Volume 15,Issue 4,2022 Table of Contents

1 Clinical outcome of orbital apex syndrome in COVID associated mucormycosis patients in a tertiary care hospital

Smiti Rani Srivastava , Purban Ganguly , Debasis Barman , Sudip Das , Manimoy Bandyopadhyay , Asim Kumar Ghosh , Subhra Sarkar , Amitabha Sengupta , Sarbari Swaika , Pritam Chatterjee , Amit Kumar Gupta , Alok Ranjan Mondal , Soumyajit Guha , Sinjita Dutta , Souvik Adhikari , Aditi Kaushik , Partha Sundar Biswas , Asif Ayub

2022, 15(4):527-532. DOI: 10.18240/ijo.2022.04.01

[Abstract](740) [HTML](0) [PDF 857.36 K](572)

Abstract:
AIM: To share clinical pattern of presentation, the modalities of surgical intervention and the one month post-surgical outcome of rhino-orbito-mucormycosis (ROCM) cases. METHODS: All COVID associated mucormycosis (CAM) patients underwent comprehensive multidisciplinary examination by ophthalmologist, otorhinolaryngologist and physician. Patients with clinical and radiological evidence of orbital apex involvement were included in the study. Appropriate medical and surgical intervention were done to each patient. Patients were followed up one-month post intervention. RESULTS: Out of 89 CAM patients, 31 (34.8%) had orbital apex syndrome. Sixty-six (74.2%) of such patients had pre-existing diabetes mellitus, 18 (58%) patients had prior documented use of steroid use, and 55 (61.8%) had no light perception (LP) presenting vision. Blepharoptosis, proptosis, complete ophthalmoplegia were common clinical findings. Seventeen (19.1%) of such patients had variable amount of cavernous sinus involvement. Endoscopic debridement of paranasal sinuses and orbit with or without eyelid sparing limited orbital exenteration was done in most cases, 34 (38.2%) patients could retain vision in the affected eye. CONCLUSION: Orbital apex involvement in CAM patients occur very fast. It not only leads to loss of vision but also sacrifice of the eyeball, orbital contents and eyelids. Early diagnosis and prompt intervention can preserve life, vision and spare mutilating surgeries.

2 Effects of baffle and intraocular pressure on aerosols generated in the noncontact tonometer measurement during COVID-19

Yuan Tang , Yan-Yan Chen , Chun-Chun Li , Zhang-Yan Chen , Chen Chen , Si-Qi Wen , Xiao-Qiong Huang , Jia Qu , Yan-Miao Chen , Ai-Ai Chen

2022, 15(4):533-540. DOI: 10.18240/ijo.2022.04.02

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Abstract:
AIM: To investigate the effects of baffle and intraocular pressure (IOP) on the aerosols generated in the noncontact tonometer (NCT) measurement and provide recommendations for the standardized use of the NCT during coronavirus disease 2019 (COVID-19). METHODS: This clinical trial included 252 subjects (312 eyes) in The Eye Hospital, Wenzhou Medical University from March 7, 2020, to March 28, 2020. Sixty subjects (120 eyes) with normal IOP were divided into two groups. One group used an NCT without a baffle, another group used an NCT with a baffle. Another 192 subjects (192 eyes) were divided into four groups: Group A1 (without a baffle+normal IOP), Group A2 (without a baffle+high IOP), Group B1 (with a baffle+normal IOP) and Group B2 (with a baffle+high IOP). Particulate matter (PM) 2.5 and PM10 generated by all subjects were quantified during the NCT measurement. The IOP values were recorded simultaneously. Effects of baffle and IOP on aerosols generated during the NCT measurement were analyzed. RESULTS: In the normal eye group with a baffle, the aerosol density decreased in a wave-like shape near the NCT with the increase in the number of people measured for IOP, demonstrating no cumulative effect. However, in the normal eye group without a baffle, there was a cumulative effect. PM2.5 and PM10 in Group A2 were higher than Group A1 (both P<0.001). The PM2.5 and PM10 in Group B2 were higher than Group B1 (P<0.01, P<0.001 respectively). The PM10 of Group B1 was lower than Group A1 (P<0.01). PM2.5 in Group B2 were lower than Group A2 (P<0.01). The median of per capita PM2.5 and PM10 in the combined Group A1+A2 were 0.80 and 1.10 μg/m3 respectively, which were higher than 0.20 and 0.60 μg/m3 in the combined Group B1+B2 (both P<0.01). The median of per capita PM2.5 and PM10 in the combined Group A1+B1 were 0.10 and 0.20 μg/m3 respectively, which were lower than 1.30 and 1.70 μg/m3 in the combined Group A2+B2 (both P<0.001). CONCLUSION: More aerosols could be generated in patients with high IOP. After the NCT is equipped with a baffle, per capita aerosol density generated decreased significantly near the NCT; And with the increase in the number of people measured for IOP, the aerosols gradually dissipated near the NCT, demonstrating no cumulative effect. Therefore, it is suggested that the NCT should be equipped with a baffle, especially for patients with high IOP.

