Stellate multiform amelanotic choroidopathy (SMACH) is a rare choroidal disease that can cause persistent subretinal fluid (SRF). It is more common in young individuals, with a similar male-to-female ratio, it is most often unilateral, and its clinical manifestations are diverse. The pathogenesis of SMACH is not well understood, but it may be a form of congenital choroidal dysplasia. The progressive impact of the lesion on the choroidal capillaries and the retinal pigment epithelium may be the cause of SRF. Its characteristic multimodal imaging changes include optical coherence tomography showing hyperreflective fibrous-like changes located in the inner choroidal stroma. Typical finger-like projections arranged in a stellate configuration are best seen on near-infrared imaging, indocyanine green angiography, and en face optical coherence tomography. The lesion is stable, with no progressive changes, and is unresponsive to treatment. Clinicians have limited knowledge about SMACH, which can lead to patients undergoing unnecessary or inappropriate treatments. Therefore, it is necessary to understand and recognize SMACH early in clinical practice.

Stellate multiform amelanotic choroidopathy (SMACH) is a rare choroidal disease that can cause persistent subretinal fluid (SRF). It is more common in young individuals, with a similar male-to-female ratio, it is most often unilateral, and its clinical manifestations are diverse. The pathogenesis of SMACH is not well understood, but it may be a form of congenital choroidal dysplasia. The progressive impact of the lesion on the choroidal capillaries and the retinal pigment epithelium may be the cause of SRF. Its characteristic multimodal imaging changes include optical coherence tomography showing hyperreflective fibrous-like changes located in the inner choroidal stroma. Typical finger-like projections arranged in a stellate configuration are best seen on near-infrared imaging, indocyanine green angiography, and en face optical coherence tomography. The lesion is stable, with no progressive changes, and is unresponsive to treatment. Clinicians have limited knowledge about SMACH, which can lead to patients undergoing unnecessary or inappropriate treatments. Therefore, it is necessary to understand and recognize SMACH early in clinical practice.

Peripapillary pachychoroid syndrome (PPS), a new entity in pachychoroid disease spectrum, is characterized by the thickening of the choroid in the peripapillary area.PPS is more likely to occur in middle-aged and older males, and some of the affected eyes are hyperopic and have short axial lengths.The diagnosis and differentiation of PPS depends mainly on the imaging characteristics.Optical coherence tomography shows that dilated Haller layer vessels are located in the nasal macula and associated with intraretinal fluid in the corresponding locations.Indocyanine green angiography shows dilated large choroidal vessels and choroidal hyperpermeability in the nasal maculal and peripapillary region.PPS should be differentiated from uveal effusion syndrome, central serous chorioretinopathy, and pachychoroid neovascularization.Photodynamic therapy may improve retinal effusion in patients with PPS.At present, the research on PPS is insufficient.It is still controversial whether PPS can be considered as a separate entity.The effectiveness of treatment needs more prospective studies.Further research is needed to provide new insights into the definition, diagnosis, treatment and pathogenesis of PPS.

Perifoveal exudative vascular anomalous complex (PEVAC) is a very rare macular vascular disease characterized by an isolated large aneurysmal lesion in the fovea, with accompanied by small retinal hemorrhage and exudation. The main clinical symptoms of the patients are various degree of impaired vision. Clinically, it is often confused with type 1 macular telangiectasia and type 3 macular neovascularization. A thorough understanding of the clinical features of PEVAC is particularly important for its differential diagnosis. Due to the unclear pathogenesis of PEVAC, there is no specific treatment for the cause of disease. Most scholars use intravitreal injection against vascular endothelial growth factor drugs for treatment, but can not improve patients' visual acuity. At present, many attempts have been made to eliminate abnormal exudation of the lesion, maintain visual function and achieve a good prognosis by simple or combined laser photocoagulation. At present, it is still necessary to explore the pathogenesis of PEVAC, improve the understanding of the disease, and find a better treatment plan.

