Abstract:AIM: To conduct a classification study of high myopic maculopathy (HMM) using limited datasets, including tessellated fundus, diffuse chorioretinal atrophy, patchy chorioretinal atrophy, and macular atrophy, and minimize annotation costs, and to optimize the ALFA-Mix active learning algorithm and apply it to HMM classification. METHODS: The optimized ALFA-Mix algorithm (ALFA-Mix+) was compared with five algorithms, including ALFA-Mix. Four models, including ResNet18, were established. Each algorithm was combined with four models for experiments on the HMM dataset. Each experiment consisted of 20 active learning rounds, with 100 images selected per round. The algorithm was evaluated by comparing the number of rounds in which ALFA-Mix+ outperformed other algorithms. Finally, this study employed six models, including EfficientFormer, to classify HMM. The best-performing model among these models was selected as the baseline model and combined with the ALFA-Mix+ algorithm to achieve satisfactory classification results with a small dataset. RESULTS: ALFA-Mix+ outperforms other algorithms with an average superiority of 16.6, 14.75, 16.8, and 16.7 rounds in terms of accuracy, sensitivity, specificity, and Kappa value, respectively. This study conducted experiments on classifying HMM using several advanced deep learning models with a complete training set of 4252 images. The EfficientFormer achieved the best results with an accuracy, sensitivity, specificity, and Kappa value of 0.8821, 0.8334, 0.9693, and 0.8339, respectively. Therefore, by combining ALFA-Mix+ with EfficientFormer, this study achieved results with an accuracy, sensitivity, specificity, and Kappa value of 0.8964, 0.8643, 0.9721, and 0.8537, respectively. CONCLUSION: The ALFA-Mix+ algorithm reduces the required samples without compromising accuracy. Compared to other algorithms, ALFA-Mix+ outperforms in more rounds of experiments. It effectively selects valuable samples compared to other algorithms. In HMM classification, combining ALFA-Mix+ with EfficientFormer enhances model performance, further demonstrating the effectiveness of ALFA-Mix+.

Abstract:AIM: To predict best-corrected visual acuity (BCVA) by machine learning in patients with ocular trauma who were treated for at least 6mo. METHODS: The internal dataset consisted of 850 patients with 1589 eyes and an average age of 44.29y. The initial visual acuity was 0.99 logMAR. The test dataset consisted of 60 patients with 100 eyes collected while the model was optimized. Four different machine-learning algorithms (Extreme Gradient Boosting, support vector regression, Bayesian ridge, and random forest regressor) were used to predict BCVA, and four algorithms (Extreme Gradient Boosting, support vector machine, logistic regression, and random forest classifier) were used to classify BCVA in patients with ocular trauma after treatment for 6mo or longer. Clinical features were obtained from outpatient records, and ocular parameters were extracted from optical coherence tomography images and fundus photographs. These features were put into different machine-learning models, and the obtained predicted values were compared with the actual BCVA values. The best-performing model and the best variable selected were further evaluated in the test dataset. RESULTS: There was a significant correlation between the predicted and actual values [all Pearson correlation coefficient (PCC)>0.6]. Considering only the data from the traumatic group (group A) into account, the lowest mean absolute error (MAE) and root mean square error (RMSE) were 0.30 and 0.40 logMAR, respectively. In the traumatic and healthy groups (group B), the lowest MAE and RMSE were 0.20 and 0.33 logMAR, respectively. The sensitivity was always higher than the specificity in group A, in contrast to the results in group B. The classification accuracy and precision were above 0.80 in both groups. The MAE, RMSE, and PCC of the test dataset were 0.20, 0.29, and 0.96, respectively. The sensitivity, precision, specificity, and accuracy of the test dataset were 0.83, 0.92, 0.95, and 0.90, respectively. CONCLUSION: Predicting BCVA using machine-learning models in patients with treated ocular trauma is accurate and helpful in the identification of visual dysfunction.

Abstract:AIM: To explore hub genes for glaucoma based on bioinformatics analysis and an experimental model verification. METHODS: In the Gene Expression Omnibus (GEO) database, the GSE25812 and GSE26299 datasets were selected to analyze differentially expressed genes (DEGs) by the GEO2R tool. Through bioinformatics analysis, 9 hub genes were identified. Receiver operating characteristic (ROC) curves and principal component analysis (PCA) were performed to verify whether the hub gene can distinguish glaucoma from normal eyes. The mouse model of glaucoma was constructed, and the real-time reverse transcriptase-polymerase chain reaction (RT-qPCR) assay was performed to detect the expression levels of hub genes in glaucoma. RESULTS: There were 128 overlapping DEGs in the GSE25812 and GSE26299 datasets, mainly involved in intracellular signalling, cell adhesion molecules and the Ras signalling pathway. A total of 9 hub genes were screened out, including GNAL, BGN, ETS2, FCGP4, MAPK10, MMP15, STAT1, TSPAN8, and VCAM1. The area under the curve (AUC) values of 9 hub genes were greater than 0.8. The PC1 axle could provide a 70.5% interpretation rate to distinguish glaucoma from normal eyes. In the ocular tissues of glaucoma in the mice model, the expression of BGN, ETS2, FCGR4, STAT1, TSPAN8, and VCAM1 was increased, while the expression of GNAL, MAPK10, and MMP15 was decreased. CONCLUSION: Nine hub genes in glaucoma are identified, which may provide new biomarkers and therapeutic targets for glaucoma.

