconnection and increase comparabilityof research data, improve the accuracy of assessing related risk factors and provide scientific evidence for the prevention and control of myopia. (Chin J Ophthalmol, 2019, 55: 561-564)

Diabetic retinopathy (DR) is one of the most important etiologies of diabetic blindness. The vascular endothelial growth factor (VEGF) is thought to mediate pathophysiological changes of DR. Anti-VEGF therapy for DRdevelops rapidly. However, there are some misunderstandings about its clinical application, and the strategy is not clear. Sometimes its therapeutic effects are even exaggerated. In this article, by discussing whether anti-VEGF therapy can reverse the course of DR disease, promote the absorption of vitreous hemorrhage, and replace fundus laser therapy, the application strategy of anti-VEGF therapy for DR is proposed. At present, anti-VEGF therapy cannot completely replace retinal photocoagulation therapy, and its clinical application value should not be exaggerated. More innovative drugs and therapies are expected to provide new ways forthe treatment of DR while preserving visual function. (Chin J Ophthalmol, 2019, 55: 565-568)

Drugs are one of the important methods for clinical treatment of glaucoma. As the disease progresses, intraocular pressure-lowering therapy in most glaucoma patients requires the combination of single-component drugs. In order to safely and effectively use a variety of drugs to treat glaucoma, drug compound preparation has gradually become the development trend of treatment. In order to guide ophthalmologists to reasonably select drug compound preparations for the treatment of glaucoma and give full play to the advantages of drugs, the Glaucoma Group of Ophthalmology Branch of Chinese Medical Association put forward a consensus opinion for reference.(Chinese Journal of Ophthalmology, 2019, 55:569-571)

Different opinions were put forward on the title, the definition of children, and the consistency and rigor of written expression in the "Expert Consensus on Optometry and Safe Medication for Children with Ciliary Muscle Palsy in China (2019)" promulgated by the Strabismus and Pediatric Ophthalmology Group of the Ophthalmology Branch of the Chinese Medical Association, and discussed with the author.(Chinese Journal of Ophthalmology, 2019, 55:572-573)

In view of the discussion with the authors of the Expert Consensus on Optometry and Safe Medication for Children with Cilioplegia in China (2019), the author replies to the discussion opinions mainly involving written expressions in the Expert Consensus on Optometry and Safe Medication for Children with Cilioplegia in China (2019), in order to help more ophthalmologists deepen their knowledge and understanding, and promote the standardization of optometry and medication for children with cilioplegia in China.(Chinese Journal of Ophthalmology, 2019, 55:574-575)

To investigate the methods of optometric refraction adopted for adolescents in spectacles stores in Anyang city of Henan Province and the professional performance of optometric refraction.

Cross-sectional study. Maps and yellow pages were used to collect the information of 131 spectacles stores in Anyang city. A questionnaire was used to investigate spectacles stores that had optometry equipment and can provide refraction prescription and spectacles in this city. The questionnaire covered (1) the process of optometric refraction, including whether cycloplegic refraction was conducted for adolescents and children if it was their first-time optometry and the type of cycloplegics,and (2) the opticians′ knowledge on optometric refraction for adolescents and children, such as necessity of cycloplegic refraction for adolescents and children and age cut-offs. According to whether they used a comprehensive refractometer, the optometry methods were divided into conventional optometry and medical optometry.

Of 131 spectacles stores in Anyang city, 127 were enrolled. A total of 127 questionnaires were distributed and returned with an effective rate of 100%. Conventional optometric refraction was performed in 53 stores (41.73%), and medical optometric refraction was performed in 74 stores (58.27%). Cycloplegic refraction was conducted in only 4 spectacles stores (3.15%) for adolescents and children upon their first-time optometry. The fogging method of refraction was adopted in 31 stores (24.41%), while optometric refraction was directly conducted in 92 stores (72.44%) without controlling accommodation. As for the use of cycloplegia at initial optometric refraction of children, cycloplegia was objected to in 4 stores,and thought to be no need in 28 stores including 6 stores in which the fogging method was used to replace cycloplegia. In 68 stores, cycloplegia was performed if wanted, or children could go to a hospital for it. In 12 stores, the use of cycloplegics was determined by children′s vision and diopters. In 5 stores, children were suggested to go to a hospital for cycloplegic refraction. Cycloplegic refraction was required in only 4 stores. As to the age cut-offs of cycloplegic refraction, 6 years old, 12 years old, and 18 years old were considered as the boundary in 7 stores, 33 stores, and 9 stores, respectively.In 11 stores, age was only considered for amblyopia and hyperopia, and in 67 stores, it was not realized.

