Volume 55 · Issue 09 · 2019

This issue focuses on the research progress of diagnosis and treatment of ocular trauma. Professor Yan Hua is the responsible editorial committee responsible for the planning, composition and review of the key contents of this issue.

The emergency management of ocular trauma has direct effects on the final results of second-stage surgical treatment and prognosis. Therefore, it is necessary to attach great importance to the emergency treatment of ocular trauma, and to adopt practical and effective methods. Based on our analysis the existing problems relevant to emergency management of ocular trauma in China, we put forward some measures, including further standardizing the ocular trauma emergency management, developing ocular trauma emergency management training, improving the relevant system and mechanism for the emergency management of ocular trauma, and strengthening the registration work of ocular trauma emergency and etc. The aim is to significantly improve the level of emergency management of ocular trauma in China. (Chin J Ophthalmol, 2019, 55: 641-644)

Exploratory pars plana vitrectomy (EPPV) made one quarter of injured eyes with no light perception (NLP) rescued. Previously, the clinical routine in making a decision of enucleation for injured eyes with NLP was based on preoperative evaluation. Such ideas, however, have altered with development of EPPV. Some extraordinary lesions can be explored in those moribund eyes during EPPV and dealt with newly developed techniques. This article reveals the pathological basis of traumatized NLP eyes and the advantages and effects of EPPV, and puts forward the concept that decision making of enucleation should be based on findings obtained during EPPV. (Chin J Ophthalmol, 2019, 55: 645-646)

In recent years, medical institutions in China have extensively carried out emergency treatment of ocular trauma, but the effect of emergency treatment is uneven. Emergency patients with ocular trauma have complicated and acute injuries, so they need to be diagnosed and treated correctly in a short time, and the effect of emergency treatment is related to prognosis. In order to improve the treatment level, the ocular trauma group of Ophthalmology Branch of Chinese Medical Association reached a consensus opinion after careful discussion, which can be used by ophthalmologists for reference in clinical work.(Chinese Journal of Ophthalmology, 2019, 55:647-651)

At present, posterior chamber intraocular lens implantation in phakic eyes is gradually popularized in clinical practice, but its indications, preoperative preparation, surgical procedure, prevention and treatment of surgical complications need to be standardized urgently. After discussion, the Optometry Group of Ophthalmology Branch of Chinese Medical Association and experts in related fields reached a consensus, in order to provide a reference for ophthalmologists in the field of refractive surgery.(Chinese Journal of Ophthalmology, 2019, 55:652-657)

To evaluate the clinical effect of three-dimensional printing combined with surgical navigation and endoscopy for orbital fracture reconstruction.

A case series study. Twenty-eight patients (28 eyes) with orbital fractures (20 males and 8 females, aged 10-61 years, with simple orbital fractures in 22 patients and composite orbital fractures in 6 patients) were treated with three-dimensional printing combined with surgical navigation and endoscopy for orbital fracture reconstruction at Affiliated Eye Hospital of Nanchang University from July 2016 to June 2018. With the help of three-dimensional printed models and guides, navigation positioning guidance and endoscopic visualization performance, the soft tissue incarcerated in the orbital fracture area was loosened, and the repair material was implanted (video attached). Postoperative follow-up was conducted at 1 week and 3 months. The follow-up observation included the best corrected visual acuity, diplopia, dyskinesia of the eyes, enophthalmos, and orbital volume. The data were analyzed by the paired t-test, Wilcoxon and the Mann-Whitney U rank sum test.

The best corrected visual acuity before and 1 week after surgery was 4.714±0.400 and 4.732±0.377, respectively, and the difference was not statistically significant (t=1.724, P=0.096). The enophthalmos before and 1 week after surgery was 2.2 (2.0-5.0) mm and 0.3 (0.0-2.3) mm, respectively, and the difference was significant (Z=-4.604, P<0.01). The orbital volume before and 1 week after surgery was 2 008.10 (6.84-11 200.00) mm³ and 478.76 (5.01-7 286.00) mm³, respectively, and the difference was statistically significant (Z=-3.735, P<0.01).The preoperative diplopia degree was 0, Ⅰ, Ⅱ, and Ⅲ in 14, 11, 3, and 0 eyes, while the degree of diplopia 3 months after surgery was 0, Ⅰ, Ⅱ, and Ⅲ in 22, 6, 0, and 0 eyes, respectively. The difference was statistically significant (Z=-2.359, P=0.018). The preoperative dyskinesia degree of the eyes was 0, Ⅰ, Ⅱ, and Ⅲ in 11, 11, 3, and 3 eyes, while the dyskinesia degree of the eyes 3 months after surgery was 0, Ⅰ, Ⅱ, and Ⅲ in 23, 5, 0, and 0 eyes, respectively. The difference was statistically significant (Z=-3.456, P=0.001). No implant infection, displacement, and other serious complications were observed during the follow-up of 3 to 12 months.

