Volume 13,Issue 7,2020 Table of Contents

1 Standard precaution measurements during ophthalmology practice in the pandemic stage of COVID-19

Ahmed Mohamed Reda , Wael M. Ahmed

2020, 13(7):1017-1022. DOI: 10.18240/ijo.2020.07.01

[Abstract](1556) [HTML](0) [PDF 1.39 M](736)

Abstract:
AIM: To take specific precautions and keep a safe practice during providing ophthalmology health services without compromising the patient’s safety as well as the team workers and the community in the pandemic stage of corona virus disease 2019 (COVID-19). METHODS: Applying patient circulation scheme implemented in our ophthalmology centers with the guidance of ministry of health infection control guidelines started from the moment that we receive a call or WhatsApp message or Facebook inquiry from patients until 21d after patients first visit if any. Four directions were taken. First, community awareness of the disease and the ophthalmology related advices in how eye can transfers the infection and how to protect our eyes not to be infected through videos interviews of our consultants and distribution in social media like Instagram, Facebook, WhatsApp pages radio and TV interviews as well as leaflet health awareness for distribution for public. Second, scheduling of patients’ appointments to prevent overcrowdings and cross infection. Third, protective measurements tools in the center to detect and prevent any exposure of the patients to patients and to protect medical staff, COVID-19 scoring system was set up to identify patients with fever, respiratory symptoms, acute conjunctivitis or recent travel to outbreak areas and to encourage these individuals to postpone their appointments for at least 21d. Proper use of personal protective equipment was implemented. Stopping all the elective surgeries keeping only the emergency types advised by fourth: how to deal with our patients if they need an urgent ophthalmological intervention and how to deal with suspected cases of corona if any cases detected. RESULTS: Our measures helped our colleagues to try to keep providing ophthalmology health services without increasing the incidence of infection for COVID-19 until this pandemic is over. CONCLUSION: In our practice, ophthalmologists should work with new aura of social media to facilitate the non-direct communication with the patients through maximizing the use of communication technology to keep contact with their patients and deal safely with COVID-19 cases.

2 Effect of natural extract eye drops in dry eye disease rats

Soo Youn Choi , Youngsub Eom , Jee Yong Kim , Dong Hoon Jang , Jong Suk Song , Hyo Myung Kim

2020, 13(7):1023-1030. DOI: 10.18240/ijo.2020.07.02

[Abstract](1362) [HTML](0) [PDF 1.39 M](728)

Abstract:
AIM: To investigate the therapeutic effect of natural extract eye drops containing bee venom, musk, and deer antlers in dry eye disease (DED) animal models. METHODS: Scopolamine-injected DED rats and lacrimal gland-excised rats were allocated into control, saline, and natural extract groups respectively and a normal group (lacrimal gland excision was not performed) in lacrimal gland-excised rats. After eye drop instillation 4 times a day for 5d, corneal fluorescein staining (CFS) scores, tear MUC5AC levels, and tear lactic dehydrogenase (LDH) levels were measured. RESULTS: In scopolamine-injected rats, the natural extract-treated group had significantly lower CFS scores (1.7±0.5, 4.7±1.4, 3.8±1.9, P=0.006) and tear LDH levels (0.10±0.01, 0.19±0.01, 0.16±0.08 OD, P=0.014) but higher tear MUC5AC levels (12.9±3.7, 7.9±2.0, 9.7±3.6 ng/mL, P=0.041) compared with the control and saline-treated groups. There were no significant differences between the control and saline-treated groups. In lacrimal gland-excised rats, the natural extract-treated group also had lower CFS scores (4.3±1.2, 11.5±2.3, 9.0±1.9, P<0.001, P=0.001) and tear LDH levels (0.30±0.08, 0.48±0.12, 0.39±0.05 OD, P<0.05) but higher tear volume (4.3±0.9, 1.9±0.7, 2.8±1.1 mm, P=0.005, P=0.124) and tear MUC5AC levels (8.2±2.0, 2.9±1.2, 5.4±2.2 ng/mL, P<0.001, P=0.047) compared with the control and saline-treated groups. There were no significant differences in the CFS scores, tear MUC5AC level, and tear LDH level between the normal and natural extract-treated groups. CONCLUSION: The natural extract consisting of bee venom, musk, and deer antlers may have effectiveness in DED treatment by restoring the damaged ocular surface, increasing tear volume, and recovering the tear mucin layer in DED rats.