Abstract:AIM: To construct an in vitro model of oxygen-glucose deprivation/reperfusion (OGD/R) induced injury to the optic nerve and to study the oxidative damage mechanism of ischemia-reperfusion (I/R) injury in 661W cells and the protective effect of ginsenoside Rg1. METHODS: The 661W cells were treated with different concentrations of Na2S2O4 to establish OGD/R model in vitro. Apoptosis, intracellular reactive oxygen species (ROS) levels and superoxide dismutase (SOD) levels were measured at different time points during the reperfusion injury process. The injury model was pretreated with graded concentrations of ginsenoside Rg1. Real-time polymerase chain reaction (PCR) was used to measure the expression levels of cytochrome C (cyt C)/B-cell lymphoma-2 (Bcl2)/Bcl2 associated protein X (Bax), heme oxygenase-1 (HO-1), caspase9, nuclear factor erythroid 2-related factor 2 (nrf2), kelch-like ECH-associated protein 1 (keap1) and other genes. Western blot was used to detect the expression of nrf2, phosphorylated nrf2 (pnrf2) and keap1 protein levels. RESULTS: Compared to the untreated group, the cell activity of 661W cells treated with Na2S2O4 for 6 and 8h decreased (P<0.01). Additionally, the ROS content increased and SOD levels decreased significantly (P<0.01). In contrast, treatment with ginsenoside Rg1 reversed the cell viability and SOD levels in comparison to the Na2S2O4 treated group (P<0.01). Moreover, Rg1 reduced the levels of caspase3, caspase9, and cytC, while increasing the Bcl2/Bax level. These differences were all statistically significant (P<0.05). Western blot analysis showed no significant difference in the protein expression levels of keap1 and nrf2 with Rg1 treatment, however, Rg1 significantly increased the ratio of pnrf2/nrf2 protein expression compared to the Na2S2O4 treated group (P<0.001). CONCLUSION: The OGD/R process is induced in 661W cells using Na2S2O4. Rg1 inhibits OGD/R-induced oxidative damage and alleviates the extent of apoptosis in 661W cells through the keap1/nrf2 pathway. These results suggest a potential protective effect of Rg1 against retinal I/R injury.

Abstract:AIM: To evaluate effects of endogenous dopamine induced by low concentration atropine eye drops on choroidal neovascularization (CNV) in high myopia mice. METHODS: The C57BL/6J mice were deprived of the right eye for 4wk, and the high myopia was diagnosed by optometry, the diopter was less than -6.00 D, and CNV was induced by 532 nm laser. The changes of dopamine D1 receptor (DRD1), dopamine D2 receptor (DRD2), and vascular endothelial growth factor A (VEGFA) were detected by Western blot technology at 0.5, 1, 2h, and 7d after 0.01%, 0.05%, and 0.1% atropine eye drops, respectively, the area of CNV was measured. RESULTS: Significant increases were observed on the expression of DRD2 in mouse high myopia model at 0.5, 1, 2h, 7d with 0.05% and 0.1% atropine eye drops (P<0.05). Significant decreases were observed on the expression of DRD1 and VEGFA in mouse high myopia model at 0.5, 1, 2h, 7d with 0.05% and 0.1% atropine eye drops (P<0.05). The area of CNV induced by laser in the drug-treated group was significantly smaller than that in the control group, and the higher the concentration, the more significant the inhibitory effect (P<0.05). CONCLUSION: The 0.01%, 0.05%, 0.1% atropine eye drops can decrease the level of VEGFA and inhibit high myopia CNV indirectly by up-regulating the level of DRD2 and down-regulating the level of DRD1, and the effect of 0.05% and 0.1% atropine eye drops is more significant.

