Abstract:AIM:To describe and evaluate a new ophthalmic endoscope surgical technique combined with phacoemulsification andintraocular lens (IOL) implantation to treat goniosynechialysis and manage primary angle-closure glaucoma (PACG).METHODS:Endoscope-assisted goniosynechialysis combined with phacoemulsification andIOL implantation was performed in 32 eyes of 29 patients with PACG. Regular follow-up was performed 1 week and 1 month, 3, and 6 months after surgery to assess complications, intraocular pressure (IOP), anterior chamber depth, visual acuity, and anterior chamber angle.RESULTS:Preoperative mean IOP was 24.88±7.22mmHg with pharmacological treatment, and was 13.70±4.02, 13.06±3.74, 14.29±4.70, and 14.33±5.01mmHg 1 week, 1 month, 3 months, and 6 months after surgery, respectively. The postoperative decrease in IOP was significant (P<0.05). The rate for all eyes with IOP of 21mmHg or less was 93.8% (30 eyes) at the final visit without ocular hypotensive agents. The average preoperative anterior chamber depth was 1.60±0.64mm, and this value significantly increased to 2.72±0.62, 2.76±0.70, 2.73±0.68, and 2.74±0.71mm at 1 week, 1 month, 3 months, and 6 months, respectively. Visual acuity was improved in 28 eyes (87.5%) at 6 months postoperatively. The anterior chamber angle had increased in 25 eyes (78.1%) at the final visit; it was adhesive 90°-180° in 6 eyes, 180°-270° in only 1 eye. Two eyes exhibited minimal hyphema in the early postoperative period, but it could gradually be absorbed. Fibrinous reaction was observed in five eyes and spontaneously disappeared within 7 days. No shallow anterior chamber, iridodialysis, choroidal detachment, or malignant glaucoma was found in any eyes.CONCLUSION:Endoscope-assisted goniosynechialysis combined with phacoemulsification and IOL implantation to manage PACG has several advantages, including optimized visualization, greater accuracy, and improved safety. Our results suggest that it has certain curative effects and clinical application value.

Abstract:AIM: To record aberrations with a corneal topographic device on the anterior surface of the cornea at different time-points prior to wearing and following discontinued use of rigid gas permeable (RGP) contact lenses. The effect of wearing RGP on the anterior surface of the cornea was discussed to provide guidance for clinical refractive error correction.METHODS: The study objects were 24 eyes from 24 patients. All patients underwent identical examination procedures prior to lens use, as well as afterwards, including slit-lamp examination, non-contact tonometer measurement, computer optometry and corneal curvature measurement, subjective refraction test, and corneal topography analysis. The patients wore contact lenses everyday for 1 month and then discontinued. Corneal topographies were recorded at certain time points of 30 minutes, 1 day, 3, 7 and 14 days following use.RESULTS: Total corneal aberration at each time point following discontinued use of RGP contact lenses was less than the time point prior to use. Detailed results were as follows:root mean square (RMS) (pre)=(1.438±0.328)μm, RMS (30 minutes)=(1.076±0.355)μm, RMS (1 day)=(1.362±0.402)μm, RMS (3 days)=(1.373±0.398)μm, RMS (7 days)=(1.387±0.415)μm, and RMS (14 days)=(1.430±0.423)μm. Results showed that at 30 minutes after discontinued use of RGP contact lenses, almost all 2^nd- and 3^rd-order aberrations change. Quadrafoil Z10 and spherical Z12 of the 4^th-order were also changed. Alterations to Z5, Z6, and Z12 at 1 day after discontinued use were significant differences compared with the time period prior to RGP use:Z5 and Z6 decreased, and Z12 increased slightly. Z5 and Z6 remained decreased at 3 days after discontinued use, but Z9 and Z10 continued to increase and Z12 returned to levels prior to RGP use. At 14 days after discontinued use, all aberrations were not significantly different from the values prior to use.CONCLUSION: The use RGP contact lenses greatly reduced total aberration of the anterior surface of the cornea. Changes to 2^nd- and 3^rd-order aberrations (including Z3, Z4, Z5, Z6, Z7, and Z8) were more significant. Following discontinued use of RGP contact lenses, the majority of lower order aberrations returned to original levels in a short period of time. During this process, a transient higher order aberration appeared, but all changes disappeared within 14 days after discontinued use of RGP contact lenses.

