Association between Vortex Vein Engorgement and Treatment Outcomes of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy

Purpose@#To investigate the influence of the number of engorged vortex veins on treatment outcomes in eyes with treatment-naïve polypoidal choroidal vasculopathy (PCV) undergoing intravitreal aflibercept monotherapy. @*Methods@#The medical charts of 65 patients with PCV who underwent intravitreal aflibercept injection were reviewed retrospectively. The number of quadrants of vortex vein engorgement was evaluated in the middle phase of ultra-widefield indocyanine green angiography, which was classified as extended engorgement if the dilated choroidal vessels expanded the macula. Associations between treatment outcomes with age, subfoveal choroidal thickness (SFCT), central retinal thickness, and vortex vein engorgement were investigated using univariate and multivariate analyses. @*Results@#There were no significant differences in best-corrected visual acuity (BCVA), SFCT, and central retinal thickness at baseline and 12 months, according to the number of vortex vein engorgement. However, an increase in the number of vortex vein engorgement extending to the macula was associated with a thick SFCT (p = 0.038), a greater number of injections (p = 0.041), low BCVA at 12 months (p = 0.038), and a less dry macula at 12 months (p = 0.026). In the multivariate analysis, the number of quadrants with vortex vein engorgement extending to the macula was significantly associated with BCVA changes at 12 months, total number of injections, and a dry macula at 12 months (p = 0.030, p = 0.030, p = 0.020, respectively). @*Conclusions@#More quadrants with vortex vein engorgement extending to the macula in PCV was associated with unfavorable visual outcomes, a less dry macula at 12 months, and a greater number of injections at 1 year after intravitreal aflibercept injection. Clinicians should keep in mind that vortex vein engorgement extending to the macula may be a new biomarker in predicting treatment outcomes in PCV.

Bupivacaine-lidocaine versus Ropivacaine-lidocaine Retrobulbar Anesthesia in Vitreoretinal Surgery

Purpose@#To compare efficacies of bupivacaine-lidocaine and ropivacaine-lidocaine mixtures in terms of inducing retrobulbar anesthesia during vitrectomy. @*Methods@#Sixty patients who underwent retrobulbar anesthesia during vitrectomy were divided into two groups. Patients in group 1 received a mixture of bupivacaine and lidocaine (n = 30); patients in group 2 received a mixture of ropivacaine and lidocaine (n = 30). The effects of the two combinations were retrospectively compared and analyzed. The onset times of analgesia and akinesia were measured. Two hours after surgery, sensory blockade was assessed by touching the corneas with cotton swabs and by communicating with patients. Ocular movement was evaluated in four gaze direction quadrants. A 10-point visual analog pain scale was used to assess pain during and 2 hours after surgery. Intra- and postoperative complications were recorded. @*Results@#The mean analgesia onset times in groups 1 and 2 were 94.62 ± 28.87 and 92.32 ± 35.53 seconds, respectively (p = 0.071); the mean akinesia onset times were 147.89 ± 59.35 and 132.57 ± 76.38 seconds (p = 0.223), respectively. Patients in group 2 reported significantly less postoperative pain and exhibited less postoperative ocular movement, compared with patients in group 1 (both p = 0.002). One patient in group 1 experienced respiratory depression after retrobulbar blockade. @*Conclusions@#When retrobulbar anesthesia is required during vitrectomy, a ropivacaine-lidocaine mixture and a bupivacaine-lidocaine mixture induce anesthesia with similar rapidity. However, the ropivacaine-lidocaine mixture is safer and affords better-quality intra- and postoperative anesthesia.

Long-term Longitudinal Changes in Choroidal Thickness with Intraocular Pressure Reduction after Glaucoma Surgery

PURPOSE: We investigated the long-term longitudinal changes in axial length (AL), mean ocular perfusion pressure (MOPP), and choroidal thickness (CT) according to the reduction of intraocular pressure (IOP) after glaucoma surgery. The potential variables associated with CT changes were also evaluated.METHODS: This was a prospective study for 1 year after glaucoma surgery, which included 71 eyes of 71 patients with primary open-angle glaucoma. The subfoveal CT (SFCT) and peripapillary CT (PPCT) were measured using spectral-domain optical coherence tomography preoperatively and 1 week, 1 month, 2 months, 6 months, and 1 year postoperatively. MOPP was calculated from the IOP and blood pressure. The AL was measured using partial coherence interferometry. Regression analysis was conducted to assess the possible association of variables.RESULTS: The AL decreased and the MOPP, SFCT, and PPCT increased significantly with IOP reduction at 1 year post-operatively (all, p < 0.001). The changes in SFCT and PPCT were significantly associated with IOP reduction at 1 year postoperatively (r = −0.519 and r = −0.528, respectively). Importantly, greater increases in SFCT and PPCT were found in patients with IOP reduction more than 30% from baseline, when compared with those with less than 30% reduction (p = 0.001 and p = 0.002, respectively). The SFCT increased more significantly in patients with AL ≤ 24 mm, compared with patients with AL > 24 mm (p = 0.044).CONCLUSIONS: Reduction in the IOP, increase in the MOPP, decrease in the AL, and increase in the CT after glaucoma surgery persisted for 1 year during a long-term follow-up. These results suggested that glaucoma surgery reduced mechanical compression on the optic nerve fiber and increased intraocular blood flow.