Abstract:AIM: To evaluate the difference and the correlation between the concentrations of cytokines in the aqueous humor of eyes with macular edema secondary to diabetic retinopathy (DR) or retinal vein occlusion (RVO). METHODS: This is a retrospective case control study. The aqueous humor samples were collected during intravitreal injection of anti-vascular endothelial growth factor (VEGF) for patients diagnosed with macular edema secondary to DR (DME) or RVO (RVO-ME) at Xijing Hospital from August 2021 to July 2022. Meanwhile, aqueous humor samples during vitrectomy from patients with idiopathic macular hole (IMH) were also collected and served as controls. The aqueous humor concentrations of VEGF, platelet-derived factor (PDGF), interleukin (IL)-6, IL-8, IL-18, tumor necrosis factor-α (TNF-α) and monocyte chemoattractant protein 1 (MCP-1) were measured with Human Premixed Multi-Analyte Kit (Luminex). The difference of the aqueous cytokines and the correlation between the two diseases were analyzed. RESULTS: A total of 40 eyes of 38 patients were enrolled in the study, including 13 eyes of 11 DME patients (DME group), 16 eyes of 16 RVO-ME patients (RVO-ME group) and 11 eyes of 11 IMH patients (control group). The VEGF, PDGF, IL-6, IL-8, and MCP-1 levels of the aqueous humor were higher in both DME and RVO-ME groups compared with the control group (all P<0.05), the levels of TNF-α was higher in the DME group than in the control group (P<0.05). The VEGF, IL-6, MCP-1, and TNF-α levels in the aqueous humor were significantly higher in the DR group than those in the RVO group (all P<0.05). Correlation analyses revealed that there were complex positive correlations between IL-6, IL-8, IL-18, MCP-1, and TNF-α levels in the aqueous humor of eyes with two diseases. CONCLUSION: Although ischemic and inflammatory factors are similarly involved in the pathogenesis of DME and RVO-ME, the roles of these factors are more significant or more likely to be activated in DR patients, suggesting different treatment strategies should be considered for the two diseases.

Abstract:AIM: To describe the subcutaneous pedicled propeller flap technique for the microscopic reconstruction of eyelid defects and evaluate its outcomes. METHODS: The clinical data of 23 patients (23 eyes) who underwent microscopic reconstruction of eyelid defects with the subcutaneous pedicled propeller flap technique were retrospectively analyzed. All patients underwent eyelid tumor resection and one-stage microscopic reconstruction with the subcutaneous pedicled propeller flap for anterior- or posterior-layer eyelid defects. The survival rate of the propeller flap, eyelid function and appearance, tumor recurrence rate, and patient satisfaction were evaluated after the surgery. RESULTS: The patients consisted of 12 men and 11 women, aged 31–82y (mean, 58.9y). The longest follow-up time was 5y, and the shortest was 3mo. All the propeller flaps survived well. There was no significant difference in color and luster between the flap and adjacent tissues, and there was no dog ear phenomenon. No obvious scarring was observed. There were no obvious abnormalities of eyelid morphology or function, and no adverse complications such as exposure keratitis, entropion, ectropion, ptosis, and eyelid retraction. No tumor recurrence was found at the time of the last follow-up. All patients were satisfied with the surgical results. CONCLUSION: The subcutaneous pedicled propeller flap technique for the microscopic reconstruction of eyelid defects has satisfactory outcomes in terms of eyelid function and esthetics, and merits clinical application.

Abstract:AIM: To evaluate the effect of lid scrubbing using a gel combining different natural extracts on ocular signs and symptoms of dry eye patients. METHODS: A retrospective study was performed on 19 dry eye patients (51.1±16.0y). Non-invasive tear break-up time, tear meniscus height, meibomian gland loss, lipid layer thickness, conjunctival redness, corneal staining, ocular surface disease index (OSDI), and ocular pain intensity were measured before (baseline), 1wk, and 2mo after lid scrubbing with a gel containing different natural extracts (okra extract, aloe vera leaf juice, hydrolysed soy protein, caffeine, citrus unshiu peel extract, and raspberry seed oil). RESULTS: Compared with the baseline, there was a statistically significant improvement in both first (P=0.048) and average (P=0.026) non-invasive tear break-up time 2mo after treatment, as well as in corneal staining (P=0.043, 0.012), OSDI (P<0.001), and ocular pain intensity (P<0.001) after 1wk and 2mo. In addition, there was no correlation between ocular signs and symptoms. CONCLUSION: The lid scrubbing with a gel combining different natural extracts show beneficial effects on tear film stability, corneal damage, and ocular symptoms, which is the reason why this therapeutic procedure is proposed as an alternative for dry eye management. However, it is not possible to attribute this beneficial effect solely to the presence of the natural extracts in the gel, primarily due to the absence of a negative control group.

