Two Stage Surgical Correction for Bilateral Sixth Nerve Palsy with Large-angle Esotropia

Purpose@#We report the postoperative results of a two stage surgical procedure for bilateral sixth nerve palsy with large-angle esotropia due to a traumatic event. Case summary: A 66-year-old female had a traffic accident and sustained a subdural hemorrhage. After the accident, the patient complained of diplopia. Using the Krimsky test, large-angle esotropia of about 90 prism diopters at the primary position, and -6 limitation of lateral gaze eye movement were observed in both eye. At 14 months after the accident, we performed medial rectus recession and augmentation of the superior rectus, and inferior rectus transposition at the lateral rectus insertion along the spiral of Tillaux in a two stage surgical correction. Two months after the second operation, the patient’s eye alignments showed slight exophoria of about 2 prism diopters at the primary position on the far and near alternate prism cover test. Abduction and adduction limitations of -1 were found in both eyes and her diplopia had disappeared. @*Conclusions@#We report a case of bilateral sixth nerve palsy with large-angle esotropia due to trauma. Although it was difficult to predict the surgical outcome, two stage surgery provided a stable surgical result, and additional sutures between the transposed muscle and the lateral rectus muscle, resulted in improvement of the abduction disorder.

Two Stage Surgical Correction for Bilateral Sixth Nerve Palsy with Large-angle Esotropia

Purpose@#We report the postoperative results of a two stage surgical procedure for bilateral sixth nerve palsy with large-angle esotropia due to a traumatic event. Case summary: A 66-year-old female had a traffic accident and sustained a subdural hemorrhage. After the accident, the patient complained of diplopia. Using the Krimsky test, large-angle esotropia of about 90 prism diopters at the primary position, and -6 limitation of lateral gaze eye movement were observed in both eye. At 14 months after the accident, we performed medial rectus recession and augmentation of the superior rectus, and inferior rectus transposition at the lateral rectus insertion along the spiral of Tillaux in a two stage surgical correction. Two months after the second operation, the patient’s eye alignments showed slight exophoria of about 2 prism diopters at the primary position on the far and near alternate prism cover test. Abduction and adduction limitations of -1 were found in both eyes and her diplopia had disappeared. @*Conclusions@#We report a case of bilateral sixth nerve palsy with large-angle esotropia due to trauma. Although it was difficult to predict the surgical outcome, two stage surgery provided a stable surgical result, and additional sutures between the transposed muscle and the lateral rectus muscle, resulted in improvement of the abduction disorder.

Clinical Significance of Tear Film Osmolarity for Non-Sjögren Dry Eye Diagnosis

PURPOSE: To evaluate the diagnostic value of tear film osmolarity for non-Sjogren dry eye syndrome through measuring the correlation between tear osmolarity and several conventional dry eye parameters. METHODS: In this observational cross-sectional study, 274 patients (274 eyes) with non-Sjogren dry eye syndrome were examined using tear film osmolarity and the following conventional dry eye parameters: Schirmer's test, tear film break-up time, ocular surface disease index (OSDI), and corneal staining score. The correlations between tear film osmolarity and each conventional dry eye parameter were assessed using Spearman's correlation coefficients. RESULTS: The mean tear film osmolarity of the study population was 296.34 ± 21.08 mOsm/L. The tear film osmolarity was significantly negatively correlated with the Schirmer's test value (r = -0.431, p < 0.001) and tear break-up time (r = -0.131, p = 0.031), while it was significantly positively correlated with the OSDI scores (r = 0.191, p = 0.001) and corneal staining scores (r = 0.150, p = 0.013). CONCLUSIONS: Tear film instability was significantly correlated with other conventional dry eye parameters. However, additional studies are required to determine its feasibility as a stand-alone diagnostic tool.