3 Alarmins from conjunctival fibroblasts up-regulate matrix metalloproteinases in corneal fibroblasts

Lin Chen , Ye Liu , Xiao-Shuo Zheng , Hui Zheng , Ping-Ping Liu , Xiu-Xia Yang , Yang Liu

2020, 13(7):1031-1038. DOI: 10.18240/ijo.2020.07.03

[Abstract](1026) [HTML](0) [PDF 1.19 M](757)

Abstract:
AIM: To explore the effects of alarmins produced by necrotic human conjunctival fibroblasts on the release of matrix metalloproteinases (MMPs) by human corneal fibroblasts (HCFs). METHODS: A necrotic cell supernatant (NHCS) was prepared by subjecting human conjunctival fibroblasts to three cycles of freezing and thawing. The amounts of interleukin (IL)-1β and tumor necrosis factor (TNF)-α in NHCS were determined by enzyme-linked immunosorbent assays. HCFs exposed to NHCS or other agents in culture were assayed for the release of MMPs as well as for intracellular signaling by immunoblot analysis. The abundance of MMP mRNAs in HCFs was examined by reverse transcription and real-time polymerase chain reaction analysis. RESULTS: NHCS increased the release of MMP-1 and MMP-3 by HCFs as well as the amounts of the corresponding mRNAs in the cells. NHCS also induced activation of mitogen-activated protein kinase (MAPK) signaling pathways mediated by extracellular signal-regulated kinase (ERK), p38, and c-Jun NH2-terminal kinase (JNK) as well as elicited that of the nuclear factor (NF)-κB signaling pathway by promoting phosphorylation of the endogenous NF-κB inhibitor IκB-α. Inhibitors of MAPK and NF-κB signaling as well as IL-1 and TNF-α receptor antagonists attenuated the NHCS-induced release of MMP-1 and MMP-3 by HCFs. Furthermore, IL-1β and TNF-α were both detected in NHCS, and treatment of HCFs with these cytokines induced the release of MMP-1 and MMP-3 in a concentration-dependent manner. CONCLUSION: Alarmins, including IL-1β and TNF-α, produced by necrotic human conjunctival fibroblasts triggered MMP release in HCFs through activation of MAPK and NF-κB signaling. IL-1β and TNF-α are therefore potential therapeutic targets for the amelioration of corneal stromal degradation in severe ocular burns.

4 Blocking VEGF signaling augments interleukin-8 secretion via MEK/ERK/1/2 axis in human retinal pigment epithelial cells

Lin-Bin Zhou , Ye-Qi Zhou , Xin-Yu Zhang

2020, 13(7):1039-1045. DOI: 10.18240/ijo.2020.07.04

[Abstract](1229) [HTML](0) [PDF 997.46 K](904)

Abstract:
AIM: To identify proangiogenic factors engaged in neovascular age-related macular degeneration (AMD) except vascular endothelial growth factor (VEGF) from human retinal pigment epithelial (hRPE) cells and investigate the underlying mechanisms. METHODS: VEGF receptor 2 (VEGFR2) in ARPE-19 cells was depleted by siRNA transfection or overexpressed through adenovirus infection. The mRNA and the protein levels of interleukin-8 (IL-8) in ARPE-19 cells were measured by quantitative real-time polymerase chain reaction and enzyme-linked immunosorbent assay respectively. The protein levels of AKT, p-AKT, MEK, p-MEK, ERK1/2, p-ERK1/2, JNK, p-JNK, p38 and p-p38 were detected by Western blotting. A selective chemical inhibitor, LY3214996, was employed to inhibit phosphorylation of ERK1/2. Cell viability was determined by MTT assay. RESULTS: Knockdown of VEGFR2 in ARPE-19 cells robustly augmented IL-8 production at both the mRNA and the protein levels. Silencing VEGFR2 substantially enhanced phosphorylation of MEK and ERK1/2 while exerted no effects on phosphorylation of AKT, JNK and p38. Inhibiting ERK1/2 phosphorylation by LY3214996 reversed changes in VEGFR2 knockdown-induced IL-8 upregulation at the mRNA and the protein levels with no effects on cell viability. VEGFR2 overexpression significantly reduced IL-8 generation at the mRNA and the protein levels. CONCLUSION: Blockade of VEGF signaling augments IL-8 secretion via MEK/ERK1/2 axis and overactivation of VEGF pathway decreases IL-8 production in hRPE cells. Upregulated IL-8 expression after VEGF signaling inhibition in hRPE cells may be responsible for being incompletely responsive to anti-VEGF remedy in neovascular AMD, and IL-8 may serve as an alternative therapeutic target for neovascular AMD.

5 Identification of differentially expressed metastatic genes and their signatures to predict the overall survival of uveal melanoma patients by bioinformatics analysis

Dan-Dan Zhao , Xin Zhao , Wen-Tao Li

2020, 13(7):1046-1053. DOI: 10.18240/ijo.2020.07.05

[Abstract](1926) [HTML](0) [PDF 3.45 M](774)