Objectives:To investigate common problems analysis and improvements of medical records writing in the standardized residency training of ophthalmology.Methods:A total of 100 defective medical records of Renmin Hospital of Wuhan University from September 2019 to January 2020 were collected and analyzed for the problems and the reasons, as well as the improvements.Results:A total of 286 defects were found in these 100 medical records. Of which, content-related defects were detected in 89 medical records (31.12%), while quality-related problems were found in 151 records (52.80%). In addition, other defects were found in 46 records (16.08%). Major reasons included personal attitude, insufficient ophthalmic knowledge, heavy workload, lack of standardized guidance and insufficient communicational skills.Conclusion:By analyzing the major reasons of medical records writing, the following approaches, including standardized pre-job training, learning of medical dispute cases and online training, communicational skills training, in-time feedback and evaluation improvement, would be help to reduce the defects in the medical records written by ophthalmic residents.

It has been revealed that hypoxia is dynamic in hypertrophic scars; therefore, we considered that it may have different effects on hypoxia-inducible factor-1α (HIF-1α) and p53 expression. Herein, we aimed to confirm the presence of a teeterboard-like conversion between HIF-1α and p53, which is correlated with scar formation and regression. Thus, we obtained samples of normal skin and hypertrophic scars to identify the differences in HIF-1α and autophagy using immunohistochemistry and transmission electron microscopy. In addition, we used moderate hypoxia in vitro to simulate the proliferative scar, and silenced HIF-1α or p53 gene expression or triggered overexpression to investigate the changes of HIF-1α and p53 expression, autophagy, apoptosis, and cell proliferation under this condition. HIF-1α, p53, and autophagy-related proteins were assayed using western blotting and immunofluorescence, whereas apoptosis was detected using flow cytometry analysis, and cell proliferation was detected using cell counting kit-8 (CCK-8) and 5-bromo-2'-deoxyuridine (BrdU) staining. Furthermore, immunoprecipitation was performed to verify the binding of HIF-1α and p53 to transcription cofactor p300. Our results demonstrated that, in scar tissue, HIF-1α expression increased in parallel with autophagosome formation. Under hypoxia, HIF-1α expression and autophagy were upregulated, whereas p53 expression and apoptosis were downregulated in vitro. HIF-1α knockdown downregulated autophagy, proliferation, and p300-bound HIF-1α, and upregulated p53 expression, apoptosis, and p300-bound p53. Meanwhile, p53 knockdown induced the opposite effects and enhanced HIF-1α, whereas p53 overexpression resulted in the same effects and reduced HIF-1α. Our results suggest a teeterboard-like conversion between HIF-1α and p53, which is linked with scar hyperplasia and regression.
Apoptosis ; Autophagy ; Cell Hypoxia ; Fibroblasts/metabolism* ; Humans ; Hypoxia-Inducible Factor 1, alpha Subunit/metabolism* ; Tumor Suppressor Protein p53/metabolism*

Objective To clarify the clinical features of dysthyroid optic neuropathy (DON), so as to provide evidence for early diagnosis and treatment of DON. Methods The general characteristics and data of thyroid function conditions, ophthalmologic and imaging examinations were retrospectively analyzed in 98 patients (196 eyes) with DON diagnosed from Jan. 2015 to Dec. 2017 in our hospital. According to relevant references, the 196 eyes were diagnosed as having definite, equivocal, or no DON. All patients with equivocal or definite DON in at least one eye were recruited. Results Among 98 DON patients, 59 were male and 39 were female, and the ratio of male to female was 1.51: 1. The average age of 98 patients was (52.51 ±10.25) years old, ranging from 34 to 74 years old. All patients had a history of smoking or passive smoking. Ninetysix patients had hyperthyrea. Of 98 patients, 80 had definite DON and 18 equivocal, with 122 eyes being definite, 56 being equivocal and 18 having no DON. The mean clinical activity score was (4.44±1.53) in all patients, of whom 30 cases scored≤3. Of 178 definite and equivocal DON eyes, 142 eyes had best corrected visual acuity≤0.6, 130 had reduced colour vision, 38 had optic disc oedema, 56 had optic disc pallor, and 84 had normal optic disc. Seventeen out of 18 eyes without DON had normal optic disc. The exophthalmos≤21 mm was found in 38 definite DON eyes. Orbital imaging examination showed that all 80 definite DON patients had crowded orbital apex syndrome, with 67 cases (83.75%) having bilateral and 13 (16.25%) having unilateral one. Conclusion Older age, male, smoking and hyperthyrea are risk factors of DON. Crowded orbital apex syndrome is the most important pathological basis of DON. Impaired visual acuity, reduced colour vision and optic disc swelling are the most specific clinical features of DON.