Three-dimensional printing technology combined with nasal endoscopy and surgical navigation, which is applied in the reconstruction of orbital fracture, can significantly improve the symptoms of diplopia, ocular dyskinesia, and ocular depression. It is a feasible assistant method. (Chin J Ophthalmol, 2019, 55: 658-664)

To assess the effectiveness of osseointegrated implant supported prostheses in the rehabilitation of severe orbital deformity.

Retrospective case series. The study collected 6 patients (6 eyes) with severe orbital deformity, who were treated with osseointegrated implant supported prostheses between 2010 and 2016 in Beijing Tongren Eye Center, Beijing Tongren Hospital. Data included demographic characteristics, causes of the deformity, the history of radiotherapy, the site, number and survival of implants, and the ability to wear prostheses.

Among the 6 patients, 4 were males, and 2 were females, with a mean age of 27 (16-44) years. The deformity resulted from evisceration or enucleation and radiotherapy for malignancies in 4 patients, from evisceration because of inflammatory pseudotumor in 1 patient, and from enucleation and debridement because of explosion injury and secondary infection in 1 patient. Each patient received 3 implants at the first operation. A total of 18 implants were installed, including 9 placed into the lateral aspect of the supraorbital rim, 6 into the lateral aspect of the infraorbital rim, 1 into the medial aspect of the supraorbital rim, and 2 into the medial aspect of the infraorbital rim. One superior lateral implant failed half a year after implantation, and an additional implant was implanted into the medial aspect of the inferior medial orbital rim for prostheses retention. All the patients were followed up for more than 2 years. No other failures were observed. The soft tissue reaction was acceptable in all patients. All of them were able to wear prostheses with satisfying appearance.

Osseointegrated implants provid excellent retention for orbital prostheses. This technique could be used in patients with severe orbital deformity to improve their life quality. (Chin J Ophthalmol, 2019, 55: 665-669)

To analyze clinical effects of modified Yokoyama′s surgery combined with medial rectus muscle recession for treatment of high myopic strabismus fixus.

Retrospective analysis of records of 9 patients (14 eyes) with high myopic strabismus fixus treated from February 2013 to December 2016 in the Department of Ophthalmology, Xiangya Hospital, Central South University. All patients underwent modified Yokoyama′s surgery. The temporal 1/2 of the superior rectus (SR) and the superior 1/2 of the lateral rectus (LR) were united 12 to 14 mm, combined with medial rectus muscle recession. The angle of deviation of primary position, the mobility of the affected eye, and the change of CT imaging were observed and analyzed before and 6 months after surgery. Statistical analysis was performed by Mann-Whitney U test.

The patients were 5 females and 4 males with an average age of (60±10) years. The duration of high myopia was (33.33±6.61) years. The refractive power was (-23.32±5.95) D, and the axial length was (33.04±2.63) mm. The recession mount of medial rectus was (7.2±2.1) mm (4.0-10.0 mm) intraoperatively. At 6 months, the median esotropia improved from 130 (80-140) prism diopter (PD) to 0 (0-10) PD, and the hypotropia from 20 (15-25) PD to 0 (0-5) PD. The median abduction limitation decreased from -3 (-4--1) to -1 (-2-0), and the median limitation of elevation decreased from -2 (-4--1) to 0 (-1-0). The angle of esotropia and hypotropia significantly improved (Z=-2.67, -2.70; P=0.008, 0.007), and the restriction of abduction and elevation decreased (Z=-3.35, -3.24; both P=0.001). Only 3 patients′ CT images were enrolled in a comparative study. Preoperative orbital CT scans showed inferior LR displacement and medial SR displacement with the posterior portion of the eyeball to the superotemporal quadrant of the orbit. After surgery, the mean reduction ratio of dislocation degree of the 3 patients was 28.97%, the dislocation of LR and SR was reduced, and the posterior global part was correctly positioned within the orbit.

The modified Yokoyama′s surgery combined with medial rectus muscle recession can effectively correct high myopic strabismus fixus, recover the eyeball anatomical position, and evidently improve eye mobility. The clinical effects are satisfactory. (Chin J Ophthalmol, 2019, 55: 670-676)

To compare the blood flow around the optic disc and related factors in patients with acute and chronic non-arteritic anterior ischemic optic neuropathy (NAION) and healthy volunteers with small disc cups under the same anatomical structure.

