Hainan Eye Hospital

BACKGROUND: Myopia is a pervasive global public health concern, particularly among the younger population. However, the escalating prevalence of myopia remains uncertain. Hence, our research aims to ascertain the global and regional prevalence of myopia, along with its occurrence within specific demographic groups. METHODS: An exhaustive literature search was performed on several databases covering the period from their inception to 27 June 2023. The global prevalence of myopia was determined by employing pooled estimates with a 95% CI, and further analysis was conducted to assess variations in prevalence estimates across different subgroups. Additionally, a time series model was utilised to forecast and fit accurately the future prevalence of myopia for the next three decades. RESULTS: This study encompasses a comprehensive analysis of 276 studies, involving a total of 5 410 945 participants from 50 countries across all six continents. The findings revealed a gradual increase in pooled prevalence of myopia, ranging from 24.32% (95% CI 15.23% to 33.40%) to 35.81% (95% CI 31.70% to 39.91%), observed from 1990 to 2023, and projections indicate that this prevalence is expected to reach 36.59% in 2040 and 39.80% in 2050. Notably, individuals residing in East Asia (35.22%) or in urban areas (28.55%), female gender (33.57%), adolescents (47.00%), and high school students (45.71%) exhibit a higher proportion of myopia prevalence. CONCLUSION: The global prevalence of childhood myopia is substantial, affecting approximately one-third of children and adolescents, with notable variations in prevalence across different demographic groups. It is anticipated that the global incidence of myopia will exceed 740 million cases by 2050.

Angiogenesis, in which vascular endothelial growth factor receptor (VEGFR) 2 plays an essential role, is associated with a variety of human diseases including proliferative diabetic retinopathy and wet age-related macular degeneration. Here we report that a system of adeno-associated virus (AAV)-mediated clustered regularly interspaced short palindromic repeats (CRISPR)-associated endonuclease (Cas)9 from Streptococcus pyogenes (SpCas9) is used to deplete VEGFR2 in vascular endothelial cells (ECs), whereby the expression of SpCas9 is driven by an endothelial-specific promoter of intercellular adhesion molecule 2. We further show that recombinant AAV serotype 1 (rAAV1) transduces ECs of pathologic vessels, and that editing of genomic VEGFR2 locus using rAAV1-mediated CRISPR/Cas9 abrogates angiogenesis in the mouse models of oxygen-induced retinopathy and laser-induced choroid neovascularization. This work establishes a strong foundation for genome editing as a strategy to treat angiogenesis-associated diseases.Abnormal angiogenesis causes many ocular diseases. Here the authors employ CRISPR/Cas9 gene editing technology to silence VEGFR2, a major regulator of angiogenesis, in retinal endothelium and abrogate angiogenesis in the mouse models of oxygen-induced retinopathy and laser-induced choroid neovascularization.

The current study aimed to examine the short-term choroidal response to optical defocus in schoolchildren. Myopic schoolchildren aged 8-16 were randomly allocated to control group (CG), myopic defocus group (MDG) and hyperopic defocus group (HDG) (n = 17 per group). Children in MDG and HDG received additional +3D and -3D lenses, respectively, to their full corrections on the right eyes. Full correction was given to their left eyes, and on both eyes in the CG. Axial length (AXL) and subfoveal choroidal thickness (SFChT) were then measured by spectral domain optical coherence tomography. Children wore their group-specific correction for 2 hours after which any existing optical defocus was removed, and subjects wore full corrections for another 2 hours. Both the AXL and SFChT were recorded hourly for 4 hours. The mean refraction of all subjects was -3.41 ± 0.37D (± SEM). SFChT thinned when exposed to hyperopic defocus for 2 hours but less thinning was observed in response to myopic defocus compared to the control group (p < 0.05, two-way ANOVA). Removal of optical defocus significantly decreased SFChT in the MDG and significantly increased SFChT in the HDG after 1 and 2 hours (mean percentage change at 2-hour; control vs. hyperopic defocus vs. myopic defocus; -0.33 ± 0.59% vs. 3.04 ± 0.60% vs. -1.34 ± 0.74%, p < 0.01). Our results showed short-term exposure to myopic defocus induced relative choroidal thickening while hyperopic defocus led to choroidal thinning in children. This rapid and reversible choroidal response may be an important clinical parameter in gauging retinal response to optical defocus in human myopia.

PURPOSE: To characterize the early ocular-surface changes or tear inflammatory-mediators levels following small-incision lenticule extraction (ReLEx smile) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK). METHODS: Forty-seven myopic subjects were recruited for this prospective study. Fifteen underwent ReLEx smile and thirty-two underwent FS-LASIK. Corneal fluorescein (FL) staining, tear break-up time (TBUT), Schirmer I test (SIT), ocular surface disease index (OSDI) and central corneal sensitivity were evaluated in all participants. Tears were collected and analyzed for interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), nerve growth factor (NGF) and intercellular adhesion molecule-1 (ICAM-1) levels using multiplex magnetic beads. All measurements were preformed preoperatively and 1 day, 1 week, 1 month and 3 months postoperatively. RESULTS: FL scores in ReLEx smile group were lower than those of FS-LASIK group 1 week postoperatively (P = 0.010). Compared to the FS-LASIK group, longer TBUT were observed in ReLEx smile group 1 month (P = 0.029) and 3 months (P = 0.045) postoperatively. No significant differences were found in tear secretion for the two groups (P>0.05). OSDI scores were higher in FS-LASIK group 1 month after surgery (P = 0.020). Higher central corneal sensitivity was observed in ReLEx smile group 1 week, 1 month and 3 months (P<0.05) postoperatively. Compared to FS-LASIK group, lower and faster recovery of IL-6 and NGF levels in tears was observed in ReLEx smile group postoperatively (P<0.05). Tears TNF-α and ICAM-1 concentrations were not significantly different between the two groups at any follow-up time (P>0.05). Moreover, IL-6 and NGF levels correlated with ocular surface changes after ReLEx smile or FS-LASIK. CONCLUSIONS: In the early postoperative period, ReLEx smile results in milder ocular surface changes than FS-LASIK. Furthermore, the tear inflammatory mediators IL-6 and NGF may play a crucial role in the ocular surface healing process following ReLEx smile and FS-LASIK.

