Volume 59 · Issue 07 · 2023

Pupil abnormalities may be physiological, pathological or pharmacological. It can indicate the underlying disease of the visual afferent system or visual efferent system. Examination of the pupils is therefore a part of eye examination. Insufficient knowledge and inconsistent methods in the pupillary examination by some ophthalmologists lead to mistakes or unreliable results, hampering the disease diagnosis and clinical assessment. This article emphasizes the significance of pupillary examination outcomes, advocates for standardized examination methods, and highlights the need to enhance the awareness of pupillary abnormalities, aiming to provide a guide on how to recognize and interpret the clinical implications of pupillary abnormalities, and to offer valuable insights for clinical practice.

Blepharoptosis in children is one of the common pediatric eye diseases. It is not only a matter of aesthetics, but also affects visual and psychological development. How to choose the right time to operate has been controversial in clinical practice. Based on the domestic and foreign research progress and clinical experience, we propose that factors, such as the etiology of blepharoptosis, visual and psychological development characteristics of children, developmental characteristics of eyelid-related muscles, and types of blepharoptosis, should be considered for selection of the timing of surgery in a personalized and standardized manner, so as to provide reference and guidance for the clinical diagnosis and treatment of blepharoptosis in children.

Vogt-Koyanagi-Harada (VKH) syndrome is an autoimmune disorder characterized by bilateral granulomatous uveitis, and it is one of the common uveitis entities causing blindness in China. The clinical manifestations of VKH disease vary significantly at different stages. Most patients can achieve a complete control of the uveitis and good visual prognosis if appropriate treatment is initiated. Therefore, an extensive investigation and literature review on this disease have been performed by the experts in the Uveitis and Ocular Immunology Group of Chinese Ophthalmologist Association and the Ocular Immunology Group of Ophthalmology Society of Chinese Medical Association. Consensus opinions on VKH syndrome have been developed in an attempt to provide general guidance and reference in the diagnosis and treatment of this disease.

To investigate the characteristics of spontaneous brain activity in children with congenital cortical cataract amblyopia.

A cross-sectional study was conducted. Twenty cases of unilateral congenital cortical cataract amblyopia (unilateral amblyopia group) and 14 cases of bilateral congenital cortical cataract amblyopia (bilateral amblyopia group) were enrolled from January 2022 to December 2022 at the First Affiliated Hospital of Zhengzhou University. Seventeen age and gender matched children with normal visual acuity were recruited as the healthy control group. Resting-state functional MRI (fMRI) was performed on all participants, and the amplitude of low-frequency fluctuations (ALFF) technique was used to analyze their spontaneous brain activities. The original ALFF value of each voxel was divided by the average ALFF value of the whole brain to obtain the standardized ALFF value (referred to as ALFF value), which reflected the intensity of spontaneous brain activity in different brain regions. General demographic data were compared using one-way analysis of variance, Kruskal-Wallis test, and chi-square test. Comparison of ALFF values was conducted using one-way analysis of variance.

There were no significant differences in age, gender, distribution of amblyopic eye or non-dominant eye, and degree of refractive error among the three groups (all P>0.05). Compared to the healthy control group, the unilateral amblyopia group showed higher ALFF values in the right posterior lobe of the cerebellum (67 voxels, t=3.48) and left posterior lobe of the cerebellum (71 voxels, t=4.09), and lower ALFF values in the right postcentral gyrus (91 voxels, t=-3.91), right inferior parietal lobule (73 voxels, t=-4.88), right inferior frontal gyrus (78 voxels, t=-4.09), left inferior parietal lobule (556 voxels, t=-4.82), and left inferior frontal gyrus (122 voxels, t=-4.27) (all P<0.01). The bilateral amblyopia group showed higher ALFF values in the right insula (60 voxels, t=3.54), right Rolandic operculum (69 voxels, t=3.73), right posterior lobe of the cerebellum (54 voxels, t=3.43), and left posterior lobe of the cerebellum (143 voxels, t=3.69), and lower ALFF values in the left inferior frontal gyrus (99 voxels, t=-4.39), left postcentral gyrus (231 voxels, t=-4.28), and right inferior parietal lobule (54 voxels, t=-3.77) (all P<0.01). Compared to the unilateral amblyopia group, the bilateral amblyopia group showed higher ALFF values in the left middle frontal gyrus (52 voxels, t=3.15, P=0.029), left posterior lobe of the cerebellum (77 voxels, t=3.39, P=0.001), and right Rolandic operculum (53 voxels, t=3.59, P=0.007).