Abstract:
AIM: To identify metastatic genes and miRNAs and to investigate the metastatic mechanism of uveal melanoma (UVM). METHODS: GSE27831, GSE39717, and GSE73652 gene expression profiles were downloaded from the Gene Expression Omnibus (GEO) database, and the limma R package was used to identify differentially expressed genes (DEGs). Gene Ontology (GO) term enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were performed using the DAVID online tool. A comprehensive list of interacting DEGs was constructed using the Search Tool for the Retrieval of Interacting Genes (STRING) database and Cytoscape software. The Cytoscape MCODE plug-in was used to identify clustered sub-networks and modules of hub genes from the protein-protein interaction network. GEPIA online software was used for survival analysis of UVM patients (n=80) from the The Cancer Genome Atlas (TCGA) cohort. OncomiR online software was used to find that the miRNAs were associated with UVM prognosis from the TCGA cohort. TargetScan Human 7.2 software was then used to identify the miRNAs targeting the genes. RESULTS: There were 1600 up-regulated genes and 1399 down-regulated genes. The up-regulated genes were mainly involved in protein translation in the cytosol, whereas the down-regulated genes were correlated with extracellular matrix organization and cell adhesion in the extracellular space. Among the 2999 DEGs, five genes, Znf391, Mrps11, Htra3, Sulf2, and Smarcd3 were potential predictors of UVM prognosis. Otherwise, three miRNAs, hsa-miR-509-3-5p, hsa-miR-513a-5p, and hsa-miR-1269a were associated with UVM prognosis. CONCLUSION: After analyzing the metastasis-related enriched terms and signaling pathways, the up-regulated DEGs are mainly involved in protein synthesis and cell proliferation by ribosome and mitogen-activated protein kinase (MAPK) pathways. However, the down-regulated DEGs are mainly involved in processes that reduced cell-cell adhesion and promoted cell migration in the extracellular matrix through PI3K-Akt signaling pathway, focal adhesion, and extracellular matrix-receptor interactions. Bioinformatics and interaction analysis may provide new insights on the events leading up to the development and progression of UVM.

6 Dystrophia canthorum in Waardenburg syndrome with a novel MITF mutation

Xia-Jing Tang , Xi-Yuan Ping , Chen-Qi Luo , Xiao-Ning Yu , Ye-Lei Tang , Xing-Chao Shentu

2020, 13(7):1054-1059. DOI: 10.18240/ijo.2020.07.06

[Abstract](1160) [HTML](0) [PDF 1.66 M](706)

Abstract:
AIM: To reveal a novel MITF gene mutation in Waardenburg syndrome (WS), which is an autosomal dominant inherited neurogenic disorder that consists of various degrees of sensorineural deafness and pigmentary abnormalities in the eyes, hair and skin. METHODS: The genetic analysis of the Chinese family was conducted by whole-exome sequencing, then the results were confirmed by Sanger sequencing. RESULTS: WS is classified into type I to IV, which are identified by the W index, clinical characteristics and additional features. The MITF gene mostly accounts for WS type II. In this study, a de novo heterozygous mutation in the MITF gene, c.638A>G in exon 7, was identified in the patient diagnosed with WS type I features, as the W index was 2.17 (over 2.10), with dystrophia canthorum, congenital bilateral profound hearing loss, bilateral heterochromia irides, premature greying of the hair, and excessive freckling on the face at birth. She also underwent refractive errors and esotropia, reduced pigmentation of the choroid and visible choroid vessels. The mutation was not found in previous studies or mutation databases. CONCLUSION: The novel mutation in the MITF gene, which altered the protein in amino acids 213 from the glutamic acid to glycine, is the genetic pathological cause for WS features in the patient. Those characteristics of this family revealed a novel genetic heterogeneity of MITF in WS, which expanded the database of MITF mutations and offered a possible in correcting the W index value of WS in distinct ethnicities. Moreover, ocular symptoms should be emphasized in all types of WS patients.

7 Objective optical quality and visual outcomes after the PresbyMAX monocular ablation profile

Dan Fu , Jing Zhao , Xing-Tao Zhou

2020, 13(7):1060-1065. DOI: 10.18240/ijo.2020.07.07

[Abstract](1204) [HTML](0) [PDF 462.69 K](754)

Abstract:
AIM: To assess objective visual quality after presbyopia correction using the PresbyMAX monocular mode. METHODS: This prospective, nonrandomized study included 28 eyes from 18 patients (mean age 50.4±5.6y) who underwent presbyopia correction with the PresbyMAX monocular mode. Monocular and binocular visual acuities were evaluated preoperatively, 1d, 1wk, 1, 3mo, and 1y after surgery. Optical quality was analyzed by Hartmann-Shack wavefront aberration supported cornea ablation. Modulation transfer function (MTF) cutoff frequency, Strehl ratio, and objective scattering index (OSI) were analyzed using an optical quality analysis system. RESULTS: One year after surgery, 100% and 94.4% of patients achieved binocular uncorrected distance and near visual acuity of 20/25, respectively. At the last visit Spherical aberration and total higher aberration were higher than the corresponding preoperative levels (P<0.001); however, no significant difference was found in MTF, OSI, or Strehl ratio. Transient decreases in OSI and MTF mainly occurred in the nondominant eyes. There was no significant difference in optical quality between the dominant and nondominant eyes, except for spherical aberration and horizontal coma (P<0.05). CONCLUSION: The PresbyMAX monocular mode is safe and effective for presbyopia correction. It has little effect on optical quality, though short-term degraded optical quality occurred mainly in the bi-aspheric ablated eyes.