Associations between Intraocular Pressure and Systemic Parameters according to the KNHNES 2008-2011

PURPOSE: In this study, we evaluated the associations between intraocular pressure (IOP) and systemic and socioeconomic factors. METHODS: A population-based cross-sectional study using a nation-wide, stratified, multistage, clustered sampling method included 15,421 subjects aged ≥20 years with no history of ocular surgery or glaucoma who participated in the Korean National Health and Nutritional Examination Survey 2008-2011. RESULTS: Univariate regression analyses showed statistically significant linear relationships between IOP and body mass index (BMI), smoking status, heavy drinking, systolic blood pressure, fasting blood glucose, total cholesterol, triglycerides, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), metabolic syndrome (p < 0.001, respectively), low density lipoprotein cholesterol (p = 0.003), refractive error (p < 0.001), and office work (p = 0.029). In addition, analysis of variance (ANOVA) showed statistically significant differences in IOP and refraction according to occupation (p < 0.001, all). CONCLUSIONS: We concluded that increased IOP was associated with age, BMI, heavy drinking, systolic blood pressure, total cholesterol, and refraction. There were statistically significant differences in IOP and refraction according to occupation.

The Effects of Lower Lid Laxity to the Response of Dry Eye Treatments

PURPOSE: To compare the response of dry eye treatment in patients divided by the degree of lower lid laxity. METHODS: Thirty patients were classified into three groups - normal, moderate and severe, according to the degree of lower lid laxity. Tear break-up time (TBUT), Schirmer test (ST), ocular surface disease index (OSDI) scores and changes in OSDI score in each group were compared before and at 3 months after the treatment. RESULTS: TBUT, ST and OSDI scores were not different among the three groups at baseline. TBUT improved to 6.60 +/- 1.43, 6.0 +/- 2.54 and 6.0 +/- 1.45 sec in normal, moderate and severe lower lid laxity group, respectively at 3 months after the treatment and no difference among the groups was found. ST scores did not increase after the treatment, while OSDI scores improved to 12.20 +/- 1.40, 16.10 +/- 4.63 and 20.80 +/- 4.52 in each group, respectively and they were significantly different (p = 0.029, 0.029, <0.001, respectively). The response to the dry eye treatment as assessed by changes in OSDI scores was poorer in patients in the severe lower lid laxity group (p = 0.019 vs. moderate laxity group, <0.01 vs. normal group). CONCLUSIONS: As the degree of lower lid laxity increases, the response to dry eye treatment becomes poorer even when TBUT increases.

Quality of Life after Strabismus Surgery

PURPOSE: To assess the effect of strabismus surgery on the quality of life by performing a quality of life-related health survey. METHODS: This study was comprised of 213 patients (163 patients under 15 years of age, and 50 patients over 15 years of age). After strabismus surgery, patients were asked to complete a standardized confidential questionnaire which evaluated the quality of life and specific concerns related to the surgery. RESULTS: There was a significant change in the quality of life after strabismus surgery in both groups. No patient reported decreased quality of life after the surgery. Significant score improvement related to the questions designed to evaluate vision, stereopsis, diplopia and social relation was observed (p < 0.05). The number of surgeries did not affect the quality of life postoperatively. Multivariate regression analysis showed that change in the quality of life had significant correlation with social relationships (in both groups) and income (only in patients under 15 years of age). Surgery cost was the most common burden to strabismus patients. CONCLUSIONS: The present study showed that strabismus surgery significantly improves quality of life. Scores evaluating the change in quality of life did show significant correlation with scores evaluating social relationships and income.

Sequential Correction for Large Exotropia: A Case of Iatrogenic Exotropia Developed after Excision of Medial Rectus Muscle During Functional Endoscopic Sinus Surgery (FESS)

PURPOSE: To report a case of iatrogenic exotropia caused by accidental excision of medial rectus muscle during functional endoscopic sinus surgery (FESS), which was successfully corrected by sequential surgical intervention (superior and inferior rectus muscle transposition followed by lateral rectus muscle recession). CASE SUMMARY: Forty one year old male patient visited our clinic with large exotropia of the right eye developed after functional endoscopic sinus surgery (FESS) which was performed one year ago. At the initial visit in our clinic, there was a large exotropia (95 PD) of the right eye and transection of the medial rectus muscle was observed at the orbital MRI. In order to correct this large iatrogenic exotropia, sequential surgery was planned. Initially, full-tendon transposition of the right superior and inferior rectus muscle was performed which reduced the deviation to 35 PD. Six weeks after the initial surgery, 7 mm right lateral rectus muscle recession was additionally performed, which resulted in exotropia of 10 PD. Diplopia was also improved and the patient was esthetically satisfied with the result. CONCLUSIONS: Even in a case of iatrogenic exotropia following one year after an accidental excision of medial rectus muscle during intranasal sinus surgery, sequential surgery such as transposition of superior and inferior rectus muscle followed by lateral rectus muscle recession can result in satisfying cosmetic and functional improvement.