3 CCPG1 involved in corneal Aspergillus fumigatus infection

Li-Mei Wang , Xiao-Meng Chen , Hai-Jing Yan , Shu Yan , Xiao-Yan Sun , Da-Wei Zhang , Hua Yang , Dan-Li Lu , Cheng-Ye Che

2022, 15(4):541-546. DOI: 10.18240/ijo.2022.04.03

[Abstract](1012) [HTML](0) [PDF 900.75 K](752)

Abstract:
AIM: To investigate whether non-canonical autophagy transport receptor cell cycle progression 1 (CCPG1) is involved in the corneal antifungal immune response. METHODS: Human corneal epithelial cells (HCECs) and human myeloid leukemia mononuclear cells (THP-1) macrophages stimulated by Aspergillus fumigatus (A. fumigatus) were used as cell models. The expression of CCPG1 mRNA was detected by qRT-PCR. Western blot was used to determine the protein expression of CCPG1 and interleukin-1β (IL-1β). The dectin-1 neutralizing antibody was used to detect the association between dectin-1 and CCPG1. Immunofluorescence was used to observe the colocalization of CCPG1 and C-type lectin-like receptor-1 (CLEC-1) in THP-1 macrophages. RESULTS: The expression of CCPG1 started to increase at 4h after infection and increased in a time-dependent manner in HCECs and THP-1 macrophages. With dectin-1 neutralizing antibody pretreatment, the expression of IL-1β was down-regulated. CCPG1 up-regulation in response to A. fumigatus infection was independent of dectin-1. Immunofluorescence showed the colocalization of CCPG1 and CLEC-1 in THP-1 macrophages. CONCLUSION: As a specific autophagy protein of non-canonical autophagy pathway, CCPG1 is involved in corneal infection with A. fumigatus.

4 Anti-scarring effect of sodium hyaluronate at filtration pathway after filtering surgery in rabbits

Yu-Jue Wang , Le-Meng Feng , Cheng Zhang , Wu-Long Zhang , Wei-Tao Song

2022, 15(4):547-553. DOI: 10.18240/ijo.2022.04.04

[Abstract](733) [HTML](0) [PDF 1.85 M](567)

Abstract:
AIM: To investigate the anti-scarring effect of sodium hyaluronate (HA) at filtration pathway after filtering surgery in a rabbit model. METHODS: Fifteen healthy adult New Zealand white rabbits were selected for trabeculectomy in both eyes. The right eyes were used as HA group with 0.1 mL HA injected into the anterior chamber at the end of the operation; the left eyes were used with 0.1 mL sodium lactate Ringer’s solution (RS) injected into the anterior chamber as RS group. Intraocular pressure (IOP), filtering blebs morphology, inflammatory reaction and complications were observed at the 7, 60, and 90d after surgery. RESULTS: One day after surgery, the IOP of HA and RS groups were 12.75±1.92 and 10.50±1.59 mm Hg (P=0.005). At the 7th day postoperative, the filtering blebs of each group were functional type and TGF-β expression was significantly difference in both groups (0.10±0.01 vs 0.14±0.02, P=0.024). After 60d of the operation, all filtering blebs were scarring and alpha-smooth muscle actin (α-SMA) expression was significantly difference in both groups (0.40±0.04 vs 0.35±0.02, P=0.032). α-SMA positive cells were mainly distributed in the junction of conjunctiva and sclera and around the blood vessels. The collagen volume fraction (CVF) of HA and RS group was (75.49±7.01)% and (79.93±5.35)% (P=0.044). On the 90th day after the operation, CVF was (82.57±5.19)% and (88.08±1.75)% in HA and RS groups (P=0.036). There was no α-SMA positive cell in HA group, while a few positive cells were observed in RS group (P=0.000). CONCLUSION: HA has effect of anti-scar and anti-inflammation on filtration pathway after filtering surgery within 3mo by inhibiting fibroblast proliferation and collagen deposition.

5 Leptin activates the JAK/STAT pathway to promote angiogenesis in RF/6A cells in vitro

Le Zhang , Rong Li , Bing-Hui Wu , Ting-Ting Liang , Zhe Liu , Wei Ju , Yi Wang , Yu-Ting Wen , Ming-Cui Liu , Jun-Hui Du

2022, 15(4):554-559. DOI: 10.18240/ijo.2022.04.05

[Abstract](1000) [HTML](0) [PDF 5.20 M](703)