8 Evaluation of chronic ocular sequelae in patients with symblepharon caused by ocular burns

Liang-Bo Chen , Si-Yi Zhang , Chen-Xi Yan , Qin-Ke Yao , Chun-Yi Shao , Yao Fu

2020, 13(7):1066-1073. DOI: 10.18240/ijo.2020.07.08

[Abstract](1080) [HTML](0) [PDF 1.75 M](620)

Abstract:
AIM: To evaluate chronic ocular sequelae in patients with symblepharon caused by ocular burns and propose an objective grading system. METHODS: This was a retrospective, single-center clinical study. Patients with symblepharon caused by ocular burns at least six months later were assessed. Chronic ocular sequelae were classified into 3 categories (eyelid, conjunctiva, and cornea) and 9 chronic ocular sequelae [friction factors, exposure factors, conjunctival hyperemia, length of symblepharon, scope of adhesion, lacrimal area adhesion, loss of the palisades of Vogt (POV), corneal neovascularization, and corneal opacification]. Each ocular sequela was graded from 0 to 3, depending on the increasing severity. The 9 ocular sequelae were evaluated to obtain the total severity score for each eye. The total severity score was defined as Grade I (1-9), Grade II (10-18), and Grade III (19-27). Moreover, the correlation between the severity of chronic ocular sequelae and visual acuity, surgical strategy, and the prognosis was analyzed, respectively. RESULTS: Cases of 79 eyes with symblepharon caused by ocular burns were included in this study. Of these, 20 (25.32%) were defined as Grade I, 43 (54.43%) as Grade II, and 16 (20.25%) as Grade III. Eyes with a high total severity score had reduced visual acuity, required complicated surgery strategies, and poor prognosis (P<0.001). Multivariate regression analysis showed that the scope of adhesion, corneal opacification, and corneal neovascularization significantly affected visual acuity, surgical strategy, and prognosis (all P<0.001). CONCLUSION: The evaluation of chronic ocular sequelae enabled the development of an objective grading system for patients with symblepharon caused by ocular burns. This grading system can be applied to guide the treatment and predict the prognosis.

9 Medical treatment of inflammatory punctual stenosis monitored by anterior segment optical coherence tomography

Hanan Youssef Elalfy , Mahmoud A Elsamkary , Ahmed M Shafek Elridy , Tarek M Saad , Saad Mohamed Rashad , Samah M Fawzy

2020, 13(7):1074-1078. DOI: 10.18240/ijo.2020.07.09

[Abstract](1144) [HTML](0) [PDF 1.22 M](648)

Abstract:
AIM: To evaluate the role of medical treatment in the management of inflammatory punctum stenosis guided by spectral domain anterior segment optical coherence tomography (OCT). METHODS: This prospective study included 60 patients complaining of epiphora due to inflammatory punctual stenosis. They were divided into two groups: Group A (30 patients) treated with a combination of preservative free hydrocortisone sodium phosphate 3.35 mg/mL eye drops, and preservative free artificial tears based on sodium hyaluronate, polyethylene and propylene Glycol; Group B (30 patients) treated with the same preservative free artificial tears only. Thirty normal subjects were included for comparison of pre-treatment anatomical parameters. Before starting treatment, all patients underwent anterior segment assessment including slit lamp examination, measurement of intraocular pressure (IOP), fluorescein dye disappearance test, and measurement of the outer punctum diameter (OPD) by Spectral domain anterior segment OCT. All assessments were repeated at each follow up done at 1 and 3mo later, together with subjective evaluation of patient’s satisfaction of the treatment outcome by simple rating questionnaire. RESULTS: Punctual diameter increased significantly with treatment in both groups (P<0.0001); although the widening was more in Group A as compared to group B (16.2% vs 8% of the original punctual size, mean difference of 28.933 μm, P=0.0076). Subjective satisfaction with treatment outcome was also better in group A (70% vs 40%, Chi-square P=0.0397). CONCLUSION: A combination of preservative free steroid eye drops and artificial tears causes significant widening of inflammed stenotic punctae and improvement of the associated epiphora.

10 Conjunctival flap advancement with or without scleral graft for hypotony maculopathy after trabeculectomy

Abdelhamid Shaker Elhofi , Mohamed Fahmy Doheim , Amir AbouSamra

2020, 13(7):1079-1086. DOI: 10.18240/ijo.2020.07.10

[Abstract](653) [HTML](0) [PDF 2.35 M](626)

Abstract:
AIM: To investigate the outcomes of adaptive conjunctival flap advancement surgical techniques with or without scleral graft for patients undergoing revision surgery after trabeculectomy. METHODS: This retrospective study included 28 eyes of 28 subjects from December 2015 to April 2018. A group of 15 eyes underwent conjunctival advancement only while the other 13 eyes did conjunctival advancement with partial thickness scleral graft. In both study groups, we considered the intraocular pressure (IOP) as our primary outcome and visual acuity (VA) as our secondary outcome. Both were assessed pre- and post-operatively till the last follow-up possible point. Additionally, we classified the patients according to complete and qualified success criteria. RESULTS: The mean age of the conjunctival advancement group was 36.87±19.25y, while it was 44.08±18.04 in the other group. In both study groups, the mean IOP significantly increased after revision surgery at 1, 2, 3mo and the last follow-up visit when compared to prior the surgery (P<0.001). Moreover, VA was significantly improved (P=0.03) in the final follow-up for both surgical techniques. When we compared the change from baseline in both groups, there was no significant difference between IOP improvement in 1mo (P=0.263), while the difference was significant in 2mo (P=0.03), 3mo (P=0.02) and in the final follow-up visit postoperatively. However, this difference was not significant regarding VA (P=0.5). CONCLUSION: The both adaptive techniques of conjunctival advancement and conjunctival advancement with scleral graft are effective for treating patients with late-onset hypotony. Yet, more prospective studies are needed to assert upon these results.

