Abstract:AIM: To determine if tranilast affects human corneal fibroblast (HCFs) contraction. METHODS: HCFs cultured in a three-dimensional type I collagen gel were treated with or without transforming growth factor beta (TGF-β) or tranilast. Gel diameter was measured as an indicator for collagen contraction. Immunoblot was performed to evaluate myosin light chain (MLC) and paxillin phosphorylation. Confocal microscopy was employed to examine the focal adhesions and actin stress fiber formation. Immunoblot analysis and gelatin zymography were performed to detect tissue inhibitors of metalloproteinases and matrix metalloproteinases (MMPs) in supernatant. RESULTS: The inhibitory effect of tranilast on HCFs-mediated collagen gel contraction induced by TGF-β was dose-dependent. The significant effect of tranilast was started from 100 μmol/L and maximized at 300 μmol/L. The peak effect of 300 μmol/L tranilast also relied on the duration of treatment, which showed statistical significance from day 2. TGF-β-induced paxillin and MLC phosphorylation, stress fiber formation, focal adhesions, and MMP-1, MMP-2, and MMP-3 secretion in HCFs were also inhibited by tranilast. CONCLUSION: Tranilast suppresses the HCFs-cultured collagen gel contraction induced by TGF-β. It attenuates actin stress fibers formation, focal adhesions, and the secretion of MMPs, with these actions likely contributing to the inhibitory effect on HCF contractility. By attenuating the contractility of corneal fibroblasts, tranilast treatment may inhibit corneal scarring.

Abstract:AIM: To study the potential role of fasudil as a treatment for posterior capsular opacification (PCO) of the human crystalline lens. METHODS: Human lens epithelial cells (HLECs; line SRA01/04) was exposed to transforming growth factor-β2 (TGF-β2) to induce the process of epithelial-mesenchymal transition (EMT). Fasudil was applied to the cell samples. Its effect on overall HLECs proliferation and migration was studied, as was its influence on EMT induction by TGF-β2 using cell migration assay, MTT colorimetric assay and Western blot assay. RESULTS: Fasudil inhibited the proliferation of SRA01/04. Its effect was time- and concentration-dependent. The migration of SRA01/04 cells was significantly reduced 24-72h after fasudil treatment, and the half maximal inhibitory concentration (IC50) was 22.37 μmol/mL at 72h. Reversal of the elongated, fibroblast-like shape changes induced by TGF-β2 in SRA01/04 cells was observed. Fasudil up-regulated the expression of Connexin43 protein and down-regulated the expression of α-SMA protein compared with the cells treated with TGF-β2. Furthermore, when exposed to fasudil, the phosphorylation of Rho-associated protein kinase (Rock) and myosin light chain (MLC) could not be activated in the cell preparations. CONCLUSION: Fasudil suppresses the proliferation and migration of SRA01/04 cells, and inhibits the process of EMT induced by TGF-β2. These results suggest that fasudil may serve as a therapeutic agent for PCO.

Abstract:AIM: To reveal the insight mechanism of liver metastasis in uveal melanoma, we investigated cell functions of microRNA-21 in three different uveal melanoma cell lines and analyze the relationship of target gene p53 and its downstream targets. METHODS: Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was used to detect microRNA-21 expression in normal uveal tissue and uveal melanoma cell lines. Lenti-virus expression system was used to construct OCM-1, MuM-2B and M619 cell line with stable overexpression and inhibition of microRNA-21. In vitro cell function tests such as cell proliferation, cell apoptosis, cell circle and abilities of migration and invasion were examined by MTT, BrdU assay, flow cytometry, transwell assay and Matrigel invasion assay respectively. The target gene was predicted by bioinformatics and confirmed by using a dual luciferase reporter assay. The expression of p53 and its suspected downstream targets LIM and SH3 protein 1 (LASP1) and glutathione S transferase pi (GST-Pi) were determined by qRT-PCR in mRNA level and Western blotting analysis in protein level. Finally, the effect of microRNA-21 in a xenograft tumor model was assessed in four-week-old BALB/c nude mice. RESULTS: Compared to normal uveal melanoma, expressions of microRNA-21 were significantly higher in uveal melanoma cell lines. Overexpression of microRNA-21 promoted proliferation, migration, and invasion of OCM-1, M619 and MuM-2B cells, while inhibition of microRNA-21 reveal opposite effects. Wild type p53 was identified as a target gene of microRNA-21-3p, and proved by dual luciferase reporter assay. Up-regulated microRNA-21 inhibited the expression of wild type p53 gene, and the increased expression of LASP1 in mRNA level and protein level, while down-regulated microRNA-21 presented opposite way. However, GST-pi showed the potential pattern as expected, but relative mRNA level showed no statistically significant difference in OCM-1 cells. Furthermore, the mRNA expression of GST-pi was decreased in microRNA-21 overexpressing MuM-2B, and increased in M619 cells with inhibition of microRNA-21. In vivo, inhibition of microRNA-21 reduced tumor growth with statistically significant difference. CONCLUSION: These findings provide novel insight into molecular etiology of microRNA-21 in uveal melanoma cell lines, and suggest that microRNA-21 might be a potential candidate for the diagnosis and prognostic factor of human uveal melanoma.