Abstract:AIM: To investigate the effect of bicanalicular silicone tube intubation (BSTI) in the treatment of functional epiphora after endoscopic dacryocystorhinostomy (En-DCR). METHODS: Clinical data of 84 patients (95 eyes) with functional epiphora after En-DCR were retrospectively analyzed. Functional epiphora was confirmed as persistent or recurrent epiphora by fluorescein dye disappearance test (FDDT), lacrimal irrigation test, as well as endoscopic examination. Secondary BSTIs were recommended for patients with functional epiphora. These tubes were removed 1mo after surgery. Functional success and associated complications were assessed after 2y of follow-up. RESULTS: Seven patients (9 eyes) refused intervention, 5 patients (6 eyes) did not complete postoperative follow-up, and 1 patient (1 eye) developed tube prolapse within 1mo after surgery. Seventy-one patients (79 eyes) were included at last. Functional success ratios at six months, one year, as well as two years post-operation were 94.9% (75/79), 92.4% (73/79), and 91.1% (72/79), respectively. Three eyes presented with punctal slitting (2 eyes without epiphora), 1 eye with proximal canaliculus slitting, 1 eye with canaliculus stenosis and 4 eyes with still present functional epiphora without detectable abnormal at the last follow-up. CONCLUSION: Secondary intubation is an effective procedure with low recurrence probability for functional epiphora after En-DCR. Punctal and canaliculus injury are the main tube-associated complications after secondary intubation.

Abstract:AIM: To investigate whether the two-step strategy [conjunctival flap covering surgery (CFCS) combined with secondary deep anterior lamellar keratoplasty (DALK)] is effective for patients with high-risk fungal keratitis (FK). METHODS: In this noncomparative, retrospective case series, 10 subjects (6 males, 4 females) with a mean age of 56.5±7.1 (range 47-72)y with high-risk FK undergone the two-step strategy were included. Reported outcome measures were healing of the corneal ulcer, recurrence of FK, reject reaction, improvement in best corrected visual acuity (BCVA) and relevant complications. RESULTS: The average diameter of corneal infiltrates was 7.50±0.39 mm, ranging from 6.94 to 8.13 mm. The mean depth of corneal infiltrates was 422.4±77.1 μm, ranging from 350 to 535 μm. The mean corneal thickness was 597.4±117.3 μm, ranging from 458 to 851 μm. Hypopyon and endothelial plaques were presented in all patients. The period between the two steps was 3.65±0.9 (ranging from 3 to 5)mo. The graft diameter was 7.75±0.39 mm. At the last follow-up (average 9.25±3.39, ranging from 5.5 to 17mo), no fungal recurrence or graft rejection appeared, and all patients showed improvement of BCVA. One patient suffered from liver function impairment due to oral voriconazole for 4wk and recovered spontaneously after 1wk of drug withdrawal. CONCLUSION: The two-step strategy is safe and effective in the treatment of high-risk FK by transforming intentional therapeutic penetrating keratoplasty during acute infection to later optical DALK. It is a practical strategy, especially in areas lacking fresh donor corneas and eye bank services.

Abstract:AIM: To evaluate the safety and efficacy of posterior scleral application (a modified technique) of an antimetabolite mitomycin C-soaked sponge in trabeculectomy for patients with glaucoma. METHODS: This retrospective study included 101 patients (115 eyes) with glaucoma (aged 12–83y) who underwent trabeculectomy using a modified mitomycin C-soaked sponge placement method. A piece of 3.5×10 mm2 sponge was placed vertically and posteriorly with the long side perpendicular to the limbus. The mitomycin C concentration and exposure time were 0.2–0.5 mg/mL and 1–5min, respectively. Intraocular pressure, best-corrected visual acuity, and hypotensive medications were recorded at baseline and at the final visit. Complications, interventions required, and bleb morphology were recorded postoperatively. The primary outcome was trabeculectomy safety, including complications and bleb morphology; the secondary outcome was the trabeculectomy success rate. RESULTS: At the final follow-up [median 28mo, range 7–67mo and interquartile range (IQR) 13mo], the qualified (cumulative) success rate was 93.0% and the complete success rate was 60.0%. No bleb-related complications were observed. The mean height, extent, and vascularity grades were 0.6±0.9, 1.1±0.4, and 2.4±0.9, respectively. All Seidel tests were negative. The mean posteriority grade was 0.8±0.4. CONCLUSION: Trabeculectomy with the long side of a mitomycin C-soaked sponge placed perpendicular to the corneal limbus is safe and effective.