This was a prospective case-control study. NAION patients with unilateral onset and healthy volunteers of the same phase were included in the study conducted at the Department of Ophthalmology of Peking Union Medical College Hospital between February 2017 and September 2018. Patients with a course of ≤ 3 months were categorized in the acute phase of NAION, and those with a course of >3 months were in the chronic phase of NAION. Healthy volunteers were in the control group. All subjects underwent the examination of best corrected visual acuity converted to logarithm of the minimum angle of resolution (LogMAR), measurement of non-contact intraocular pressure, slit lamp examination, small pupil fundus examination, and axial measurement. Optical coherence tomography was used to measure the thickness of retinal nerve fiber layers (RNFL) and retinal ganglion cell complex (GCC). Optical coherence tomography angiography was used to measure the vessel density around the optic disc. NAION patients underwent the visual field examination. Analysis of variance, non-parametric Mann-Whitney U test and Spearman coefficient was used for statistical analysis.

This study included 16 patients with acute phase of NAION, aged (57±9) years, 6 males and 10 females. There were 17 patients with chronic disease, aged (56±10) years, 7 males and 10 females. There were 15 healthy controls, aged (57±10) years old, 6 males and 9 females. There were no significant differences in age and gender between the groups (both P>0.05). The RNFL and the GCC in the NAION chronic phase group were significantly thinner than those in the acute phase group [(78±38) μm vs. (191±99) μm, (75±19) μm vs. (98±28) μm; t=4.389, 2.758; both P<0.05]. The cup/disc area ratio, cup/disc vertical diameter ratio and cup/disc horizontal diameter ratio in the chronic phase group were larger than those in the acute phase group [0.18 (0.11, 0.31) vs. 0.05 (0.01, 0.18), 0.45 (0.39, 0.56) vs. 0.22 (0.11, 0.41), 0.39 (0.28, 0.54) vs. 0.20 (0.07, 0.42)], and the difference was statistically significant (U=212.000, 208.000, 205.000; all P<0.05). Compared with the optic disc vessel density in the control group (53%±6%), there was a significant decrease in the acute phase group and the chronic phase group (45%±7%, 41%±8%; t=3.705, 4.940; both P<0.01). The blood vessel density in the nasal inferior of the chronic phase group was significantly lower than that in the acute phase group (36%±8% vs. 42%±7%, P=0.039), other sections didn′t have significant difference (all P>0.05). There were tortuous capillaries in 8/16 of the acute phase cases, with a low blood flow density and visual field defect in relative positions. Correlation analysis showed that the whole density and peripapillary density in the NAION patients were negatively correlated with LogMAR, mean visual field defect, cup/disc area ratio, focal loss of volume of GCC and general loss of volume of GCC (r=-0.510, -0.733, -0.372, -0.532, -0.648; all P<0.01), but positively correlated with GCC and RNFL thickness (r=0.604, 0.508; both P<0.01).

The optic disc vessel density in the acute phase and chronic phase of NAION is significantly reduced. The vessel density in the nasal area of the chronic phase is significantly reduced compared with the acute phase. The vessel density is correlated with visual acuity, visual field defect, disc indexes, thickness of RNFL and GCC. (Chin J Ophthalmol, 2019, 55: 677-686)

To analyze the difference among expression of aqueous humor proteins in acute primary angle-closure glaucoma (APACG).

Case-control study. The patients with APACG combined cataract (APACG with cataract group) and patients with cataract (cataract group), who had undertaken surgical treatment at the Tianjin Medical University Eye Hospital from October 2016 to June2017 were collected. Upon receipt of patient′s consent, 50 μl of aqueous humor were collected with 1 ml syringe and No.1 needle through the surgical access during the surgery, and then injected into a sterile collection tube to be stored at -80 ℃. Those proteins extracted from aqueous humor were analyzed by quantitative proteomic mass spectrometry. The differential significance test was performed by Maxquant significances A approach. The differential proteins of the two groups were screened and determined with the conditions of P<0.05 and difference multiple>2. The functions and signal pathway of differential proteins in aqueous humor were annotated in biological big data, on the basis gene ontology (GO) and the Kyoto gene and genomic encyclopedia (KEGG) analyses.

