Outcomes of Anterior-Side Rectangular 4-Snip Punctoplasty for Patients with Punctal Stenosis

PURPOSE: To evaluate the efficacy of anterior-side rectangular 4-snip punctoplasty, a modification of posterior ampullectomy that is currently used in patients with punctal stenosis. METHODS: We performed a retrospective chart review of patients with punctal stenosis who underwent anterior-side rectangular 4-snip punctoplasty at our hospital. Fluorescein dye disappearance test (FDT) and questionnaire on tearing symptoms and tear meniscus height (TMH) based on spectral-domain optical coherence tomography (SD-OCT) were evaluated in preoperative and postoperative follow-up examinations of the patients. Anatomical success was defined as punctum without re-stenosis at last visit; functional success was defined as FDT grade of 0 or 1, or tearing symptom score of 2 or less. RESULTS: A total of 44 anterior-side 4-snip punctoplasty procedures were performed in 27 patients. The average age of all subjects was 56.0 +/- 11.0 years (range, 39 to 82 years). The mean follow-up period was 9.4 months (range, 6 to 20 months). FDT, tearing symptom score (p < 0.01, Wilcoxon signed-rank test), and TMH (p < 0.01, paired t-test) were significantly decreased after surgery. Anatomical success was 40/44 cases (90.9%) and functional success was 38/44 cases (86.4%). There were no complications such as skin defect or cosmetic problems. CONCLUSIONS: Anterior-side rectangular 4-snip punctoplasty is an effective surgical procedure for patients with punctal stenosis, maintaining functions of the lacrimal drainage system without re-stenosis of punctum.

A Comparison of Two Brands of Clopidogrel in Patients With Drug-Eluting Stent Implantation

BACKGROUND AND OBJECTIVES: Although generic clopidogrel is widely used, clinical efficacy and safety between generic and original clopidogrel had not been well evaluated. The aim of this study was to evaluate the clinical outcomes of 2 oral formulations of clopidogrel 75 mg tablets in patients with coronary artery disease (CAD) undergoing drug-eluting stent (DES) implantation. SUBJECTS AND METHODS: Between July 2006 and February 2009, 428 patients that underwent implantation with DES for CAD and completed >1 year of clinical follow-up were enrolled in this study. Patients were divided into the following 2 groups based on treatment formulation, Platless(R) (test formulation, n=211) or Plavix(R) (reference formulation, n=217). The incidence of 1-year major adverse cardiovascular and cerebrovascular event (MACCE) and stent thrombosis (ST) were retrospectively reviewed. RESULTS: The baseline demographic and procedural characteristics were not significantly different between two treatment groups. The incidence of 1-year MACCEs was 8.5% {19/211, 2 deaths, 4 myocardial infarctions (MIs), 2 strokes, and 11 target vessel revascularizations (TVRs)} in Platless(R) group vs. 7.4% (16/217, 4 deaths, 1 MI, 2 strokes, and 9 TVRs) in Plavix(R) group (p=0.66). The incidence of 1-year ST was 0.5% (1 definite and subacute ST) in Platless(R) group vs. 0% in Plavix(R) group (p=0.49). CONCLUSION: In this study, the 2 tablet preparations of clopidogrel showed similar rates of MACCEs, but additional prospective randomized studies with pharmacodynamics and platelet reactivity are needed to conclude whether generic clopidgrel may replace original clopidogrel.

A Case of the Type B Insulin Resistance Syndrome with Chronic Hepatitis B

Type B insulin resistance syndrome is rare autoimmune disease that is characterized by various abnormalities of glycemic homeostasis, from hyperglycemia caused by extreme insulin resistance to fasting hypoglycemia. It can combine with other autoimmune diseases, most commonly systemic lupus erythematosus. It usually occurs in women and accompanies acanthosis nigricans, hyperandrogenism, and, in many cases, ovary dysfunction. The diagnosis of type B insulin resistance syndrome is based largely on the presence of insulin receptor autoantibodies and hyperglycemia, or hypoglycemia and hyperinsulinemia. In some cases, patients with the type B insulin resistance have been successfully treated with immunosuppressive therapy and plasmapheresis. We experienced type B insulin resistance syndrome in a patient with chronic hepatitis B and used only plasmapheresis for treatment. The immunosuppressive therapy was omitted due to the state of activation of chronic hepatitis B. We present this case with a review of relevant literature.

