PurposeTo develop CT-based machine learning radiomics models used for the diagnosis of dysthyroid optic neuropathy (DON).Materials and MethodsThis is a retrospective study included 57 patients (114 orbits) diagnosed with thyroid-associated ophthalmopathy (TAO) at the Beijing Tongren Hospital between December 2019 and June 2023. CT scans, medical history, examination results, and clinical data of the participants were collected. DON was diagnosed based on clinical manifestations and examinations. The DON orbits and non-DON orbits were then divided into a training set and a test set at a ratio of approximately 7:3. The 3D slicer software was used to identify the volumes of interest (VOI). Radiomics features were extracted using the Pyradiomics and selected by t-test and least absolute shrinkage and selection operator (LASSO) regression algorithm with 10-fold cross-validation. Machine-learning models, including random forest (RF) model, support vector machine (SVM) model, and logistic regression (LR) model were built and validated by receiver operating characteristic (ROC) curves, area under the curves (AUC) and confusion matrix-related data. The net benefit of the models is shown by the decision curve analysis (DCA).ResultsWe extracted 107 features from the imaging data, representing various image information of the optic nerve and surrounding orbital tissues. Using the LASSO method, we identified the five most informative features. The AUC ranged from 0.77 to 0.80 in the training set and the AUC of the RF, SVM and LR models based on the features were 0.86, 0.80 and 0.83 in the test set, respectively. The DeLong test showed there was no significant difference between the three models (RF model vs SVM model: p = .92; RF model vs LR model: p = .94; SVM model vs LR model: p = .98) and the models showed optimal clinical efficacy in DCA.ConclusionsThe CT-based machine learning radiomics analysis exhibited excellent ability to diagnose DON and may enhance diagnostic convenience.

PURPOSE:Orbital cellulitis (OC) is a vision-threatening infection requiring prompt medical and/or surgical intervention. This study evaluates clinical features, management outcomes, and predictors of surgical necessity in pediatric and adult OC patients. METHODS:Retrospective analysis of 40 OC patients (13 pediatric, 27 adult, ages: 34.8 ± 23.9 y) at Xi'an Fourth Hospital (2011-2023). The data collected and analyzed retrospectively including demographics, signs and symptoms, concomitant diagnoses, inpatient management, imaging results, surgical culture results, visual acuity at presentation and last follow-up, duration of intravenous antibiotic treatment, and sequelae of disease were collected. RESULTS:Surgery was required in 84.6% (11/13) of pediatric and 88.9% (24/27) of adult patients. Staphylococcus aureus (17.1%), Staphylococcus epidermidis (11.4%), and MRSA (8.6%) predominated in cultures; 31.4% showed no growth. Ceftriaxone (45%) and cefotaxime (7.5%) were primary antibiotics. Surgical intervention significantly increased hospital costs (¥13,317 ± ¥5351 versus ¥1843 ± ¥509; P < 0.0001) but improved adult visual acuity (VA) from 0.5 ± 0.3 to 0.6 ± 0.4 ( P = 0.04). All patients achieved symptom resolution. CONCLUSION:OC necessitates surgery in >80% of cases regardless of age, driven by abscess formation or medical failure. Staphylococcal species (including MRSA) are key pathogens, warranting tailored empiric therapy. Cost-effective management algorithms integrating Chandler staging and vaccine history are recommended.