There were 3 males and 7 females with an average age of (68±6) years in the APACG group. The cataract group included 2 males and 8 females with an average age of (71±8) years. There were no statistical differences in gender ratio and age between the two groups (both P>0.05). A total of 91 differential proteins were detected in this experiment, including 50 up-regulated proteins (annexinA1, vimentin, S100 calcium binding protein A8, interleukin 6, C reactive protein, laminin β2, etc.) and 41 down-regulated (keratin 85, γ-crystallin D, syntaxin-binding protein 5, semaphoring 4B, matrilin 2, cathepsin O, cadherin 4, semaphoring 3B, platelet-derived growth factor D, transforming growth factor β, etc.). On one hand, the functions of differential proteins involved in many aspects. AnnexinA1, CD163, S100 calcium-binding protein A8, C reactive protein, interleukin 6 are involved in the inflammatory reaction, cadherin 4 and laminin β2 regulate cell adhesion, matrilin 2, vimentin and laminin β2 participate in tissue fibrosis; on the other hand, KEGG analysis showed that the differential proteins participate diverse signaling pathways such as phosphatidylinositol-3-kinase-protein kinase B signaling pathway, transformation growth factor β signaling pathway, mitogen activated protein kinase signaling pathway, Toll-like receptor signaling pathway, the nuclear factor κ-light chain enhancer of the activated B cells signaling pathway, focal adhension and extracellular matrix receptor interaction pathway and so on.

The expression of annexin A1 is significantly up-regulated in the aqueous humor in APACG, while some other factors such as transformation growth factor β, cadherin-4, and matrilin 2 are down-regulated. The change of proteins in aqueous humor is related with the outbreak of APACG. (Chin J Ophthalmol, 2019, 55: 687-694)

To study the imaging characteristics and accumulate data of optical coherence tomography (OCT) of the lacrimal punctum in normal adults.

From September to November 2018, 59 healthy adults (90 eyes) with normal lacrimal punctum structure were enrolled in this cross-sectional study conducted at the Lacrimal Center of Ophthalmology, Third Medical Center of PLA General Hospital, including 21 males (34 eyes) and 38 females (56 eyes), aged 18-65 years. All the subjects were examined by slit lamp microscopy to measure the maximum transverse diameter. OCT was performed to observe the inferior lacrimal punctum, including the external punctal diameter, the punctal diameter at 100 μm and 200 μm depth. The difference in the diameter of different parts of the punctum was analyzed. Independent sample t test and single factor analysis of variance were used for statistical analysis.

In normal adults, the maximum transverse diameter under a slit lamp was (545.6±149.3) μm, the external punctal diameter on OCT images was (548.4±130.5) μm, and the punctal width at 100 μm and 200 μm depth on OCT images was (262.8±120.8) μm and (179.2±110.0) μm, respectively. There was no significant difference between the maximum transverse diameter of the punctum under a slit lamp microscope and the OCT outer diameter of the punctum ( t=0.133, P=0.894). There were significant differences between the diameter of the lacrimal punctum in the different scanning sites of the OCT (F=213.237, P<0.01). There was significant difference between the punctal width at 100 μm and the external punctal diameter on OCT images ( t=15.229, P<0.01). There was significant difference between the punctal width at 200 μm and the external punctal diameter on OCT images ( t=20.517, P<0.01). There was significant difference between the punctal width at 100 μm and 200 μm depth on OCT images ( t=4.855, P<0.01).

The width of different parts of the lacrimal punctum in healthy adults is different on OCT images, and the punctal width at 200 μm depth is the narrowest. (Chin J Ophthalmol, 2019, 55: 695-699)

An elderly male patient with a complaint of left eye disappearance for 10 days after trauma was consulted to the ophthalmology department. CT examination showed that the left eyeball was dislocated in the left ethmoid sinus, and the diagnosis was left eyeball dislocation. Three months after left eyeball reduction, the visual acuity of the patient's left eye recovered from no light perception to 0.05.(Chinese Journal of Ophthalmology, 2019, 55:700-702)

A patient with double vision after height fall injury 1.5 months ago went to the ophthalmology department. After ophthalmology and brain CT examination, he was clinically diagnosed with traumatic abducens nerve paralysis of left eye. The conservative treatment effect was not good. Three-dimensional steady-state acquisition and rapid imaging of skull base thin-slice MRI showed that the abducens nerve of left eye avulsed from the brainstem, and the final diagnosis was traumatic abducens nerve avulsion of left eye and abducens nerve paralysis of left eye. Seven months later, left eye strabismus correction was performed. After operation, left eye could rotate slightly left and right, and there was no obvious diplopia in all directions.(Chinese Journal of Ophthalmology, 2019, 55:703-704)