11 Subconjunctival injections of triamcinolone acetonide to treat uveitic macular edema

Yi Qu , Xin-Shu Liu , An-Yi Liang , Jun-Yan Xiao , Chan Zhao , Fei Gao , Mei-Fen Zhang

2020, 13(7):1087-1091. DOI: 10.18240/ijo.2020.07.11

[Abstract](1074) [HTML](0) [PDF 546.79 K](652)

Abstract:
AIM: To evaluate the efficacy and safety of subconjunctival triamcinolone acetonide (TA) injections for treating uveitic macular edema (UME). METHODS: This retrospective case series study included patients with UME who received subconjunctival TA injections with a minimum follow-up period of 6mo. The main outcome measure was central macular thickness (CMT). The secondary outcome measures included best-corrected visual acuity (BCVA), recurrence rate and intraocular pressure (IOP). RESULTS: In total, 65 patients (80 eyes), mainly including idiopathic uveitis in 33 patients (50.77%) and Vogt-Koyanagi-Harada (VKH) syndrome in 19 patients (29.23%), were enrolled in this study. The mean CMT decreased from 457.6±173.0 μm at baseline to 325.9±176.8, 302.7±148.2, 332.2±177.3 and 270.6±121.6 μm at 1-, 2-, 3- and 6-months postinjection, respectively (all P<0.001). BCVA increased from logMAR 0.5±0.3 at baseline to logMAR 0.4±0.3, 0.4±0.3, 0.4±0.4 and 0.4±0.3 at the 1-, 2-, 3- and 6-months postinjection visits, respectively (all P<0.001). Twenty-one (21/80, 26.25%) eyes underwent relapse of UME within 6mo. A total of 20/80 (25%) eyes exhibited elevated IOPs, of which 13 eyes were controlled with topical IOP-lowering agents and 7 eyes underwent surgical removal of subconjunctival TA deposit. CONCLUSION: Subconjunctival TA injections appear to be safe and effective for UME.

12 Efficiency analysis by mfERG and OCT of intravitreal injection with ranibizumab on diabetic macular edema

Hong-Xia Bian , Meng-Ting Bian , Wei-Hong Liu , Rui-Ying Liu , Mi Guo

2020, 13(7):1092-1096. DOI: 10.18240/ijo.2020.07.12

[Abstract](911) [HTML](0) [PDF 446.70 K](604)

Abstract:
AIM: To analyze the clinical efficacy of intravitreal injection of ranibizumab (IVR) on diabetic macular edema (DME) with multifocal electroretinography (mfERG) and optical coherence tomography (OCT). METHODS: A total of 41 patients (41 eyes) with DME were treated with IVR. The best corrected visual acuity (BCVA), mfERG results, and OCT were analyzed to compare to the baselines at 1wk, 1, and 3mo after operation. RESULTS: The BCVA was significantly improved in all eyes at each time point (P<0.001). The macular area leakage and edema were reduced 1wk and 1mo after IVR, and the central fovea thickness (CFT) was significantly reduced compared to baseline (P<0.001). The mfERG, two-dimensional and three-dimensional images all showed that the macular fovea (1 ring) response density decreased, and the fovea and macular area spikes significantly decreased or disappeared. The amplitude density of the P1 wave was increased, and the latency of the P1 wave was shortened than preoperation (P<0.001). At 1wk and 1mo after the operation, there was a negative correlation between the amplitude density of P1 waves and CFT. CONCLUSION: OCT and mfERG fully demonstrate the importance of IVR for DME patients from the macular morphology and function, especially the significance of mfERG in this disease.

13 Application of pediatric ocular trauma score in pediatric open globe injuries

Chao Xue , Li-Chun Yang , Yi-Chun Kong

2020, 13(7):1097-1101. DOI: 10.18240/ijo.2020.07.13

[Abstract](1189) [HTML](0) [PDF 412.38 K](641)