Purpose: To assess the correlation of upper eyelid retraction and the disease natural course of untreated thyroid eye disease patients, using multiple radial midpupil lid distance, for individualized eyelid morphological treatment. Methods: Semiautomatic photographic analysis was performed using ImageJ. Temporal/nasal multiple radial midpupil lid distance ratios of the same angles with respect to the midline was calculated. The influence of several variable factors on the asymmetrical upper eyelid retraction was evaluated. Results: One hundred and fifty‐one eyes of 85 untreated thyroid eye disease patients were included. The mean age of patients was 45.4 ± 14.7 years. Multiple radial midpupil lid distance ratios increased during the first 12 months, 105°/75° ( r = 0.196, p = 0.087), 120°/60° ( r = 0.250, p = 0.028), 135°/45° ( r = 0.309, p = 0.006), and 150°/30° ( r = 0.275, p = 0.015). The ratios then slowly decreased, 120°/60° ( r = −0.332, p = 0.006), 135°/45° ( r = −0.297, p = 0.014), and 150°/30° ( r = −0.254, p = 0.037). The ratios plateaued at 13 months but were still greater than normal range. No correlation found between smoking history ( p = 0.230), family history ( p = 0.382), exophthalmometry ( p = 0.597), and natural course. Women had a higher likelihood of upper eyelid retraction asymmetry, 120°/60° ( p = 0.041) and 135°/45° ( p = 0.048). The absence of systemic disease was associated with a lower likelihood of upper eyelid retraction asymmetry in 120°/60° ( p = 0.036). No significant difference was found in the contralateral eye of unilateral patients. Conclusion: Multiple radial midpupil lid distance is a valuable method for measuring asymmetrical upper eyelid retraction, enabling improved understanding in upper eyelid contour with the duration of untreated thyroid eye disease. Allowing a better decision on individualized treatment.

To investigate the therapeutic effects of puerarin in reducing adipogenesis and controlling inflammation in primary orbital fibroblasts derived from patients with thyroid eye disease (TED), and to explore the potential underlying mechanisms. After primary fibroblast culture and identification, the Cell Counting Kit-8 (CCK-8) was used to estimate the cytotoxic effects of puerarin. Wound-healing test was performed to assess the impact of puerarin on cellular migration. Adipogenic models were built with or without puerarin and inflammation model was built with the induction of IL-1β. Levels of IL-6, IL-8, CXCL-1, ADIPOQ, FABP4, and PPARγ were determined using quantitative real-time polymerase chain reaction (PCR). IL-6 and IL-8 in the cell supernatant were measured using enzyme-linked immunosorbent assay (ELISA). We performed network pharmacology and molecular docking to identify possible pathway and validated with Western blot. Puerarin significantly reduce the wound healing area and lipid area (p < 0.001, p = 0.004, p < 0.001 for 5µM, 10µM and 25µM, respectively) but no difference was found between the different puerarin groups. The levels of ADIPOQ, FABP4, and PPARγ were significantly decreased in the 5µM-puerarin treated group (p = 0.032, 0.041, 0.008, respectively), and the levels of IL-6 and IL-8 were significantly decreased in the puerarin-treated inflammation group (p < 0.01). PIK3CA and AKT 1 were identified as core targets, and the results were further supported by western blotting. Puerarin has anti-adipogenic and anti-inflammatory effects on the fibroblasts of patients with TED. These effects may be mediated by the PI3K-AKT pathway. Puerarin may be a potential treatment option for TED.

AIM: To conduct a bibliometric analysis of studies on microphthalmos and anophthalmos (M/A), explore research hotspots, and provide information on future research interests in this field to benefit clinicians and researchers. METHODS: Totally 751 publications related to M/A from the year 2004 to 2023 were collected from the Web of Science Core Collection database. These publications consist of both original and review articles, that are composed in English. The contributions of different countries, institutions, journals, and authors were analyzed, and network analysis was conducted by using Microsoft Excel 2021, VOSviewer, and R Studio to visualize research hotspots. RESULTS: Among all publications included, the highest number of publications came from USA (218, 29.03%). China followed with 99 publications (13.18%), and England with 86 publications (11.45%). The publications from the USA had the highest frequency of citations, with 16 699 citations, and the highest H-index of 49. The American Journal of Medical Genetics Part A (43, 5.73%) published the largest number of papers, and the University of London had the most publications (41, 5.46%). The genetic and molecular mechanisms of M/A were still unclear and the clinical intervention for M/A had gained a lot of attention as an emerging area of interest. CONCLUSION: Data have been gathered on the yearly count of published materials and citations, as well as the rise in publication trends, the efficiency of regions or countries, authors, journals, and organizations, along with the high-cited publications in M/A. The recent trend of research has shifted from genetic mechanisms to different clinical phenotypes and corresponding clinical interventions, which can give direction to future research.