Abstract:AIM: To investigate the effect of gold nanoparticles on retinal angiogenesis in vitro and in vivo, and to reveal the possible mechanism. METHODS: Seed growth method was used to synthesize gold nanoparticles (GNPs). The size, zeta potential, absorption spectrum and morphology of GNPs were identified using Malvern Nano-ZS, multimode reader (BioTek synergy2) and transmission electron microscope. Cell viability was analyzed using cell counting kit-8 method and cell growth was assessed with EdU kit. Transwell chamber was used to investigate cell migration. Tube formation method was used to assess the angiogenic property in vitro. Oxygen induced retinopathy (OIR) model was used to investigate the effect of GNPs on retinal angiogenesis. Confocal microscope and Western blot were used to study the possible mechanism of GNPs inhibited angiogenesis. RESULTS: The GNPs synthesized were uniform and well dispersed. GNPs of 10 μg/mL and 20 μg/mL were able to inhibit human umbilical vein endothelial cells proliferation (50% and 72% separately, P<0.001), migration (54% and 83% separately, P<0.001) and tube formation (52% and 90% separately, P<0.001). Further data showed that GNPs were able to improve the retinopathy in an OIR model. The possible mechanism might be that GNPs were able to induce autophagy significantly (P<0.05). CONCLUSION: The present study suggests that GNPs are able to inhibit retinal neovascularization in vitro and in vivo. GNPs might be a potential nanomedicine for the treatment of retinal angiogenesis.

Abstract:AIM: To investigate the effect of interleukin-8 (IL-8) on neural retinal ganglion cells (RGCs) and whether it can be alleviated by G31P. METHODS: RGC-5 cells were exposed to IL-8 with or without its specific receptor antagonist G31P for 24h, and the cell viability was assessed by Cell Counting Kit 8 (CCK-8). Apoptosis was measured by examining nuclear morphology and quantifying with flow cytometry. Reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR) and Western blot were used to investigate the expression of apoptosis-related genes. RESULTS: CCK-8 assay showed that IL-8 significantly inhibits the viability of RGC-5 cells in a dose-dependent manner. Cell apoptosis assays exhibited higher apoptotic rate in IL-8 treatment group compared to control group. We further found that IL-8 could promote Bax and caspase-3 expressions, but decrease the level of Bcl-2 in the aspect of mRNA and protein. However, pre-treatment with G31P partly attenuated these effects in RGC-5 cells (P<0.05). CONCLUSION: These results indicate that anti-proliferation effects of IL-8 through induction of cell apoptosis regulated by Bcl-2, Bax and caspase-3 expressions, can be ameliorated by G31P.

Abstract:AIM: To investigate the effects of the phosphatidylinositol 3-kinase (PI3K) inhibitor LY294002 on retinal neovascularization (RNV) in the oxygen-induced retinopathy (OIR) mouse model and human umbilical vein endothelial cells (HUVECs). METHODS: C57BL/6J mice were randomly divided into normoxia-control, OIR-control and LY294002 treatment groups. LY294002 or phosphate-buffered solution was intraperitoneally injected daily into mouse pups from P6 to P9 in LY294002 treatment group or OIR-control group. Morphological and pathological changes in RNV, as well as expression levels of PI3K, serine-threonine kinase (AKT) and vascular endothelial growth factor (VEGF) were observed. HUVECs treating with LY294002 were exposed to hypoxia; the expression of PI3K, AKT and VEGF were examined by Western blot and RT-PCR analyses. RESULTS: Compared with the OIR-control group, LY294002 significantly inhibit RNV. Adenosine diphosphatase (ADPase) staining and hematoxylin and eosin staining indicated that the clock hour scores of neovascularization and the nuclei of pre-retinal neovascular cells in the LY294002 treatment group were clearly less than those in the OIR-control group (1.41±0.52 vs 6.20±1.21; 10.50±1.58 vs 22.25±1.82, both P<0.05). Intravitreal injection of LY294002 (in the LY294002 treatment group) markedly decreased PI3K/AKT-VEGF expression compared with the OIR-control group by immunohistochemistry, Western blotting and RT-PCR (all P<0.05). In HUVECs treated with hypoxia, expression of PI3K, AKT and VEGF were downregulated in the hypoxia-LY294002 group (all P<0.05). CONCLUSION: The PI3K inhibitor LY294002 can inhibit RNV by downregulating PI3K, AKT, and VEGF expression in vivo and in vitro. LY294002 may provide an effective method for preventing retinopathy of prematurity (ROP).

Abstract:AIM: To report the long-term outcomes of a large cohort of upper lid retraction patients treated with subconjunctival triamcinolone acetonide injections. METHODS: This retrospective clinical study was conducted from 2009 to 2016. The documents of 97 patients (126 eyes) were reviewed. The patients were treated with subconjunctival triamcinolone acetonide injections monthly and evaluated pre- and post-treatment by taking measurements of the upper margin reflex distance (MRD1, the distance between the upper-lid margin and the pupil center), lid aperture, lagophthalmos and proptosis. The patients were divided into the cured group, the improved group and the ineffective group based on the final treatment effectiveness. The improved group and the ineffective group were combined into non-cured group. RESULTS: The follow-up time was 23.45±14.86mo. Of the patients, 63 (64.9%) were assigned to the cured group, 22 (22.7%) in the improved group, 12 (12.4%) in the ineffective group. Injection times for cured group was 4.66±1.74, and for non-cured group was 5.17±2.08 (P≤0.05). The MRD1 was significantly reduced between baseline and 1mo after the initiation of treatment in the cured and improved groups (P<0.001). The values did not change significantly after 4mo for the improved group, while they continued to decrease in the cured group. In the ineffective group, the MRD1 did not significantly change after treatment. A statistically significant difference was observed between the baseline and post-treatment values of the mean muscle thickness (2.95±0.99 mm vs 2.04±0.63 mm, P<0.05) and surface area (27.27±10.5 mm2 vs 18.3±7.04 mm2, P<0.05) of the levator superioris with magnetic resonance imaging examination. Twelve patients (12.4%) relapsed after treatment and required additional subconjunctival injections. The main side effects included menstrual cycle disturbances (32%) and elevations of intra-ocular pressure (18.6%). CONCLUSION: A repeated subconjunctival injection of triamcinolone is an effective and relatively safe treatment for upper lid retraction due to thyroid-associated ophthalmopathy. This is related to the anti-inflammation effect of the medicine and the levator thickness can become thinner. Patients must be monitored regularly for recurrences and side effects.