Volume Control by Using the Body Composition Monitor in a Puerperal Patient on Hemodialysis

Accurate measurement of the volume status in hemodialysis patients is important as it can affect mortality. However, no studies have been conducted regarding volume management in cases where a sudden change of body fluid occurs, such as during puerperium in hemodialysis patients. This report presents a case in which the patient was monitored for her body composition and her volume status was controlled using a body composition monitor (BCM) during the puerperal period. This case suggests that using a BCM for volume management may help maintain hemodynamic stability in patients with a rapidly changing volume status for a short term period, such as during puerperium.

Two Cases of Necrotizing Fasciitis in Patients with SLE

Necrotizing fasciitis (NF) is an uncommon, life-threatening infection of the subcutaneous tissue and superficial fascia. The clinical course of NF is rapid and progressive, and it is often fatal despite the appropriate therapy. The prognosis of NF depends on a timely diagnosis and then proper treatment. At onset it may not be possible to clearly distinguish NF from minor soft-tissue infections. Although infection are common due to the use of steroids and immunosuppressive agents in patients with systemic lupus erythematous (SLE), it is interesting that NF has rarely been reported with SLE. Here, we present two cases of NF with SLE.

Kaposi's Sarcoma in a Patient on Hemodialysis / 대한신장학회지

Kaposi's sarcoma (KS) is an unusual multifocal neoplasm of vascular endothelial cell origin. The trunk, arms, head, and neck are the most common sites. It is common in men and has four distinct variants: classic, Africa-endemic, immunosuppressive drug-associated, and acquired immunodeficiency syndrome-associated KS. KS appears to develop immunosuppressed patients, but is uncommon in patients on dialysis. A 79-year-old man on hemodialysis for 2 months presented with pruritus over the entire body and multiple, discrete, variable-sized, dark blue papulonodules (papuloplaques, maculopapules) on the left arm and shoulder. A biopsy specimen form the left arm showed spindle cells with slit-like spaces and extravasated red blood cells. The specimen was positive for CD 34 antigen, and human herpesvirus 8 was detected. We report a case of KS that occurred in a 79-year-old patient on hemodialysis.

Small Incision for Ptosis Repair

PURPOSE: To assess the results and effectiveness of a small incision technique for ptosis repair. METHODS: Twenty three ptotic eyelids of 17 patients were repaired through a small incision between March 2005 and December 2005. Levator function and pre- and postoperative upper eyelid marginal reflex distances (MRD1) were checked. The small incision was executed on the eyelid crease, with a length of approximately 10.0~12.0 mm. Two 6-0 Ethilon stitches were placed to the tarsus after detecting levator aponeurosis with a Desmarres retractor. RESULTS: Of the 32eyes, 9 eyes had congenital ptosis and 23 eyes had acquired ptosis. The mean follow-up time was 12.1+/-3.4 months, with a levator function of 7.6+/-2.1 mm, preoperative MRD1 of 0.2+/-0.4 mm, and postoperative MRD1 of 2.6+/-0.3 mm. Two eyelids remained mildly undercorrected and required an additional operation. CONCLUSIONS: The small incision technique for ptosis correction is safe and precise, allowing more rapid recovery from surgery. The Desmarres retractor allows the levator to be found easily without complications. In addition, the small incision technique for levator repair is useful for congenital ptosis with good levator function as well as acquired ptosis.

Neurochemical Characterization of the TRPV1-Positive Nociceptive Primary Afferents Innervating Skeletal Muscles in the Rats

OBJECTIVE: Transient receptor potential vanilloid subfamily type 1 (TRPV1), a most specific marker of the nociceptive primary afferent, is expressed in peptidergic and non-pepetidergic primary afferents innervating skin and viscera. However, its expression in sensory fibers to skeletal muscle is not well known. In this study, we studied the neurochemical characteristics of TRPV1-positive primary afferents to skeletal muscles. METHODS: Sprague-Dawley rats were injected with total 20 microliter of 1% fast blue (FB) into the gastrocnemius and erector spinae muscle and animals were perfused 4 days after injection. FB-positive cells were traced in the L4-L5 (for gastrocnemius muscle) and L2-L4 (for erector spinae muscle) dorsal root ganglia. The neurochemical characteristics of the muscle afferents were studied with multiple immunofluorescence with TRPV1, calcitonin gene-related peptide (CGRP) and P2X(3). To identify spinal neurons responding to noxious stimulus to the skeletal muscle, 10% acetic acids were injected into the gastrocnemius and erector spinae muscles and expression of phospho extracellular signal-regulated kinase (pERK) in spinal cords were identified with immunohistochemical method. RESULTS: TRPV1 was expressed in about 49% of muscle afferents traced from gastrocnemius and 40% of erector spinae. Sixty-five to 60% of TRPV1-positive muscles afferents also expressed CGRP. In contrast, expression of P2X3 immnoreaction in TRPV1-positive muscle afferents were about 20%. TRPV1-positive primary afferents were contacted with spinal neurons expressing pERK after injection of acetic acid into the muscles. CONCLUSION: It is consequently suggested that nociception from skeletal muscles are mediated by TRPV1-positive primary afferents and majority of them are also peptidergic.