Purpose: This study aims to analyze the literature on periocular basal cell carcinoma, identify research trends, and offer insights into future research areas in this field to assist clinicians and researchers. Methods: 903 publications on periocular basal cell carcinoma were collected from the Web of Science Core Collection database. We assessed the contributions from various countries, institutions, journals, and authors, and performed network analysis using Excel, VOSviewer, and R Studio to represent the prominent areas of research visually. Results: The country with the highest number of publications and citations in this study was the United States of America, with 250 publications, 5917 citations, and the highest H-index of 44. Ophthalmic Plastic and Reconstructive Surgery is the leading journal. The UTMD Anderson Cancer Center had the highest number of publications, accounting for 43, or 4.76% of the total. Selva D from the University of Adelaide, Australia, is the top author with 26 publications, and 751 citations. Targeted therapy for PBCC-related pathways has been a hot topic in recent years. Conclusions: This study using bibliometrics seeks to explore the patterns and focal points of research and analyzes publication patterns, key research areas, influential authors, and prominent journals in periocular basal cell carcinoma during the last 2 decades.

BackgroundSelf-inflating hydrogel expanders have been used to treat anophthalmia and blind microphthalmia. This study aimed to investigate the long-term outcomes of treatment with self-inflating hydrogel expanders for congenital anophthalmia and blind microphthalmia.MethodsIn this retrospective study, the medical records of 161 patients with anophthalmia and blind microphthalmia who underwent hydrogel expansion were reviewed. We measured the palpebral fissure height (PFH), palpebral fissure length (PFL), and distance between the inner canthal and mid-nasal line (ICMN) before and after surgery. Cox regression analysis was conducted to determine which variables were related to the implantation of spherical expanders following hemispherical expander implantation.ResultsAfter treatment, the PFH and PFL increased significantly (p < 0.001). Complications including expander migration and extrusion occurred in 15 cases. Five patients needed enucleation or further dermis fat graft implantation because of insufficient expansion. The necessity for further spherical expansion was substantially related to a relative axial length (rAL) <0.5 (p = 0.007).ConclusionSelf-inflating hydrogel expansion can significantly increase the lid fissure. The occurrence of complications is rare, and surgical intervention can effectively address them. Abnormal eyes with a rAL of less than 0.5 demonstrate a higher possibility of needing additional orbital expansion.

Background Familial hypercholesterolemia (FH) is a common inherited metabolic disease that causes premature atherosclerosis, cardiovascular disease, and even death at a young age. Approximately 95% of FH-causing genetic variants that have been identified are in the LDLR gene. However, only 10% of the FH population worldwide has been diagnosed and adequately treated, due to the existence of numerous unidentified variants, uncertainties in the pathogenicity scoring of many variants, and a substantial number of individuals lacking access to genetic testing.Objective The aim of this study was to identify a novel variant in the LDLR gene that causes FH in a Chinese family, thereby expanding the spectrum of FH-causing variants.Methods Patients were recruited from Beijing Anzhen Hospital, Capital Medical University. FH diagnosis was made according to the Dutch Lipid Clinical Network (DLCN) criteria. Whole-exome sequencing (WES) was conducted to identify the FH-causing variant in the proband, and amplicon sequencing was used to verify the variant in his family members.Results A three-generation Chinese family was recruited, and two FH patients were clinically diagnosed, both without known FH-causing variants. These two FH patients and another possible patient carried a novel variant, NC_000019.9(NM_000527.5):c.89_92dup (NP_000518.1:p.Phe32Argfs*21), in the ligand-binding domain of the low-density lipoprotein (LDL) receptor that led to a frameshift. The FH adults in the family showed severe clinical symptoms and statin therapy resistance.Conclusion This study identified a novel pathogenic LDLR variant, c.89_92dup, associated with severe FH clinical manifestations and statin therapy resistance.

This study aims to establish a random forest model for detecting the severity of Graves Orbitopathy (GO) and identify significant classification factors. This is a hospital-based study of 199 patients with GO that were collected between December 2019 and February 2022. Clinical information was collected from medical records. The severity of GO can be categorized as mild, moderate-to-severe, and sight-threatening GO based on guidelines of the European Group on Graves' orbitopathy. A random forest model was constructed according to the risk factors of GO and the main ocular symptoms of patients to differentiate mild GO from severe GO and finally was compared with logistic regression analysis, Support Vector Machine (SVM), and Naive Bayes. A random forest model with 15 variables was constructed. Blurred vision, disease course, thyroid-stimulating hormone receptor antibodies, and age ranked high both in mini-decreased gini and mini decrease accuracy. The accuracy, positive predictive value, negative predictive value, and the F1 Score of the random forest model are 0.83, 0.82, 0.86, and 0.82, respectively. Compared to the three other models, our random forest model showed a more reliable performance based on AUC (0.85 vs. 0.83 vs. 0.80 vs. 0.76) and accuracy (0.83 vs. 0.78 vs. 0.77 vs. 0.70). In conclusion, this study shows the potential for applying a random forest model as a complementary tool to differentiate GO severity.