A Case of Inferior Rectus Muscle Enlargement after Taking Sildenafil Citrate

PURPOSE: Sildenafil citrate was developed to treat angina, but was found to also inhibit PDE in the corpus callosum and is now widely used to treat impotence. We report a case of enlargement of the inferior rectus muscle after sildenafil citrate ingestion. CASE SUMMARY: A 58-year-old male presented with binocular diplopia which started 2 weeks prior. He had no underlying disease. The patient had taken sildenafil citrate on 3 different occasions 2 weeks prior, and 2 days after his first ingestion, his right conjunctiva was injected and binocular diplopia started. On the first visit, he showed 16 PD hypotropia of the right eye with limitation of motion at upgaze. The MRI scan showed enlargement and enhancement of the inferior rectus muscle, and 50 mg of prednisone was prescribed. The amount of hypotropia decreased to 8 PD 2 weeks later. CONCLUSIONS: Enlargement of extraocular muscle caused by sildenafil citrate ingestion has not been reported in Korea, and related mechanisms are yet to be researched. Additional case reports and research are necessary in the future.

Treatment of Epiphora in Patients with Conjunctivochalasis Using Conjunctival Fixation to the Sclera

PURPOSE: To report the effects and complications of conjunctival fixation to the sclera in conjunctivochalasis patients with inferior punctal occlusion. METHODS: The authors of the present study evaluated the degree of conjunctivochalasis and performed Fluorescein Dye Disappearance Test (FDT) in 15 eyes of 8 patients diagnosed with conjunctivochalasis with inferior punctal occlusion. Under topical anesthesia, the inferior bulbar conjunctiva was attached to the sclera with 3 8-0 vicryl stitches 8 mm posterior from the limbus. After surgery, the relief of symptoms, postoperative complications and improvement of conjunctivochalasis were observed. RESULTS: One week after the surgery, all 15 eyes achieved a subjective improvement of symptoms and the degree of conjunctivochalasis and FDT showed statistical difference after surgery (p = 0.000, 0.000, respectively). A complication occurred in 1 eye which was a retinal hemorrhage due to scleral puncture. CONCLUSIONS: Conjunctival fixation to the sclera could improve epiphora in conjunctivochalasis patients with inferior punctal occlusion. However, this procedure should be performed with caution.

Risk Factors for Dry Eye in Thyroid-Associated Ophthalmopathy

PURPOSE: To investigate the risk factors for dry eye in thyroid-associated ophthalmopathy patients. METHODS: The present retrospective study was conducted on 78 eyes in 39 patients diagnosed with thyroid-associated ophthalmopathy. The risk factors for dry eye in thyroid-associated ophthalmopathy patients were examined by analyzing data including tear break-up time, Schirmer's test, age, gender, thyroid function status, palpebral fissure width, lagophthalmos, eyelid retraction, and exophthalmos through multiple logistic regression analysis. RESULTS: The risk factors for dry eye disease were palpebral fissure width (OR = 3.422, p = 0.022) and lagophthalmos (OR = 13.068, p = 0.049). Age, gender, thyroid hormone status, eyelid retraction and exophthalmos did not show significant association with dry eye in multiple logistic regression analysis. The only risk factor for tear film break-up time less than 10 seconds was palpebral fissure width (OR = 2.787, p = 0.045), and none of the risk factors for Schirmer's test less than 10 mm at 5 minutes were statistically significant. CONCLUSIONS: Risk factors for dry eye in thyroid ophthalmopathy patients were palpebral fissure width and lagophthalmos.