Modified Simple Excision for Epicanthal Folds

PURPOSE: To evaluate the effect of modified simple excision for epicanthal folds. METHODS: Eight patients with the epicanthal folds were treated using a modified simple excision method from June to December 2005. After medial traction of the epicanthal fold to expose the medial canthus, parabola-shaped marking was done near mucocutaneous junction. Under local anesthesia, incision of skin, dissection of subcutaneous tissue and excision of subcutaneous fibrous tissue and orbicularis oculi muscle were done. After marking the medial canthus on the skin, a wedge-shaped excision of the extra skin was done. Fixation sutures to the medial canthal tendon and skin sutures were then performed. RESULTS: Eight participants were evaluated (four males and four females) with a mean age of 16.71+/-8.34 years. The mean follow-up period was 42.86+/-5.80 days. After the operation, the skin scar was not visible due to its deep position, and no complication, such as damage to the lacrimal canaliculus or sac, was observed. CONCLUSIONS: Modified simple excision for epicanthal folds is an effective method that does not leave a visible scar.

Treatment of Distichiasis or Trichiasis combined with Entropion

PURPOSE: To evaluate the clinical efficacy of a reverse eyelid splitting technique that we performed in cases of trichiasis or distichiasis combined with entropion. METHODS: The study comprised 43 eyes of 31 patients with trichiasis or distichiasis combined with entropion treated from November 2004 to December 2005. After skin incision, the muscular layer and tarsus were reversely dissected to find abnormal follicles. The abnormal hair follicle was cauterized under the muscular layer, and 2~3 rotating sutures were done with Ethilon 6-0 to fix the tarsus and skin. Success was defined as having the meibomian gland located in front of the junction of skin and mucosa, without an abnormal hair protruding into the eye for at least three months. RESULTS: Fifteen patients were male and sixteen patients were female. The mean age was 62.1+/-15.2 years. The patients were followed up for an average of 12.4+/-2.0 months after surgery. Surgery was successful in 74.4% (32 of the 43 eyelids) of the cases, and the recurrence rate was 25.6% (11 of the 43 eyelids). No severe complications occurred, such as infection, hemorrhage, wound dehiscence, or granuloma. However, foreign body sensation (1 eye) and eyelid notch (l eye) did occur. CONCLUSIONS: This reverse eyelid splitting technique produced satisfactory results in both cosmetic and functional aspects. Moreover, it resulted in a low recurrence rate and low complication rate in patients with trichiasis or distichiasis combined with entropion.

Treatment of the Lacrimal Fistula with Punctal Plug

PURPOSE: To evaluate the results and complications of the punctal plug insertion through lacrimal fistula. METHODS: Four patients diagnosed with congenital lacrimal fistula had a punctual plug inserted through the lacrimal fistula without anesthesia from January to May 2005. RESULTS: Mean follow-up period was 6.8 months. In two pediatric patients whose mean age was 5.0 years, the fistula was not associated with nasolacrimal duct. In two adult patients, it was associated nasolacrimal duct obstruction, whose mean age was 49.0 years. In all cases epiphora improved. There was a puncal plug prolapse in one case and no other complications. CONCLUSIONS: Punctal plug insertion is considered a simple and useful technique for lacrimal fistula without congenital nasolacrimal obstruction in children especially whose parents refuse general anesthesia. Punctal plug insertion can be useful to reduce scarring in adult patients that receive endoscopic dacryocystorhinostomy with nasolacrimal obstruction.