Abstract:AIM: To evaluate the clinical, radiological, and treatment features of lacrimal gland tumors. METHODS: Retrospective review of 99 eyes of 92 patients with lacrimal gland tumors diagnosed and managed in a single institution between January 1999 and March 2017. Clinical and radiological features, histopathology, treatment methods, and prognosis were evaluated. RESULTS: The mean patient age was 40.3 (range: 7-80)y. The diagnosis was made histopathologically in 91 (91.9%) tumors and on a clinical and radiological basis in 8 (8.1%) tumors. Final diagnoses included idiopathic orbital inflammation (pseudotumor) in 46 (46.5%) lesions, pleomorphic adenoma in 14 (14.1%), adenoid cystic carcinoma in 12 (12.1%), granulomatous inflammation in 10 (10.1%), lymphoma in 5 (5.0%), benign reactive lymphoid hyperplasia in 3 (3.0%), dacryops in 3 (3.0%), carcinoma ex pleomorphic adenoma in 2 (2.0%), adenocarcinoma in 1 (1.0%), dermoid cyst in 1 (1.0%), cavernous hemangioma in 1 (1.0%), and leukemic infiltration in 1 (1.0%). Non-epithelial tumors comprised 64.6% (n=64) of all lacrimal gland tumors, epithelial tumors 32.3% (n=32), dermoid cyst 1% (n=1), cavernous hemangioma 1% (n=1), and leukemic infiltration 1% (n=1). There were in total 78 (78.8%) benign and 21 (21.2%) malignant tumors. CONCLUSION: Overall, 65% of lacrimal gland tumors were of non-epithelial origin and 32% of epithelial origin. By histopathology and clinical evaluation, 79% of lacrimal gland tumors were benign. The most common lacrimal gland tumors include idiopathic orbital inflammation (46.5%), epithelial (32.3%), and lymphoproliferative (8.1%) lesions.

Abstract:AIM: To evaluate the visual, refractive and corneal asphericity changes after intrastromal corneal ring segment (ICRS) implantation for visual rehabilitation of keratoconus. METHODS: A total of 42 eyes of 32 patients were included. After creation of intrastromal tunnels of 5.01±0.03 mm inner diameter, 5.71±0.03 mm outer diameter and at 384.21±34.12 μm depth, 1 or 2 ICRS of 150-300 μm thickness and 90°-210° arc length were implanted. Changes in uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive errors, mean simulated keratometry readings (SimKavg), anterior and posterior corneal asphericity values (Qant and Qpost, respectively) measured with Scheimpflug topography were evaluated retrospectively. RESULTS: There was a significant improvement in UDVA and CDVA, along with a significant decrease in refractive spherical equivalent (SE), cylinder and SimKavg postoperatively (P<0.001 for all). Mean Qant increased from -1.06±0.48 to -0.57±0.58 postoperatively (P<0.001). Change in mean Qpost was insignificant (P=0.92). Postoperative changes in UDVA and CDVA were not correlated with the postoperative changes in SE and cylinder (P>0.05 for all); but were correlated with the preoperative SimKavg and Qant values (P<0.001 for all). CONCLUSION: ICRS implantation seems to approximate the anterior corneal asphericity of “advanced prolate” shape to “optimal prolate” shape and an “ideal Q value” of -0.46; which may have a role in improved UDVA and CDVA postoperatively, besides decreased refractive cylinder values.

Abstract:AIM: To compare intraoperative phacoemulsification parameters and its effect on the corneal endothelium of eyes undergoing femtosecond laser-assisted cataract surgery (FLACS) versus conventional phacoemulsification (CP) cataract surgery. METHODS: Two hundred eyes from one hundred patients were included in a prospective, non-blinded, randomized, controlled, intraindividual clinical study. One hundred eyes underwent FLACS while their one hundred fellow eyes underwent CP. All surgeries were performed using the Victus® femtosecond laser platform and Infinity® Vision System phacoemulsification machine. Primary outcome measure was endothelial cell density 6mo after surgery. Secondary outcome measures included central corneal thickness (CCT), average cell area, standard deviation, coefficient of variation and hexagonality before surgery and 6mo after surgery and endothelial cell density loss during this period were also evaluated. Intraoperative efficiency parameters [cumulative dissipated energy (CDE), total intraocular surgery time, total ultrasound time, total phacoemulsification time, total torsional energy time, total aspiration time, ultrasound energy, torsional amplitude and fluid required during surgery] were also collated. RESULTS: Data from these patients was not considered for analysis. Data from 92 patients were analysed. Postoperative endothelial cell density (cells/mm2) between groups (2211.88±392.49 CP; 2246.31±403.48 FLACS) was not statistically significant (P=0.869). Total ultrasound time, torsional energy time, CDE and fluid requirements were significantly lower the FLACS group (P<0.05). Other parameters did not show statistically significant difference between FLACS and CP. CONCLUSION: FLACS displays significant improvements in phacoemulsification parameters in comparison to CP. There are no significant differences in corneal endothelium measures between FLACS and CP.