BACKGROUND: Reducing perioperative blood loss in total hip arthroplasty is a hot topic for joint surgeons. Both intravenous infusion and intra-articular injection of tranexamic acid significantly reduce perioperative blood loss, blood transfusion volume, and need for blood transfusion in patients undergoing total hip arthroplasty. However, differences between the intravenous and intra-articular methods are not clear.OBJECTIVE: To evaluate the effects of these two tranexamic acid administration methods on perioperative blood loss in patients undergoing total hip arthroplasty.METHODS: We are conducting a prospective, single-center, open-label, randomized, controlled clinical trial at the Tengzhou Central People's Hospital, China. Ninety patients undergoing unilateral total hip arthroplasty have been randomized into three groups. In the intravenous infusion group (n=30), 15 mg/kg tranexamic acid diluted in 100 mL physiological saline was infused intravenously at the beginning of surgery and 20 mL of physiological saline was injected intra-articularly after deep fascia suturing. In the intra-articular injection group (n=30), 100 mL of physiological saline was infused intravenously at the beginning of surgery and a mixture of 1.5 g tranexamic acid and 20 mL physiological saline was injected intra-articularly after deep fascia suturing. In the control group (n=30), 100 mL of physiological saline was infused intravenously at the beginning of surgery and 20 mL of physiological saline was injected intra-articularly after deep fascia suturing. The primary outcome is hidden blood loss at 1 and 3 days postoperatively. The secondary outcomes are visible blood loss, need for blood transfusion, and mean blood transfusion volume intraoperatively and on days 1 and 3 postoperatively. Other outcomes are the incidence of adverse reactions and complications within 3 months of surgery. The study protocol has been approved by the Ethics Committee of Tengzhou Central People's Hospital of China, approval number 2015-026. All protocols will be performed in accordance with the Ethical Principles for Medical Research Involving Human Subjects in the Declaration of Helsinki. Written informed consent was provided by each patient and their family members after they indicated that they fully understood the treatment plan.DISCUSSION: This trial was designed in April 2015. Cases were collected in July 2015. Data analysis will be finished in December 2017. This study is designed to investigate the effects of intravenous infusion versus intra-articular injection of tranexamic acid on perioperative blood loss in patients undergoing total hip arthroplasty to determine the more effective mode of administration.