Economic Evaluation of Different Initial Treatments for Primary Open Angle Glaucoma: A Markov Model

PURPOSE: To perform an economic evaluation of the different treatment methods available for primary open-angle glaucoma in a Korean setting, including medication, selective laser trabeculoplasty, or surgery. METHODS: Three independent Markov chains were constructed for each treatment option to simulate treatment progress and to evaluate the total treatment costs for each initial strategy. The Markov chain consisted of different stages (5, 10, 20 stages), with each stage being one year. Assuming 1000 patients, a Monte Carlo simulation was iterated 1000 times to evaluate the cost of treatment over 5, 10 and 20 years. RESULTS: During the initial five years, medication as the initial treatment was the most expensive, whereas laser trabeculoplasty was the cheapest. After ten years, surgery became the cheapest treatment. In ten years, if the success rate of surgery is greater than 30.1%, it was more economic to choose surgery as the initial treatment. For laser trabeculoplasty, if the success rate was greater than 16.3%, laser treatment was more economical than was medication. Our model shows that only if the annual cost of medication decreases to 60,000 won or 55,000 won, then the cost of choosing medication as the initial treatment strategy will be more economical than that of laser therapy or surgery, respectively. CONCLUSIONS: The economic value of choosing laser therapy as the initial treatment strategy is the greatest over five simulated-years, whereas surgery had the greatest economic value over more than ten years.

Baerveldt Tube Implantation After Bleb Dysesthesia: Case Report

PURPOSE: To report a case of bleb dysesthesia successfully treated after Baerveldt tube implantation. CASE SUMMARY: A 37-year-old woman presented with a history of persistent foreign body sensation and pain in the left eye. The patient was referred to our hospital and was diagnosed as having had plateau iris syndrome. Having shown no improvement with conservative management, she eventually received trabeculectomy in the left eye six months prior to her current presentation. Under the impression of bleb dysesthesia, she received artificial tears and a bandage contact lens. These, however, failed to alleviate her symptoms. She then had a compression suture of the bleb and bleb revision. These were performed sequentially but neither was effective. Finally, a Baerveldt tube implantation was performed successfully, and, three months later, bleb revision was performed using a donor sclera, which resulted in no further complaint of ocular discomfort. CONCLUSIONS: Bleb dysesthesia, although not a common postoperative complication, can occur after trabeculectomy and can be successfully treated with Baerveldt tube implantation. Patients should receive appropriate counseling and advice on bleb dysesthesia prior to undergoing trabeculectomy.

Retinal Nerve Fiber Layer Thickness in Children With Glaucoma

PURPOSE: To find the optimal parameter of retinal nerve fiber layer (RNFL) analysis in optical coherence tomography (OCT) for diagnosing glaucoma in children. METHODS: The study was comprised of 127 eyes of 84 patients (aged 6 to 18 years) who visited our institute between March 2006 and February 2008. Subjects were classified into normal, glaucoma suspect and glaucoma groups, and each eye was scanned using Stratus 3.0 OCT. Routine ophthalmic examinations including fundus examination, visual field test and OCT RNFL analysis were performed. RESULTS: There were 55 normal eyes, 27 glaucoma suspect eyes and 45 glaucomatous eyes. The average RNFL thickness was the most useful parameter to differentiate between the glaucoma and non-glaucoma groups. The next most useful parameter was inferior average thickness, followed by superior RNFL thickness. The sensitivity and specificity of the new discriminant of the formula used were 78%, and 68.6%, respectively. CONCLUSIONS: In OCT analysis, the average RNFL thickness is the most useful parameter in the diagnosis of glaucoma in children. The new discriminant of the formula is useful in the diagnosis of pediatric glaucoma patients.

Herbal Medication Aggravates Cataract Formation: A Case Report

We report a case of complicated cataract aggravated after taking herbal medication for atopic dermatitis. An 11-yr-old boy was referred for the evaluation of decreased visual acuity in both eyes for 2 months. Past history showed that he had been diagnosed with atopic dermatitis when he was 1 yr old. He had been treated only with herbal medication for a period of 8 months prior to visiting our clinic. He had his visual acuity checked in a local ophthalmic clinic one year before, and the visual acuity was 20/20 in both eyes at that time. When attending our clinic the ophthalmologic examination showed that his best corrected visual acuity was 20/200 in both eyes. Lenses of both eyes had severe posterior subcapsular and posterior capsular opacity. Phacoemulsification, posterior chamber intraocular lens implantation, and posterior continuous curvilinear capsulectomy were performed in both eyes. After 3 months postoperatively, the best corrected visual acuity was recovered to 20/20 in both eyes without any complication. Our case suggests that there may be a risk of aggravation of cataract or development of cataract after treatment with some unidentified herbal medication in a patient with atopic dermatitis.