New Incision Line for Epiblepharon Repair

PURPOSE: To evaluate the clinical efficacy of a procedure using a new incision line in cases of epiblepharon. METHODS: This study comprises 199 eyes of 105 patients (56 males, 49 females) clinically diagnosed with epiblepharon. The mean period of follow-up was 4.42 months. After marking the punctal position, the medial limit of the incision line was determined so as not to exceed the medial canthus, and the lateral limit was determined so as not to touch the cilia. The lower incision line was a folded line of skin formed after pulling the upper skin of the medial canthal area or after a downward gaze of the patient. The upper incision line was parallel to the lid margin from the medial limit and met the lower incision line at the lateral limit. RESULTS: Recurrence happened in three eyes, but only one of them underwent re-operation. The other 2 eyes showed weak touching not to need operation. There were no postoperative complications. CONCLUSIONS: This procedure with a newly designed incision line for cases of epiblepharon showed a low recurrence rate and good cosmetic results, with a reduced operation time.

Length Indicator of Lacrimal Pathway in Probing with Congenital Nasolacrimal Duct Obstruction

PURPOSE: To differentiate complex obstruction from the nasal cavity floor when performing probing in congenital nasolacrimal obstruction. METHODS: Twenty-five eyes of 23 patients with congenital nasolacrimal duct obstruction were treated by probing from January to December 2003. We measured the length between the medial canthus and nasal ala and between the punctum and nasal floor after positioning the probe in the nasal cavity and compared the two lengths. RESULTS: There were 15 males and 10 females. Their mean age was 11.48+/-4.32 months. The mean length between the lower punctum and nasal floor was 3.28+/-0.34 cm, and the mean length between the medial canthus and nasal ala was 2.82+/-0.26 cm. The length between the punctum and nasal floor was longer than that between the medial canthus and nasal ala (p<0.01). There was a positive relationship between two lengths (r=0.805, p<0.01). CONCLUSIONS: Measuring the length between the medial canthus and nasal ala before probing in patients with congenital nasolacrimal obstruction is helpful to distinguish the nasal floor from complex nasolacrimal obstruction when a hard stop is encountered.

Effects of Cauterization with Suturing in Treatment of Conjunctivochalasis: 4 Cases

PURPOSE: We performed cauterization and suturing without resection and evaluated the technique's efficacy in the treatment of conjunctivochalasis. METHODS: Four eyes of three patients diagnosed with conjunctivochalasis were treated with cauterization and suturing. After opening the eyelids, the loosened bulbar conjunctiva was pulled down tensely. After local anesthesia near the inferior fornix (about 8 mm below the limbus), the bulbar conjunctiva and Tenon's capsule were gripped together by bipolar cautery (UM 150A). The cauterization was performed in one second. Still gripped by the bipolar cautery, the bulbar conjunctiva and Tenon's capsule were fixed to the sclera with Vicryl 6-0. Identical procedures were performed on two other sites along the inferior fornix. The suture stitch were removed 10 days after the surgical procedure. RESULTS The objects were 4 eyes of 3 patients (1 male, 2 females with an average age of 63 years). The mean follow-up period was 4 months. There were no recurrences or any postoperative complications caused by cauterization. CONCLUSIONS: We successfully treated conjunctivochalasis with a simple procedure of conjunctival fixation to the sclera through cauterization and suturing.

Effects of Cauterization with Suturing in Treatment of Conjunctivochalasis: 4 Cases

PURPOSE: We performed cauterization and suturing without resection and evaluated the technique's efficacy in the treatment of conjunctivochalasis. METHODS: Four eyes of three patients diagnosed with conjunctivochalasis were treated with cauterization and suturing. After opening the eyelids, the loosened bulbar conjunctiva was pulled down tensely. After local anesthesia near the inferior fornix (about 8 mm below the limbus), the bulbar conjunctiva and Tenon's capsule were gripped together by bipolar cautery (UM 150A). The cauterization was performed in one second. Still gripped by the bipolar cautery, the bulbar conjunctiva and Tenon's capsule were fixed to the sclera with Vicryl 6-0. Identical procedures were performed on two other sites along the inferior fornix. The suture stitch were removed 10 days after the surgical procedure. RESULTS The objects were 4 eyes of 3 patients (1 male, 2 females with an average age of 63 years). The mean follow-up period was 4 months. There were no recurrences or any postoperative complications caused by cauterization. CONCLUSIONS: We successfully treated conjunctivochalasis with a simple procedure of conjunctival fixation to the sclera through cauterization and suturing.