Cycloplegic refraction was found to be conducted for adolescents and children in only 3% of the spectacles stores in Anyang city. Moreover, most of the spectacles store opticians did not support to use cycloplegia before optometric refraction for adolescents and children and lacked knowledge on the age cut-offs of cycloplegic refraction.Standardized training of cycloplegic refraction should be further strengthened. (Chin J Ophthalmol, 2019, 55: 576-581)

To investigate the unidimensionality, reliability and validity of the Chinese version of the Low Vision Quality of Life Questionnaire (CLVQOL) on the basis of Rasch analysis.

All participants completed the CLVQOL. The psychometric properties of the CLVQOL were tested using Rasch analysis,including the unidimensionality,person separation index (PSI),person reliability (PR), infit mean square MNSQ and differential item functioning (DIF).

One hundred and forty seven residents,including 58 males (39.46%) and 89 females (60.54%),were enrolled. The mean age of the participants was (67±10) years old. The CLVQOL had 4 original scales. The first scale was found to be multidimensional and was subsequently divided into 2 scales. A new 5-scale CLVQOL was then developed, and all 5 scales were shown to be unidimensional. All PSIs exceeded 2,and all PRs exceeded 0.8,indicating the favorable discriminant ability of the questionnaire. Notable DIF was not found for any item across different age or gender subgroups.

A Rasch model can be used in improving the rating questionnaires for evaluating vision-related quality of life (VRQoL). All 25 items demonstrated an acceptable fit in Rasch analysis,and a new 5-scale CLVQOL was developed.(Chin J Ophthalmol, 2019, 55: 582-588)

To assess the prevalence and influence factors of cataract at different altitudes in Gansu Province.

A total of 7 560 permanent residents aged 50 years and over in seven regions of Gansu Province (altitude, 900 meters to 3 500 meters) were selected as subjects, including 2 402 males and 5 158 females, with an average age of 62.04 years. The cluster random sampling method was used to conduct the survey at village or township health service centers. The investigation procedure included questionnaire survey, pre-investigation, visual acuity examination, intraocular pressure measurement, slit lamp microscopy and fundus examination. The diagnostic criterion for cataract was typical opacity of the lens or no other eye diseases that led to visual impairment but with visual acuity less than 0.7. The prevalence of cataract was calculated according to factors such as altitude, age and sex. The Chi-square test and two-element unconditional logistic regression were used for statistical analyses.

A total of 7 560 people were surveyed. The prevalence rate of cataract was 39.7%, and the age-standardized prevalence was 37.7%. The prevalence of cataract increased with age (χ²=2 107.19, P<0.01). It was 14.1% in the group of 50-59 years, 42.9% in the group of 60-69 years and 79.2% in the group of over 70 years. The prevalence of cataract also increased with altitude (χ²=33.66, P<0.01). It was 36.9% in the group of altitude less than 1 000 meters, 39.0% in the group of altitude between 1 000 meters and 1 999 meters, 45.9% in the group of altitude between 2 000 meters and 2 999 meters, and 51.5% in the group of altitude more than 3 000 meters. With age stratification, the prevalence of cataract at high altitude was higher than that at low altitude (χ²=26.74, 16.06, P<0.01). Multivariate regression analysis showed that the risk of cataract was higher in subjects at altitude of 2 000-2 999 meters than those below 1 000 meters (OR=1.42, 95%CI 1.11-1.82), and even higher in those at altitude of 3 000 meters (OR=1.76, 95%CI 1.01-3.06).