Comparison of Delayed-Onset Glaucoma and Early-Onset Glaucoma after Infantile Cataract Surgery

PURPOSE: To investigate the causes and characteristics of glaucoma in children following cataract surgery. METHODS: Twenty-four patients (37 eyes) with uncomplicated congenital cataracts who developed glaucoma after cataract surgery were studied retrospectively. Variables included cataract morphology, surgical techniques, post-operative complications, time to the onset of glaucoma, gonioscopic findings, presence of microcornea and the histopathologic characteristics of the filtration angle (in one case). RESULTS: There was a bimodal onset of glaucoma after cataract surgery. Early-onset glaucoma occurred at a mean age of 6 months in 15 eyes and delayed-onset glaucoma at a mean age of 12 years in 22 eyes. Early-onset glaucoma was significantly (p=0.018) more likely to be due to angle closure than delayed-onset glaucoma. With delayed-onset glaucoma, the filtration angle was open in 86% of eyes and significantly (p=0.006) more eyes in the delayed-onset group had microcornea. Medical treatment was sufficient to control intraocular pressure in the delayed-onset group while the early-onset group required surgical treatment (P<0.001). CONCLUSIONS: The onset of glaucoma after cataract surgery during infancy follows a bimodal pattern that is correlated with the configuration of the filtration angle. The early-onset glaucoma group had high incidence of angle closure requiring surgical treatment, while in the delayed-onset group non-surgical treatment was sufficient to control intraocular pressure. Prophylactic iridectomy in eyes at risk for pupillary block is recommended. Eyes with delayed-onset glaucoma have open filtration angles yet also have findings of incomplete development of filtration structures. Microcornea is a risk factor for delayed-onset glaucoma.

Graded Partial Tenotomy of Vertical Rectus Muscles for Treatment of Hypertropia

PURPOSE: To evaluate the effectiveness of graded (adjustable intraoperatively) partial vertical rectus muscle tenotomy at the insertion in correcting small degrees of hypertropia. METHODS: All patients with best corrected visual acuity of better than 6/30 in both eyes who had undergone only partial tenotomy of vertical rectus muscle(s) over a 30-month period were included. Improvement was evaluated 6 weeks postoperatively as the change in alignment in prism diopters (PD) in primary gaze and in the field of action of the affected rectus muscle(s). Binocular function was evaluated by Titmus stereoacuity and the Worth 4-light tests. RESULTS: All 24 patients who met the inclusion criteria had diplopia preoperatively, and this had resolved in 17 (71%) postoperatively (P<0.005). Prisms were used by 6 preoperatively vs. 2 postoperatively (P<0.05). The average vertical deviation in primary gaze decreased from 8 PD to 2 PD (P<0.005). In the field of action of the treated rectus muscle, hypertropia decreased from an average of 8 PD to 3 PD (P<0.005). For the available pre- and post-operative assessments, stereoacuity improved after 10 of the 18 (56%) procedures and Worth 4-light testing showed improvement or maintenance of fusion after 13 of 19 procedures (68%). CONCLUSIONS: Graded vertical rectus partial tenotomy can effectively reduce small degrees of hypertropia and associated diplopia, improve binocular function, and reduce or eliminate the need for prism correction.

A Case of Surgical Repair in Strabismus Fixus with Ptosis

Strabismus fixus is very rare and the convergent form is rarely accompanied by blepharoptosis. We successfully treated one patient with high myopia whose convergent strabismus fixus, accompanied by blepharoptosis, became severe after cataract surgery. We report the case with a discussion of its pathology. We performed levator advancement operation, bilateral lateral rectus 11 mm resection, and bilateral medial rectus 8 mm recession. The suture was removed after maintaining temporary traction suture for 6 days. Blepharoptosis was completely corrected by postoperative 2 months. Esodeviation was 15PD, which was not increased compared with immediately after surgery. Satisfactory cosmetic outcome was obtained.