Exposure to sunlight has recently been postulated as responsible for the effect that more time spent outdoors protects children from myopia, while early life exposure to natural light was reported to be possibly related to onset of myopia during childhood. In this study, we had two aims: to determine whether increasing natural light exposure has a protective effect on hyperopic defocus-induced myopia, and to observe whether early postnatal exposure to natural light causes increased risk of refractive error in adolescence. Eight rhesus monkeys (aged 20-30 days) were treated monocularly with hyperopic-defocus (-3.0D lens) and divided randomly into two groups: AL group (n=4), reared under Artificial (indoor) Lighting (08:00-20:00); and NL group (n=4), exposed to Natural (outdoor) Light for 3 hours per day (11:00-14:00), and to indoor lighting for the rest of the light phase. After being reared with lenses for ca. 190 days, all monkeys were returned to unrestricted vision until the age of 3 years. Another eight age-matched monkeys, reared with unrestricted vision under artificial lighting since birth, were employed as controls. The ocular refraction, corneal curvature and axial dimensions were measured before lens-wearing (at 23±3 days of age), monthly during the light phase, and at the age of puberty (at 1185+3 days of age). During the lens-wearing treatment, infant monkeys in the NL group were more hyperopic than those in the AL group (F=5.726, P=0.032). Furthermore, the two eyes of most NL monkeys remained isometropic, whereas 3 of 4 AL monkeys developed myopic anisometropia more than -2.0D. At adolescence, eyes of AL monkeys showed significant myopic anisometropia compared with eyes of NL monkeys (AL vs NL: -1.66±0.87D vs -0.22±0.44D; P=0.002) and controls (AL vs Control: -1.66±0.87D vs -0.05±0.85D; P<0.0001). All differences in refraction were associated with parallel changes in axial dimensions. Our results suggest that exposure to natural outdoor light might have an effect to reduced hyperopic defocus-induced myopia. Also, the data imply that early life exposure to sunlight may help to maintain normal development of emmetropization later in life, and thus lower the risk of myopic anisometropia in adolescent monkey.

PURPOSE: To evaluate the feasibility and efficacy of small-incision femtosecond laser-assisted intracorneal concave lenticule implantation (SFII) and penetrating keratoplasty (PKP) in patients with progressive keratoconus. METHODS: All the patients were clinically diagnosed with progressive keratoconus. Twenty patients underwent PKP (PKP group), and 11 patients underwent SFII (SFII group). Visual acuity, intraocular pressure, corneal topography, corneal visualization Scheimpflug technology, anterior segment optical coherence tomography, and in vivo confocal microscopy were analyzed. RESULTS: Vision improved at 3 months postoperatively in the SFII group. In the PKP group, corrected distance visual acuity improved 1 week after surgery. Corneal topography showed a statistically significant decrease in the anterior K1 and K2. Corneal visualization Scheimpflug technology showed that changes in the biomechanical parameters of the SFII group were also statistically different from those of the PKP group. All the grafts from both groups were clearly visible by anterior segment optical coherence tomography observation. The central corneal thickness of both groups was stable during the 24-month study period. In vivo confocal microscopy showed a few dendritic cells in the subepithelial region in the SFII group. At 3 months after surgery, many dendritic cells and inflammatory cells were observed in the basal epithelium and stroma in the PKP group. CONCLUSIONS: Both SFII and PKP surgical procedures resulted in a stable corneal volume and improved visual acuity in this long-term study. SFII was less invasive and more efficient compared with PKP.

PURPOSE: Based on current evidence, the efficiency and safety of Descemet's membrane endothelial keratoplasty (DMEK) was compared with that of Descemet's stripping endothelial keratoplasty (DSEK). METHODS: Pubmed, Embase, Web of Science, the Cochrane Database and conference abstracts were comprehensively searched for studies that compared the efficacy and safety of DMEK and DSEK. The efficacy outcome was the postoperative best-corrected visual acuity (BCVA). The safety outcomes included the postoperative endothelial cell density (ECD) and complications such as graft detachment, graft rejection, graft failure, postoperative elevated intraocular pressure (IOP), tissue loss, etc. The outcomes were pooled using random-effects models with Stata 13.0 software. Heterogeneity was qualified with Q statistic and I2/H2 statistic. Publication bias was assessed using funnel plot, Begg rank correlation test, and Egger or Horbard linear regression. RESULTS: 19 articles were eligible, and 1124 eyes and 1254 eyes were included in the DMEK and DSEK groups, respectively. The overall pooled estimates showed a significantly better postoperative BCVA, a comparable ECD and an increased graft detachment rate in the DMEK group compared with the DSEK group (BCVA: mean difference (MD) = -0.15, 95% CI = -0.19 to -0.11, P<0.001; ECD: MD = 14.88, 95% CI = -181.50 to 211.27, P = 0.882; graft detachment rate: OR = 4.56, 95% CI = 2.43 to 8.58, P<0.001). Except for the postoperative ECD, which was changed to be higher in the DSEK group than the DMEK group, the learning curve did not have a marked effect on the comparison outcome of the BCVA and graft detachment rate based on the estimates pooled from studies that collected data during the DMEK learning phase (ECD (learning curve): MD = -361.24, 95% CI = -649.42 to -73.07, P = 0.014). CONCLUSION: Although DMEK is a more technically difficult and challenging procedure, it may represent a safe and more efficient alternative to DSEK for the treatment of corneal endothelial diseases, even during its learning curve.