Abstract:
AIM: To evaluate the predictive value of pediatric penetrating ocular trauma score (POTS) on the visual outcome in children with open globe injury. METHODS: A retrospective study in 90 children (60 males and 30 females) aged 1-15y (average, 7.48±2.86y) with penetrating ocular trauma was performed. Each patient’s POTS was calculated. The effects of POTS on final visual acuity (FVA) were examined. Correlation between factors affecting POTS and the FVA was established. RESULTS: All patients presented with single-eye trauma. The follow-up time was 3-21mo (average, 10.23±3.54mo). Among the 90 cases of penetrating wounds, 71 eyes (78.89%) were injured in Zone I (wound involvement limited to the cornea, including the corneoscleral limbus), 17 eyes (18.89%) were injured in Zone II (wound involving the sclera and no more posterior than 5 mm from the corneoscleral limbus), and 2 eyes (2.22%) were injured in Zone III (wound involvement posterior to the anterior 5 mm of the sclera). Analysis of POTS and FVA showed important correlation between them (r=0.414, P=0.000). Initial visual acuity (P=0.00), age (P=0.02), injury location (P=0.002), traumatic cataract (P=0.00), vitreous hemorrhage (P=0.027), retinal detachment (P=0.003), and endophthalmitis (P=0.03) were found to be statistically significant factors for the FVA outcome. CONCLUSION: Ocular trauma presents serious consequences and poor prognosis in children. The POTS may be a reliable prognostic tool in children with open globe injury.

14 Physical activity of patients with a primary open angle glaucoma

Halina Olszewska , Joanna Kosny , Piotr Jurowski , Anna Jegier

2020, 13(7):1102-1108. DOI: 10.18240/ijo.2020.07.14

[Abstract](870) [HTML](0) [PDF 755.68 K](659)

Abstract:
AIM: To assess physical activity (PA) including its intensity in primary open angle glaucoma (POAG). METHODS: PA was characterized by the use of questionnaires: Seven-Day Physical Activity Recall and Historical Leisure Activity Questionnaire. A questionnaire of 36 questions, developed by the authors, was used to assess the level of knowledge about glaucoma RESULTS: The study was conducted among 625 adults. The study group comprised 312 POAG patients aged over 40y, including 238 women (76%) and 74 men (24%). The control group consisted of 313 adults (>40 years old), including 202 (65%) women and 111 men (35%). The duration of current PA with an intensity of 4 metabolic equivalents (METs) was significantly shorter among people with POAG. PA in the past was significantly lower among people from the study group, regardless of gender. The level of glaucoma knowledge in patients with POAG was poor and significantly lower in men. CONCLUSION: Regular PA is an important and underestimated factor predisposing to the progression of POAG. There is a necessity to undertake educational and preventive actions with a view to modify the health behavior of glaucoma patients.

15 Fractal analysis of retinal vasculature in normal subjects on ultra-wide field fluorescein angiography

Wen-Ying Fan , Alan Fleming , Gavin Robertson , Akihito Uji , Jano van Hemert , Michael Singer , Min Sagong , Michael Ip , SriniVas R. Sadda

2020, 13(7):1109-1114. DOI: 10.18240/ijo.2020.07.15

[Abstract](902) [HTML](0) [PDF 777.05 K](655)

Abstract:
AIM: To evaluate the fractal feature of the retinal vasculature of normal eyes on a stereographic projected and montaged ultra-wide field (UWF) fluorescein angiography (FA). METHODS: Prospective, observational, cross-sectional study. Totally 59 eyes of 31 normal subjects were imaged using the Optos 200Tx. Images obtained at different gaze angles stereographically projected and montaged. The early-phase UWF FA frames were processed to segment the retinal vasculature and the results were exported as binary masks. The fractal dimension (FD) was calculated using the box-counting method. RESULTS: The global FD for the entire retina was 1.6±0.04, with no difference between males and females (1.59±0.04 vs 1.61±0.04, P=0.084) or between right and left eyes (1.6±0.04 vs 1.6±0.05, P=0.61). FD was non-uniformly distributed among four quadrants (P<0.001) and decreased as the distance from the fovea increased (P<0.001). A negative association was observed between FD and age (R=-0.37, P=0.006), and this relationship was observed in the posterior and mid-peripheral retina (P<0.05) but absent in far-periphery (P>0.05). CONCLUSION: Fractal geometry is non-uniformly distributed across the retina in normal eyes and decreases from the fovea to the far-periphery. Subjects with an older age tend to have a smaller FD, however, the FD in the far-periphery does not appear to be influenced by age.

16 Knowledge, attitudes and practices related to seeking medical eyecare services by adults with moderate-to-severe visual impairment in rural Yueqing, Wenzhou, China: a cross-sectional survey

Lin-Shan Li , Zheng-Yan Ge , Lynne Lohfeld , Kun Zhou , Wei-He Zhou , Le-Le Cui , Jia Qu , Yuan-Bo Liang

2020, 13(7):1115-1123. DOI: 10.18240/ijo.2020.07.16

[Abstract](1265) [HTML](0) [PDF 517.78 K](753)