Abstract:AIM: To investigate the effect of Cionni-modified capsular tension ring (CTR) implantation in patients with severely traumatic subluxated cataracts. METHODS: All patients who totally had traumatic cataracts and lost zonule support and underwent cataract surgery were retrospectively analyzed. Corrected distance visual acuity (CDVA), extent of zonulysis, intraocular lens (IOL) position, intraoperative presentation, and complications were assessed. The primary outcomes included IOL centration stability and other postoperative complications. RESULTS: Twenty patients (20 eyes) were included in this study. The mean age in this study was 58.0±11.3y, and the average follow-up time was 17.3±12.8mo. Capsule bags were saved by Cionni-modified CTR. Nine eyes (45%) underwent simultaneously anterior vitrectomy due to the presence of vitreous in the anterior chamber. The preoperative mean CDVA was 0.83±0.24 logMAR, and the postoperative average CDVA was 0.23±0.30 logMAR (P<0.05). The horizontal and vertical IOL decentration after surgery was 0.27±0.12 mm and 0.41±0.19 mm, respectively; the vertical and horizontal IOL tilt after surgery was 5.5°±2.5° and 6.1°±2.2°, respectively. None of the eyes had obvious IOL decentration during the follow-up time. Eight eyes (40%) had posterior capsule opacification (PCO) that was severe enough to cause poor vision. Neodymium: YAG laser capsulotomy were performed on these eyes when the CTR was stabilized. CONCLUSION: With the help of Cionni-modified CTR, capsular bag preservation and better IOL concentration can be achieved without major complications in patients with severely traumatic subluxated cataracts.

Abstract:AIM: To evaluate corneal astigmatic outcomes of femtosecond laser-assisted arcuate keratotomies (FAKs) combined with femtosecond-laser assisted cataract surgery (FLACS) over 12mo follow-up. METHODS: Totally 145 patients with bilateral cataracts and no ocular co-morbidities were recruited to a single-centre, single-masked, prospective randomized controlled trial (RCT) comparing two monofocal hydrophobic acrylic intraocular lenses. Eyes with corneal astigmatism (CA) of >0.8 dioptres (D) received unpaired, unopened, surface penetrating FAKs at the time of FLACS. Visual acuity, subjective refraction and Scheimpflug tomography were recorded at 1, 6, and 12mo. Alpins vectoral analyses were performed. RESULTS: Fifty-one patients (61 eyes), mean age 68.2±9.6y [standard deviation (SD)], received FAKs. Sixty eyes were available for analysis, except at 12mo when 59 attended. There were no complications due to FAKs. Mean pre-operative CA was 1.13±0.20 D. There was a reduction of astigmatism at all post-operative visits (residual CA 1mo: 0.85±0.42 D, P=0.0001; 6mo: 0.86±0.35 D, P=0001; and 12mo: 0.90±0.39, P=0.0001). Alpins indices remained stable over 12mo. Overall, the cohort was under-corrected at all time points. At 12mo, 61% of eyes were within ±15 degrees of pre-operative astigmatic meridian. CONCLUSION: Unpaired unopened penetrating FAKs combined with on-axis phacoemulsification are safe but minimally effective. CA is largely under-corrected in this cohort using an existing unmodified nomogram. The effect of arcuate keratotomies on CA remained stable over 12mo.

Abstract:AIM: To identify and analyze the genotype of the patients with special ocular manifestations of familial vitreous amyloidosis (FVA) in a Chinese Han family. METHODS: Pars plana vitrectomy (PPV) surgery was performed on a 52-year-old Chinese woman presented with vitreous amyloidosis and progressive visual impairment, without evidence of cardiac, renal, gastrointestinal, central nervous system or peripheral nervous system dysfunction. During the surgery, the patient presented with a gray-white dense and thick cotton wool-like change in the vitreous body, accompanied by complete retinal detachment. Additionally, hard, free and movable yellow-white deposits were observed in the posterior pole and surrounding retina, the vitreous and subretinal deposits were examined by Congo red staining and immunohistochemical pathological examination, and whole exome sequencing was performed on blood samples from the patient and her cousin. RESULTS: During the operation, it was discovered that there was a complete detachment of the retina and a significant amount of hard, free-floating yellow-white deposits were observed beneath the posterior pole and surrounding retina. This is an exceedingly rare ocular manifestation. Pathological examination of the vitreous and subretinal deposit specimens revealed positive Congo red staining, as well as elevated vascular endothelial growth factor (VEGF) expression in vascular endothelial cells within the sediment specimens upon immunohistochemical examination. The patient and her cousin both exhibited a heterozygous mutation in Glyl03Arg within the transthyretin (TTR) gene, resulting in a substitution of glycine (Gly) at position 103 with arginine (Arg). CONCLUSION: FVA may present with various ocular manifestations, but panretinal detachment is a rare occurrence. In cases where retinal detachment persists for an extended period of time, amyloid deposits may form under the retina through retinal tears, leading to subretinal deposits that can impede retinal reattachment and negatively impact visual prognosis. Elevated levels of VEGF in the eyes of FVA patients may indicate an overexpression state, necessitating careful postoperative follow-up. The heterozygous mutation Gly103Arg may represent a unique pathogenic site in Chinese individuals.

