Chinese Journal of Optometry Ophthalmology and Visual science

Objective To analysis each layer of retinal thickness， especially the ganglion cell layer （GCL） in the macular area， in patients with primary open-angle glaucoma （POAG） using an RTVue OCT； to assess its value in the diagnosis of glaucoma. Methods In this prospective case-control study， 76 patients （91 eyes） with POAG （30 patients [30 eyes] in the early stage， 25 patients [29 eyes] in the middle stage and 21 patients [32 eyes] in late stage） and 32 healthy age- and gender-matched controls （32 eyes） were recruited. The macular area was scanned with an RTVue OCT， and the retina was divided into nine layers with self-programming retinal image processing software. The thickness of each layer and the total retinal thickness were calculated and an LSD-t test was used to compare the average thickness of the macular area in each retinal layer for early， middle and late POAG patients and the control group. Results In the early stage of POAG， the mean thicknesses of the retinal nerve fiber layer （RNFL） and ganglion cell layer （GCL） were 31.6±9.2 μm and 33.9±5.0 μm， respectively， becoming thinner （P＜0.05） than healthy controls. In the middle stage， the mean thicknesses of the RNFL and GCL were 31.2±3.4 μm and 34.1±3.9 μm， respectively， which was thinner than the control group （P＜0.05）. In the late stage， the mean thicknesses of the RNFL， GCL， inner plexiform layer （IPL）， inner segment of the photoreceptor （IS）， and total retina （TR） were 18.8±7.6 μm， 24.2±7.9 μm， 38.0±6.4 μm， 22.8±4.4 μm and 299.5±15.1 μm， respectively， and all measurements were thinner than the controls （P＜0.05）. The mean thickness of the inner nuclear layer （INL） was 39.1±6.6 μm， which was thicker than the controls （P＜0.05）. Conclusion The mean thickness of the retinal macular area of POAG patients became obviously thinner. The GCL was especially affected by early POAG. GCL combined with clinical observations can be used as an early diagnostic indicator of POAG.

Objective To use anatomical parameters as one of the references for primary angle-closure glaucoma （PACG） surgery; to discuss surgical indications by monitoring the clinical results from three surgical methods and related factors. Methods This was a retrospective case series study. One hundred ninety-one eyes of 164 patients who were diagnosed with PACG between February 2008 and January 2009 in Qingdao Eye Hospital were divided into an acute group （91 patients， 91 eyes） and a chronic group （73 patients， 100 eyes）. Patients with conditions such as hypertension， diabetes， and other causes of eye disease were excluded from the study. Fewer than 3.2% of the patients were lost at the time of any follow-up visit. Based on expert consensus and differences in anatomical parameters， all groups included patients who underwent trabeculectomy （54 cases， LT=4.77±0.50 mm）， phacotrabeculectomy （57 cases， LT=5.02±0.61 mm） and phacoemulsification （53 cases， LT=5.02±0.37 mm）. The mean follow-up period was 3.05±0.12 years. Statistical data included age， gender， course of disease， anatomical parameters， follow-up visual acuity， intraocular pressure， and complications after surgery. SPSS 17.0 was used to analyze the anatomical parameters， the Kruskal-Wallis test was used to analyze IOP fluctuation from the three surgeries， the Wilcoxon matched pairs signed-ranks test was used to compare preoperative and postoperative indices， a chi square test or Fisher′s exact test were used to compare postoperative filtering bleb and complications. Results Postoperative intraocular pressure decreased significantly with the three surgeries， and the differences were statistically significant （Z=2.201， P<0.05）. Postoperative IOP with phacotrabeculectomy was lower than with the other two procedures and the difference was statistically significant （LSD-t： P<0.05）. There were no significant differences in postoperative IOP fluctuation for the three surgeries. The reopening angle accounted for 38% （phacoemulsification） and 22% （phacotrabeculectomy） and the acute group was higher than the chronic group （?字2=6.310， P<0.05）. MD and PSD were not significantly different compared to preoperative levels. Complications were not significantly different among the three operations nor was bleb morphology different between phacotrabulectomy and trabulectomy. Although half the patients had no obvious filtering bleb， IOP was lower than 21 mmHg. Conclusion In PACG， with a shorter axial length and thicker lens， the lens can be removed when combined with trabeculectomy. IOP control is better in phacotrabeculectomy. The residual subscleral filtration tract may have a real function in the outflow of aqueous humor.