High altitude and old age are important risk factors for cataract, and high altitude is an independent risk factor for cataract. It is necessary for local health institutions to take measures to reduce the prevalence of blindness and low vision, especially the blindness caused by cataract. (Chin J Ophthalmol, 2019, 55:589-594)

To explore the effect of different types of visual display terminals (VDT) on visual fatigue.

A total of 68 subjects were enrolled and divided into flat screen group, metal screen group and glass bead screen group. The subjects watched a video in the same environment for 60 minutes. Before and after watching, they were asked to fill in a visual fatigue rating scale and underwent visual function examinations. The blink rate of subjects was recorded during the experiment.

After watching the video, for the metal screen, glass bead screen, and flat screen group respectively: (1)The median (interquartile range, IQR) of visual fatigue rating increased significantly (before: 1.0 (1.2), 1.3 (1.6), 0.5 (0.9); after: 2.1 (1.9), 2.1 (1.7), 1.2 (1.0); Z=-4.72, -4.83, -3.75; all P<0.05). (2) The median (IQR) of blink frequency increased significantly (before: 11.5 (10.6), 15.3 (11.9), 7.0 (13.0) times/minute; after: 15.0 (13.0), 17.0 (16.0), 15.0 (12.0) times/minute; Z=-2.64, -2.74, -4.12; all P<0.05). (3) The mean (±standard deviation) of critical flicker fusion frequency (CFF) decreased significantly [before: (35.76±2.98), (35.84±2.79), (35.44±2.21) Hz; after: (35.09±2.78), (34.94±2.67), (34.57±2.33) Hz; t=-2.64, -2.38, -4.12; all P<0.05). (4)The median (IQR) of near point of convergence (NPC) became significantly larger [before: 3.9 (2.6), 4.0 (2.5), 4.3 (2.7) cm; after 5.4 (3.8), 4.8 (2.7), 6.1 (3.9) cm; Z=-3.39, -2.27, -3.36; all P<0.05]. (5)The median of negative relative accommodation (NRA) reduced significantly [before: 2.00 (0.50), 2.00 (0.56), 2.00 (0.25) cm; after 1.75 (0.50), 1.75 (0.25), 1.75 (0.50) cm; Z=-1.98, -2.09, -2.53; all P<0.05]. Meanwhile, no significant changes were found for the positive relative accommodation (PRA), accommodative amplitude, accommodative response, negative relative vergence in all groups after watching the video. The comparisons between the three groups showed that, after watching the video, the participants in the two kinds of projection screen group (the metal and glass bead screen group) had more subjective visual fatigue than those in the flat screen group respectively (Z=-2.09, -2.21; all P<0.05), while there was no significant difference in subjective visual fatigue between the two projection screen groups (P>0.05). In addition, positive fusional vergence recovery point and break point decreased after watching the video in the metal screen and glass bead screen group, respectively (t=4.15, 2.07; all P<0.05). However, no such change was found in the flat screen group.

Short-term and long-distance VDT operations have significant effects on visual fatigue, which may be due to the decreased positive convergence ability. VDT operations over projection screens may result in more visual fatigue than LED flat panel display, while the effect of different projection screen types have insignificant influences on visual fatigue. (Chin J Ophthalmol, 2019, 55:595-600)

To analyze the sensitivity and specificity of fungal fluorescent staining in the diagnosis of fungal keratitis, and to compare it with conventional fungal culture, in vivo confocal microscopy (IVCM) and Giemsa staining. To explore its value of clinical application.

Prospective case-control study. A total of 105 consecutive patients (105 eyes) diagnosed with infectious keratitis at Beijing Tongren Hospital from August 2017 to April 2018 were included. Patients with infectious keratitis were divided into fungal keratitis (FK) group and non-fungal keratitis (NFK) group by slit lamp microscopy, corneal in vivo confocal microscopy (IVCM) examination, and the results of Giemsa staining, fluorescent staining and pathogenic culture of corneal scraping from ulcer. The sensitivity and specificity of the above-mentioned examination methods for the diagnosis of fungal keratitis were analyzed. The receiver operating characteristic curve (ROC curve) and Area Under Curve (AUC) values were calculated to determine the diagnostic value of fungal fluorescent staining for fungal keratitis.