AIM: To evaluate volume differences between anterior and posterior orbit and demographic characteristics of Chinese patients with congenital microphthalmia. METHODS: A retrospective cohort study, involving 169 unilateral congenital microphthalmia patients aged between 1 and 57 years old was conducted. Three-dimensional images of the orbit were generated from past CT scans, and digital orbital volume comprehensive measurement was done. The measured data included orbital volume (OBV), posterior orbital volume (POV), orbital width (OBW), orbital height (OBH), orbital depth (OBD), and posterior orbital area ratio. RESULTS: Significant differences were observed among OBV, POV, OBW, OBH, and OBD of the affected and unaffected eyes in different age-based groups (all P<0.001). Among them, OBH had the greatest different. The mean microphthalmic to contralateral ratio (MCR) of OBV, POV, OBW, and OBH continuously increased from 1 to 3 years old, whereas the MCR of POV decreased from 3 to 17 years old. The MCR of OBD was not found to be correlated to age. There was no significant difference between OBV, POV, OBW, and OBH in ages from 13 years old to adulthood (all P>0.05). The difference in posterior orbital area ratio between the affected and unaffected groups was not statistically significant (P>0.05). CONCLUSION: OBH is maximally affected, whereas OBD is minimally affected by microphthalmia. Posterior orbital retardation began 2y prior to orbital retardation and occurred at 3 years old in the affected eye, suggesting that intervention therapy should be done before the age of 4.

PurposeThis article aimed to explore the correlation between the periorbital morphology determined using a 3D scanning system and CT in congenital microphthalmia.MethodsFifty-two children with microphthalmia aged 0-6 were enrolled in this study. All the participants were subjected to orbital CT scans and 3D scanning. The CT and 3D scanning images were separately processed to obtain the orbital and facial parameters. Multivariate regression was used to analyze the correlation between 3D parameters and orbital volume.ResultsThe orbital volume of the affected side (15.25 +/- 3.35 cm(3)) was generally smaller than the unaffected side (18.58 +/- 2.65 cm(3), p < .001). Based on CT, at all ages, the parameters of the unaffected orbit were greater than the affected side. In the 3D scanning and 3D reconstruction based on CT, both unaffected and affected sides were highly correlated. A multiple linear regression equation including three 3D scanning factors was obtained for the orbital volume (R-2 = 0.808, p < .001).ConclusionsThe retarded orbital volume could be estimated by the parameters based on 3D scanning, along with axial length. In the follow-up stage, 3D scanning can be a novel alternative method to assess the degree of orbital growth retardation in congenital microphthalmia.

Objective:To analyze the stimulating effect of axial length development on orbital volume development in patients (ages 12-60 years) with congenital microphthalmia.Methods:This retrospective cohort study included 43 patients (86 eyes) with congenital microphthalmia. Three-dimensional images of the orbit were generated from past computed tomography scans, and digital orbital volume and axial length measurements were taken. The patients were divided into four age groups for analyses. Paired t tests and one-way analysis of variance tests were used to compare orbital volume and axial length between the affected and unaffected eyes. Pearson correlation analyses and scatter plots were used to investigate the correlations between age, orbital volume, and axial length in the affected and unaffected eyes. Linear regression analysis was used to determine the association between orbital volume and axial length.Results:The mean orbital volume in the affected and unaffected eyes was 17.08 +/- 2.88 and 20.80 +/- 2.55 cm3, respectively. The mean axis length in the affected and the unaffected groups was 12.73 +/- 3.54 and 23.84 +/- 1.43 mm, respectively. Significant differences were observed among orbital (t = 13.538, P < 0.001) volume and axial length (t = 21.339, P < 0.001) in the affected and the unaffected groups. There were no significant differences in affected orbital volume (F = 0.527, P > 0.05), unaffected orbital volume (F = 1.628, P > 0.05), affected axial length (F = 0.946, P > 0.05), and unaffected axial length (F = 2.217, P > 0.05) among the four age groups. According to the Pearson correlations, there were no significant correlations between age and affected volume, unaffected volume, affected axis, and unaffected axis (r = 0.095, 0.097, 0.084, and 0.022, respectively; all P > 0.05). Orbital volume was moderately correlated with axial length in the affected and unaffected groups (r = 0.470 and 0.410, respectively; both P < 0.01). Linear regression analysis revealed that a 1 mm change in axis length was associated with a 0.38 cm3 and 0.73 cm3 change in orbital volume in the affected and unaffected groups, respectively.Conclusions:In individuals ages 12 to 60 years old with congenital microphthalmia, the effect of axis length on the orbital volume growth of the affected eye is only half that of the unaffected eye. The eyeball, orbital tissue, and craniofacial development all play an important role in the growth of orbital volume.