Effects of Double Silicone Tube Intubation for Nasolacrimal Duct Obstruction in Adults

PURPOSE: To evaluate the effectiveness of double silicone tube intubation in the treatment of nasolacrimal duct (NLD) obstruction in adults. METHODS: We treated 159 eyes of 159 patients with NLD obstruction. The resolution of preoperative symptoms and signs of NLD obstruction was evaluated two months after the removal of the silicone tubes. RESULTS: The mean age of patients was 57.9 years and the mean follow-up period was 8.5 months. The symptoms and signs of NLD obstruction were reduced in 85.6% of the patients. The partially obstructed group showed a higher lacrimal patency rate (93.0%) than the completely obstructed NLD group (82.7%). There was no discomfort due to the double silicone tubes. There was a punctal slit in 13 eyes, prolapse of silicone tubes to ocular side in 5 eyes and 3 eyes had punctum to punctum adhesion after the procedure. CONCLUSIONS: Double silicone tube intubation is an effective therapy in adults with NLD obstruction, especially for those with partially obstructed NLD. Indications were seen that these tubes keep greater dilatation of the NLD.

Management of Prolapsed Silicone Tube Inserted for Treatment of Nasolacrimal Duct Obstruction

PURPOSE: To introduce a new surgical management for the prolapsed silicone tube into the ocular surface which was inserted for treatment of nasolacrimal duct obstruction. METHODS: Five eyes of 179 eyes treated with silicone tube intubation for nasolacrimal duct obstruction from May to December 2003 had a prolapsed silicone tube during the follow-up period. After local anesthesia, a Ritleng probe was inserted into the nasolacrimal duct. A polypropylene thread was passed into the Ritleng probe, and after removal of the probe, the thread was tied to a prolapsed silicone tube near a punctum and was pulled through the nose. The silicone tube was repositioned in the nasolacrimal duct. RESULTS: All the prolapsed silicone tubes were successfully repositioned without any significant complications. CONCLUSIONS: It is difficult to reposition a prolapsed silicone tube after silicone tube intubation for the treatment of nasolacrimal duct obstruction. We introduced an easy and effective method to reposition the prolapsed silicone tube.

Treatment of Conjunctival Nevus with Argon Laser

PURPOSE: To evaluate the clinical efficacy of Argon laser photocoagulation in patients with conjunctival nevus. METHODS: Twenty-seven patients (27 eyes) who were clinically diagnosed with conjunctival nevus from January to September 2003 were included in this study. The conjunctival nevus was eliminated by Argon laser after topical anesthesia with proparacaine. The power density varied between 200 and 400 mW and the spot size ranged from 100 to 300 microgram. The duration of argon laser was 0.15~0.2 sec. The spot count was varied according to the size and degree of pigment density of conjunctival nevus. The mean follow-up period was 7.0 months. RESULTS: The wounds after Argon laser treatment were completely healed within 1 week. Twenty-three eyes were treated completely with only one laser treatment but 4 needed an additional laser treatment for more satisfactory cosmetic results. There were no postoperative complications such as infections, conjunctival degeneration or recurrence. CONCLUSIONS: Argon laser treatment for conjunctival nevus has benefits such as no intraoperative hemorrhage, low recurrence rate, easier method and good cosmetic results.

Effect of the Illumination and the Types of the Lenses on Near Visual Acuity in Low Vison Patients

To obtain adequate information of illumination and lens types for visual acuity test of low vision patient, the relation between various illumination and vision was evaluated. Visual acuity for near and effective lens types were examined. Among the 28 patients (of 36 eyes), intensities of illumination were set at 200, 500, 1000 and 2000lux and the lenses of biconvex, aspheric and aplanatic were tested. The best visible range of illumination for the low vision patients was 500-1000lux, with lower power diopter for the same visual acuity and with aspherin and aplantic lenses. Results attained by our study may be applied for appropriate condition of illumiation and type of lens in the low vision care.

Treatment of Acute Retinopathy of Prematurity with Argon Indirect Laser Opthalmoscope

Twenty two eyes of twelve infants with threshold or prethreshold retinopathy of prematurity were treated by using the Argon laser through an indirect ophthalmoscopic delivery system. Eyes that had persistent plus disease were retreated to the missed areas. Mean follow-up period was 8.1 months. 20 of 22 eyes were regressed and all of prethreshold ROP were regressed. Our results suggest that argon laser photocoagulation is as effective as cryotherapy in the treatment of ROP and excellent results can be obtained by treating prethreshold zone I or posterior zone II ROP. And laser treatment is better tolerated by infant, accurate, easy, less destructive and not requires general anesthesia.