Abstract:AIM: To evaluate the long-term outcome of implantation of black diaphragm intraocular (BDI) lens combined with penetrating keratoplasty (PKP) for managing aphakic eyes with traumatic aniridia and corneal damage.METHODS: Six aphakic eyes of six patients with traumatic aniridia and corneal damage had BDI lens implantation at Qingdao Eye Hospital, Shandong Eye Institute from June 2008 to November 2011. Medical records of the patients were reviewed. Three patients received PKP and after 12-18months were implanted with BDI lens. The other three patients completed PKP and BDI lens implantation at the same time. The corrected visual acuity, intraocular pressure and number of corneal endothelial cells were monitored.RESULTS: The patients were followed up for an average of 24.3±12.1months (range 14-48 months). All BDI lenses were located well. The best corrected visual acuity got improved in 5 patients (0.1-1.0) and decreased in 1 patient from 0.4 to 0.2. Three patients had normal intraocular pressure (IOP) after implantation. Two patients required antiglaucoma medications to control IOP within the normal range and 1 patient implanted Ahmed glaucoma valve to control IOP. The corneal grafts kept transparent in all eyes and the corneal endothelial counting >1 000/mm², although two patients experienced acute graft rejection and loss more than 30% corneal endothelial cells.CONCLUSION: Implantation of BDI lens combined with PKP is an effective option for managing aphakic eyes with traumatic aniridia and corneal damage. Although the results in our study are encouraging, additional studies of the long-term safety and efficacy are required. A larger study population and longer follow-up may be beneficial.

Abstract:AIM: To compare the effects and complications of direct cyclopexy (DC) versus vitrectomy, endophotocoagulation, and gas/silicone oil endotamponade (VEE) treatment in patients with cyclodialysis and persistent hypotony.METHODS: This is a prospective, comparative, nonrandomized clinical trial which includes 52 patients with cyclodialysis and persisting hypotony. Fifty-two patients suffering from cyclodialysis and persistent hypotony in one eye were divided into 2 groups (groups DC and VEE) and treated, respectively, with direct cyclopexy or vitrectomy, endophotocoagulation, and gas/silicone oil endotamponade. The patients were followed up for 12 months. Assessments included best corrected visual acuity (BCVA), intraocular pressure (IOP), anterior chamber depth (ACD), anterior chamber volume (ACV) and subjective rating of the pain caused by the treatments.RESULTS:After a follow-up of 12 months, significant improvement was seen in postoperative mean BCVA, IOP, ACD and ACV in both treatment groups (which were not significantly different from each other). The success rates for the treatments were not significantly different (DC:50.0% vs VEE:62.5%, P=0.383). Postoperative morbidity of cataract and subjective pain rating were significantly higher in the VEE group vs the DC group (P= 0.003 and P<0.001 respectively).CONCLUSION: DC and VEE were effective surgical procedures in treating patients with cyclodialysis and persistent hypotony. Patients had better tolerance to DC treatment and VEE was more likely lead to cataract complications. Taking into consideration the ease of the operation, success rate, and patient comfort, DC treatment seems preferable to VEE treatment in patients with simple cyclodialysis. While VEE has the advantage of treating patients with cyclodialysis combined with vitreous hemorrhage.

Abstract:AIM:To report a procedure and results of a two-stage operation to manage intractable extensive orbital implant exposure with a large conjunctival defect which was difficult to treat with dermis fat grafts due to repeated graft necrosis.METHODS:A retrospective chart review of four patients who had extensive orbital implant exposures with large conjunctival defects and had past histories of repeated autologous or preserved dermis graft failures was done. As a first-stage operation, the problematic pre-existing orbital implants were removed and autologous dermis fat grafts alone were performed on the defect area. Four months later, new orbital implants were secondarily inserted after confirmation of graft survival. The size of the conjunctival defects and state of the extraocular muscles were checked preoperatively. Success of the operations and complications were investigated.RESULTS:The mean size of the conjuctival defects was 17.3mm×16.0mm, and the mean time from the initial diagnosis of orbital implant exposure to implant removal and autologous dermis fat graft was 20.8 months. After implant removal and autologous dermis fat graft, no graft necrosis was observed in any patients. Also, implant exposure or fornix shortening was not observed in any patients after new orbital implant insertion.CONCLUSION:The secondary insertion of a new orbital implant after pre-existing implant removal and preceding dermis fat graft is thought to be an another selective management of intractable orbital implant exposure in which dermis fat grafts persistently fail.