目的 评估两种软件测量先天性小眼球患者眼眶容积的准确性.方法 横断面回顾性研究.纳入2007年1月至2019年1月就诊于北京同仁医院眼科中心的先天性小眼球患者86例(86只眼)作为研究对象.其中,男性47例(47只眼),女性39例(39只眼);年龄1～57岁,平均年龄(10.0±11.1)岁.根据患者年龄和发育情况,分为A～I组共9组.全部患者行眼眶CT检查,分别使用iPlan Cranial 2.5软件和Syngo MMWPVE 36A软件进行眼眶三维重建并测量眼眶容积.眼眶容积以均数±标准差描述.采用Bland-altman图评估两种软件测量的一致性;采用组内相关系数(ICC)分别评估患侧、健侧眼眶测量的一致性;计算眼眶容积患侧/健侧比值,并描绘年龄-比值曲线.结果 全部86例(86只眼)患者,iPlan Cranial软件和Syngo MMWP软件测量的患侧眼眶容积分别为(14.51±3.53)cm3和(14.10±3.63)cm3;健侧分别为(17.70±3.53)cm3和(17.40±3.60)cm3.iPlanCranial软件测量A～I组患者患侧的眼眶容积分别为(11.35±2.97)cm3、(13.33±2.59)cm3、(13.76±2.66)cm3、(13.82±2.68)cm3、(15.77±1.93)cm3、(15.52±1.15)cm3、(16.85±2.81)cm3、(15.85±2.00)cm3及(17.47±2.16)cm3;Syngo MMWP软件测量A～I组患者患侧的眼眶容积分别为(10.80±2.37)cm3、(13.36±2.37)cm3、(13.92±1.89)cm3、(13.36±2.66)cm3、(15.59±1.16)cm3、(15.08±1.88)cm3、(16.25±4.52)cm3、(14.99±2.76)cm3及(17.01±2.72)cm3;者iPlan Cranial软件测量A～I组患健侧的眼眶容积分别为(14.44±3.13)cm3、(16.15±2.37)cm3、(15.93±2.83)cm3、(17.37±1.40)cm3、(18.50±1.62)cm3、(19.24±1.37)cm3、(20.33±2.28)cm3、(20.29±1.23)cm3及(20.62±1.73)cm3;SyngoMMWP软件测量A～I组患者健侧的眼眶容积分别为(13.84±2.72)cm3、(16.03±2.04)cm3、(16.59±1.63)cm3、(17.16±1.21)cm3、(18.39±1.38)cm3、(18.93±1.97)cm3、(20.22±4.00)cm3、(19.09±2.27)cm3及(20.30±2.29)cm3.两种软件测量均值为0.4 cm3,95％一致性区间为(-3.0 cm3,+3.7 cm3);患侧眼眶容积测量的信度良好,经检验有统计学意义(95％CI:ICC=0.881,0.821～0.922;P<0.05);健侧眼眶容积测量的信度良好,经检验有统计学意义(95％CI:ICC=0.886,0.830～0.924;P<0.05).iPlan Cranial软件和Syngo MMWP软件测量眼眶容积的时间分别为30 min和5 min.结论 两种软件眼眶容积测量结果的一致性好,但需注意眶口与眶尖边界识别;Syngo MMWP软件因测量便捷更适合大批量测量.