Abstract:
AIM: To investigate the effect of leptin on the angiogenesis of RF/6A cells (monkey retinal choroidal endothelial cells) in vitro and test the cellular signaling in the mechanism. METHODS: RF/6A cells were cultured in vitro and randomly divided into four groups: normal control, with leptin at 50, 100, 200 ng/mL for cell counting kit-8 (CCK8). RF/6A cell proliferation and migration were examined by Transwell assays, while RF/6A cell tube formation by Matrigel assay. JAK2, p-JAK2, STAT3, and p-STAT3 protein expression was measured by Western blotting. Cells were then divided into the following treatment groups: control, 100 ng/mL leptin and AG-490 (100 ng/mL leptin+10 μmol/L AG-490) for examinations of RF/6A cellular behaviour again. Analysis of differences was carried out using one-way ANOVA and least significant difference (LSD). RESULTS: RF/6A cell proliferation, migration and cell tube formation were promoted significantly by leptin in a dose-dependent manner (P<0.05). Western blotting showed that leptin up-regulated p-JAK2 and p-STAT3 expression levels. Treatment with the JAK/STAT pathway inhibitor, AG-490, decreased leptin-induced p-JAK2 and p-STAT3 expression, and inhibited cell proliferation, migration and cell tube formation induced by leptin (P<0.05). CONCLUSION: Leptin can promote RF/6A cell angiogenesis in vitro via activation of the JAK2/STAT3 signaling pathway.

6 Protective limb remote ischemic post-conditioning against high-intraocular-pressure-induced retinal injury in mice

Qi-Jiang Zhu , Lei Zhang , Shuang-Yu Lyu , Zhan-Jun Cui , En-She Jiang , Jun Wang

2022, 15(4):560-567. DOI: 10.18240/ijo.2022.04.06

[Abstract](738) [HTML](0) [PDF 2.64 M](635)

Abstract:
AIM: To determine whether limb remote ischemic post-conditioning (LRIC) protects against high-intraocular-pressure (IOP)-induced retinal injury, and to identify underlying molecular mechanisms. METHODS: In mice, IOP was increased to 110 mm Hg for 50min and LRIC applied to the unilateral leg for three occlusion cycles (5min/release). Three animal groups (control, high IOP, and high IOP+LRIC) were arranged in this study. Plasma was collected from LRIC treated mice. Retinal histology, oxidative stress were determined by histological section staining and chemical kit. C/EBP homologous protein (CHOP), and Iba-1 parameters were evaluated by immunofluorescent staining and Western blot. RESULTS: The data showed that LRIC treatment alleviated the retinal histological disorganization and ganglion cell loss induced by high IOP. The CHOP, Iba-1 expression and oxidative stress marker also were inhibited by LRIC treatment. To further explore underlying mechanisms, plasma from LRIC treated animals was intravenously transfused into high-IOP animals. The results showed plasma injection decreased caspase 9 expression and DHE staining signals compared with that in high IOP retinas. CONCLUSION: These data suggest that LRIC treatments exert retinal protective effects against high-IOP injury. Endogenous humoral factors release into the circulation by LRIC may contribute to homeostatic protection by reducing monocyte infiltration and/or microglia activation.

7 Outcomes of different lines of keratoconus management in a tertiary eye center in north China

Jing Zhang , Xian-Li Du , Lei Wan , Yan-Ling Dong , Li-Xin Xie

2022, 15(4):568-575. DOI: 10.18240/ijo.2022.04.07

[Abstract](698) [HTML](0) [PDF 767.45 K](502)

Abstract:
AIM: To evaluate the treatment selections and outcomes of keratoconus and discuss the grading treatment of keratoconus. METHODS: Medical records of 1162 patients (1863 eyes) with keratoconus treated with rigid gas permeable (RGP), corneal collagen crosslinking, and keratoplasty were reviewed. The patients were grouped according to the CLEK Study. The advanced group was further divided into a <60 D group and >60 D group. The best-corrected visual acuity (BCVA) and topographic data before and after treatment were recorded. RESULTS: In the 761 eyes with steep K<52 D, nonsurgical management accounted for 83.4%, while in the 735 eyes with steep K>60 D, surgical management accounted for 90.6%. A total of 618 eyes had improved BCVA at the final follow-up point (>18mo, P<0.001). When steep K was <52 D, the BCVA in the RGP group was better than those with lamellar keratoplasty (LKP; P=0.028). When steep K was >52 D, the BCVA and topographic astigmatism outcomes showed no differences among the treatment groups. When steep K was >60 D, the BCVA in eyes treated with LKP was worse than those with steep K<60 D (P=0.025). The incidence of steep K progression in the RGP group was higher in advanced group (20.0% vs 10.8%, P=0.019). The probability of future keratoplasty in RGP was higher in advanced group (14.8% vs 7.0%, P=0.027). The incidence of steep K progression in the corneal collagen crosslinking (CXL) group was higher in advanced group (32.3% vs 8.5%, P=0.007). Multivariate logistic regression revealed the following related factors for treatment options: steep K [odds ratio (OR)=1.208, 95%CI: 1.052-1.387], TA (OR=1.171, 95%CI: 1.079-1.270), and TCT (OR=0.978, 95%CI: 0.971-0.984). The level of steep K, TA, and TCT all relates to the treatment choices of both keratoplasty and non-keratoplasty, while steep K provided the highest diagnostic accuracy (AUC=0.947, P<0.001). CONCLUSION: Steep K is an important grading treatment indicator. When steep K is <52 D, RGP lenses should be recommended. It is the best time for LKP when the steep K ranges from 52 to 60 D.