Abstract:AIM: To evaluate the efficacy of surgical treatment of vitrectomy combined with silicone oil tamponade in the treatment of severely traumatized eyes with the visual acuity of no light perception (NLP).METHODS: This was a retrospective uncontrolled interventional case-series of 19 patients of severely traumatized eyes with NLP who underwent vitrectomy surgery at the Affiliated Hospital of Medical College, Qingdao University (Qingdao, China) during a 3-year period. We recorded perioperative factors with the potential to influence functional outcome including duration from the injury to intervention; causes for ocular trauma; open globe or closed globe injury; grade of vitreous hemorrhage; grade of endophthalmitis; grade of retinal detachment; size and location of intraocular foreign body (IOFB); extent and position of retinal defect; grade of proliferative vitreoretinopathy (PVR); type of surgery; perioperative complications and tamponade agent. The follow-up time was from 3 to 18 months, and the mean time was 12 months.RESULTS: After a mean follow-up period of 12 months (3-18 months) 10.53% (2/19) of eyes had visual acuity of between 20/60 and 20/400, 52.63% (10/19) had visual acuity less than 20/400 but more than NLP, and 36.84% (7/19) remained NLP. Visual acuity was improved from NLP to light perception (LP) or better in 63.16% (12/19) of eyes and the rate of complete retinal reattachment was 73.68% (14/19). Good visual acuity all resulted from those patients of blunt trauma with intact eyewall (closed globe injury). The perioperative factors of poor visual acuity prognosis included delayed intervention; open globe injury; endophthalmitis; severe retinal detachment; large IOFB; macular defect; a wide range of retinal defects and severe PVR.CONCLUSION:The main reasons of NLP after ocular trauma are severe vitreous hemorrhage opacity; refractive media opacity; retinal detachment; retinal and uveal damages and defects, especially defects of the macula; PVR and endophthalmitis. NLP after ocular trauma in some cases does not mean permanent vision loss. Early intervention of vitrectomy combined with silicone oil tamponade and achieving retinal reattachment of the remaining retina, may make the severely traumatized eyes regain the VA of LP or better.

Abstract:AIM: To document common ocular abnormalities in children with spastic subtype of cerebral palsy (CP) and to find out whether any correlation exists between their occurance and etiologic factors.METHODS: Totally 194 patients with the diagnosis of spastic type CP were enrolled in this retrospective study. Detailed ophthalmic examinations were performed. Demographic data and neuroradiological findings were documented. Kruskal-Wallis, Mann Whitney U, Pearson Chi-square tests and Student’s t tests were used in the statistical analysis.RESULTS: The mean age was 64.7±44.2 months on the first ophthalmic examination. Prevalences of diplegia (47.4%) and tetraplegia (36.1%) were found to be higher than the frequency of hemiplegia (16.5%) in our study population. Etiologic factor was asphyxia in 60.8% of the patients. Abnormal ocular findings were present in 78.9% of the patients. Statistically significant poor vision was detected in tetraplegia group among all the spastic ubtypes of CP (P=0.000). Anisometropia and significant refractive error were found in 14.4% and 70.1% of the patients, respectively. Thirty-six children (18.6%) had nystagmus and 107 children (55.2%) had strabismus. Lower gestational age and birth weight were statistically higher in patients with esotropia than exotropia (P=0.009 and P=0.024, respectively). Abnormal morphology of the optic disc was present in 152 eyes (39.2%). Severe periventricular leukomalacia (PVL) was found in 48 patients and statistically significant poor vision was detected in the presence of PVL (P=0.000).CONCLUSION: Spastic diplegic or tetraplegic CP patients with positive neuroradiological symptoms, younger gestational age and lower birth weight ought to have detailed ophthalmic examinations as early as possible to provide best visual rehabilitation.