Children with congenital cortical cataract amblyopia exhibit altered spontaneous brain activity in multiple brain regions, and there are differences in spontaneous brain activity changes between unilateral and bilateral amblyopia.

To investigate the characteristics of Guyton′s exaggerated forced duction test (FDT) and torsional FDT in patients with congenital superior oblique palsy (CSOP) and their correlation with clinical features.

This cross-sectional study included single-eye CSOP patients and intermittent exotropia (IXT) patients scheduled for strabismus correction surgery at Tianjin Eye Hospital from September 2021 to March 2022. Prior to surgery, measurements of fovea-disc angle (FDA) and maximum cross-sectional area of the superior oblique muscle (max-CSA) were obtained in both eyes of the patients. The Guyton′s exaggerated FDT and torsional FDT were performed intraoperatively to assess the degree of superior oblique muscle relaxation. The characteristics of the two FDT tests and their correlation with vertical strabismus angle, FDA, and max-CSA were analyzed. Statistical analyses were conducted using t-test, ANOVA, Tukey′s test, Mann-Whitney U test, and chi-square test.

A total of 42 patients (84 eyes) were included in the study, including 19 IXT patients (38 eyes) and 23 CSOP patients (46 eyes, 23 eyes with palsy and 23 eyes without palsy). There were no statistically significant differences in gender composition or age between the IXT and CSOP patients (all P>0.05). The degrees of superior oblique muscle relaxation measured by the Guyton′s exaggerated FDT were (-2.52±1.20), (-0.35±0.71), and (-0.03±0.16) for the palsy eye, non-palsy eye, and IXT eyes, respectively, showing significant differences (F=88.10, P<0.001). The torsional FDT measurements yielded external rotation angles of 48.70°±9.67°, 37.39°±5.40°, and 38.95°±2.88° for the palsy eye, non-palsy eye, and IXT eyes, respectively, showing significant differences (F=16.67, P<0.001). There was no statistically significant difference in internal rotation angles (F=2.36, P=0.100). The FDA values were-12.11°±7.42° for IXT patients and-19.02°±4.95° for CSOP patients, while the max-CSA values for the palsy eye and non-palsy eye of CSOP patients were (7.59±4.69) mm² and (11.63±3.64) mm², respectively, all showing significant differences (all P<0.001). The degree of superior oblique muscle tendon relaxation assessed by the Guyton′s exaggerated FDT was negatively correlated with the external rotation angle measured by the torsional FDT (r=-0.64, P=0.001). They were positively correlated with max-CSA (r=0.45, P=0.030) and negatively correlated with max-CSA (r=-0.52, P=0.011). However, there was no correlation with vertical and rotational strabismus angle (r=-0.12, P=0.579; r=0.33, P=0.126) and FDA (r=-0.02, P=0.921; r=-0.23, P=0.309).

Guyton′s exaggerated FDT and torsional FDT can both assess the degree of superior oblique muscle relaxation in patients with CSOP. Furthermore, these two tests are correlated with changes in superior oblique muscle morphology. However, FDT cannot reflect the degree of vertical and rotational strabismus in patients.

To investigate the clinical effects of the bow-tie adjustable suture technique in managing overcorrection in patients with intermittent exotropia after surgery.