Abstract:AIM: To compare the corneal endothelial cell counts pre- and post-operation, ultrastructure of anterior lens capsule and surgical completion after diathermic high-frequency capsulorhexis (DHC) and continuous curvilinear capsulorrhexis (CCC) applied in phacoemulsification (PHACO) of white cataract surgery. METHODS: Sixty-six eyes of 66 patients (33 males and 33 females) with cataract aged between 60 and 80y (mean 72.5±5.5) were recruited and undergone the surgery from June 2014 to November 2016. Anterior lens capsule, derived from two kinds of capsulorhexis, were randomly divided into two groups according to random number table. The ultrastructure of the capsule edge and its closer tissue were observed by transmission electron microscopy (TEM) and optical microscopy respectively. The surgical completion conditions and corneal endothelial cell counts were analyzed pre- and post-operation after two capsulorhexis. RESULTS: The capsule derived from CCC had smooth edge, well-organized cellular structure and the cells filling into the cutting edge under TEM and optical microscopy. The capsule derived from DHC had an approximate 60 banded area of cell degeneration and necrosis, with dentiform prominences at the edge of the capsule, and no cell structure was observed at this area. The corneal endothelial cell counts of both groups were slightly declined 1wk post-operation compared with that of pre-operation. There was no statistical difference between the two groups (t=1.63, P>0.05). CONCLUSION: DHC shows good clinical value in white mature and hypermature cataract surgery.

Abstract:AIM: To investigate the incidence rate and risk factors for grade III flat anterior chamber (FAC) after glaucoma filtration surgery based on 5-year data. METHODS: Patients who underwent glaucoma filtration surgery in Daping hospital from January 2009 to December 2013 were enrolled in this retrospective study. The incidence of grade III FAC following glaucoma filtration surgery was determined. Regression analysis was performed to investigate the influence of glaucoma type, surgical approach, age, and preoperative intraocular pressure (IOP) on the risk of postoperative FAC. RESULTS: A total of 2179 eyes receiving anti-glaucoma surgery were included. Ninety-one eyes suffered from postoperative FAC, with an overall incidence rate of 4.18%. Of 471 eyes with primary open angle glaucoma (POAG), grade III FAC occurred in only 3 eyes (0.64%). Primary angle- closure glaucoma (PACG) was diagnosed in 1076 eyes, 39 (3.62%) of which developed grade III FAC, including 12 eyes (12/300, 4%) with acute PACG (aPACG) and 27 eyes (27/776, 3.48%) with chronic PACG (cPACG). Six of 259 eyes (2.32%) with secondary glaucoma, 28 of 186 eyes (15.05%) with neovasular glaucoma, 1 of 66 eyes (1.52%) with congenital glaucoma, and 14 of 115 eyes (12.17%) with remnant glaucoma suffered from grade III FAC. Of 6 eyes with mixed glaucoma, none developed grade III FAC after surgery. When stratified by surgical approach, 24 of 766 eyes (3.13%) undergoing trabeculectomy, 21 of 924 eyes (2.27%) treated by trabeculectomy plus mitomycin C (MMC), 18 of 109 eyes (16.51%) undergoing Ahmed glaucoma valve implantation, 23 of 201 eyes (11.44%) managed by Ahmed implantation plus MMC, and 5 of 133 eyes (3.76%) treated by Ahmed implantation plus lens extraction or vitrectomy developed grade III FAC. Logistic regression analysis revealed that factors including neovasular glaucoma, remnant glaucoma, glaucoma valve implantation, glaucoma valve implantation+MMC, glaucoma valve implantation+vitrectomy, age>60y, and IOP at admission >50 mm Hg were significantly associated with an increased risk for grade III FAC. CONCLUSION: The overall incidence of grade III FAC after glaucoma filtration surgery is 4.18%. Patients with neovasular glaucoma and remnant glaucoma are at a higher risk of developing FAC. Ahmed glaucoma valve implantation is associated with a higher risk for grade III FAC compared with trabeculectomy. No significant correlation was observed between the use of MMC in glaucoma filtration surgery and the risk of postoperative FAC. Higher IOP at admission (>50 mm Hg) and old age (>60y) are risk factors for grade III FAC.