Many potential complications resulting from retrobulbar injection have been reported, from the more commonly encountered retrobulbar hemorrhage to the life-threatening respiratory arrest. As one of the major complications, the occurrence of amaurosis fugax may not be noted by the doctor during surgery since the patient may take it as normal and not report it to the surgeon after injection. Fortunately, in most of the cases the visual loss is transient and the patients with amaurosis fugax may recover their vision soon after an injection. We searched PubMed and several other databases for investigations about amaurosis fugax, but found that relevant reports about the complication in the literature were very limited in number. Herein, we aim to analyze the predisposing cause of amaurosis fugax, to find out whether amaurosis fugax could be self-healing without treatment, and to determine in which situation surgery could be allowed to proceed after the complication happens. Numerous complications associated with retrobulbar anesthesia in eye and orbit have been reported, such as retrobulbar hemorrhage (1.3% in 1083 cases,1 0.75% in 3453 cases2), central retinal artery occlusion (0.015% in 19 700 cases),3 paralysis of the extra-ocular muscles,4 perforation of the eye globe,5 injury and atrophy of the optic nerve,6 and accidental injection of anesthetic into the subdural or subarachnoid space.4 Systemic symptoms (0.267% in 6000 cases)7 include respiratory distress, elicitation of the oculocardiac reflex, bradycardia, nausea, grand mal seizures, low-blood pressure, toxic reaction, loss of consciousness, brain stem anesthesia with unconsciousness, and apnea. These complications are rare in retrobulbar surgery. Amaurosis fugax, however, occurs more often due to retrobulbar injection during the surgery. Although there is no statistical presentation about the morbidity of amaurosis fugax after retrobulbar injection,8 most surgeons prefer to examine the vision of patients at the end of the surgery. THEORETICAL BASIS Several causes might explain the happening of amaurosis fugax, including vascular spasm, sensory blockade of the optic nerve, anesthetic toxicity, and psychological factors. Vascular changes One possible explanation for the happening of amaurosis fugax is the increase in intra-orbital pressure and vascular compression by injection, which might lead to vasospasm of the central retinal artery.6 Akar et al9 and Sergott et al10 found that under funduscopy, patients with amaurosis fugax showed vasospasm of the central retinal artery and optic disk pale. However, in some other reports, normal retinas and optic discs were shown. In some investigations, Color Doppler Imaging was introduced in detecting ischemia changes of blood flow in patients with amaurosis fugax. Sergott et al10 evaluated the blood flow velocity and vascular resistance of the retinal artery in patients with amaurosis fugax using Color Doppler Imaging, and found that all of the patients with normal blood flow in the retina were in the pain-free interval. More interestingly, the vessel resistance was shown to increase in some cases of amaurosis fugax.11 It is worth mentioning that adrenaline, usually mixed with the anesthetic in the injection, may increase the vessel resistance and was shown to be less likely to cause amaurosis fugax in retrobulbar injection.12,13 Sensory block Another explanation of amaurosis fugax is that retrobular anesthesia might cause a sensory blockade of the optic nerve by the connection between normal electroretinogram and former analogous visual evoked potentials, in which consistent increase in latency and decrease in amplitude of the waves were shown.14,15 Machanical trauma Furthermore, retrobulbar injection may lead to an increased risk of direct injury of the optic nerve. A sharp needle tip might cause penetration of the optic nerve, and the anesthetic may be injected into the optic nerve sheath,6 causing mechanical compression, drug toxicity, and allergic reaction. Anesthetic toxicity Anesthetics may play an important role in causing amaurosis fugax. It was shown by Kitagawa et al16 that Lidocaine directly disintegrated the nerve membrane and thus resulted in nerve injury, while Covino and Wildsmith17 found that bupivacaine was less neurotoxic than lidocaine. As we know, lidocaine and bupivacaine are both commonly used in ocular surgery. The anesthetics are usually given through subconjunctival, periocular, and block injection. However, the potential toxicity on periocular anesthetics is still unclear. Clinical profiles of neurotoxicity of the anesthetics were reported in cauda equina or spinal anesthesia.18 Therefore, the ocular neurotoxicity was not yet known. Psychological factors Anxiety might be a predisposing cause of amaurosis fugax.19 Patients with anxiety may