Purpose: Vascular endothelial growth factor receptor 2 (VEGFR2) plays a key role in VEGF-induced angiogenesis. The goal of this project was to test the hypothesis that editing genomic VEGFR2 loci using the technology of clustered regularly interspaced palindromic repeats (CRISPR)-associated DNA endonuclease (Cas)9 in Streptococcus pyogenes (SpCas9) was able to block VEGF-induced activation of Akt and tube formation. Methods: Four 20 nucleotides for synthesizing single-guide RNAs based on human genomic VEGFR2 exon 3 loci were selected and cloned into a lentiCRISPR v2 vector, respectively. The DNA fragments from the genomic VEGFR2 exon 3 of transduced primary human retinal microvascular endothelial cells (HRECs) were analyzed by Sanger DNA sequencing, surveyor nuclease assay, and next-generation sequencing (NGS). In the transduced cells, expression of VEGFR2 and VEGF-stimulated signaling events (e.g., Akt phosphorylation) were determined by Western blot analyses; VEGF-induced cellular responses (proliferation, migration, and tube formation) were examined. Results: In the VEGFR2-sgRNA/SpCas9-transduced HRECs, Sanger DNA sequencing indicated that there were mutations, and NGS demonstrated that there were 83.57% insertion and deletions in the genomic VEGFR2 locus; expression of VEGFR2 was depleted in the VEGFR2-sgRNA/SpCas9-transduced HRECs. In addition, there were lower levels of Akt phosphorylation in HRECs with VEGFR2-sgRNA/SpCas9 than those with LacZ-sgRNA/SpCas9, and there was less VEGF-stimulated Akt activation, proliferation, migration, or tube formation in the VEGFR2-depleted HRECs than those treated with aflibercept or ranibizumab. Conclusions: The CRISPR-SpCas9 technology is a potential novel approach to prevention of pathologic angiogenesis.

The storage of facial images in medical records poses privacy risks due to the sensitive nature of the personal biometric information that can be extracted from such images. To minimize these risks, we developed a new technology, called the digital mask (DM), which is based on three-dimensional reconstruction and deep-learning algorithms to irreversibly erase identifiable features, while retaining disease-relevant features needed for diagnosis. In a prospective clinical study to evaluate the technology for diagnosis of ocular conditions, we found very high diagnostic consistency between the use of original and reconstructed facial videos (κ ≥ 0.845 for strabismus, ptosis and nystagmus, and κ = 0.801 for thyroid-associated orbitopathy) and comparable diagnostic accuracy (P ≥ 0.131 for all ocular conditions tested) was observed. Identity removal validation using multiple-choice questions showed that compared to image cropping, the DM could much more effectively remove identity attributes from facial images. We further confirmed the ability of the DM to evade recognition systems using artificial intelligence-powered re-identification algorithms. Moreover, use of the DM increased the willingness of patients with ocular conditions to provide their facial images as health information during medical treatment. These results indicate the potential of the DM algorithm to protect the privacy of patients' facial images in an era of rapid adoption of digital health technologies.

Importance: Although augmenting large language models (LLMs) with knowledge bases may improve medical domain-specific performance, practical methods are needed for local implementation of LLMs that address privacy concerns and enhance accessibility for health care professionals. Objective: To develop an accurate, cost-effective local implementation of an LLM to mitigate privacy concerns and support their practical deployment in health care settings. Design, Setting, and Participants: ChatZOC (Sun Yat-Sen University Zhongshan Ophthalmology Center), a retrieval-augmented LLM framework, was developed by enhancing a baseline LLM with a comprehensive ophthalmic dataset and evaluation framework (CODE), which includes over 30 000 pieces of ophthalmic knowledge. This LLM was benchmarked against 10 representative LLMs, including GPT-4 and GPT-3.5 Turbo (OpenAI), across 300 clinical questions in ophthalmology. The evaluation, involving a panel of medical experts and biomedical researchers, focused on accuracy, utility, and safety. A double-masked approach was used to try to minimize bias assessment across all models. The study used a comprehensive knowledge base derived from ophthalmic clinical practice, without directly involving clinical patients. Exposures: LLM response to clinical questions. Main Outcomes and Measures: Accuracy, utility, and safety of LLMs in responding to clinical questions. Results: The baseline model achieved a human ranking score of 0.48. The retrieval-augmented LLM had a score of 0.60, a difference of 0.12 (95% CI, 0.02-0.22; P = .02) from baseline and not different from GPT-4 with a score of 0.61 (difference = 0.01; 95% CI, -0.11 to 0.13; P = .89). For scientific consensus, the retrieval-augmented LLM was 84.0% compared with the baseline model of 46.5% (difference = 37.5%; 95% CI, 29.0%-46.0%; P < .001) and not different from GPT-4 with a value of 79.2% (difference = 4.8%; 95% CI, -0.3% to 10.0%; P = .06). Conclusions and Relevance: Results of this quality improvement study suggest that the integration of high-quality knowledge bases improved the LLM's performance in medical domains. This study highlights the transformative potential of augmented LLMs in clinical practice by providing reliable, safe, and practical clinical information. Further research is needed to explore the broader application of such frameworks in the real world.