Background Intravitreal injection of ranibizumab (IVR) is one of the most effective therapies for neovascular age-related macular degeneration (nAMD).Understanding the influence of IVR on retinal pigment epithelium (RPE) and choroidal thickness is helpful for us to choose the operative times and timing based on pharmacologic effects and tissue response.However,limited studies are available about quantitative analysis of RPE atrophic area and subfoveal choroidal thickness after IVR for nAMD.Objective This study was to report the changes of RPE atrophic area and subfoveal choroidal thickness after IVR for nAMD.Methods A prospective series cases-observational study was designed.Forty-one eyes of 41 consecutive patients with nAMD were enrolled in Renmin Hospital of Wuhan University from January 2015 to June 2015,and written informed consent was obtained from each patient prior to entering the cohort.The affected eyes received intravitreal injection of 0.05 ml ranibizumab (10 mg/ml) and then followed up monthly for 12 months.The RPE atrophy area around macula and subfoveal choroidal thickness were measured by a newly developed RPE analysis software spectral-domain optical coherence tomography (OCT) and enhanced depth imaging of SD-OCT (EDI-OCT),respectively,and the RPE atrophy area and choroidal thickness changes were compared before IVR and 3,6 and 12 months after IVR.The correlation between RPE atrophy area and choroidal thickness before and after IVR was analyzed.Results All the patients finished the treating procedure and follow up.The visual acuity (logMAR) after IVR was considerably improved in comparison with before IVR (F=7.631,P＜0.001).The mean subfoveal choroidal thickness value was (264.55 ± 100.95) μm before IVR,and that of 3,6,12 months after IVR was (247.42±105.46),(246.81± 99.85) and (253.97±101.15)μm,respectively,showing a significant difference among different time points (F =2.030,P ＜ 0.05),and the mean subfoveal choroidal thickness values 3,6,12 months after IVR were evidently thinned in comparison with before IVR (all at P＜0.05).No significant difference was found in RPE atrophic area among different time points (F=0.116,P =0.951).Weak linear correlations were seen between RPE atrophy area and choroidal thickness (r =-0.185),the RPE atrophy area change values and choroidal thickness change values between IVR ＞ 6 times and ≤ 6 times (r =0.297,-0.327),but these results were not statistically significant (P =0.248,0.282,0.103).At the end of the follow up,weak linear correlations were seen in RPE atrophy area change values and choroidal thickness change values with IVR times (r,=-0.266,0.342),but these results were not statistically significant (P =0.148,0.060).Conclusions IVR for nAMD can lead to subfoveal choroid atrophy instead of RPE atrophy.IVR does not accelerate the atrophy progression of both RPE and choroid.

Objective To observe the angiographic features of patients with retinal vein occlusion (RVO) by ultra-wide-field fluorescein angiography (UWFA) and compare with the conventional 7 standard field (7SF) imaging. Methods This is a retrospective clinical description study. Fifty-eight eyes of 56 RVO patients were included. There were 25 males (26 eyes) and 31 females (32 eyes). The age ranged from 25 to 69 years, with a mean age of (48.12±18.56) years. The course of disease was from 2 days to 25 months, with a mean course of (12.78±11.35) months. Thirty eyes were diagnosed with central RVO (51.72%), 26 eyes were diagnosed with branch RVO (44.83%) and 2 eyes were diagnosed with hemicentral RVO (3.45%). Retinal laser photocoagulation was performed in 11 eyes (18.97%). All patients received examinations of UWFA (British Optomap 200Tx imaging system) and optical coherence tomography (OCT). Using the protocol for obtaining 7SF images as described in the Early Treatment Diabetic Retinopathy Study, 7 circular regions with a range of 30 degrees were combined as the 7SF template to determine the observation area. This template was then overlaid on the UWFA image to identify the potential viewable area of 7SF. The visualized retinal area, retinal non-perfusion area, retinal neovascularization area, and laser spot area of UWFA and 7SF were quantified by a retinal specialist. In addition, the OCT images of the affected eye were observed and analyzed to confirm the existence of macular edema. Correlation analysis was done between retinal non-perfusion, retinal neovascularization and macular edema detected by UWFA. Results The results of UWFA and 7SF examination were the same. Compared with 7SF, UWFA showed 3.53 times more retinal visual area, 3.31 times more non-perfusion area, 1.94 times more neovascularization area, and 3.59 times more laser spots (t=72.13, 4.69, 1.76, 5.78;P=0.000, 0.005, 0.102, 0.000). Lesions of 11 eyes (18.97%) were found outside the range of 7SF images. By UWFA, non-perfusion area correlated with neovascularization and macular edema (χ2=12.13, 4.82;P=0.000, 0.028;C=0.42, 0.28). Non-perfusion area anterior to the equator have significantly correlations with macular edema (χ2=6.32, P=0.012, C=0.31), but non-perfusion posterior to the globe equator have no relevance with macular edema (χ2=2.88, P=0.090, C=0.22). Conclusions UWFA can detect more peripheral retinal lesions than 7SF images. By UWFA, non-perfusion area has correlation with neovascularization and macular edema.