Objective To evaluate the effectiveness and safety of phacoemulsification and viscogoniosynechialysis in managing refractory acute angle-closure glaucoma （ACG）. Methods This was a retrospective case series. The medical records of 23 patients（25 eyes） with refractory primary acute angle-closure glaucoma who underwent combined phacoemulsification and viscogoniosynechialysis from March 2011 to June 2012 at Peking Union Medical College Hospital were examined. Eyes were divided into an atonic pupil group （12 eyes） and a normal pupil group （13 eyes） based on pupil function. Phacoemulsification and viscogoniosynechialysis were performed and a 4.5 mm diameter continuous curvilinear capsulorhexis （CCC） was made in the atonic pupil group. Intraocular pressure （IOP）， visual acuity， anterior chamber depth （ACD） and need for drops were recorded with a mean follow-up of 23.5±6.2 months （18-33 months）. Pre- and post-operative data were compared with a paired-samples t test. Intraocular pressure curves of the atonic pupil group and normal pupil group were plotted. Complications and treatments were recorded. Results Significant differences were found preoperatively and postoperatively for mean IOP （38.20±6.04 mmHg vs. 15.20±2.41 mmHg）， BCVA （1.03±0.53 vs. 0.13±0.20）， anterior chamber depth （1.92±0.18 mm vs. 2.58±0.26 mm） and number of antiglaucoma medications （2.96±0.89 vs. 0.20±0.81）（P<0.01）. One patient （4%） had two complications and 1 patient （4%） had 1 complication. Conclusion Combined phacoemulsification and viscogoniosynechialysis is an effective and relatively safe procedure to relieve an episode of laser and medically unresponsive ACG.

Objective To compare the efficacy of using of FP-7 and S2 Ahmed glaucoma valve implantations （AGI） for refractory glaucoma and to monitor postoperative complications. Methods A retrospective study was conducted to document patients with refractory glaucoma who underwent S2 （26 eyes from 26 patients） or FP-7 （23 eyes from 23 patients） AGI in the Center Hospital of Cangzhou. The change in IOP， the surgical success rate， and postoperative complications were recorded and analyzed. A variance analysis of repeated measurement data was used for comparison of preoperative and postoperative IOP and the effect of reducing IOP in the 2 observation groups. Cumulative survival rates were calculated using survival analysis and compared using a log-rank. The Fisher exact test was used for the comparison of complication rates. Results IOP was reduced from 38.19±10.56 mmHg to 14.54±4.11， 15.83±5.76， 17.19±4.96， and 18.84±5.28 mmHg at month 1， month 6， month 12， and month 24 postoperatively in the S2 group and reduced from 39.91±9.12 mmHg to 14.41±5.14， 15.95±4.32， 17.11±4.75， and 19.06±6.55 mmHg in the FP-7 group. There was no statistically significant difference between the 2 groups for their effect on lowering IOP. At the last follow-up， the cumulative probabilities of success and of total success were 82% and 74% in the S2 group， and 80% and 75% in the FP-7 group. There was no statistically significant difference between the 2 groups. Conclusion FP-7 AGI was equal to S2 AGI in reducing IOP in refractory glaucoma. The complication rate in the S2 group was no higher than it was in the FP-7 group.