This was a retrospective case series study. Clinical data were collected from children with intermittent exotropia who underwent strabismus correction surgery, including the bow-tie adjustable suture technique and conventional techniques, at the Department of Strabismus and Pediatric Ophthalmology, Shanxi Eye Hospital, from January 2020 to September 2021. Children with postoperative esodeviation≥15 prism diopters (PD) within the first 6 days were treated differently based on the surgical technique and their individual conditions, including suture adjustment and conservative treatment. The overcorrection rate and its changes among different surgical groups, the recovery of ocular alignment and binocular visual function after different treatment methods in children with overcorrection on the sixth postoperative day, and the postoperative complications in different surgical groups were observed. Statistical analysis was performed using independent samples t-test, Wilcoxon rank-sum test, repeated-measures analysis of variance, Bonferroni test, chi-square test, or Fisher′s exact probability test, as appropriate.

A total of 643 children who underwent intermittent exotropia correction surgery were included in the study. Among them, 325 children underwent the bow-tie adjustable suture technique, with 185 males and 140 females, and the mean age was (9.50±2.69) years. The remaining 318 children underwent conventional techniques, with 176 males and 142 females, and the mean age was (9.90±2.67) years. There were no statistically significant differences in age and gender distribution between the two surgical groups (all P>0.05). On the first postoperative day, among children who underwent the bow-tie adjustable suture technique, 40 had an esodeviation of≥10 PD, resulting in an overcorrection rate of 12.3% (40/325), while among children who underwent conventional techniques, 32 had an esodeviation of≥10 PD, resulting in an overcorrection rate of 10.1% (32/318). On the sixth postoperative day, these rates decreased to 5.5% (18/325) and 3.1% (10/318) in the two groups, respectively. At 1, 6, and 12 months postoperatively, the overcorrection rate in children who underwent the bow-tie adjustable suture technique was 0, while in children who underwent conventional techniques, the overcorrection rate did not show a significant decrease compared to before surgery. The differences between the two surgical groups were statistically significant (all P<0.05). On the sixth postoperative day, among children with an esodeviation of≥15 PD, 13 underwent suture adjustment and 7 received conservative treatment. The results of repeated-measures analysis of variance showed statistically significant differences in near and distance esodeviation angles among children who received different treatment methods (F=145.20, 106.87, both P<0.001), as well as statistically significant differences in near and distance esodeviation angles at different time points within each group of children (F=81.67, 35.09, both P<0.001). There were also significant differences in the trends of change in near and distance esodeviation angles at different time points among children who received different treatment methods (F=79.90, 36.73, both P<0.001). Further pairwise comparisons showed significant differences in near and distance esodeviation angles between the sixth postoperative day and 1, 6, and 12 months postoperatively in children who underwent suture adjustment (all P<0.05), while no statistically significant differences were observed in children who received conservative treatment (all P>0.05). At 12 months postoperatively, among the 13 children who underwent suture adjustment, 12 achieved stereopsis, while among the 7 children who received conservative treatment, all became stereo-blind after removing the prismatic correction. No serious complications occurred in any of the children postoperatively.

The proportion of children with intermittent exotropia who achieved orthotropic alignment one year after surgery was relatively low among those who had an overcorrection of≥15 PD on the sixth postoperative day. The bow-tie adjustable suture technique is a simple and effective approach for managing overcorrection in patients with intermittent exotropia. Adjusting the sutures on the sixth postoperative day can reduce the overcorrection rate and is considered a safe and effective method.

To measure the peripapillary retinal nerve fiber layer (RNFL) cross-sectional area in individuals aged 50 years and above with different refractive errors, and analyze its correlation with axial length and refractive error.