To provide the general information on corneal transplantation (CT) in China, China Cornea Society designed a questionnaire on CT from 2014 to 2018 and entrusted it to 31 committee members for implementation of the survey nationwide. This article presents the results of the survey and compares the indicators used in the survey and those in the annual statistical report released by the Eye Bank Association of America (EBAA). The number of corneal transplantations completed by the 64 hospitals from 2014 to 2018 was respectively 5377, 6394, 7595, 8270 and 8980, totally 36,616 (22,959 male and 13,657 female). The five largest hospitals by the number of corneal transplantations completed 15,994 surgeries in total, accounting for 43.68% of all the surgeries performed in the 64 hospitals. The most common indication for corneal transplantations was corneal leukoma (7683, 20.98%), followed by bacterial keratitis (4209, 11.49%), corneal dystrophies (4189, 11.44%), keratoconus (3578, 9.77%) and corneal perforation (2839, 7.75%). The main surgical techniques were penetrating keratoplasty (PK) (19,896, 54.34%), anterior lamellar keratoplasty (ALK) (13,869, 37.88%). The proportion of PK decreased from 57.97% in 2014 to 52.88% in 2018 while the proportion of ALK increased from 36.04% in 2014 to 37.92% in 2018. The geographical distribution of keratoplasties performed in China is unbalanced. PK and ALK were the main techniques of CT and corneal leukoma, bacterial keratitis and corneal dystrophies were the main indications for CT in China.

BACKGROUND: The aim of this study was to evaluate central corneal sensitivity after small incision lenticule extraction (SMILE) versus femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia. METHODS: Eligible studies were identified by systematically searching PubMed, the Cochrane Library, Embase and the Chinese Biomedicine Database. Central corneal sensitivity after SMILE versus FS-LASIK was assessed by the pooled weighted mean differences (WMDs) of the reduction from pre-operation levels to 1 week, 1, 3 and 6 months following the operation. The quality of the included literature was assessed by the Quality Index. Data were synthesized by Stata 12.0 SE for Windows. RESULTS: Five studies involving 245 patients (363 eyes; 189 eyes in the FS-LASIK group and 174 eyes in the SMILE group) were included in the meta-analysis. The pooled results showed that there were no significant differences in central corneal sensitivity between FS-LASIK and SMILE before surgery (WMD = 0 mm, 95 % CI: -0.23 to -0.23, p = 0.998). At 1 week, 1 and 3 months after surgery, the central corneal sensitivity after FS-LASIK was lower than with SMILE (WMD = -17.35 mm, 95 % CI: -26.54 to -8.16, p <0.001; WMD = -17.52 mm, 95 % CI: -25.10 to -9.94, p <0.001; WMD = -14.64 mm, 95 % CI: -20.08 to -9.21, p <0.001, respectively). However, central corneal sensitivity after FS-LASIK was similar with SMILE 6 months after surgery (WMD = -2.02 mm, 95 % CI: -4.23 to 0.19, p = 0.074). CONCLUSION: Central corneal sensitivity exhibited a small decrease and a faster recovery after the SMILE procedure compared to FS-LASIK during the first three postoperative months. Corneal sensitivity after SMILE and FS-LASIK was similar at 6 months after surgery. However, these results should be interpreted with caution due to the limited number of studies.

SIGNIFICANCE: The cornea is a viscoelastic tissue with viscous and elastic properties. The information of corneal biomechanical changes in high myopia has implications for understanding the pathogenesis of high myopia and primary open angle glaucoma. However, the knowledge of corneal biomechanics in high myopia is limited. PURPOSE: To compare the corneal biomechanical properties in high-myopia subjects and emmetropia subjects. METHODS: Dynamic Scheimpflug imaging technology was used to measure intraocular pressure, central corneal thickness, and corneal biomechanical parameters, including time at the first applanation, velocity at the first applanation, length at the first applanation, deformation amplitude at the first applanation, time at the second applanation, A2V (velocity at the second applanation), length at the second applanation (A2L), deformation amplitude at the second applanation, time at the highest concavity, radius curvature at the highest concavity (HCR), maximal deformation amplitude (MDA), and peak distance. RESULTS: This study included 40 subjects with high myopia and 61 emmetropia subjects. The high-myopia demonstrated greater MDA compared with the emmetropia (1.07 ± 0.01 vs. 1.02 ± 0.01 mm; P < .001) after adjusting for age and intraocular pressure. Pooling analysis found that the high myopia exhibited a smaller HCR, greater MDA, faster A2V and shorter A2L, with a pooled mean difference of -0.21 mm (95% confidential interval [95% CI], -0.30 to -0.13; P < .001) for HCR, 0.05 mm (95% CI, 0.04 to 0.06; P < .001) for MDA, -0.03 m/s (95% CI, -0.06 to -0.002; P = .034) for A2V, and -0.05 mm (95% CI, -0.08 to -0.02; P = .001) for A2L. CONCLUSIONS: Eyes with high myopia showed a significantly smaller HCR, greater MDA, faster A2V, and shorter A2L than did those with emmetropia, which indicated that the cornea in an eye with high myopia becomes weaker and more deformable.