8 Factors associated with corneal astigmatism change after ptosis surgery

Natpatsorn Mongkolareepong , Nattapong Mekhasingharak , Oranicha Pimpha

2022, 15(4):576-580. DOI: 10.18240/ijo.2022.04.08

[Abstract](836) [HTML](0) [PDF 375.38 K](553)

Abstract:
AIM: To evaluate the predictive factors of postoperative corneal astigmatism change in ptosis patients who underwent ptosis surgical repair. METHODS: Patients who underwent levator resection at Oculoplastic service of the Department of Ophthalmology, Naresuan University Hospital, Thailand between September 2017 and August 2019 were retrospectively evaluated. Changes in degree and axis of corneal astigmatism after ptosis surgery were compared based on patient factors consisting of age at operation, sex, preoperative margin-reflex distance (MRD) 1, and preoperative degree and axis of corneal astigmatism. RESULTS: Forty-two eyes of 28 patients were included in the study. Wilcoxon signed ranks test showed a significant postoperative corneal astigmatism change only in a subgroup of eyes with preoperative astigmatism of ≥1.5 diopters (D; P=0.006). Furthermore, 72.2% (13/18) of the eyes with preoperative astigmatism of ≥1.5 D showed a reduction of astigmatism after eyelid surgery, with the mean astigmatic change of 0.65 D. Majority of preoperative eyes demonstrated with-the-rule astigmatism pattern (45.2%), of which 57.9% showed a reduced degree of astigmatism. CONCLUSION: In patients undergoing ptosis surgery, the data demonstrate for the first time the association between postoperative corneal astigmatism change and a preoperative corneal astigmatism of ≥1.5 D. Thus, we encourage considering severity of corneal astigmatism prior to cataract or refractive surgery planning in ptosis patients, especially with toric-intraocular lens, to avoid the possibility of calculation error.

9 Comparing surgical efficiencies between phacoemulsification systems: a single surgeon retrospective study of 2000 eyes

Luis Escaf-Jaraba , Jorge Escobar-DiazGranados , Bartolomé Valdemarín

2022, 15(4):581-585. DOI: 10.18240/ijo.2022.04.09

[Abstract](437) [HTML](0) [PDF 556.92 K](529)

Abstract:
AIM: To compare under similar conditions intraoperative surgical efficiencies metrics between an active fluidics and a gravity based phacoemulsification systems. METHODS: Adult patients who were diagnosed with a cataract that compromised visual acuity inferior to 20/40 were included in the study. Patients were excluded from the study if they had a history of severe retinal disorders, clinically significant corneal endothelial dystrophy or history of corneal disease. All phacoemulsification surgeries were performed by a single surgeon. Both phacoemulsification systems used the 0.9 mm 45-degree aspiration bypass system Intrepid Balanced tip and the 0.9 mm Intrepid Ultra infusion sleeve. All cataracts were classified using the Lens Opacities Classification System III, cumulative dissipated energy (CDE) and aspiration fluids were measured in each surgery. RESULTS: Totally 2000 eyes were included in the study. Phacoemulsification was performed in 1000 (50%) eyes with an active fluid dynamics system and in 1000 (50%) eyes with a gravity-based fluidic system. Mean CDE until fracture of the lens was 1.1 and 1.9 percent-seconds and total mean CDE used was 5.6 and 7.2 percent-seconds using an active fluidics dynamics system and gravity-based fluidic system, respectively (P<0.001). Mean aspiration fluids used were 70 mL using an active fluidics dynamics system and 85 mL using a gravity-based fluidic system (P<0.001). CONCLUSION: This study evidences that surgeries performed under similar conditions (same surgeon, phaco tip and sleeve) with the active fluidics dynamics system required significantly lower CDE and aspiration fluids.

10 Intraoperative complication rates in cataract surgery performed by resident trainees and staff surgeons in a tertiary eyecare center in Hungary

Márton Magyar , Gábor László Sándor , László Ujváry , Zoltán Zsolt Nagy , Gábor Tóth

2022, 15(4):586-590. DOI: 10.18240/ijo.2022.04.10

[Abstract](574) [HTML](0) [PDF 418.09 K](541)

Abstract:
AIM: To compare the incidence of intraoperative complications during primary phacoemulsification (phaco) surgery between resident surgeons (residents) and staff surgeons (specialists) and to objectively determine the difficulty of stages in phaco surgery. METHODS: This retrospective study included cases of phaco cataract surgery performed between January and December 2019. There were no exclusion criteria. For each patient, demographics, clinical history, case complexity, type of surgeon, and operative details were reviewed. Primary outcomes included intraoperative complication rates and the objective measure of difficulty in the steps of the surgery performed by residents and specialists. RESULTS: A total of 3272 cases were included; 7.4% (n=241) of cases were performed by residents. The overall complication rate was 5.4% (n=177). The intraoperative complication rate was significantly higher (P<0.001) in residents (n=33, 13.7%) than in specialists (n=144, 4.8%). The most frequent complications were posterior capsule tear (n=85, 2.6%), anterior capsule tear (n=50, 1.53%), zonular fiber loss (n=45, 1.38%), and dropped nucleus (n=15, 0.46%). Objectively, the most difficult steps during surgery were phaco in 66 (60.0%), capsulorhexis in 21 (19.1%), irrigation/aspiration in 13 (11.8%), hydrodissection in 9 (8.2%), and intraocular lens (IOL) implantation in 1 (0.9%) case. CONCLUSION: Intraoperative complication rates are higher in residents than in specialists. The order of objective difficulty in phaco surgery steps is in line with the subjective findings of other surveys, revealing that the most challenging parts of phaco surgery are phaco and capsulorhexis.