This was a cross-sectional study conducted as part of the "Beijing Eye Study". The study was population-based and longitudinally designed. In 2001, a cohort of individuals aged 40 years and above from five urban communities in Haidian District and three rural communities in Daxing District, Beijing, were surveyed. Follow-up examinations were conducted in 2011. In this study, the follow-up data from 2011 were collected and analyzed. One eye of each participant was randomly selected, and the participants were categorized into four groups based on their spherical equivalent: emmetropia group (-0.50 D≤spherical equivalent≤0.50 D), low myopia group (-3.00 D≤spherical equivalent<-0.50 D), moderate myopia group (-6.00 D≤spherical equivalent<-3.00 D), and high myopia group (spherical equivalent<-6.00 D). Spectral-domain optical coherence tomography (OCT) was used to perform circular scans with a diameter of 12° centered on the optic disc. ImageJ software and Heidelberg Eye Explorer software were used to calculate the RNFL cross-sectional area. One-way analysis of variance was used to compare the differences in RNFL thickness and RNFL cross-sectional area among different groups. Linear regression analysis was performed to analyze the correlation between RNFL thickness and axial length and spherical equivalent, as well as the correlation between RNFL cross-sectional area and axial length and spherical equivalent.

A total of 184 participants (184 eyes) were included in the study, including 88 males and 96 females. The median age was 59 (54, 66) years, with 87 right eyes and 97 left eyes. There were 50 participants (50 eyes) in the emmetropia group, low myopia group, and moderate myopia group, and 34 participants (34 eyes) in the high myopia group. There were no significant differences in age, gender, and eye laterality among the groups (all P>0.05). The RNFL cross-sectional areas in the emmetropia, low myopia, moderate myopia, and high myopia groups were (1.115±0.106), (1.122±0.136), (1.105±0.105), and (1.096±0.106) mm², respectively, with no significant differences observed (F=0.43, P=0.730). The RNFL thickness in the emmetropia, low myopia, moderate myopia, and high myopia groups were (102.5±9.5), (102.5±12.1), (94.2±8.3), and (90.2±8.9) μm, respectively, with a significant difference observed (F=16.42, P<0.001). Univariate linear regression analysis was performed with spherical equivalent as the independent variable and peripapillary RNFL thickness as the dependent variable, yielding the regression equation: peripapillary RNFL thickness=102.651+1.634 × spherical equivalent (R²=0.21, P<0.001). Similarly, when axial length was used as the independent variable and peripapillary RNFL thickness as the dependent variable, the regression equation was: peripapillary RNFL thickness=174.161-3.147 × axial length (R²=0.18, P<0.001). There was no significant correlation between RNFL cross-sectional area and spherical equivalent (P=0.065) or axial length (P=0.846).

There were no significant differences in peripapillary RNFL cross-sectional area among individuals aged 50 years and above with different axial lengths or refractive errors.

To investigate the multimodal imaging characteristics of acute macular retinopathy (AMR) and/or parafoveal acute middle maculopathy (PAMM) in patients with coronavirus disease 2019 (COVID-19).

It was a cross-sectional study. Eight patients (15 eyes) diagnosed with AMN and/or PAMM, who presented for their initial visit at Kaifeng Eye Hospital between December 17 and December 31, 2022 and were also confirmed positive for COVID-19, were enrolled as the observation group. The patients were classified into four types based on swept-source optical coherence tomography (SS-OCT) findings. Fifteen healthy volunteers (15 eyes) without ocular or systemic diseases were recruited as the healthy control group, and one eye was randomly selected for analysis. All participants underwent detailed ophthalmic examinations, including best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, fundus photography (FP), intraocular pressure measurement, fundus infrared imaging, OCT and OCT angiography (OCTA). The foveal avascular zone (FAZ) area of the macular center was measured. General information and multimodal imaging findings were collected and analyzed. The superficial capillary plexus vessel density (SCP-VD) and deep capillary plexus vessel density (DCP-VD) were measured in circular areas with diameters of 1.0 mm, >1.0 mm and ≤3.0 mm, and>3.0 mm and ≤6.0 mm centered on the foveal center, recorded as SCP-VD1.0, 3.0, 6.0 and DCP-VD1.0, 3.0, 6.0. Statistical analyses were performed using t-tests, Mann-Whitney U tests, and chi-square tests.