BACKGROUND Pythium insidiosum keratitis is a rare but sight-threatening disease with a high morbidity rate. It can be misdiagnosed as fungal keratitis in clinic settings. We report a case of severe Pythium insidiosum keratitis in a Chinese child, treated with combined approaches. CASE REPORT A 7-year-old boy from Hainan province in the south of China developed a suppurative corneal ulcer after being in a forest. A mass of hyphae was detected by confocal imaging in vivo, fungal smear test, and histochemical examination. Treatment with Natamycin, fluconazole, and Voriconazole for 1 month was unsuccessful, and a penetrating keratoplasty with anterior vitrectomy was performed. The infection reappeared 1 day after surgery, immediately after which anterior chamber irrigation with 0.02% Fluconazole and amphotericin B solution was performed. Finally, the globe was saved and there was no further recurrent infection. A cultured mycelial organism, which was hard to identify by biomorphology, was confirmed by PCR to be Pythium insidiosum. The zoospores were observed in water environments. The imaging characteristics of P. insidiosum in confocal microscopy are described herein. CONCLUSIONS This is the first case of Pythium insidiosum keratitis reported in China. It can be misdiagnosed as fungal keratitis in the clinic. Improving the awareness of clinicians, promoting early diagnosis, and a multidisciplinary approach, especially early surgery, improve the prognosis.

BACKGROUND: Central corneal thickness (CCT) is an important indicator of corneal status. Its measurement provides valid information about corneal physiological condition and possible changes associated with diseases, traumas, and hypoxia. It is an integral part for interpretation of intraocular pressure and glaucoma patient management and in prerefractive procedure assessment. OBJECTIVE: The aim of this study is to determine the mean CCT among a normal Iraqi population and to correlate between CCT and age, gender, refraction, and corneal curvature. PATIENTS AND METHODS: This cross-sectional study was carried out at Ibn Al-Haitham Teaching Eye Hospital. A total of 418 eyes from 209 healthy individuals with an age range from 20 to 75 years were studied. CCT was measured by ultrasound pachymeter. Refraction was measured using an auto-refractor and confirmed by trial lenses and retinoscopy to calculate the spherical equivalent. Corneal curvature was measured using an auto-refracto-keratometer to calculate the average corneal curvature (AVK). RESULTS: The mean CCT was 543.95±32.58 μm with a range from 422 to 636 μm. CCT was not affected by gender. CCT significantly negatively correlated with age and AVK. CCT significantly positively correlated with the spherical equivalence. CONCLUSION AND RECOMMENDATION: Among an Iraqi population, CCT significantly decreased with age. Myopics had significantly thinner corneas. There was weak but significant negative correlation between CCT and corneal curvature. We recommend further studies about the relationship between central corneal thickness and other ocular parameters in Iraqi population such as the axial length.

Purpose: To report on the safety and efficacy of the 256-channel Intelligent Micro Implant Eye epiretinal prosthesis system (IMIE 256). Methods: The IMIE 256 implants were implanted in the right eyes of five subjects with end-stage retinitis pigmentosa. Following implantation, the subjects underwent visual rehabilitation training for 90 days, and their visual performance was evaluated using the grating visual acuity test, Tumbling E visual acuity test, direction of motion, square localization, and orientation and mobility test. To evaluate the safety of the IMIE 256, all adverse events were recorded. Results: Subjects performed significantly better on all evaluations with the IMIE 256 system on as compared with the performance at baseline or with the system off. There was a steady improvement in performance at each observation interval, indicating that the training and/or practice helped the subjects use the IMIE 256. There were two serious adverse events-electrode array movement and low intraocular pressure in one subject, which resolved with surgery. There were no other adverse events observed except those expected in the course of postoperative healing. Conclusions: These results show an improved safety and efficacy profile compared with that of the Argus II implant. Further clinical trials are needed to confirm these results in a larger number of subjects and over longer durations. Translational Relevance: To our knowledge, this study reports the first in-human data from a high-density (256 electrodes) epiretinal implant to restore sight to a subset of blind patients.

PURPOSE: The purpose of this study is to determine the influence of sex on choroidal thickness (CT) in healthy adults. METHODS: Healthy Chinese adults were recruited and complete ophthalmic examinations were performed. The choroid was imaged by swept-source optical coherence tomography and the macular CT in Early Treatment Diabetic Retinopathy Study grids was obtained by the intrinsic automated segmentation software. CT in males and females was compared after controlling other factors. All of the published studies in PubMed were systemically tracked, and a syntheses analysis of the combined data of the present study and previous studies was performed to address this issue further. RESULTS: A total of 104 healthy adults were included, of whom 38 (37%) were male and 66 (63%) were female. Older age and longer axial length (AL) each were significantly associated with thinner CT. After controlling for age and AL, the foveal CT and average macular CT were 25.5 μm (95% CI: 0.5-50.4 μm) and 22.1 μm (95% CI: 2.7-41.4 μm) thicker in men than in women, respectively. Significant differences in CT between males and females were also observed in inner and outer rings after controlling for age and AL (P < 0.05). After strict screening, 15 previously reported studies were determined to be eligible for inclusion. The combination of data collected from 2821 males and 3389 females provided further evidence that the choroid is thicker in males, with a pooled mean difference of 19.5 μm (95% CI: 11.4 to 27.6) for foveal CT and 14.7 μm (95% CI: 6.8 to 22.6) for average CT. CONCLUSION: Our study of Chinese subjects, along with the syntheses analysis, strengthens the evidence that CT is greater in males than in females, based on OCT measurements. This observation may be pertinent for the sex disparities in some clinical conditions related to CT.