Abstract:AIM: To compare the macular ganglion cell-inner plexiform layer (GCIPL) thickness, retinal nerve fiber layer (RNFL) thickness, optic nerve head (ONH) parameters, and retinal vessel density (VD) measured by spectral-domain optical coherence tomography (SD-OCT) and analyze the correlations between them in the early, moderate, severe primary angle-closure glaucoma (PACG) and normal eyes. METHODS: Totally 70 PACG eyes and 20 normal eyes were recruited for this retrospective analysis. PACG eyes were further separated into early, moderate, or severe PACG eyes using the Enhanced Glaucoma Staging System (GSS2). The GCIPL thickness, RNFL thickness, ONH parameters, and retinal VD were measured by SD-OCT, differences among the groups and correlations within the same group were calculated. RESULTS: The inferior and superotemporal sectors of the GCIPL thickness, rim area of ONH, average and inferior sector of the retinal VD were significantly reduced (all P<0.05) in the early PACG eyes compared to the normal and the optic disc area, cup to disc ratio (C/D), and cup volume were significantly higher (all P<0.05); but the RNFL was not significant changes in early and moderate PACG. In severe group, the GCIPL and RNFL thickness were obvious thinning with retinal VD were decreasing as well as C/D and cup volume increasing than other three groups (all P<0.01). In the early PACG subgroup, there were significant positive correlations between retinal VD and GCIPL thickness (except superonasal and inferonasal sectors, r=0.573 to 0.641, all P<0.05), superior sectors of RNFL thickness (r=0.055, P=0.049). More obvious significant positive correlations were existed in moderate PACG eyes between retinal VD and superior sectors of RNFL thickness (r=0.650, P=0.022), and temporal sectors of RNFL thickness (r=0.740, P=0.006). In the severe PACG eyes, neither GCIPL nor RNFL thickness was associated with retinal VD. CONCLUSION: The ONH damage and retinal VD loss appears earlier than RNFL thickness loss in PACG eyes. As the PACG disease progressed from the early to the moderate stage, the correlations between the retinal VD and RNFL thickness increases.

Abstract:AIM: To determine the incidence and predictive factors for epiretinal membrane (ERM) formation in eyes with complicated primary rhegmatogenous retinal detachment (RRD) tamponaded with silicone oil (SO). METHODS: This retrospective case-control study included 141 consecutive patients with (51 eyes) and without (90 eyes) ERM formation after primary pars plana vitrectomy (PPV) and SO tamponade for complicated RRD. The risk factors for ERM were assessed using logistic regression analysis. RESULTS: The prevalence of postoperative ERM was 36.2% (51/141). Multivariate logistic regression analysis showed that the risk factors for ERM in SO-tamponaded eyes included preoperative proliferative vitreoretinopathy [PVR; odds ratio (OR), 2.578; 95% confidence interval (CI) 1.580–4.205, P<0.001], preoperative choroidal detachment (OR, 4.454; 95%CI 1.369–14.498, P=0.013), and photocoagulation energy (OR, 2.700; 95%CI 1.047–6.962, P=0.040). The duration of the preoperative symptoms, intraocular SO tamponade time, giant retinal tear, preoperative vitreous hemorrhage, preoperative best-corrected visual acuity, number of breaks, quadrants of RRD, axial length, and photocoagulation points were not predictive factors for ERM formation. CONCLUSION: Preoperative PVR, choroidal detachment, and photocoagulation energy are risk factors of ERM formation after complicated RRD repair. Better ophthalmic care as well as patient education are necessary for such patients with risk factors.