The observation group consisted of 6 males (11 eyes) and 2 females (4 eyes) with a mean age of (26.87±11.56) years. The healthy control group included 11 males (11 eyes) and 4 females (4 eyes) with a mean age of (28.75±12.30) years. There were no statistically significant differences in age and gender distribution between the two groups (all P>0.05). All patients in the observation group experienced high fever (≥39.0 ℃) and developed ocular symptoms during the febrile period or within 24 hours after fever resolution. Among all patients, there were 5 cases (7 eyes) of Type Ⅰ, 1 case (1 eye) of Type Ⅱ, 3 cases (4 eyes) of Type Ⅲ, and 2 cases (3 eyes) of Type Ⅳ. In Type Ⅲ and Ⅳ, 3 cases (4 eyes) exhibited weakly reflective cystic spaces in the outer plexiform or outer nuclear layers, and fundus photography revealed multiple gray or reddish-brown lesions in the macular region. One case (1 eye) showed retinal superficial hemorrhage. Cotton wool spots were observed in 2 cases (4 eyes). Fundus infrared imaging showed that Type Ⅰ manifested as weak reflectivity lesions in the parafoveal central zone, with the tip pointing towards the fovea. Type Ⅱ showed no apparent abnormalities in the macular region, while Type Ⅲ and Ⅳ displayed map-like weak reflective lesions spanning the foveal center. OCTA findings demonstrated that SCP-VD1.0 in the observation group was 6.93% (4.77%, 6.93%), significantly lower than the healthy control group′s 10.66% (8.05%, 10.55%) (U=174.00, P=0.016). SCP-VD3.0 in the observation group was 37.14% (32.15%, 43.48%), also lower than the healthy control group′s 43.06% (38.95%, 46.55%) (U=174.00, P=0.016). DCP-VD3.0 in the observation group was 48.20% (46.11%, 50.33%), lower than the healthy control group′s 51.10% (50.04%, 53.02%) (U=188.00, P=0.009). DCP-VD6.0 in the observation group was 49.27% (47.26%, 51.67%), lower than the healthy control group′s 52.43% (50.07%, 53.82%) (U=70.00, P=0.004). There were no significant differences in SCP-VD6.0 and DCP-VD1.0 between the two groups (both P>0.05).

Acute macular retinopathy in patients with COVID-19 can involve all retinal layers and present as segmental hyper-reflectivity on SS-OCT. Fundus infrared imaging reveals weak reflectivity in the affected area, fundus photography shows multiple gray or reddish-brown lesions in the macular region, and OCTA demonstrates a decrease in SCP-VD and DCP-VD.

The patient is a 40-year-old male who presented to the ophthalmology clinic due to easy visual fatigue for the past 3 months. Two months ago, the patient was misdiagnosed with "bilateral posterior uveitis", but the diagnosis was ruled out after ineffective treatment with corticosteroids. During the current visit, fundus examination revealed yellow-white material exudation below the macular center in both eyes. Considering the results of the ophthalmic examination and the genetic testing of the patient and his son, the patient was diagnosed with autosomal recessive bestrophinopathy.

A 32-year-old female patient presented with bilateral vision loss for 2 months following her intake of various antiparasitic drugs, including closantel, a veterinary drug, for a self-perceived intraocular parasitic infection. Swept-source optical coherence tomography revealed diffuse hyperreflectivity between the outer nuclear layer and the retinal pigment epithelium, as well as the largely indistinguishable outer retinal layers. This case was clinically diagnosed with veterinary closantel-induced toxic retinopathy and had a poor visual prognosis after nerve nutrition and circulation improvement therapy due to the long duration of the disease.