Objective To study the relationship between the expression of CREB1 and retinal neovascularization （RNV） in a mouse model of oxygen-induced retinopathy （OIR）． Methods Postnatal day 7 （P7） mice （n=134） were randomly assigned to two groups： a control group （n=67） and an OIR group （n=67）． OIR was induced by exposing P7 mice to （75±2）% O2 for 5 days， followed by exposure to room air for an additional 5 days. P17 OIR mice were raised in the normal environment for additional 4 days. The mice from the control group were raised in a normal environment for 21 days． The P17 mice from the two groups were sacrificed， and retinal sections for HE staining and flat mounts after cardiac perfusion with FITC-dextran were used to detect RNV. Immunofluorescence of the frozen retinal sections showed the expression and location of the P-CREB1 protein. Real-time PCR and Western Blot were used to detect the expression of CREB1 in the retina． Two-way ANOVA was used for data comparison of the two groups at different time points and a Bonferroni post-test was used for comparison between two time points within a group. An independent samples t test at the same time points between the groups was used for statistical analysis. Results The number of cellular nuclei in the vascular endothelium breaking through the retinal internal limiting membrane was significantly higher in the OIR group than in the control group at P17 （t=11.31， P<0.05）. Areas of new retinal blood vessels and avascular zones were （21.40±2.72）% and （30.61±3.12）%， respectively， in OIR mice at P17 P-CREB1 protein was expressed more strongly in the inner nuclear layer and ganglion cell layer of the retinas in the OIR group than in the control group. The results of real-time PCR and Western Blot showed that the relative expression levels of mRNA and CREB1 protein gradually increased from P7 to P17， followed by decreased expression at P21 in the control group. But the values were significantly higher in the OIR group than in the control group in mice of all ages except for P7 mice （P<0.05）． Conclusion These results indicate a space-time corresponding relationship between the expression of CREB1 and RNV． The overexpression of CREB1 could be involved in the process of RNV in the OIR model．

Objective To study the lid wiper area in vivo and in real time with confocal microscope， to understand the anatomy and histology of the region， and to provide the basis for further clinical diagnosis and treatment of lid-wiper epitheliopathy （LWE） and early dry eye. Methods Cases series study. Five volunteers without LWE and 15 patients with moderate to severe LWE were enrolled in the study at Beijing Jishuitan Hospital between September 2013 and March 2014. The lid wiper area was observed by confocal microscope， and the images were collected and analyzed. Results The lid wiper epithelium had a conjunctival structure of cuboidal cells which were different from the stratified squamous epithelium of the free lid margin. There was a clear dividing line in the meibomian gland′s openings. The lid wiper epithelium contained white cells and goblet cells. Compared to the volunteers without LWE， more holes and cracks were observed in the lid wiper epithelium in patients with moderate to severe LWE. Conclusion The anatomy， histology and pathological changes in the lid wiper area can be observed noninvasively， clearly and in real time with confocal microscope in vivo. The result can help us understand the mechanism of LWE， and provide the basis for further clinical diagnosis and treatment of LWE and early dry eye.

Surgical treatment tends to be the best choice for primary open-angle glaucoma （POAG） patients after medication or laser therapy fails to control intraocular pressure effectively. Trabeculectomy is currently the leading surgery for POAG even though it has complications such as hyphema， hypotony， and bleb scarring， which are commonly observed during or after operations. With the gradual improvement in surgical techniques， some new surgeries for POAG have been introduced recently. The Ex-PRESS glaucoma filtration device has been developed successfully and is in widespread use for decreasing intraocular pressure. This device is unique because it features small incision surgery and fewer complications as well as no tissue removal. Moreover， the gold micro shunt implant， artificial nano drainage implant， Glaukos iStent trabecular micro-bypass， Eyepass glaucoma implant， AquaFlow collagen implant， canaloplasty and trabectome are often performed in different aspects of POAG treatments. All of these new surgical methods are reviewed in detail.

It is generally accepted that abnormal blood supply to the optic nerve is involved in glaucomatous optic neuropathy. Since the blood supply of the prelaminar area of the optic nerve head originates from branches within the peripapillary choroid， the relationship between glaucoma and choroidal blood flow has attracted much attention. Moreover， in terms of the pathogenesis of glaucoma， choroidal expansion is regarded as one of the contributing factors that induce an acute attack of primary angle-closure glaucoma. With the use of enhanced depth imaging spectral-domain optical coherence tomography， the human choroid can be measured accurately in vivo in the clinic. In this article， we review the study of choroidal thickness in glaucoma patients， and further discuss the role of the choroid in the development and progression of glaucoma.