Abstract:AIM: To explore the relationship between different parameters of Ocular Response Analyzer (ORA) and Corvis ST (CST) in a sample of healthy Iranian school-aged children and the relationship between parameters of these 2 instruments against intraocular pressure (IOP), measured by the Goldmann applanation tonometer (GAT-IOP), age and gender, and find possible correlation between ORA and CST with GAT. METHODS: This cross-sectional study included 90 healthy children. A general interview and complete eye examination were performed. Following successful GAT-IOP measurement, ORA and CST were conducted. The CST parameters were A 1/2 length (A1L, A2L), A 1/2 velocity (A1V, A2V), highest concavity deformation amplitude (HCDA), radius of curvature (RoC), peak distance (PD), central corneal thickness (CCT) and IOP. The ORA parameters were corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann-correlated IOP (IOP-G) and corneal compensated IOP (IOP-CC). Extracted data was analyzed using the Statistical Package for Social Science software. RESULTS: Totally 39 males with age of 9.08±1.60 (6-12)y and 51 females with age of 8.96±1.55 (6-13)y were included. Many CST parameters were significantly correlated with CH, CRF, IOP-G and IOP-CC. Some CST parameters had a significant correlation with GAT-IOP, including IOP-CST in both eyes and HCDA, A2L, PD, and RoC in the left eye, but none with age, except A2L in the right eye. The CRF measurement showed a significant correlation with GAT-IOP in both eyes and CH in the right eye, yet, none with age. Among all CST and ORA parameters, CCT-CST in both eyes and A1L in right eye had a significant correlation with gender, although this was a negligible negative correlation. Comparison of mean IOP values by different devices showed a significantly highest IOP overestimation by CST and lowest by IOP-CC compared with GAT. Also, IOP-G versus IOP-CST significantly had the lowest IOP overestimation among others. Overall, either low positive correlation or negligible correlation was found between IOP measurements by 3 instruments. CONCLUSION: The study finds the highest IOP overestimation by CST and lowest by IOP-CC compared with GAT. Overall, either low positive correlation or negligible correlation is found between IOP measurements by the 3 instruments.

Abstract:AIM: To determine whether glaucoma patients exhibit an abnormal melatonin concentration in serum and the effects of psychiatric disorders caused by glaucoma in melatonin secretion. METHODS: A sample of 80 primary angle-closure glaucoma (PACG) patients, 120 primary open angle glaucoma (POAG) patients, and 120 normal controls were enrolled in this study. All the participants were asked to complete the following questionnaires: Pittsburgh sleep quality index (PSQI), self-rating anxiety scale (SAS), and self-rating depression scale (SDS). Variance analysis was used to compare the subscores between the groups. After that, we chose 58 patients with primary glaucoma and 20 non-glaucoma control patients to collect their serum samples at 7-10 a.m. Serum melatonin levels were measured using enzyme linked immunosorbent assay (ELISA). RESULTS: Of all participants, the scores of PSQI, SAS, and SDS in PACG and POAG group were 9.38±0.40, 46.08±8.99, 51.11±10.72 and 7.43±0.35, 45.42±9.87, 49.04±12.24 respectively, significantly higher than those in control group (4.16±0.28, 35.49±9.18, 40.31±13.08). The serum melatonin levels in PACG (37.29±2.99 pg/mL) and POAG (35.97±3.64 pg/mL) were significantly higher than the controls (29.96±3.94 pg/mL) (P<0.001). But no difference was found between the PACG and POAG (P=0.216). Glaucoma patients with sleep disorders, anxiety and depression were more likely resulting in the increase of melatonin levels. CONCLUSION: There is a significant increase in serum melatonin levels in glaucoma patients compared to the controls especially in glaucoma patients with psychiatric disorders such as sleep disorders, anxiety and depression.

Abstract:AIM: To investigate the intraocular retinal thickness asymmetry of peripapillary retinal nerve fiber layer (pRNFL) and macular layers measured by spectral-domain optical coherence tomography (SD-OCT) in patients with early stage of primary open angle glaucoma (POAG) and normal tension glaucoma (NTG). METHODS: A total of 117 patients with early stage of glaucoma (54 patients with POAG and 63 patients with NTG) and 32 normal subjects were recruited for the study. The pRNFL thickness, total macular layer (TML) thickness, and isolated inner macular layer (IML) thickness were measured by SD-OCT. Hemisphere TML thickness asymmetry measured by the posterior pole asymmetry scan was evaluated. Thickness differences of pRNFL and IML between superior and inferior quadrants were calculated. Asymmetry indices (AIs) of the pRNFL, TML and isolated IML were also computed. Areas under the receiver-operating characteristic curves (AROCs) were generated to determine the diagnostic capabilities of different parameters. RESULTS: Intraocular pRNFL thickness differences and AIs between the superior and inferior quadrants were significantly different between normal and NTG groups (P=0.009 and P<0.001, respectively). Intraocular pRNFL thickness differences and AIs between the temporal-superior and temporal-inferior sectors were also significantly different between normal and NTG groups (P=0.035 and P<0.001, respectively). The thickness differences and AIs of TML between superior and inferior hemispheres were significantly different between normal and NTG groups (P=0.001 and P=0.001, respectively) and between normal and POAG groups (P=0.032 and P=0.020, respectively). The thickness differences and AIs of macular ganglion cell layer (mGCL) between superior and inferior quadrants were significantly different between normal and NTG groups (P=0.013 and P=0.004, respectively), and between NTG and POAG groups (P=0.015 and P=0.012, respectively). The thickness difference of TML between superior and inferior hemispheres showed the highest diagnostic capability for early NTG eyes (AROC=0.832). CONCLUSION: Intraocular retinal thickness asymmetry in pRNFL, TML and mGCL are found in early stage of NTG. Hemisphere TML thickness asymmetry is also found in POAG eyes. Asymmetry analysis of retinal thickness can be an adjunctive modality for early detection of glaucoma.