The patient was a 27-year-old female. Because of the inward deviation of his eyes for 15 years, he went to Shenzhen Aier Eye Hospital. He suffered from ocular and cutaneous albinism since childhood, his parents were not close relatives, and there were no other albinism patients in his family. Full body examination: The whole body skin is white, the hair color is light yellow, and the eyebrows and eyelashes are white. Eye examination: Right eye naked visual acuity was 0.04 and corrected visual acuity was 0.05 (-15.00 DS-4.00 DC ×5°); The left eye was 0.04 for the naked eye and the corrected visual acuity was 0.05 (-15.00 DS-4.00 DC x 175°); IOP was 18 mmHg (1 mmHg =0.133 kPa) in the right eye and 19 mmHg in the left eye; The axial length was 30.44 mm for the right eye and 30.53 mm for the left eye; The degree of strabismus>+45° was examined by 33 cm corneal photometry, and the level of eyeball tremor in both eyes was observed; See Quintessence Picture 1 for the anterior segment of both eyes; See Quintessence Pictures 2 and 3 for both fundus. Clinical diagnosis: common esotropia; Nystagmus in both eyes; Refractive error in both eyes; Oculocutaneous albinism.

In addition to the abnormalities of the extraocular muscles themselves and the nervous system innervating the extraocular muscles, the tissue pulley abnormalities around the extraocular muscles may lead to the occurrence of strabismus. In recent years, researchers have shown the intramuscular nerve distribution of the extraocular muscles using the Sihler technique. With the continuous progress of imaging technology, magnetic resonance imaging, computed tomography, anterior segment optical coherence tomography and ultrasound biomicroscopy can be used to observe the attachment sites of the extraocular muscles. This review summarizes the latest research progress on the neuroanatomy of the extraocular muscles, in order to provide reference for the clinical diagnosis and treatment of strabismus.

Comitant strabismus is a common type of strabismus, the etiology and pathogenesis of which remain unclear. It is currently believed to be associated with various factors, including anatomy, refractive errors, accommodation, genetics, and neural factors. In recent years, with the improvement of MRI technology and analysis methods, multidimensional presentations of structural and functional changes in different brain regions related to comitant strabismus have been achieved. Undoubtedly, the application of MRI has the potential to contribute to the etiology of strabismus, particularly the study of central mechanisms. This review article summarizes the research progress on cranial MRI in comitant strabismus, with a focus on summarizing the changes and patterns in brain structures, functions, and interconnections in patients with comitant strabismus reported in previous studies. The aim is to provide new insights into the etiology and pathogenesis of comitant strabismus.

The development of ocular organoids, which closely mimic the tissue structure and functionality of the human eye, has emerged as a prominent area of research in the field of ophthalmology. These organoids serve as valuable models for investigating the mechanisms and interventions of eye-related diseases. However, the establishment of in vitro models that accurately represent the tissue structure and functionality of the human eye has long been a challenge in ophthalmic research. Numerous efforts have been made to enhance the fidelity of ocular organoid models, aiming to improve their suitability for studying disease pathogenesis and drug efficacy. With advancements in technology, it has become possible to construct individual components of the eye, such as the cornea and retina, in vitro. This review summarizes the recent advancements in ocular organoid research, with a focus on corneal and retinal organoids.

Inferior oblique muscle weakening surgery is the most common type of extraocular muscle surgery. It contains a variety of surgical procedures and each has its own characteristics. After many years of development, it is still being improved. This paper reviews and summarizes the development of different surgical procedures for lower oblique muscle weakening, including lower oblique muscle amputation and partial resection, inferior oblique muscle retrogression, inferior oblique muscle anterior transposition, inferior oblique muscle weakening surgery through the nasal side of inferior rectus muscle, inferior oblique muscle radical denervation, and inferior oblique muscle weakening surgery without inferior oblique muscle amputation, so as to provide reference for accurately grasping the indications and operation specifications of various surgical procedures in clinical work, avoiding possible complications and obtaining satisfactory surgical results.

This issue focuses on the research progress of strabismus and pediatric ophthalmology. The responsible editorial committee responsible for the planning, composition and review of this issue is Professor Zhang Wei.