Abstract:AIM: To analyze the differences, agreements, and correlation among total corneal power parameters generated by different instruments after myopic keratorefractive surgery. METHODS: The prospective cross-sectional study included patients who underwent myopic keratorefractive surgery and received measurements of corneal power 3mo after surgery. Automated keratometer was used for the measurement of simulated keratometry (SimK), swept-source optical coherence tomography (SS-OCT) based biometer for total keratometry (TK), anterior segment-OCT for real keratometry (RK), and Scheimpflug keratometer for the true net power (TNP), the total corneal refractive power (TCRP) and equivalent K-readings (EKR). The differences among these parameters were analyzed, and the agreements and correlation between SimK and other total corneal power parameters were investigated. RESULTS: A total of 70 eyes of 70 patients after myopic keratorefractive surgery were included. The evaluated corneal power parameters were as follows: SimK 38.32±1.93 D, TK 37.54±2.12 D, RK 36.64±2.09 D, TNP 36.56±1.97 D, TCRP 36.70±2.01 D, and EKR 37.55±2.00 D. Pairwise comparison showed that there were significant differences (P<0.001) among all parameters except for between TK and EKR, RK and TNP, RK and TCRP (P=1.000, 1.000, 1.000, respectively). The limits of agreement between SimK and TK, RK, TNP, TCPR, and EKR were 1.08, 1.08, 1.43, 1.48, and 1.73 D, respectively. All parameters showed good correlation with SimK, and the correlation coefficients were 0.995, 0.994, 0.983, 0.982, and 0.975. CONCLUSION: Among the corneal power parameters after myopic keratorefractive surgery, the value of SimK is the largest, followed by TK and EKR, with TCRP, RK, and TNP being the smallest. The differences among the parameters may be attributable to the different calculation principles. Correct understanding and evaluation of corneal power parameters can provide a theoretical basis for taking advantage of the total corneal power to improve the accuracy of intraocular lens calculation after keratorefractive surgery.

Abstract:AIM: To elucidate the safety and visual quality of implantable collamer lens with central hole (ICL V4c) implantation for correcting moderate and high myopia for at least 5y. METHODS: This retrospective study was conducted on 58 patients (114 eyes) who were followed up for at least 5y after ICL V4c implantation. The observation was done before and on 1d, 1mo, 1 and 5y or more after the surgical procedure. The visual acuity, subjective refraction, intraocular pressure, vault, axial length, central hole position, pupil diameter, visual quality, and adverse events were analyzed. The visual quality includes aberration, the modulation transfer function cutoff frequency (MTF cutoff), objective scattering index (OSI), Stroller’s ratio (SR), and visual quality questionnaire. RESULTS: The average follow-up period was 69.25±3.80mo (range 60–82mo) and the preoperative spherical equivalent (SE) was -8.66±1.97 D. At 5y after operation, the safety index was 1.01±0.02 and the efficacy index was 0.99±0.42 and SE was -0.65±0.63 D. The 59.6% of the eyes achieved an uncorrected distance visual acuity of 20/20, 76.3% of the eyes had SE within ±1.0 D at the last visit. The axial length increased by 0.29±0.71 mm 5y after the surgery (t=-3.843, P<0.001). The mean vault at the last follow-up was 510.59±245.61 μm. The central hole was on the temporal side in 80 eyes (84.2%). The visual quality questionnaire showed that 98.2% patients were satisfied with the surgical procedure. Adverse events occurred in 4 eyes (3.5%), including the posttraumatic toric ICL rotation (2 eyes), iris incarceration (1 eye), and posttraumatic ICL displacement (1 eye) at the last follow-up. CONCLUSION: Long-term ICL V4c implantation is safe, effective, and stable for correcting moderate and to high myopia, and the visual quality with patients is excellent and satisfactory, but the progression of axial length still needs attention after surgery.

Abstract:AIM: To provide comprehensive data on nonmetallic intraorbital foreign bodies (IOFBs) by summarizing and analyzing material types, clinical manifestations, imaging features, and treatment strategies. METHODS: Totally 28 nonmetallic IOFB cases treated at Shengjing Hospital of China Medical University from 2012 to 2020 were retrospectively reviewed. The types of foreign bodies, clinical features, imaging manifestations, and treatment outcomes were analyzed. RESULTS: Among all cases, 67.8% (19/28) of the foreign bodies were organic. The top three entrances were the upper eyelid skin (7/28), lower fornix conjunctiva (6/28), and lower eyelid skin (4/28). In most cases (11/28, 39.3%), foreign bodies remained in the medial orbits. The major clinical manifestations included eyelid redness and swelling (20/28, 71.4%), conjunctival congestion and edema (17/28, 60.7%), and ophthalmoptosis (15/28, 53.6%). Infection was the main complication, which occurred in 57.1% (16/28) of all cases. Computerized tomography (CT) values differed for different foreign bodies and varied in the different periods after injury. The plant- and grease-derived foreign bodies and the surrounding pus cysts showed different signals on magnetic resonance imaging (MRI). The prognosis varied with different foreign body types, surgery timing, and intraoperative management. CONCLUSION: The majority of nonmetallic IOFBs are organic and often remain in the superior, medial, and inferior areas of the orbit. Clinical manifestations vary owing to their different textures. CT and MRI facilitate the identification of foreign body materials. Plant-derived foreign bodies should be completely removed, and surgical treatment is a complicated process.