Abstract:AIM: To describe the clinical features of congenital double elevator palsy (CDEP) and to evaluate various surgical outcomes between the standard Knapp and augmented Knapp procedures, based on improvements in primary eye position and ocular motility. METHODS: Twenty-two patients with CDEP at Shanghai Children’s Hospital were enrolled from July 2014 to January 2018. The forced duction test (FDT) was negative in 21 patients, aged 8mo to 12y (mean 5.4y). Patients were divided into two treatment groups: 16 patients underwent the standard Knapp procedure (group A), with or without horizontal squint procedure; and 5 patients underwent the augmented Knapp procedure (Foster procedure; group B). One patient underwent inferior rectus recession in the affected eye and superior rectus recession in the sound eye because of a positive FDT. The pre- and postoperative vertical deviations in the primary position and ocular motility were compared in the two groups. RESULTS: Twenty-one eyes of the 22 patients (95%) were aligned within 10 prism diopters (PD), and all patients (100%) reached ≥25% elevation improvement after surgery. The average corrected vertical deviation in group B was statistically better than that of group A. For group A, the vertical deviation in the primary position decreased from 24.75Δ±8.35Δ to 4.56Δ±8.07Δ after surgery, for an improvement of 23.06Δ±6.51Δ (P<0.05). In group B, the decrease was from 35.00Δ±5.00Δ (range 30Δ-40Δ) to 1.00Δ±2.24Δ, for an improvement of 34.00Δ±4.18Δ (P<0.05). There were significant differences between the pre- and postoperative elevation in each group (group A, P<0.05; group B, P<0.05). The average scale of improved elevation in group B (1.80±0.45) was not significantly better than that of group A (1.69±0.87; Z=-0.732, P=0.548). The average follow-up periods lasted 21mo in group A and 18mo in group B. CONCLUSION: For vertical deviations <30Δ, the standard Knapp procedure can be chosen. For deviations greater than 30Δ-40Δ, the Foster procedure should be chosen. Because of our early interference, the inferior rectus (IR) muscle did not show mechanical restriction. Monocular elevation deficiency (MED) should be diagnosed early so that complications will be reduced and the procedure will be easier for the surgeon.

Abstract:AIM: To evaluate the relationship between early postoperative deviation and long-term outcome after unilateral recession and resection surgery for adult exotropia, and to evaluate exotropic shift after surgery. METHODS: This was a retroprospective study involving adult patients with exotropia who underwent unilateral recession and resection surgery and were followed up for at least 2y. The results were evaluated at 2y and the final visit. Factors influencing a successful outcome were analyzed. Early postoperative deviation at 1wk was used to evaluate relationship with long-term outcome. The long-term outcome was classified into 3 groups: successful, acceptable, and poor. Successful outcome was defined as a distance deviation between esodeviation 8 prism diopters (PD) and exodeviation 10 PD. RESULTS: Forty-two patients were enrolled. The mean age at surgery was 26y (range, 15-49y). The median follow-up period was 30mo (range, 24-108mo). Successful outcome was found in 81% of patients at 2y and in 71% at the final visit. Overcorrection at 1wk postoperatively was associated with a successful outcome at 2y. Initial postoperative alignment between orthotropia and esodeviation of 8 PD had the highest chance of a successful outcome (RR=2.2). The mean postoperative exotropic drift was 4.7 PD at the first month and 9.3 PD at 2y. CONCLUSION: Initial postoperative deviation can predict long-term outcome after unilateral recession and resection surgery for adult exotropia. The most desirable outcome at 1wk post-operatively was orthotropia to small esodeviation. Most patients have exotropic drift at a subsequent follow-up, especially in the first month after surgery.

Abstract:AIM: To evaluate the long-term results of different orbital decompression techniques performed in patients with Graves' ophthalmopathy (GO). METHODS: Totally 170 cases with GO underwent orbital decompression between 1994 and 2014. Patients were divided into 4 groups as medial-inferior, medial-lateral (balanced), medial-lateral-inferior, and lateral only according to the applied surgical technique. Surgical indications, regression degrees on Hertel exophthalmometer, new-onset diplopia in the primary gaze and new-onset gaze-evoked diplopia after surgery and visual acuity in cases with dysthyroid optic neuropathy (DON) were compared between different surgical techniques. RESULTS: The study included 248 eyes of 149 patients. The mean age for surgery was 42.3±13.2y. DON was the surgical indication in 36.6% of cases, and three-wall decompression was the most preferred technique in these cases. All types of surgery significantly decrease the Hertel values (P<0.005). Balanced medial-lateral, and only lateral wall decompression caused the lowest rate of postoperative new-onset diplopia in primary gaze. The improvement of visual acuity in patients with DON did not significantly differ between the groups (P=0.181). CONCLUSION: The study show that orbital decompression surgery has safe and effective long term results for functional and cosmetic rehabilitation of GO. It significantly reduces Hertel measurements in disfiguring proptosis and improves visual functions especially in DON cases.