Among the 105 patients with infectious keratitis, 66 were fungal keratitis, 39 were non-fungal keratitis (29 cases of bacterial keratitis and 10 cases of acanthamoeba keratitis). Isolation from fungal keratitis were mainly Fusarium spp. (43.5%), followed by Alternaria spp. (21.7%) and Aspergillus spp. (19.6%). After fluorescent staining of the ulcer smear, the background of tissue demonstrated homogeneous black or weak blue fluorescence. The cell wall of fungi showed bright blue-violet to blue fluorescence, and the morphology, structure and hyphal density were easily recognized. The sensitivity of different methods for the diagnosis of corneal fungal infection were smear fluorescence staining (97.0%), IVCM (87.9%) , Giemsa staining (86.7%), and fungal culture (69.7%); the specificity of fungal culture was the highest (100%), followed by IVCM and Giemsa staining (94.9%), and fluorescent staining (87.2%). The ascending order of AUC values was: fungal culture (0.848) <Giemsa staining (0.906) <IVCM (0.914) <fluorescence staining (0.921).

Fungal fluorescent staining is a rapid and sensitive screening method under microscope with high sensitivity and specificity for the diagnosis of fungal keratitis. It is especially suitable for the diagnosis of patients with low load of hypha or after antifungal therapy. (Chin J Ophthalmol, 2019, 55:601-608)

To discuss the clinical features and treatment of juxtapapillary retinal capillary hemangioma (JRCH).

Retrospective study of the clinical data of 6 patients (7 eyes) who were diagnosed with JRCH, among which 2 eyes were treated by laser therapy (thermotherapy TTT or photodynamic therapy PDT), 2 eyes were treated by intravitreal anti-VEGF injection, 2 eyes with vitreous hemorrhage were treated with vitrectomy (PPV)+ anti-VEGF, and 1 eye was untreated.

In the 6 cases, the gender ratio of male to female is 2∶1 with average age of 46 years. Four eyes were associated with macular edema(57.1%), vitreous hemorrhage(n=2, 28.6%), and epiretinal membrane(n=1, 14.2%) in the initial examination. Three patients were associated with von Hippel-Lindau(VHL). During the follow-up period, the visual acuity of the 2 patients treated by TTT decreased. Among the 2 eyes treated by anti-VEGF, the visual acuity of 1 eye associated with macular edema increased, and the visual acuity of 1 eye with macular epiretinal membrane did not change significantly, the visual acuity of both 2 eyes treated by PPV+anti-VEGF improved, the vision of the 1 eye untreated appeared to be stable.

Juxtapapillary retinal capillary hemangioma is the orange or red vascular hamartomas that occur on or adjacent to the optic nerve head. It is often associated with macular edema, vitreous hemorrhage, and local subretinal effusion. Symptomatic treatment of complications can effectively improve the visual acuity of patients, while long-term follow-up observation should be organized for patients without complications, laser treatment appears to be ineffective. (Chin J Ophthalmol, 2019, 55:609-615)

Stickler syndrome is a rare hereditary collagen connective tissue disease, which is characterized by eye, orofacial, joint and hearing damage. This patient was a 21-year-old female with high myopia and poor hearing since childhood. The heterozygous missense mutation of c.C1693T and p.R565C in COL2A1 (NM_001844) gene was detected by gene sequencing. The family separation found that the proband's father heterozygous carried the same mutation, and the comprehensive clinical manifestations were diagnosed as Stickler syndrome.(Chinese Journal of Ophthalmology, 2019, 55:616-618)

The patient was a 13-year-old female with a history of wearing orthokeratology lenses for 1 year. Five months ago, the patient had left eye discomfort symptoms after wearing orthokeratology lens. After treatment with bacterial and viral keratitis drugs, the symptoms worsened, corneal ulcers appeared, corneal scraping showed Acanthamoeba cysts, and orthokeratology lens box fluid Acanthamoeba culture was positive, and it was confirmed that he was left eye Acanthamoeba keratitis. Eyelash mites were tested positive during anti-amoeba therapy, and symptoms improved after combined anti-mite therapy.(Chinese Journal of Ophthalmology, 2019, 55:619-620)