Fulminant Toxoplasmic Chorioretinitis Following Intravitreal Dexamethasone Implantation

PURPOSE: To report a case of fulminant toxoplasmic chorioretinitis following intravitreal dexamethasone implantation monotherapy in a stabilized toxoplasmic chorioretinitis patient with initial treatment. CASE SUMMARY: A 60-year-old healthy female presented with decreased visual acuity in the left eye. On fundus examination, focal chorioretinitis and yellow-white infiltration were observed. Laboratory work-up, including blood chemistry, complete blood count, and serum serology, was negative; however, toxoplasmic chorioretinitis could not be ruled out. The primary lesion improved with antibiotics and prednisolone treatment. However, the patient did not come in for her follow-up visit, as she had already received an intravitreal dexamethasone implant for recurrent vitreous inflammation elsewhere. On her return, she presented with necrotic retinitis with extensive infiltration. She underwent diagnostic vitrectomy and implant removal. A diagnosis of toxoplasma antigen was confirmed by polymerase chain reaction analysis; the lesions stabilized after anti-toxoplasmic therapy. CONCLUSIONS: Intravitreal dexamethasone implant monotherapy with stabilized toxoplasmic chorioretinitis without systemic antibiotics can lead to fulminant toxoplasmic chorioretinitis and should be used with caution.

Association between Normal-tension Glaucoma and Allergic Rhinitis in a Korean Population-based Study

PURPOSE: The purpose of this study was to investigate the association between normal-tension glaucoma (NTG) and allergic rhinitis in a population-based setting using data from the Korea National Health and Nutrition Exam Survey (2010–2012). METHODS: The authors selected a total of 8,614 participants aged 40 years and older for this study. All participants completed an ophthalmic examination required for diagnosis of NTG based on the International Society for Geographical and Epidemiological Ophthalmology criteria. An interview regarding nasal symptoms was also performed. The included participants were classified into NTG (n = 604) and control (n = 8,010) groups. The authors compared the groups in terms of prevalence of allergic rhinitis and identified risk factors of NTG. RESULTS: In NTG patients, allergic rhinitis prevalence was 29.1% (176/604), which was significantly higher than that of the control group (25.0%, 2,000/8,010; p = 0.023). There were significant associations between NTG and allergic rhinitis (odds ratio [OR]= 1.34, 95% confidence interval [CI] = 1.12–1.62, p = 0.002), even after adjusting for potential confounders (age, sex, diabetes, hypertension, number, of family members, household income quartile, frequency of eating out, and smoking status). In particular, patients with NTG aged 60–69 years, those aged 70–79 years, and those who were male had significantly higher ORs for prior allergic rhinitis compared with control subjects (OR = 1.62, 95% CI = 1.16–2.26, p = 0.005; OR = 1.52, 95% CI = 1.06–2.18, p = 0.024; and OR = 1.42, 95% CI = 1.10–1.83, p = 0.007, respectively). CONCLUSIONS: This study showed a significant association between NTG incidence and allergic rhinitis, especially in males and elderly patients (>60 years of age). These results suggested that allergic rhinitis may have a potential role in the development of NTG. Therefore, ophthalmologists and allergic rhinitis patients should remain vigilant to this potential risk factor.

A Case of Surgical Treatment of Large-angle Esotropia after Scleral Buckling without Buckle Removal

PURPOSE: Strabismus can occur after retinal reattachment surgery with scleral buckling (SB). We performed surgical treatment of a large-angle esotropia after SB without buckle removal and achieved good surgical outcome. CASE SUMMARY: A 21-year-male revisited our clinic for surgical treatment of esotropia. He had cicatricial retinopathy of prematurity in the right eye, and retinal detachment developed when he was 4 years old. Retinal reattachment surgery was performed with a 360-degree encircling band, a radial buckle at the 8 o'clock position, and a circumferential buckle ranging from the 7 to 11 o'clock position. He was not available for follow-up 2 years after surgery due to a change of residence, but exhibited a 5 prism diopters (PD) esotropia at the last visit. He demonstrated 55 PD esotropia of the right eye in the primary position with limited abduction. Surgery was performed without buckle removal, as recommended by a retinal specialist. Under general anesthesia, a forced duction test revealed a restriction of the medial rectus of the right eye. Exploration showed extensive adhesions around both the medial and lateral rectus with the buckle. Careful adhesiolysis and dissection were performed. A 8-mm resection of the lateral rectus and a 6-mm recession of the medial rectus were performed. The patient demonstrated favorable ocular alignment, and the limited abduction of the right eye improved after surgery. CONCLUSIONS: We report a case of surgical treatment of a large-angle esotropia after SB without buckle removal. This case can be helpful for surgeons planning the treatment of strabismus in patients who had undergone SB.