Abstract:AIM: To determine the effect of multiple injections of ranibizumab or bevacizumab on retinal nerve fiber layer (RNFL) and intraocular pressure (IOP) in patients with age-related macular degeneration (AMD).METHODS:This retrospective study includes 35 eyes of 35 patients treated with intravitreal bevacizumab (IVB, 1.25mg/0.05mL) and 30 eyes of 30 patients with intravitreal ranibizumab (IVR, 0.5mg/0.05mL) who had Fast RNFL analysis (Stratus?); IOP measurements were taken 30 minutes and 24 hours after each injection.RESULTS:The mean ages were 68.0±7.5 and 69.1±7.7 years in the IVR and IVB groups, respectively (P=0.55). They underwent (6.3±1.9) and (5.1±1.3) injections (P=0.07) over (13.6±2.1) and (14.05±2.6) months (P=0.45) in the IVR and IVB groups, respectively. Changes in overall and temporal RNFL thickness in IVR-treated eyes (105.3±6.9μm and 74.4±11.2μm) were not different from those in untreated eyes in the IVR group (104.6± 8.4μm and 75.1±12.6μm) (P=0.57 and P=0.41, respectively). Similarly, overall and temporal RNFL thickness in IVB-treated eyes (105.8±8.1μm and 74.5±11.8μm) were not different from those in untreated eyes in the IVB group (104.6±8μm and 74.8±12.9μm) (P=0.42 and P=0.80, respectively). The frequencies of IOP rise (P=0.60) and changes in RNFL thickness from baseline (P=0.16) were comparable between groups.CONCLUSION:Repeated intravitreal injection of ranibizumab or bevacizumab does not seem have adverse effects on RNFL thickness or IOP in wet AMD patients.

Abstract:AIM:To determine the incidence and risk factors of secondary glaucoma after pediatric cataract surgery.METHODS: Two hundred and forty nine eyes of 148 patients underwent cataract surgery without intraocular lens (IOL) implantation (group 1), and 220 eyes of 129 patients underwent cataract surgery with IOL implantation (group 2) retrospectively, were evaluated between 2000 and 2011.The outcome measure was the presence or absence of post-cataract surgery glaucoma, defined as an intraocular pressure (IOP) ≥26mmHg, as measured on at least two occasions along with corneal or optic nerve changes.RESULTS: The mean follow-up periods of group 1 and 2 were (60.86±30.95) months (12-123 months) and (62.11±31.29) months (14-115 months) respectively. In group 1, 12 eyes of 8 patients (4.8%) developed glaucoma. None of the patients developed glaucoma after surgery in group 2. The mean age of the patients at the cataract surgery was (2.58±0.90) months (1 month-4 months) and the average period for glaucoma development after surgery was (9.50±4.33) months (4-16 months) in group 1. Three of the 12 glaucomatous eyes were controlled with antiglaucomatous medication and 9 eyes underwent trabeculectomy+mitomycin C surgery. One patient underwent a second trabeculectomy + mitomycin C operation for both of his eyes.CONCLUSION: The incidence of glaucoma after pediatric cataract surgery is very low in patients in whom IOL is implanted. The aphakic eyes after pediatric cataract surgery are at an increased risk for glaucoma development particularly if they underwent surgery before 4 months of age.

Abstract:Diabetic retinopathy (DR), a major micro-vascular complication of diabetes, has emerged as a leading cause of visual impairment and blindness among working adults in the worldwide. The pathobiology of DR involves multiple molecular pathways and is characterized chronic neurovascular degeneration. Current approaches to prevent or to treat DR are still far from satisfactory. Therefore, it is important to develop new therapeutic strategies for the prevention and treatment to DR. Pigment epithelium-derived factor (PEDF), a 50-kDa secreted glycoprotein, has been described as a multi-functional protein. Some emerging evidences indicate that PEDF are able to target multiple pathways exerting neurotropic, neuroprotective, anti-angiogenic, antivasopermeability, anti-inflammation, anti-thrombogenic and anti-oxidative effects in DR. In this review, we addressed the functions of PEDF in different pathways, which could lead to potential therapeutics on the treatment to DR.