A patient with poorly differentiated adenocarcinoma of the lower lobe of the left lung, who was given albumin-bound paclitaxel chemotherapy 5 months ago, is now seen for 3 weeks due to decreased vision in both eyes. The visual acuity of both eyes was 0.1 on admission examination. The patient complained of good visual acuity since childhood, and had no previous history of ophthalmopathy and family hereditary ophthalmopathy. Coherence light tomography revealed multiple cystic cavities between neuroepithelial layers in the macular area of both eyes, most prominently in the fovea; Fluorescein fundus angiography showed petal-like strong fluorescence in late stage; Electroretinogram results were basically normal. A macular edema due to albumin-bound paclitaxel was diagnosed.(Chinese Journal of Ophthalmology, 2019, 55:621-623)

The patient was a 36-year-old female. Because of blurred vision in his right eye for 10 days, he went to Baoding Yinghua Eye Hospital. A cesarean section was performed 10 days ago due to hypertension and the preoperative blood pressure was 190/110 mmHg (1 mmHg =0.133 kPa). Eye examination: visual acuity was 0.05 for the right eye and 0.25 for the left eye; IOP was 13 mmHg in the right eye and 16 mmHg in the left eye; Mixed conjunctival hyperemia in the right eye, transparent cornea, retrocorneal deposition (+), anterior chamber plankton (+), aqueous humor flash (+), round pupil, transparent lens; There was no obvious abnormality in the anterior segment of the left eye; Fundus of both eyesQuintessence Picture 1,Quintessence Picture 2,Quintessence Picture 3。 Clinical diagnosis: binocular pregnancy-induced hypertensive chorioretinopathy.

With the growth of the global population and the acceleration of the aging process, the situation of blindness all over the world is increasingly severe. According to the latest data published by the Vision Loss Expert Group in 2017, there were an estimated 36 million blind people worldwide in 2015. The 66^th World Health Assembly has endorsed the "Universal eye health: a global action plan 2014-2019" , which aims to reduce the prevalence of avoidable visual impairment by 25% by 2019 from the baseline of 2010. As a country with the largest number of blind people in the world, China has an arduous task of preventing and treating eye diseases.This review article summarizes and analyzes the relevant literature on the prevalence of blindness, the main blinding diseases and prevention measures in China, so as to provide reference materials for ophthalmologists to better carry out eye health work and reduce the number of blind people in China. (Chin J Ophthalmol, 2019, 55:625-628)

Mucormycosis is a rare, rapidly progressive life threatening opportunistic fungal infection, with rhinocerebral mucormycosis being the most common type. Rhinocerebral mucormycosis usually presents symptoms similar to sinusitis and orbital cellulitis during its early stage,which often leads to a misdiagnosis at the very beginning,and progresses rapidly to endophthalmitis,blindness,sclera perforation, eyeball atrophy, and even gets the central nervous system involved, thus leading to death. Mucormycosis is particularly common in patients with poor glycemic control, ketoacidosis and immunosuppression. The purpose of this review is to highlight the predisposing factors, infection pathway, pathogenesis, clinical presentations, diagnosis, and management of rhinocerebral mucormycosis, hence further promote the early diagnosis and immediate treatment of the disease. (Chin J Ophthalmol,2019,55:629-633)

Epidemiology is a discipline that studies the distribution of health conditions and events in a population and determinants that affect distribution, and is used to solve health problems. In order to establish an effective glaucoma prevention and treatment system in China and reduce the blindness and disability rate of glaucoma, it is necessary to have a deep understanding of the prevalence of glaucoma in China. This paper explains the epidemiological investigation of glaucoma by Chinese glaucoma scholars and its main results, reveals the characteristics, composition and distribution of glaucoma in China, and provides reference for clinical prevention and treatment of glaucoma.(Chinese Journal of Ophthalmology, 2019, 55:634-640)