The coronavirus disease 2019 (COVID-19) pandemic has posed challenges for healthcare providers,1Wang C. Horby P.W. Hayden F.G. Gao G.F. A novel coronavirus outbreak of global health concern.Lancet. 2020; 395: 470-473Abstract Full Text Full Text PDF PubMed Scopus (5092) Google Scholar while also bringing about new opportunities for telehealth services worldwide. Although media publicity for telehealth and virtual consultations has been widespread,2Hollander J.E. Carr B.G. Virtually perfect? Telemedicine for Covid-19.N Engl J Med. 2020; 382: 1679-1681Crossref PubMed Scopus (2086) Google Scholar few peer-reviewed studies have been conducted to describe the characteristics and effectiveness of hospital-based telehealth virtual practice in response to the COVID-19 pandemic. In China, the Zhongshan Ophthalmic Center (ZOC) of Sun Yat-sen University established a virtual clinical service using several digital technologies3Ting D.S.W. Carin L. Dzau V. Wong T.Y. Digital technology and COVID-19.Nat Med. 2020; 26: 459-461Crossref PubMed Scopus (944) Google Scholar (5G telecommunication networks, big data analytics, artificial intelligence,4Gunasekeran D.V. Wong T.Y. Artificial intelligence in ophthalmology in 2020: a technology on the cusp for translation and implementation.Asia Pac J Ophthalmol (Phila). 2020; 9: 61-66Crossref PubMed Scopus (36) Google Scholar and blockchain technology5Radanović I. Likić R. Opportunities for use of blockchain technology in medicine.Appl Health Econ Health Policy. 2018; 16: 583-590Crossref PubMed Scopus (213) Google Scholar) to deliver online ophthalmic diagnosis and treatment services. This study analyzed the characteristics and effectiveness of a virtual service run by the tertiary ophthalmic center in China to construct a pragmatic paradigm for telehealth eye care services during and beyond the pandemic. With lockdown regulations for the COVID-19 epidemic being implemented, from February 1 to 7, 2020, ZOC on-site registration was open for emergencies only. Comprehensive and specialist clinics were reopened gradually beginning on February 15, 2020. The ZOC internet hospital was launched on February 1 to provide patients with diagnosis and treatment options. Three interlinked modules constituted the main body of the ZOC internet hospital: artificial intelligence prescreening by chatbot and image recognition,6Li W. Yang Y. Zhang K. et al.Dense anatomical annotation of slit-lamp images improves the performance of deep learning for the diagnosis of ophthalmic disorders.Nat Biomed Eng. 2020; 4: 767-777Crossref PubMed Scopus (46) Google Scholar virtual live consultation with ophthalmologists, and online pharmacy for prescription renewals and remote drug delivery (details in Fig S1A, available at www.aaojournal.org). We extracted clinical services records from virtual 2020, face-to-face 2020, and face-to-face 2019 encounters from February 1 through March 13 for analysis, including patient age, gender, address, date and hour for consultation, transcript records of online communications, diagnosis of on-site clinic visits, and so forth. We used the Shapiro-Wilk test to evaluate for normal distribution of each sample. The median and interquartile range (IQR) were used for the description of continuous variables that did not conform to a normal distribution. The Kruskal-Wallis test (among the 3 groups) and the Wilcoxon rank-sum test (between 2 groups) were used for comparisons. The frequency and proportion were used for descriptions of categorical variables, and the chi-square test was used for comparisons between groups. P values of less than 0.05 were considered statistically significant for all tests. This study followed the principles outlined in the Declaration of Helsinki. The study protocol was approved by the ethical board committee of the Zhongshan Ophthalmic Center, Sun Yat-sen University. The requirement for informed consent was waived because of the retrospective nature of the study. During the 6-week study period, a total of 38 038 visits online (virtual 2020) and offline (face-to-face 2020) were observed in this study, including 10 641 visits with the artificial intelligence chatbot, 9850 virtual live consultations by 127 doctors, and 17 547 on-site face-to-face clinic visits. Along with the gradual opening of the on-site outpatient and emergency services by the ZOC, the number of on-site patients showed a steep rise. Simultaneously, online service numbers steadily increased because of the increased awareness of the service, optimization of the patient-user experience, and the availability of online pharmacy service and delivery (Fig S1B). Thus, we were able to offer an end-to-end solution based on a fully virtual diagnosis and treatment. The median age of virtual 2020 patients was 32 years, significantly younger than that of the face-to-face 2019 (35 years) and face-to-face 2020 (45 years) groups. The proportions of youth (18–34 years [35.9%]) and middle-aged (35–54 years [26.8%]) patients increased in the virtual 2020 group after the COVID-19 outbreak compared with the face-to-face 2019 group. Women were more likely to use virtual live consultations (53.3% of 9850 visits) than face-to-face 2020 (47.7% of 17 547 visits) or face-to-face 2019 (51.1% of 98 225 visits) encounters. Retinopathy was one of the most common reasons for the encounter in the virtual 2020 (22.6% [1644/7273]), face-to-face 2020 (26.5% [1203/4532]), and face-to-face 2019 (20.1% [10 740/53 308]) groups. Nevertheless, more visits were for ocular surface diseases (24.2% [1761/7273]) and glaucoma (19.4% [1411/7273]) in patients who undertook a virtual live consultation. Trauma (26.3% [1194/4532]) accounted for the second-largest proportion of face-to-face 2020 encounters. Refraction problems (26.1% [13 895/53 308]) were the most common reason for face-to-face 2019 consultations. Compared with face-to-face 2019 encounters, which represented the normal state before the COVID-19 outbreak, face-to-face 2020 visits in the corresponding period involved patients more geographically concentrated around ZOC clinics from Guangdong Province (85.6% [14 050/16 405] of China) and Guangzhou City (72.9% [10 112/13 876] of Guangdong Province) because of the travel restrictions during the national lockdown. By contrast, virtual 2020 visits were significantly more dispersed, with a median geographical distance of 340 km (IQR, 64.0–677 km), significantly farther than face-to-face 2020 (2.66 km [IQR, 0.01–128 km]) and face-to-face 2019 (2.65 km [IQR, 0.00–219 km]; Table S1, available at www.aaojournal.org) encounters. We further analyzed the indications of virtual live consultations in 2020. Specific disease consultation was the most commonly cited reason for virtual live consultation and accounted for 67.0% of the total 9850 visits, followed by symptomatic conditions (56.0%), prescription renewal (54.6%), other consultations (2.2%; including drug use, procedures for attending clinics during the lockdown period, eye health consultation, etc.), and repeated consultation (1.6%). Among the symptoms addressed, ocular discomfort or appearance abnormalities constituted the overwhelming majority (87.2%). In terms of specific disease consultations, 38.7% and 26.9% of the total 6597 visits concerned follow-up and queries about surgery-related information, respectively. The top 3 most referred diseases were ocular surface diseases (26.7%), retinopathy (24.9%), and glaucoma (21.4%; Fig S2A, available at www.aaojournal.org). When stratified by age, specific disease consultation was the most common reason across all age groups, and the demand increased with age from 64.7% in children (<18 years; 1339/2069) to 70.7% in older adults (>55 years; 1131/1599). Youth (18–34 years) were the most eager to seek virtual consultation for symptoms (60.4% [2036/3539]) and other consultations (2.6% [92/3539]). Older adults (>55 years) were most likely to use virtual consultation for prescription renewal, with up to 10% more older adults requesting prescription renewal than the other age groups. Repeated consultation was the only category that children or their guardians (1.8% [37/2039]) were more likely to use (Fig S2B). The study has several limitations. First, during the 6-week study period, the ZOC online and on-site services were running separately and thus were analyzed as independent parts. We could not trace the flow of visits for a patient from online to on-site, or vice versa. Subsequently, the online and on-site healthcare interactions were integrated and incorporated in the ZOC internet hospital design. Second, the direct reproducibility of the virtual clinical services may be limited by the licensing requirements from different countries and regions. Nevertheless, we have offered lessons and collaborate with other ophthalmology services providers during and after the COVID-19 pandemic. Our results indicate that online medical services could be fully used for telehealth advantages, including time savings, bridging geographical barriers, and additional functionalities such as remote assessment, in a complementary manner to on-site face-to-face clinical services. Interestingly, we observed from the spectrum of diseases that ocular surface diseases were most cited in the virtual live consultations in 2020, which differs significantly from the most common reasons for the face-to-face 2020 (retinopathy) and face-to-face 2019 (refraction) consultations. This finding may reflect that COVID-19 may have ocular surface symptoms, although we did not record COVID-19-positive patients in our service. Alternatively, ocular surface disorders could be related to physical or psychological factors (break from regular life, overuse of digital screens, stress, anxiety during the pandemic).7Kitazawa M. Sakamoto C. Yoshimura M. et al.The relationship of dry eye disease with depression and anxiety: a naturalistic observational study.Transl Vis Sci Technol. 2018; 7: 35Crossref PubMed Scopus (46) Google Scholar Even as countries and systems adapt to the new normal after the COVID-19 pandemic, many of the virtual systems that were established to meet short-term needs eventually will evolve into long-term trends and solutions. The virtual clinical practice described herein was beneficial especially for patients with ocular surface symptoms or for those in need of follow-up medications. Furthermore, virtual evaluation could provide effective forward triage to specific on-site specialists as a useful complement. The virtual service also offered an alternative for patients with less time or those whose geographic locations made our services less accessible. The guidance and lessons from this study are a reference for other ophthalmology services in different countries during and after the COVID-19 pandemic. The authors thank the Guangdong Medical Association Ophthalmology Branch, Hubei Medical Association Ophthalmology Branch, and the Chinese Association of Artificial Intelligence for the leadership and administrative supports. The authors also thank each of the 127 voluntary ophthalmologists from the Zhongshan Ophthalmic Center and collaborating hospitals for providing virtual live consultations—Zhongshan Ophthalmic Center: Feng Wen, Xiaoming Lin, Yimin Zhong, Shaochong Zhang, Chenjin Jin, Jian Ge, Xialin Liu, Xing Liu, Yan Luo, Dongmei Cui, Xinguo Deng, Haotian Lin, Weirong Chen, Lin Lv, Tao Li, Kaili Wu, Siming Ai, Shengsong Huang, Keming Yu, Mingkai Lin, Qingjiong Zhang, Yang Gao, Xingyi Li, Sainan Xiao, Hui Xiao, Jing Yang, Xinbo Gao, Xuan Qiu, Zidong Chen, Jing Wu, Xueying Zhongliu, Xintong Jiang, Heping Wu, Xiujuan Zhao, Hui Chen, Saiqun Li, Dina Hu’an, Liangping Liu, Yingting Zhu, Rongxin Chen, Zhonghao Wang, Lingyi Liang, Jianjun Gu, Ying Kang, Junshu Wu, Danping Huang, Mingxing Wu, Lixia Luo, Quan Liu, Xianchai, Lin, Chengguo Zuo, Wei Chi, Jin Ma, Rong Lu, Xiangming Guo, Shida Chen, Fan Li, Binghua Kong, Zhengjie Xu, Xuhua Tan, Xiaoxiao Zhang, Chuangxin Huang, Qiwei Wang, Wei Xiao, Shanshan Wang, Jingjing Chen, Yao Yang, Ping Lian, Huijing Ye, Chunxiao Wang, Chang He, Lan Mi, Bing Xiao, Songshan Li, Xiling Yu, Zhenzhen Liu, Yunlan Ling, Jingchang Chen, Danying Zheng, Xiao Yang, Sheng Zhou, Zhaohui Yuan, Yangfan Yang, Ying Lin, Wenru Su, Bingqian Liu, Fang Duan, Siping Zhu, Xiaohu Ding, Lei Lei, Xiaohang Wu, Xiaoqing Chen, Wu Xiang, Linxing Chen, Shaohua Fang, Shiyi Li, Wenyan Peng, Wan Chen, Yiming Ye, Li Huang, Limei Sun, Xiaoning Liu, Feng Zhao, Xiongze Zhang, Lixia Lin, Ting Zhang, Yuying Ji, and Yin Hu; Zhongshan Ophthalmic Center, Nanchang Ophthalmic Hospital: Yingjie Li, Yu Jin, and Miao Liu; The First Hospital of Nanchang City: Yan Mei; Hainan Eye Hospital, Zhongshan Ophthalmic Center: Lingyun Wu; Yueyang Traditional Chinese Medicine Hospital: Li Zhou; Wuhan Eye and Optometry Hospital: Keneng Yan; The Central Hospital of Wuhan: Jun Jia; Zhongnan Hospital of Wuhan University: Ming Yan, Aihua Yu, Jing Zhang, and Qi Xiong; Renmin Hospital of Wuhan University: Bin Peng and Jing Yuan; Aier Eye Hospital of Wuhan University: Binxian Yan; Tai’an City Central Hospital: Shengxia Wang; Yichang Central People’s Hospital: Xuemei Wang and Hao Wu; and The Central Hospital of E-zhou: Zheng Zhang. Download .pdf (.35 MB) Help with pdf files Supplementary Figures Download .pdf (.13 MB) Help with pdf files Table S1