Abstract:Retinopathy of prematurity (ROP), a retinal vascular disease of premature infants, continues to be a major cause of preventable childhood blindness all over the world. The incidence of ROP varies among countries, being influenced by the quality of the level of neonatal intensive care. Here, we discuss the potential treatments that are now available or will soon or probably be available for ROP. Although ablation of the avascular retina with laser photocoagulation remains the current gold standard and well established therapy for ROP, some new therapeutic options including angiostatic therapies are being explored based on our knowledge of the pathophysiology of the ROP and complications and efficacy of laser treatment. However, prevention of the development of severe ROP and screening for ROP seem to be the best strategy in avoiding visual impairment caused by ROP in premature infants. New therapeutic interventions including vascular endothelial growth factor antibody administration, gene therapy and supplemental therapies should be supported with evidence-based data for the treatment of ROP.

Abstract:AIM:To determine the prevalence and risk factors for eye diseases, blindness, and low vision in Tibet, and to assist the development of eye disease prevention and treatment schemes.METHODS:We carried out a survey of eye diseases among a population living at high altitude. A total of 1 115 Tibetan permanent residents aged 40 years or older from the towns and villages of Qushui County, Lhasa Prefecture, Tibet Autonomous Region, participated in this study. All participants completed a detailed questionnaire, and underwent presenting and pinhole visual acuity tests, and a comprehensive ophthalmic examination.RESULTS:There were 187 blind eyes (8.43%), 231 eyes with low vision (10.41%). The leading cause of visual impairment was cataract of 55.0% (101/187) blindness and of 50.2% (116/231) low vision, followed by fundus lesions of 22.9% blindness and 23.8% low vision, while only a low prevalence of glaucoma of 9.6% blindness and 1.7% low vision was observed. The analysis of 2 219 eyes showed that the most common external eye disease was pterygium (27.2%) in Tibet.CONCLUSION:The high prevalence of blindness and low vision in the Tibetan population at high altitude is a serious public health issue. There is a need to establish and maintain an appropriate effective eye care program in Tibet.

Abstract:Valsalva retinopathy was described as a particular form of retinopathy, pre-retinal and subinternal limiting membrane haemorrhages in nature that rarely may break through and become subhyloid or intravitreal, secondary to a sudden increase in intrathoracic pressure. We reported a new way that Nd:YAG laser for ILM hyaloidotomy in order to drain the sub-ILM blood into vitreous cavity combined with intravitreal bevacizumab to improve the absorption of blood. Therapeutic alliance make significant outcome, protecting vision in time. We used spectralis OCT to observe sub-ILM mix cells and special ILM structure in this lesion for the first time, as the spectralis OCT can reach histology level imagination.

Abstract:AIM:To analyse previous literature and to formulate a management strategy for iris microhaemangiomas (IMH).METHODS: A review of the literature in English language articles on IMH.RESULTS: Thirty five English language articles fulfilled the criteria for inclusion to the study and based on the contents on these articles a management strategy was formulated. Age at presentation ranged from 42 to 80 years with no sex or racial predisposition. Most patients with IMH have no systemic disease but a higher incidence had been reported in patients with diabetes mellitus, myotonic dystrophy, chronic obstructive pulmonary disease (COPD) and several other systemic and ophthalmic co-morbidities. Most patients remained asymptomatic until they experienced a sudden blurring of vision due to a hyphaema. Some patients only develop a self-limiting single episode of hyphaema and therefore the laser or surgical photocoagulation of iris should be reserved for the cases complicated with recurrent hyphaema. In some patients, several laser photocoagulation sessions may be needed and the recurrent iris vascular tufts may require more aggressive treatment. Iris fluorescein angiography (IFA) is useful in identifying the true extent of the disease and helps to improve the precision of the laser treatment. Surgical excision (iridectomy) should only be considered in patients who fail to respond to repeated laser treatment. In some cases IMHs has been initially misdiagnosed as amaurosis fugax, iritis and Posner-Schlossman syndrome.CONCLUSION: Owing to its scarcity, there is no good quality scientific evidence to support the management of IMH. The authors discuss the various treatment options and present a management strategy based on the previous literature for the management for this rare condition and its complications.

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