11 Preoperative laser reduces silicone oil use in primary diabetic vitrectomy

Wen-Bin Zheng , Xiao-Hu Ding , Kun-Bei Lai , Ji-Zhu Li , Yu-Qing Wu , Yuan Ma , Zi-Ye Chen , Shi-Da Chen , Sai-Nan Xiao , Bing-Qian Liu , Ying Lin , Tao Li

2022, 15(4):591-597. DOI: 10.18240/ijo.2022.04.11

[Abstract](610) [HTML](0) [PDF 430.43 K](657)

Abstract:
AIM: To identify the predictive factors and laser photocoagulation associated with the use of silicone oil as endotamponade during primary diabetic vitrectomy. METHODS: The medical and surgical records of 690 patients (798 eyes) who underwent primary diabetic vitrectomy at a tertiary eye hospital in China from January 2018 to December 2018 were reviewed in this retrospective cohort study. The patients’ baseline characteristics and preoperative treatments were recorded. The binary Logistic regression model was used to evaluate the risk factors for the use of silicone oil as endotamponade agent during primary vitrectomy for proliferative diabetic retinopathy (PDR)-related complications. RESULTS: Among 690 patients with mean age of 52.1±10.5y (range: 18-85y), 299/690 (43.3%) were female. The 31.6% of the eyes received preoperative laser treatment, and 72.4% of the eyes received preoperative anti-VEGF adjuvant therapy. Non-clearing vitreous haemorrhage (VH) alone or combined with retinal detachment was the main surgical indication (89.5%) for primary vitrectomy. Silicone oil was used as endotamponade in 313 (39.2%) eyes. Lack of preoperative laser treatment [odds ratio (OR) 0.66, 95% confidence interval (CI): 0.48-0.92; P=0.015] and older age (OR 0.96, 95%CI: 0.95-0.98; P<0.001) were predictors of silicone oil tamponade during primary vitrectomy for PDR. CONCLUSION: The lack of preoperative laser treatment is a significant predictor of silicone oil tamponade during primary vitrectomy for PDR. However, the severity of PDR relevant to silicone oil use should be further evaluated.

12 One-year outcomes and predictable factors for microhook ab interno trabeculotomy

Daiki Sakai , Masashi Fujihara , Satoshi Yokota , Makoto Nakamura , Yasuo Kurimoto

2022, 15(4):598-603. DOI: 10.18240/ijo.2022.04.12

[Abstract](485) [HTML](0) [PDF 437.29 K](601)

Abstract:
AIM: To investigate the one-year outcomes and factors that influence the results of microhook ab interno trabeculotomy (μLOT). METHODS: The medical records of consecutive patients with open angle glaucoma who underwent μLOT (including combination of μLOT and cataract surgery) between February 2018 and July 2019 were retrospectively reviewed. Surgical success was defined as the following: an intraocular pressure (IOP)≤21 mm Hg or IOP≤preoperative IOP with a reduced number of glaucoma eye drops, without additional glaucoma surgery, and assessed using Kaplan-Meier survival analysis. A multivariate Cox proportional-hazards regression model was used to investigate the factors associated with surgical failure. RESULTS: The 59 eyes of 59 patients comprising 28 eyes with primary open angle glaucoma (POAG) and 31 with secondary open angle glaucoma (SOAG) were included. The mean IOP and number of glaucoma eye drops significantly decreased from 25.3±7.2 mm Hg and 3.9±1.1, preoperatively to 16.1±4.4 mm Hg (P<0.01) and 2.1±1.8 (P<0.01), respectively, 12mo postoperatively, with a cumulative success rate of 63.1%. The one-year success rate was significantly higher in POAG eyes than in SOAG eyes (80.0% vs 48.0%; P=0.011, log-rank test). Multivariate analyses revealed SOAG [P=0.017, adjusted hazard ratio (aHR): 3.468, 95%CI: 1.246-9.654] and the postoperative IOP spike (IOP>25 mm Hg within 2wk post-surgery; P<0.001, aHR: 5.382, 95%CI: 2.113-13.707) as independent factors associated with surgical failure. CONCLUSION: The μLOT is a good treatment option for POAG eyes. However, the postoperative course should be carefully followed in cases with postoperative IOP spike.