Abstract:
AIM: To evaluate the knowledge, attitudes, and practices regarding eye-care seeking practices of visually impaired adults in a rural area Yueqing, and explore factors influencing their behavior. METHODS: A stratified sampling method was used to select 48 villages in Yueqing, from which 2400 people were selected to receive vision screenings conducted by oculists during a household visit. Those presenting visual acuity≥0.5 logMAR in either eye completed a self-designed questionnaire investigating their knowledge about medical eye-care seeking, attitudes about eye health and eye-care-seeking behavior. RESULTS: Totally 165 people with moderate-to-severe visual impairment were identified (6.9%, 165/2400), and 146 eligible participants were recruited (response rate: 88.4%, mean age: 68.6±15.0y), among which 88 (60.3%) were female. They had 82 (56.2%) and 64 (43.8%) monocular and binocular visual impairments respectively. A total of 67 (45.9%) subjects demonstrated a high knowledge level about medical eye-care seeking and 88 (60.3%) had self-rated poor vision, with 23 (15%) receiving regular vision checks. The 105 (71.9%) subjects had never been to hospital for an eye examination. “No need” and “schedule conflicts” were the main reasons for not seeking eye care. Having extensive knowledge of medical eye-care seeking was positively associated with high education levels (OR=3.73, P=0.045) and negatively correlated with older age (OR=0.97, P=0.043). Both the self-perceived vision condition (OR=2.59, P=0.03) and regular vision check behavior (OR=6.50, P<0.01) were related with seeking eye care services. CONCLUSION: In rural Yueqing, intervention is required to increase public knowledge about seeking medical eye care among people with moderate-to-severe visual impairment, especially for the elderly and poorly education. Regular vision checks may be useful to promote their medical eye-care utilization.

17 Effect of rigid gas permeable contact lens on keratoconus progression: a review

Xiao-Han Zhang , Xuan Li

2020, 13(7):1124-1131. DOI: 10.18240/ijo.2020.07.17

[Abstract](2233) [HTML](0) [PDF 362.60 K](954)

Abstract:
The prevalence of keratoconus is 1/2000 in the general population and is high in adolescents. Keratoconus is a progressive disease, which has a great impact on patients’ quality of life and mental health. It can be managed by surgical and non-surgical means, rigid gas permeable (RGP) contact lens as its main non-surgical method is widely used in clinic. The efficacy of wearing RGP contact lens has been confirmed to some extent, but some studies have found that wearing RGP contact lens has adverse effects, which may promote disease progression. In this paper, the advantages and disadvantages of RGP contact lens in controlling keratoconus were reviewed to provide more suggestions and references for the clinical application of RGP contact lens.

18 Characterization, passive and active treatment in strabismic amblyopia: a narrative review

Myriam Milla , David P. Piñero

2020, 13(7):1132-1147. DOI: 10.18240/ijo.2020.07.18

[Abstract](2163) [HTML](0) [PDF 1.08 M](825)

Abstract:
Strabismic amblyopia is characterized by a distorted spatial perception. In this condition, the neurofunctional disorder occurring during first years of life provoke several monocular and binocular anomalies such as crowding, deficits in the accommodative response, contrast sensitivity, and ocular motility abilities. The inhibition of the binocular function of the brain by the misaligned amblyopic eye induces a binocular imbalance leading to interocular suppression and the reduction or lack of stereoacuity. Passive treatments such as occlusion, optical and/or pharmacological penalization, and Bangerter foils has been demonstrated to be potentially useful treatments for strabismic amblyopia. Recent researches have proved new pharmacological options to improve and maintain visual acuity after occlusion treatment in strabismic amblyopia. Likewise, the active vision therapy, in the last years, is becoming a very relevant therapeutic option in combination with passive treatments, especially during and after monocular therapy, in the attempt of recovering the imbalanced binocular vision.

19 Changes of lactate dehydrogenase in corneal edema after cataract surgery treated with trans-corneal oxygenation therapy

Eunike Amelina Lahagu , Jajah Fachiroh , Andreas Surya Anugrah , Wasisdi Gunawan , Indra Tri Mahayana , Suhardjo

2020, 13(7):1148-1151. DOI: 10.18240/ijo.2020.07.19

[Abstract](871) [HTML](0) [PDF 400.11 K](796)

Abstract:
AIM: To investigate the changes in levels of the lactate dehydrogenase (LDH) enzyme in corneal edema after cataract surgery with trans-corneal oxygenation therapy. METHODS: This pre-post design study design conducted on 15 patients with corneal edema after cataract surgery and receiving trans-corneal oxygenation therapy. Tear sample (using Schirmer paper, from the inferior fornix of the conjunctiva) was carried out prior to trans-corneal oxygenation therapy, on the day 2 (D2) and day 5 (D5) postoperatively before and after trans-corneal oxygenation therapy. Visual acuity [VA (LogMAR)], corneal endothelial density, central corneal thickness (CCT), and coefficient of variation corneal endothelial (CoV) were recorded. The value of LDH was measured using ELISA. The difference in mean LDH value before and after trans-corneal oxygenation therapy, between two groups were analyzed using Wilcoxon signed rank test. RESULTS: There was a decrease in LDH tear concentration at D2 (pre vs post: 1127.54±497.09 vs 696.91±489.49; P=0.002) and D5 (pre vs post: 1064.17±677.77 vs 780.28±428.95; P=0.027) after trans-corneal oxygenation therapy as well as decrease in LDH concentration on the D2 compared to D5 (P=0.041). The mean CCT was decreased significantly after the administration of trans-corneal oxygenation (pre vs post: 632.10±25.66 vs 563.90±51.54; P=0.005). The mean VA and CoV increased significantly after the administration of trans-corneal oxygenation (P=0.001 and P=0.028, respectively). However, there was no difference in mean of corneal endothelial density (P=0.814). CONCLUSION: Trans-corneal oxygenation therapy is associated with significant decrease of tears LDH levels in post cataract surgery with corneal edema. It is accompanied by clinical improvement such as significant reduction of CCT.