Abstract:AIM: To evaluate the value of ultra-wide field (UWF) imaging in the management of traumatic retinopathy under the condition of corneal scar or fixed small pupil after complicated ocular trauma. METHODS: Twenty-eight patients (28 eyes) with complicated ocular trauma were enrolled in the study from June 2016 to May 2017, including 19 males and 9 females with age ranged from 11 to 64 (43.42±12.62)y. All patients were treated with secondary vitrectomy after emergency operation for wound repair of open ocular trauma. Direct ophthalmoscopy and 45-degree fundus photography were taken at each time point of follow up for comparison of findings with UWF images. Routine eye examination including visual acuity, intraocular pressure, slit lamp examination were performed and analyzed as well. RESULTS: Among the 28 traumatized eyes, the positive rate for identification of traumatic retinopathed was 32.1% (9 cases), 14.9% (5 cases), and 85.7% (24 cases) with direct ophthalmoscopy, 45-degree fundus photography, and UWF imaging, respectively. The detective rate of UWF imaging under the condition of corneal scar or fixed small pupil was statistically greater than that of 45-degree fundus photography and direct ophthalmoscopy (Bonferroni correction, P<0.001). UWF image was obtained in 19 eyes with opaque corneal scar, otherwise their fundus could not be seen by conventional methods. The additional findings of traumatic retinopathies by UWF imaging included periretinal membranes or pre-retinal proliferating strip, retinal holes, hemorrhage in the vitreous or sub-retinal space. CONCLUSION: UWF imaging is superior to traditional fundus photography in the evaluation of traumatic retinopathies under the condition of corneal scar or fixed small pupil after complicated ocular trauma.

Abstract:AIM: To investigate the influence of astigmatism on visual acuity in school-aged children, and to define a cutoff for clinically significant astigmatism. METHODS: This is a population-based, cross-sectional study. Among 5053 enumerated children aged 5-15y in Guangzhou, 3729 (73.8%) children aged 7-15 with successful cycloplegic auto-refraction (1% cyclopentolate) and a reliable visual acuity measurement were included. Ocular measurement included external eye, anterior segment, media and fundus and cycloplegic auto-refraction. Primary outcome measures included the relationship between severity and subtypes of astigmatism and the prevalence of visual impairment. Three criteria for visual impairment were adopted: best-corrected visual acuity (BCVA) ≤0.7, uncorrected visual acuity (UCVA) ≤0.5 or <0.7 in the right eye. RESULTS: Increases of cylinder power was significantly associated with worse visual acuity (UCVA: β=0.051, P<0.01; BCVA: β=0.025, P<0.001). A substantial increase in UCVI and BCVI was seen with astigmatism of 1.00 diopter (D) or more. Astigmatism ≥1.00 D had a greater BCVI prevalence than cylinder power less than 1.00 D (OR=4.20, 95%CI: 3.08-5.74), and this was also true for hyperopic, emmetropic and myopic refraction categories. Oblique astigmatism was associated with a higher risk of BCVI relative to with the rule astigmatism in myopic refractive category (OR=12.87, 95%CI: 2.20-75.38). CONCLUSION: Both magnitude and subtypes of astigmatism influence the prevalence of visual impairment in school children. Cylinder ≥1.00 D may be useful as a cutoff for clinically significant astigmatism.

Abstract:AIM: To validate the Peek Acuity mobile phone application in pediatric populations and compare its utility, both economic and diagnostic, against conventional screening methods using a pediatric ophthalmologist examination as the gold standard. METHODS: A cohort of 393 subjects from Fernando de la Mora, Paraguay (ages 6-16y) were enrolled in the study. Subjects were randomly assigned a starting screening modality among: Peek Acuity, a single line of tumbling E optotypes set at 20/40, and Spot Vision Screener. Once completing the first screening modality, the subjects completed the two remaining techniques. Referral criteria were established based on the most current American Association of Pediatric Ophthalmology and Strabismus (AAPOS) recommendations: 20/40 for Peek Acuity and the tumbling E, and refractive error detection for the Spot Vision Screener. Subjects that failed to achieve the cut-off for any of the three screening techniques or subjects that passed the screening but were randomly selected to perform a comprehensive eye exam to determine the false negative rate, were evaluated by a pediatric ophthalmologist. This evaluation was considered the gold standard, and included vision assessment by a Snellen chart, strabismus evaluation, and cycloplegic refraction with dilated fundoscopy. RESULTS: We obtained 48% sensitivity, 83% specificity, 43% positive predictive value, and 86% negative predictive value for Peek Acuity's ability to refer compared to evaluation by a pediatric ophthalmologist, failing to achieve a desired sensitivity for implementation. Peek Acuity trended to overestimate the subject's visual acuity, providing a higher visual acuity that would not indicate referral for a comprehensive eye examination. However, its high specificity accurately predicted a significant number of children who did not need further evaluation. When comparing the three screening methods, no single screening modality outperformed the others. Peek Acuity represented a technology that was economically feasible compared to other screening modalities in low income settings, due to the prevalence of cell phone use. CONCLUSION: Peek Acuity represents an efficient tool that has potential for implementation in school screenings with different strategies aimed at pediatric populations due to its low cost and high specificity. An increase in sensitivity would improve detection of children with refractive errors.