13 Clinical characteristics and surgical treatment of idiopathic uveal effusion syndrome

Zhi-Jun Shen , Lin Shen , Hong Wang

2022, 15(4):604-608. DOI: 10.18240/ijo.2022.04.13

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Abstract:
AIM: To investigate the clinical characteristics of idiopathic uveal effusion syndrome (IUES) and to identify effective surgical modalities for its treatment. METHODS: This retrospective analysis included clinical data of 33 eyes from 26 patients with IUES at Beijing Tongren Hospital. Records of eye examinations, ocular ultrasound, ocular ultrasound biomicroscopy (UBM), and follow-up surgical treatment were reviewed and analyzed. RESULTS: Of 26 patients, 17 (65.4%) were male and 9 (34.6%) were female. The average age of disease onset was 46.8y (range: 22-64y). Seven patients (26.9%) showed retinal detachment in both eyes at presentation. B-ultrasound showed the presence of retinal detachment in one eye or both eyes. All patients had binocular ciliary leakage and detachment. Eyes with retinal detachment underwent four-quadrantic partial-thickness sclerectomy and sclerostomy. Subretinal fluid resolution was achieved within 6mo. Recurrence was observed in three eyes and was resolved with re-operation. CONCLUSION: Ophthalmic ultrasound and UBM, among others, can be helpful in the diagnosis of IUES. Sclerectomy and sclerostomy are surgical modalities that can successfully treat the disease. Some patients may experience recurrence after surgery; reoperation remains safe and effective for them. Long-term follow-up is essential in such settings.

14 Efficacy of conbercept after switching from bevacizumab/ranibizumab in eyes of macular edema secondary to central retinal vein occlusion

Tong Zhao , You Chen , Hong-Song Zhang , Yi Chen , Zhi-Jun Wang

2022, 15(4):609-614. DOI: 10.18240/ijo.2022.04.14

[Abstract](585) [HTML](0) [PDF 661.80 K](581)

Abstract:
AIM: To explore the efficacy of conbercept after switching from bevacizumab/ranibizumab in eyes of central retinal vein occlusion (CRVO) through optical coherence tomography angiography (OCTA). METHODS: Patients with prior treatment of a minimum of three consecutive intravitreal injections of either bevacizumab or ranibizumab, followed by injection of conbercept, were recruited. The minimal follow-up period after switching was 12mo. Central retinal thickness (CRT), best-corrected visual acuity (BCVA), the interval of injections was reviewed. Perfusion density (PD) and vascular length density (VLD) of superficial and deep capillary plexus were acquired from OCTA images before and after switching. RESULTS: Twenty-four eyes were included. CRT significantly decreased from 460.71±153.23 μm (before switching) to 283.92±38.27 μm at the end of follow-up (P<0.001). However, BCVA gained to some extent (from 0.98±0.33 to 0.76±0.42 logMAR) but the difference was not significant (P=0.070). After switching to conbercept the injection interval extended from 5.2±2.3wk to 8.3±3.9wk (P=0.012). At the end of follow-up, PD of deep retinal layer decreased significantly compared with before switching (from 34.62%±5.27% to 33.26%±5.82%, P=0.016), similar result was found in VLD of deep retinal layer but not in PD or VLD in superficial layer. CONCLUSION: In cases of refractory macular edema secondary to CRVO, switching to conbercept improves macular thickness and extends interval of injection. Retinal microvasculature cannot improve with treatment of conbercept.

15 Efficacy of intravitreal conbercept combined with panretinal photocoagulation for severe nonproliferative diabetic retinopathy without macular edema

Ning Zhao , Jian Guan , Na Cai , Ning-Ning Liu

2022, 15(4):615-619. DOI: 10.18240/ijo.2022.04.15

[Abstract](539) [HTML](0) [PDF 385.45 K](533)

Abstract:
AIM: To assess efficacy of intravitreal conbercept (IVC) injection in combination with panretinal photocoagulation (PRP) vs PRP alone in patients with severe nonproliferative diabetic retinopathy (SNPDR) without macular edema (ME). METHODS: Forty-eight patients with SNPDR without ME (56 eyes) were divided into the PRP group and IVC+PRP group (the pulse group) in this retrospective clinical study. Conbercept was intravitreally administered to patients in the pulse group 1wk before treatment with PRP and followed up for 1, 3, and 6mo. The best-corrected visual acuity (BCVA, logMAR), center foveal thickness (CFT), visual acuity (VA) improvement, and adverse reactions were compared between groups. RESULTS: In the PRP group, the BCVA reduced at 1 and 3mo before improving at 6mo. In the pulse group, baseline BCVA decreased continuously at 1mo, increased at 3 and 6mo. BCVA in the pulse group was better than that in the PRP group at 1, 3, and 6mo. There was an increase in CFT in the PRP group during follow-up compared with baseline. In the pulse group, CFT was increased at 1mo relative to baseline, steadily decreased to the baseline level at 3 and 6mo. There was a more significant reduction in CFT in the pulse group during follow-up compared with the PRP group. The effective rates of VA in the PRP and the pulse groups were 81.48% and 100%, respectively. CONCLUSION: As PRP pretreatment, a single dose of IVC administration has beneficial effects for preventing PRP-induced foveal thickening and increasing VA in patients with SNPDR without ME.