20 Simple transscleral fixation of IOL technique without tying up haptics

Junsung Lee , Jae-Yong Jang , Yong-Sok Ji

2020, 13(7):1152-1155. DOI: 10.18240/ijo.2020.07.20

[Abstract](929) [HTML](0) [PDF 814.77 K](591)

Abstract:
AIM: To introduce a novel technique for transscleral fixation of the posterior chamber intraocular lens (PC-IOL) that requires no sutures on the IOL haptics. METHODS: Instead of suturing polypropylene onto the IOL haptics, the method simply winds the thread on the haptics. Fifteen eyes of 15 patients underwent this technique and were followed up for more than 18mo. Surgical outcomes and post-operative complications were evaluated and compared with those of the conventional transscleral fixation method. RESULTS: Postoperative cylinder was significantly lower in the thread winding group than in the conventional transscleral fixation method group (-1.02±0.46 diopters vs -1.57±0.77 diopters; P=0.01). Further, no postoperative complications, such as optic capture, IOL dislocation, and hyphema, were detected in the thread winding group. CONCLUSION: We believe that our thread winding technique is better than previously reported methods because it is simple, mechanically stable, and free from suture-related complications.

21 Surgical management of non-syndromic ectopia lentis

Kirk AJ Stephenson , Michael O'Keefe , David J Keegan

2020, 13(7):1156-1160. DOI: 10.18240/ijo.2020.07.21

[Abstract](766) [HTML](0) [PDF 411.75 K](665)

Abstract:
AIM: To compare whether aphakic contact lenses or secondary iris-claw intraocular lenses are superior in the refractive management post-pars plana vitreolensectomy in a pedigree with an FBN1 mutation causing non-syndromic ectopia lentis (NSEL) with retinal detachment (RD). METHODS: Eight affected individuals had pars plana vitreolensectomy for bilateral ectopia lentis (EL). Twelve eyes of 6 patients had secondary iris-claw intraocular lenses inserted and 4 eyes of 2 patients were managed with contact lenses. Rhegmatogenous retinal detachment (RRD) was treated when necessary. Pre- and post-operative assessment included visual acuity, endothelial cell count and dilated fundal examination. RESULTS: Macula-on RRD was present in all individuals >18y, 64% (7/11 eyes) presenting post-vitreolensectomy with 57% having bilateral non-synchronous RRD. Surgical aphakia was managed with iris-fixated intraocular lenses (IOL group, n=6), or contact lenses (CL group, n=2). Visual acuity ≥0.3 logMAR (driving standard) was achieved in 75% of IOL group eyes and 25% of the CL group eyes. Mean loss of corneal endothelial cell count in the IOL group was 4% at 2y post-operative. CONCLUSION: In this cohort, refractive management with iris-claw IOLs provided superior outcomes to contact lenses and the authors recommend this as the optimal refractive correction in EL patients.

22 Perioperative management by WeChat under the haze of COVID-19

Yin-Hao Wang , Li-Ming Zhao , Zi-Yuan Liu , Xue-Min Li

2020, 13(7):1161-1163. DOI: 10.18240/ijo.2020.07.22

[Abstract](1206) [HTML](0) [PDF 369.24 K](622)

Abstract:

23 Corneal ulcer possibly caused by the opportunistic pathogen Schizophyllum commune

Xian-Ning Liu , Yan Cheng , Ya-Ni Wang , Jie Wu , Chao Liu , Na An

2020, 13(7):1164-1166. DOI: 10.18240/ijo.2020.07.23

[Abstract](751) [HTML](0) [PDF 697.39 K](569)

Abstract:

24 Histological observation of trabecular meshwork in a patient with Axenfeld-Rieger syndrome—a new theory for the mechanism of ectropion uvea in congenital glaucoma

Satoru Kase , Shinki Chin , Teruhiko Hamanaka , Yasuhiro Shinmei , Takeshi Ohguchi , Susumu Ishida

2020, 13(7):1167-1169. DOI: 10.18240/ijo.2020.07.24

[Abstract](945) [HTML](0) [PDF 1017.53 K](622)

Abstract:

25 Subtenon retrobulbar hyaluronidase injection for ophthalmic artery occlusion following facial filler injection

Hye Rim Choe , Se Joon Woo

2020, 13(7):1170-1172. DOI: 10.18240/ijo.2020.07.25

[Abstract](1096) [HTML](0) [PDF 751.25 K](603)

Abstract:

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Volume 13,Issue 7,2020 Table of Contents