The Effect of Intravitreal Triamcinolone Acetonide on Intraocular Pressure

PURPOSE: To Investigate the effect of intravitreal triamcinolone acetonide on intraocular pressure (IOP) and the risk factors for its elevation. METHODS: This retrospective case study comprised 25 patients (26 eyes) with diabetic macular edema and 7 (7 eyes) with retinal edema due to branch retinal vein occlusion. The IOPs before and after intravitreal injection of 4 mg triamcinolone acetonide (postoperative 2 hours, 1 day, 2, 4, 8, and 12 weeks and 6 months) were recorded by Goldmann applanation tonometer. RESULTS: The average time to maximum IOP was 3.9 weeks and the difference of maximum post-injection IOP and pre-injection IOP was statistically significant (P<0.0001). IOP at post-injection 2 hours and 8 weeks was elevated significantly (p=0.01 and p=0.028, respectively). During follow up of 6 months, 8 eyes (24.24%) demonstrated an increase in IOP of 5 mmHg or greater, and 4 eyes (12.12%) of 10 mmHg or greater. IOP was more elevated in BRVO, younger age (< 60years) and males. All eyes responded to topical glaucoma medication. CONCLUSIONS: Transient IOP elevation can develop after intravitreal triamcinolone injection, especially from 4 to 8 weeks. Patients with risk factors for the elevation of IOP should be observed closely.

Effects of Mitomycin C on Lens: in Vitro Study

PURPOSE: Cataract could occur as a complication of mitomycin C (MMC) used to increase the success rate of glaucoma surgery. Thus, the effects of MMC on cellular growth inhibition and apoptosis induction were examined by the culturing lens epithelial cells and the morphologic change in cells when MMC induced apoptosis. METHODS: Cellular morphology was observed after treating the mouse lens epithelial cell line, alpha-TN4, with MMC at different concentrations. Cellular toxicity was measured using LDH. Furthermore, IC50 inhibiting cellular proliferation and IC50 inducing apoptosis were measured. Staining and TUNEL assay were done to define apoptosis. The lens shape was observed under a transmission electron microscope, and electrophoresis was performed investigate the change in protein level when cataract was induced by MMC. RESULTS: The lens epithelial cells were atrophic even at low concentrations of MMC and more severe cellular changes along with reduced survival rate were seen at higher concentrations. According to the results of measuring cellular toxicity using LDH, the amount of LDH increased with increasing concentrations of MMC. The results of staining showed the findings of apoptosis of cells with orange-colored, compressed nuclei at low concentrations of MMC. Also on microscopic observation, the compression of chromosomes and fragmentation of nuclei were seen. Furthermore, the number of the high molecularr 53 KDa protein was increased among lens proteins of fertilized egg. CONCLUSIONS: These results demonstrated that MMC induced apoptosis of lens epithelial cells; the formation of cataract occurred in subcapsular area and the equator region; and denatuation of lens proteins and high molecular weight 53 KDa protein were increased.

The Effect of Vascular Endothelial Growth Factor on Vascularization in Porous Polyethylene Orbital Implant (Medpor(R))

PURPOSE: We investigated the effect of VEGF usage and the method of surgery on the vascularization rate of the porous orbital implant (Medpor(R)). METHODS: Thirty six Newzealand white rabbits were randomized into 2 groups according to the method of surgery (evisceration and intrascleral implantation and evisceration and retroscleral implantation). Each group was subdivided into two groups, a group treated with VEGF, and the other without VEGF treatment. The degree of vascularization was observed in the four groups at 1, 2, 4 weeks by using cryofilm transfer kit (Finetec, Tokyo, Japan). The implant was sliced at the equator with cryomicrotome and stained with Hematoxylin and Eosin, Masson's trichrome and reticulin. The sample was observed to assay the degree of fibrovascular ingrowth with light microscope. RESULTS: The group in which VEGF was used and the implant was inserted retrosclerally (n=9) showed significantly higher vascularization rate than the other three groups (P0.05). CONCLUSIONS: After using VEGF or inserting the implant retrosclerally, the vascularization of the implant was significantly incresed.