16 A new handheld fundus camera combined with visual artificial intelligence facilitates diabetic retinopathy screening

Shang Ruan , Yang Liu , Wei-Ting Hu , Hui-Xun Jia , Shan-Shan Wang , Min-Lu Song , Meng-Xi Shen , Da-Wei Luo , Tao Ye , Feng-Hua Wang

2022, 15(4):620-627. DOI: 10.18240/ijo.2022.04.16

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Abstract:
AIM: To explore the performance in diabetic retinopathy (DR) screening of artificial intelligence (AI) system by evaluating the image quality of a handheld Optomed Aurora fundus camera in comparison to traditional tabletop fundus cameras and the diagnostic accuracy of DR of the two modalities. METHODS: Overall, 630 eyes were included from three centers and screened by a handheld camera (Aurora, Optomed, Oulu, Finland) and a table-top camera. Image quality was graded by three masked and experienced ophthalmologists. The diagnostic accuracy of the handheld camera and AI system was evaluated in assessing DR lesions and referable DR. RESULTS: Under nonmydriasis status, the handheld fundus camera had better image quality in centration, clarity, and visible range (1.47, 1.48, and 1.40) than conventional tabletop cameras (1.30, 1.28, and 1.18; P<0.001). Detection of retinal hemorrhage, hard exudation, and macular edema were comparable between the two modalities, in principle, with the area under the curve of the handheld fundus camera slightly lower. The sensitivity and specificity for the detection of referable DR with the handheld camera were 82.1% (95%CI: 72.1%-92.2%) and 97.4% (95%CI: 95.4%-99.5%), respectively. The performance of AI detection of DR using the Phoebus Algorithm was satisfactory; however, Phoebus showed a high sensitivity (88.2%, 95%CI: 79.4%-97.1%) and low specificity (40.7%, 95%CI: 34.1%-47.2%) when detecting referable DR. CONCLUSION: The handheld Aurora fundus camera combined with autonomous AI system is well-suited in DR screening without mydriasis because of its high sensitivity of DR detection as well as its image quality, but its specificity needs to be improved with better modeling of the data. Use of this new system is safe and effective in the detection of referable DR in real world practice.

17 Artificial intelligence improves accuracy, efficiency, and reliability of a handheld infrared eccentric autorefractor for adult refractometry

Yi-Ting Cao , Dan-Yang Che , Yi-Lei Pan , Yun-Li Lu , Chong-Yang Wang , Xiao-Li Zhang , Yun-Fei Yang , Ke-Ke Zhao , Ji-Bo Zhou

2022, 15(4):628-634. DOI: 10.18240/ijo.2022.04.17

[Abstract](643) [HTML](0) [PDF 901.55 K](616)

Abstract:
AIM: To evaluate the accuracy, efficiency, and reliability of a handheld infrared eccentric autorefractor (hICA) with artificial intelligence (AI) by comparing its refraction measurements to those recorded using hICA and a clinical table-mounted automatic refractor (TAR). METHODS: A cross-sectional study using three optometers, including hICA with or without AI and TAR, for refractometry of adults (aged 19-49 years old) with no signs of ocular disease or trauma in the absence of cycloplegia. Right and left eye refraction data were recorded, including the spherical equivalent (SE), diopter of spherical power (DS), diopter of cylindrical power (DC) decomposed into vectors J0 and J45, and measurement times. To avoid analytical difficulties associated with the interdependence of observations between eyes from the same individual, the Generalized Estimation Equation was used to compare the SE, DS, J0 and J45 measurements, and the times thereof, among the different groups. The intraclass correlation coefficient (ICC) and Spearman’s rank correlation coefficient were used to evaluate correlations among the measurements recorded by the three different instruments. Bland-Altman were used to analyze the precision of the equipment by the agreement. RESULTS: A total of 70 patients (140 eyes; mean age: 31.37y; range: 19-49y) were assessed using refractometry. In a brightly lit environment, there was no significant difference between the mean SE recorded using TAR and that recorded using hICA with AI or without AI (both P>0.05). In an intense-light environment, hICA equipped with AI showed a better detection rate than without AI. Light intensity had a greater effect on dioptric measurements recorded using hICA without AI (P<0.001) than on those recorded using the one equipped with AI (P<0.05). Measurement times varied significantly between the different light intensities and instruments (P<0.05). CONCLUSION: For the normal human eyes, AI may improve the accuracy, efficiency, and reliability of measurements recorded using hICA in various light environments.