Importance: China has experienced both rapid urbanization and major increases in myopia prevalence. Previous studies suggest that green space exposure reduces the risk of myopia, but the association between myopia risk and specific geometry and distribution characteristics of green space has yet to be explored. These must be understood to craft effective interventions to reduce myopia. Objective: To evaluate the associations between myopia and specific green space morphology using novel quantitative data from high-resolution satellite imaging. Design, Setting, and Participants: This prospective cohort study included students grades 1 to 4 (aged 6 to 9 years) in Shenzhen, China. Baseline data were collected in 2016-2017, and students were followed up in 2018-2019. Data were analyzed from September 2020 to January 2022. Exposures: Eight landscape metrics were calculated using land cover data from high-resolution Gaofen-2 satellite images to measure area, aggregation, and shape of green space. Main Outcome and Measures: The 2-year cumulative change in myopia prevalence at each school and incidence of myopia at the student level after 2 years were calculated as main outcomes. The associations between landscape metrics and school myopia were assessed, controlling for geographical, demographic, and socioeconomic factors. Principal component analyses were performed to further assess the joint effect of landscape metrics at the school and individual level. Results: A total of 138 735 students were assessed at baseline. Higher proportion, aggregation, and better connectivity of green space were correlated with slower increases in myopia prevalence. In the principal component regression, a 1-unit increase in the myopia-related green space morphology index (the first principal component) was negatively associated with a 1.7% (95% CI, -2.7 to -0.6) decrease in myopia prevalence change at the school level (P = .002). At the individual level, a 1-unit increase in myopia-related green space morphology index was associated with a 9.8% (95% CI, 4.1 to 15.1) reduction in the risk of incident myopia (P < .001), and the association remained after further adjustment for outdoor time, screen time, reading time, and parental myopia (adjusted odds ratio, 0.88; 95% CI, 0.80 to 0.97; P = .009). Conclusions and Relevance: Structure of green space was associated with a decreased relative risk of myopia, which may provide guidance for construction and renovation of schools. Since risk estimates only indicate correlations rather than causation, further interventional studies are needed to assess the effect on school myopia of urban planning and environmental designs, especially size and aggregation metrics of green space, on school myopia.