be more apt to suffer from arteriolar constriction. Such a vascular change may aggravate transient ischemia,20 especially in patients with hypertension. Therefore, psychological situation was thought to be a contributing factor in the neurological complications in patients receiving regional anesthesia during surgery.21 Although some people would report to the doctor when amaurosis fugax happens, others may take it as a normal procedure during surgery to “turn off” his or her eyes after the retrobulbar injection. It is probable that a patient in anxiety may not be able to find the right way to communicate with the doctor. In these cases, the visual loss may not be noted by the doctor until the covering drapery is removed and the vision of the patient is checked. Such a situation may make doctors feel stressful and cause even more severe panic of the patient,22 and prolongs the self-recovery time. CLINICAL CHARACTERISTICS Several cases of amaurosis fugax after retrobulbar injection during a surgery have been reported in the literature. We reviewed the reports by Chinchurreta-Capote et al,4 Lau et al,5 and Mo23. In their investigations, the age of the cases of amaurosis fugax ranged from 45 to 75 years, and no difference in prevalence was shown between male and female patients. Most of the patients were reported to receive glaucoma, cataract, and vitreoretinal surgery. In the literature before the 1990s, such a complication was frequently reported in late-stage glaucoma cases.24 Some doctors would refrain from using retrobulbar lidocaine in late glaucoma patients.23 To date, although retrobulbar anesthesia is no longer the most frequently used anesthetic method in cataract and glaucoma surgery, cases of amaurosis fugax are still reported sometimes. By reviewing the literature, we concluded that the anesthetic commonly used in injection included 2% lidocaine injection, the complex injection of lidocaine and 0.50%-0.75% bupivacaine, and the complex injection of lidocaine and adrenaline. Marcaine, mepivacaine, and novocaine were rarely used.25 The injected volume of retrobular injections varied from 2 ml to an extreme 8 ml.7,26 Amaurosis was usually described to happen 5-20 minutes after injection,7 and in some cases it was discovered nearly at the end of the surgery. Based on reports, the self-recovery duration varied from 20 minutes to 12 hours.5,27 In most of the cases, it was reported to take 2 6 hours.4,28 Most doctors believe that amaruosis fugax could be self-healing without any treatment. This possible mechanism is based on the theory that intracellular Ca2+ concentration can be extremely increased by lidocaine or other anesthesia. Some studies showed that the group of cases injected with 1.5% lidocaine and 0.75% bupivacaine would not cause irreversible conduction block, while in the group of cases injected with 5% lidocaine permanet damage was shown.29 However, it is still hard to define when the amaurosis happens, whether any other complications happen, or whether there would be a permanent visual loss. Therefore, some doctors tend to use atropine, oxygen, or intravenous fluids to improve blood circulation of drugs.3 Based on the reports on amaurosis fugax without other complications, all patients do not suffer from permanent sequelae due to retrobulbar injection.3,23,30,31 CONCLUSIONS Effective anesthesia in major intra and extra-ocular surgery has been achieved by retrobulbar injection in the past. Until now, such an anesthetic method still has many advantages compared with general anesthesia. Laboratory and clinical experiments have shown that anesthetics may have potential neurotoxicity, which is not yet fully understood both cytological and morphological changes.32 To minimize the risks of amaurosis resulting from retrobulbar injections, we suggest surgeons pay attention to the following issues: 1. Control the injected volumes to 2 3 ml with slow injection;4 2. Find a proper position of the eye that is being operated and ask the patient to take a deep breath prior to injection to relieve their anxiety; 3. Use dull needles to prevent mechanical penetration; 4. Be extremely careful in cases with late-stage glaucoma with fragile and sensitive optic nerve fibers to the anesthetic;23 5. Enhance the confidence of the clinician to avoid anxiety. Usually the visual changes would be noted and reported by the patients when amaurosis fugax happens. In such a situation, it is imperative for the surgeon to check the periocular tissues and fundus carefully to rule out the signs of severe complications and to alleviate the anxiety of the patients. Doctors should timely discriminate transient amaurosis from permanent visual loss when the patients complain, so that immediate treatment could be applied to save vision or the surgeon could proceed with the operation.