18 Transgenic dry eye mouse models: powerful tools to study dry eye disease

Dan-Yi Qin , Li-Xiang Wang , Ying-Ping Deng

2022, 15(4):635-645. DOI: 10.18240/ijo.2022.04.18

[Abstract](1000) [HTML](0) [PDF 473.13 K](724)

Abstract:
Dry eye disease (DED) is one of the most common chronic multifactorial ocular surface diseases with high prevalence and complex pathogenesis. DED results in several ocular discomforts, vision fluctuation, and even potential damage of the ocular surface, bringing heavy burdens both on individuals and the society. The pathology of DED consists of tear film hyperosmolarity and immune responses on the ocular surface. Mice are widely used for developing models that simulate human DED features for investigating its pathogenesis and treatment. DED can be classified into aqueous-deficiency dry eye (ADDE) and evaporative dry eye (EDE). ADDE can be further divided into Sjögren syndrome dry eye (SSDE) and non-Sjögren syndrome dry eye (NSSDE). SSDE mouse models include natural strains, typified by non-obese diabetic (NOD) mice, and genetically engineered ones, like Aire-/- and Id3 knockout mice. Intrinsic EDE mainly refers to meibomian gland dysfunction (MGD). Eda-/- Tabby, Sod1-/-, Elovl1-/- are the most common transgenic MGD mouse models. Transgenic mouse models provide useful tools for studying the pathogenesis of DED and evaluating its novel therapies. This review compares the major transgenic dry eye mouse models and discusses their applications in DED research.

19 Immune checkpoint inhibitor-associated ophthalmic adverse events: current understanding of its mechanisms, diagnosis, and management

Yu-Wen Zhou , Qian Xu , Yan Wang , Ruo-Lan Xia , Ji-Yan Liu , Xue-Lei Ma

2022, 15(4):646-656. DOI: 10.18240/ijo.2022.04.19

[Abstract](873) [HTML](0) [PDF 1.41 M](782)

Abstract:
Immune checkpoint inhibitors (ICIs) targeting cytotoxic T-lymphocyte antigen 4 and programmed cell death protein 1 receptor/ligand have revolutionized cancer treatment, achieving unprecedented efficacy in numerous malignancies. Despite the excellent therapeutic effects of ICIs, medications, such as pembrolizumab, ipilimumab, nivolumab, atezolizumab, avelumab, and durvalumab, typically cause a broad spectrum of toxicity events termed as immune-related adverse events (irAEs). Out of all irAEs, ophthalmic adverse events occur infrequently and are not comprehensively recognized. The current understanding of ophthalmic irAEs is mainly derived from case reports and case series. In this review, based on relevant articles in the literature and current evidence, we summarize the incidences, manifestations, diagnoses, underlying mechanisms, treatments, and outcomes of ophthalmic irAEs and discuss possible management strategies. A better understanding of these features is critical for managing patients with ICI-associated ophthalmic adverse events.

20 Five-in-one: a novel, cost-effective yet simple use of micro needle holder

Ning Gao , Jia-Li Zhu , An-Le Su , Lie-Ling Kou , Zhao Liu

2022, 15(4):657-660. DOI: 10.18240/ijo.2022.04.20

[Abstract](515) [HTML](0) [PDF 681.10 K](503)

Abstract:
AIM: To achieve a balance between efficiency and cost in the management of medical instrument by the use of micro needle holder. METHODS: In this study, the novel multifunctional use of micro needle holders was performed between 2018 and 2019 at the Department of Ophthalmology in the 4 hospitals in Shaanxi Province. In this innovation, the micro needle holders were initially used as micro forceps to remove sutures, as eye spud to safety extract foreign body from cornea, as ciliary forceps to remove trichiasis, as well as punctal dilator to dilate most small puncta. RESULTS: Using this technique, the medical costs of both procurement and sterilization were cut off in the selected 4 hospitals. The purchase cost has dropped by roughly 50%. The sterilization cost was decreased by about 30%. CONCLUSION: The innovation in the five-in-one multifunctional use of micro needle holders saves the medical costs.

21 Y-splitting medial rectus muscle and recession in treatment for convergence excess esotropia

Li-Juan Huang , Yu-Yu Wu , Ning-Dong Li

2022, 15(4):661-665. DOI: 10.18240/ijo.2022.04.21

[Abstract](483) [HTML](0) [PDF 782.69 K](512)

Abstract:
AIM: To evaluate the surgical outcome of medial rectus (MR) recession with Y-splitting procedure in treatment of esotropia with convergence excess. METHODS: Medical records were retrospectively reviewed for those patients who underwent surgical treatment for their convergence excess esotropia (CEET) between January 2018 and December 2020. Refractive error was examined by the equipment of the VS100 (Welch Allyn). The surgical approach was bilateral MR recession with Y-splitting. The amount of recession was calculated according to the deviation angle at distance. Ocular movement and ocular alignment at distance and near were evaluated pre- and post-operatively. Binocular sensory status was evaluated by the Bagolini striated glasses at near and distance, and by stereoacuity assessment at near using the Titmus test. RESULTS: Six patients with CEET were included in this study. Four of them were hyperopia and two of them were myopia. A mean of eso-deviation angle at distance had been changed from 27.3±13.02 prism diopters (PD) preoperatively to 1.83±1.60 PD postoperatively (P<0.05), while a mean of eso-deviation angle at near had been changed from 50.00±20.74 PD preoperatively to 6.83±0.98 PD postoperatively (P<0.05). Patients had obtained binocular vision postoperatively. CONCLUSION: The surgical approach of Y-splitting MR and recession is effective in treatment of CEET.