PURPOSE: To evaluate the short-term changes in ocular surface measures and tear inflammatory mediators after femtosecond lenticule extraction (FLEx) and small-incision lenticule extraction (SMILE) procedures. METHODS: Eighteen subjects (18 eyes) underwent FLEx and 23 subjects (23 eyes) underwent SMILE in this single-center and prospective study. Central corneal sensitivity, Schirmer I test (SIT), noninvasive tear breakup time (NI-TBUT), tear meniscus height, corneal fluorescein (FL) staining, and ocular surface disease index (OSDI) were assessed in all patients. Concentrations of interleukin-1α (IL-1α), tumor necrosis factor-α (TNF-α), nerve growth factor (NGF), interferon-γ (IFN-γ), transforming growth factor-β1 (TGF-β1) and matrix metalloproteinase-9 (MMP-9) in collected tears were measured by multiplex antibody microarray. RESULTS: Central corneal sensitivity was reduced in both groups, but the scores in the SMILE group were higher than those in the FLEx group at all time points postoperatively (P<0.01). Lower FL scores and longer NI-BUT were observed in the SMILE group 1 week after surgery (P<0.05). OSDI scores in both groups increased rapidly at 1 day and 1 week postoperatively, then returned to their preoperative levels within 1 month (P<0.05). There were no significant differences in SIT or tear meniscus height between the two groups. Lower and faster recovery of tear NGF, TGF-β1 and IL-1α concentration were found in the SMILE group compared to the FLEx group postoperatively. No significant difference was found in tear TNF-α, IFN-γ and MMP-9 for either group before or after surgery. Tear NGF, TGF-β1 and IL-1α show a correlation with ocular surface changes after FLEx or SMILE surgery. CONCLUSION: SMILE has superiority over FLEx in early ocular surface changes and NGF, TGF-β1 and IL-1α may contribute to the process of ocular surface recovery. TRIAL REGISTRATION: ClinicalTrials.gov NCT02540785.