Abstract:AIM: To explore the relationship between ocular and systemic conditions and the impact of ocular complications on the quality of life (QOL) in patients after allogeneic hematopoietic stem cell transplantation (ALLO-HSCT). METHODS: Forty-four patients with severe hematopoietic disease were enrolled after ALLO-HSCT at our center from July 2018 to October 2020. They completed two questionnaires: the Ocular Surface Disease Index (OSDI) and the quality-of-life scale for Chinese patients with visual impairment (SQOL-DV1). Ocular conditions and systemic conditions were also assessed. RESULTS: Eye damage was correlated with total bilirubin (P=0.005), and gamma-glutamyl transferase (GGT) (P=0.021). There was no significant correlation between the overall QOL score and OSDI (P=0.8226) or SQOL-DV1 (P=0.9526) scores. The OSDI and the overall QOL score were not correlated with ocular conditions, including best-corrected visual acuity (BCVA), intraocular pressure, Schirmer tear test II, sodium fluorescein staining, tear film breakup time, and tear meniscus height. SQOL-DV1 was correlated with BCVA (P=0.0007), sodium fluorescein staining (P=0.007), and tear film breakup time (P=0.0146). CONCLUSION: In some patients, early ocular symptoms are not evident after ALLO-HSCT, while ocular surface complications can be observed after a comprehensive ophthalmological examination. Especially for those with elevated total bilirubin or GGT, regular ophthalmic follow-up visits are essential to diagnose and treat ocular graft versus host disease (oGVHD), especially for patients with elevated total bilirubin or GGT.

Abstract:AIM: To evaluate and compare the anatomical and functional outcomes and negative effects of the three anti-vascular endothelial growth factor (VEGF) drugs in the treatment of macular edema (ME) due to retinal vein occlusion (RVO) based on the evidence pooled from current clinical trials and observational studies. METHODS: A systematic literature search was conducted on nine online databases from inception until April 30, 2022. The main endpoints were best corrected visual acuity (BCVA), central macular thickness (CMT), and adverse events (AEs). Cumulative Meta-analysis was conducted to synthesize the outcomes of the drugs. The retrieved data were analyzed using Stata software (version 12.0). RESULTS: A total of 20 studies comprising 1674 eyes met the inclusion criteria to the Meta-analysis. It was observed that conbercept and aflibercept had better visual acuity effects compared with ranibizumab at 1mo [weight mean difference (WMD)=-0.03, P=0.001; WMD=-0.05, P=0.019], but the effects were not different from that of ranibizumab at 6mo. Moreover, there was not statistically significant difference in the proportion of patients gaining ≥15 letters at 12-24mo between aflibercept and ranibizumab [odds ratio (OR)=1.16, P=0.427]. Conbercept had higher mean CMT change effects at 1mo (WMD= -14.43, P=0.014) and 6mo (WMD=-35.63, P≤0.001) compared with ranibizumab. Meanwhile, the mean CMT change effects at 1mo (WMD=-10.14, P=0.170), 6mo (WMD=-26.98, P=0.140) and 12-24mo (WMD=-12.34, P=0.071) were comparable among the groups. Similarly, AEs were not significantly different among the treatments (OR=0.75, P=0.305; OR=1.04, P=0.89). The stability of effect size of mean BCVA and CMT improved with the increase in sample size. Aflibercept and conbercept required fewer injections compared with ranibizumab. CONCLUSION: This is the first study to evaluate the efficacy and AEs of intravitreal administration of conbercept, ranibizumab, and aflibercept in the treatment of RVO-ME. Intravitreal aflibercept or conbercept results in better mean change in vision and CMT reduction compared with ranibizumab. Conbercept can be considered to be a promising and innovative drug with good anti-VEGF effects.

Abstract:AIM: To determine and evaluate the features of highly cited articles (HCAs) in the ophthalmology category in the Science Citation Index Expanded (SCI-EXPANDED) from 1991 to 2020. METHODS: The Web of Science Core Collection documents with at least 100 citations from their publication year until December 31, 2020, were evaluated as highly cited. The examined features were the distribution of yearly output and its average number of per publication, HCAs, authors, institutions, journals, and nations. The publication performance of nations and organizations was assessed using six publication indicators. The Y-index was employed to compare the research outputs of various authors. RESULTS: Publications that had cited the most references were highly published in high-impact factor journals. The United States of America came out on top across all six publication indicators, and it was home to eight of the top 10 most productive institutions. The articles written by Breivik et al (2006) and Farrar et al (2001) were highly cited and had a significant impact in 2020. The authors had a higher number of highly cited articles published as corresponding authors than as first authors. CONCLUSION: The findings of the present study highlight the current scope of global research in ophthalmology. The findings can help policy-makers and advisory groups of research centers to develop future policies. In addition, the findings can guide researchers in this field.

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