Two patients with visual acuity loss after binocular bagectomy went to the ophthalmology department. Both patients had severe eye pain and visual acuity loss due to intraorbital hemorrhage after bagectomy. Although they received glucocorticoid shock therapy and nutritional neurotherapy, they still caused compressive optic neuropathy in the end.(Chinese Journal of Ophthalmology, 2019, 55:705-706)

One patient with a complaint of sudden loss of visual acuity in the left eye for 2 weeks was seen in the ophthalmology department. 15 years after previous trabeculectomy in both eyes and 2 years after cataract surgery in both eyes. Ocular examination showed shallow anterior chamber of left eye, low intraocular pressure, Seidel test of filtration vesicles (-), iris adhesion, and capsular pouch shrinkage; Ultrasound biomicroscopy revealed full peripheral detachment of the ciliary body in the left eye. The diagnoses were left eye ciliary body detachment, intraocular lens eye in both eyes, postoperative anti-glaucoma in both eyes, and hypertension. After conservative treatment with local hormones and cycloplegic agents for more than 4 months, the ciliary body detachment space gradually narrowed, but it still did not recover completely. The ciliary body detachment completely disappeared 2 weeks after the anterior capsule incision under neodymium-doped yttrium aluminum garnet laser.(Chinese Journal of Ophthalmology, 2019, 55:707-709)

A patient with a complaint of decreased visual acuity in both eyes for half a year was seen in the ophthalmology department. Eight months ago, the patient had been diagnosed with viral meningoencephalitis in an outside hospital. After ocular examination and Goldmann-Witmer coefficient examination of vitreous humor, viral meningoencephalitis caused by herpes zoster virus was diagnosed with acute retinal necrosis in both eyes.(Chinese Journal of Ophthalmology, 2019, 55:710-712)

Yan Hua, MD, chief physician, professor, doctoral supervisor. Deputy Secretary of the Party Committee and President of Tianjin Medical University, leader of ophthalmology. Member of Ophthalmology Branch of Chinese Medical Association and Head of Ocular Trauma Group, Expert Member of Ophthalmology Branch of Chinese Medical Association, Chairman of Ocular Trauma Professional Committee of Ophthalmologist Branch of Chinese Medical Doctors Association, Chairman of Visual Disability Rehabilitation Professional Committee of China Rehabilitation Association for the Disabled, and Vice Chairman of Asia-Pacific Ocular Trauma Society.

The patient was a 44-year-old male. Chest pain accompanied by visual loss for 3 d after chest trauma caused by car accident, was seen in the Department of Ophthalmology of the First Hospital of Jilin University. General physical examination: anterior chest tenderness (+), coarse respiratory sound on both sides of auscultation, heavy on the right side; CT of the lungs: pleural effusion. Eye examination: the visual acuity was 1.0 in the right eye and the anterior index in the left eye, which was not improved by correction; IOP was 15 mmHg (1 mmHg =0.133 kPa) in the right eye and 17 mmHg in the left eye; The eyelids of both eyes were not congested, slightly swollen, and the eye movement was normal; No obvious abnormalities were found in the examination of the anterior segment and fundus of the right eye; The conjunctiva of the left eye is not congested, the cornea is transparent, the pupil is round, about 3 mm in diameter, and the light response is slow, and the lens is transparent; The fundus examination of the left eye is shown inQuintessence Picture 1Middle A; Fluorescein fundus angiography examination is shown inQuintessence Picture 1Middle B. Clinical diagnosis: chest trauma; Pleural effusion; Distal retinopathy of the left eye.

Graft rejection and endothelial cell loss were believed to be the main reasons for graft edema following keratoplasty. With the application of various molecular biological detection methods in ophthalmology, virus infection has emerged and become an important contributing factor for graft failure. This review focused on the etiology, clinical manifestation and diagnosis methods for virus infection following keratoplasty, and discussed possible prevention and treatment.(Chin J Ophthalmol, 2019, 55: 713-716)

In recent years, with the increasing number of patients with sports-related ocular trauma, the disease has also received increasing clinical attention. It is estimated that there are about 600,000 sports-related eye injuries worldwide every year, and about 13,500 people will permanently lose their vision. Common eye injuries include corneal abrasion, hyphema, vitreous hemorrhage, retinal detachment, eyeball rupture, and orbital fracture. With adequate protection during exercise, about 90% of sports-related eye injuries can be prevented. Therefore, this paper summarizes and analyzes the status quo, characteristics, injury types and preventive measures of sports-related ocular trauma, so as to provide help for the prevention and treatment of this disease.(Chinese Journal of Ophthalmology, 2019, 55:717-720)