Abstract:AIM: To determine the prevalence and characteristics of peripheral myopic retinopathy among a sample of Guangzhou office workers. METHODS: A cross-sectional study of Guangzhou Chinese office works in different departments and units of the Guangzhou Power Supply Bureau, China, in 2016. Myopic retinopathy was recorded and analyzed with a scanning laser ophthalmoscope and by slit-lamp microscopy combined with a three-mirror contact lens. RESULTS: In total, 1910 eyes of 955 subjects (508 females and 447 males) aged 21-59y were included; 69.6% of these eyes were myopic. The myopia group had a younger age and worse uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) when compared with hyperopia and emmetropia groups (P<0.001). The axial length (AL) was significantly longer, the spherical equivalent (SE) was more serious, and the optic nerve crescent was significantly larger in subjects with myopia than with hyperopia and emmetropia. Subjects with myopia, and especially high myopia, had the highest frequency of myopic retinal 18 changes (49.4%, P<0.001) [white-without-pressure (43.8%, P<0.001), lattice degeneration (4.5%, P=0.044)] among the three groups. Logistic regression confirmed that any myopia (OR: 3.41, P<0.001) [mild myopia (OR: 1.93, P=0.001), moderate myopia (OR:3.64, P<0.001), and high myopia (OR:10.58, P<0.001)], a greater AL (OR: 1.55, P<0.001) and a much higher SE (OR: 0.77, P<0.001) increased the risk for peripheral retinal changes. CONCLUSION: Myopia-related retinal changes are positively associated with greater AL, higher SE, and myopia.

Abstract:As cataract occurs frequently in patients with glaucoma, combining phacoemulsification and endoscopic cyclophotocoagulation has been gaining attention recently due to its minimally invasive nature. A variety of studies had evaluated the efficacy and safety of this procedure and had shown extremely promising results. This review article has shown here that combined phacoemulsification and endoscopic cyclophotocoagulation procedure could effectively reduce intraocular pressure in medically uncontrolled glaucoma patients while avoiding serious complications associated with traditional cyclophotocoagulation procedure and adverse effects related to filtering surgery such as trabeculectomy.

Abstract:Posterior capsule opacification (PCO) remains the most common complication of pediatric cataract surgery despite continuous efforts to reduce its incidence. For this reason, pediatric cataract surgeons have expended considerable effort into preventing and mitigating PCO. The intraocular lens (IOL) optic capture technique has been used for the prevention of PCO after pediatric cataract surgery for more than 20y, but there is still no professional consensus. However, recent research has shown encouraging results. The IOL optic capture technique can be performed without anterior vitrectomy to prevent PCO, even in younger children. The type and characteristics of IOLs used for optic capture technique, the location of IOL and the complications of IOL optic capture in children are here reviewed.

Abstract:Retrospective review of 13 eyes that had undergone pars plana vitrectomy (PPV) for vitreomacular traction (VMT) syndrome in retinitis pigmentosa (RP) and had a postoperative follow-up period ≥9mo in order to evaluate whether it is necessary to treat VMT in RP by vitrectomy. The 13 RP eyes suffering from VMT were evaluated by means of best corrected visual acuity (BCVA), anterior and posterior binocular examination, spectral-domain optical coherence tomography (SD-OCT) before and after operation. We detected that although vitrectomy could improve the macular morphology in some RP patients with VMT, visual outcomes might be limited and unpredicted most likely because of the long-standing retinal dysfunction, but the vitrectomy is necessary in order to remain or improve the central vision in some cases.

Abstract:This study is to investigate the characteristic features of Acanthamoeba keratitis (AK) that differentiating it from herpetic epithelial keratitis (HEK) using anterior segment optical coherence tomography (AS-OCT). Medical records of three eyes of each AK and herpetic keratitis who had AS-OCT examination were reviewed in this study. Slit-lamp biomicroscopy and AS-OCT was performed on the initial visit and on every follow-up visits in all patients. In all three AK cases, reflective bands in the corneal stroma that correspond to the area of radial keratoneuritis were observed. The depth of the reflective bands varied in each case. After AK treatment, slit-lamp biomicroscopy confirmed that radial keratoneuritis had resolved and AS-OCT confirmed that reflective bands in the corneal stroma had also disappeared in all patients. Unlike the AS-OCT results found in AK, highly reflective HEK lesions were observed only in the subepithelial area, not in the stroma. AS-OCT seems to be helpful analyzing the specific depth of the lesion which enables to distinguish AK from HEK.

Abstract:We aimed to evaluate interleukin-6 (IL-6) tear concentration and clinical outcome in patients with moderate-to-severe bacterial corneal ulcers post corneal collagen cross-linking (CXL) therapy. This pre-post designed study involving 21 moderate-to-severe corneal ulcer patients who underwent CXL therapy. Patients with infectious corneal ulcer were given CXL therapy as adjunctive treatment after 5d of broadspectrum antibiotic treatment. Patients with moderate to severe infectious bacterial corneal ulcers were included in this study. Tear sampling was performed before CXL therapy, using sterile Schimer paper from conjunctival inferior fornix. CXL therapy was performed in accordance with the CXL Dresden protocol. Data recording and tear sampling were then performed at day 1 and day 7 after CXL therapy. Data recording included, presence of conjunctival hyperemia, visual analogue scale (VAS), size of corneal defects, and decemetocele. There was a decrease in IL-6 tear concentration by day 7 after CXL therapy (P=0.001). IL-6 concentration at 1h after therapy (2274.67±2120.46 pg/mL) tended to be lower than before therapy (4330.09±3169.70 pg/mL), but the difference was not statistically significant (P=0.821). The size of corneal defects decreased significantly post CXL (P=0.007). The logMAR visual acuity before and after CXL therapy was not found to be significantly different (P=0.277). There was a significant decrease in VAS values (P=0.018) and blepharospasm (P=0.011) pre and post CXL. There was no significant decrease in conjunctival hyperemia pre and post CXL (P=0.293). There was significant reduction in IL-6 tear concentration and clinical improvement in moderate-to-severe bacterial corneal ulcers which underwent CXL therapy.

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