Clinical Feature of Unilateral Ptosis with Positive Result in Phenylephrine Test

PURPOSE: To investigate the clinical features and therapeutic effects of unilateral ptosis in patients who respond to the phenylephrine (PE) test. METHODS: Patients who presented with unilateral ptosis from January 2010 to December 2014 and underwent a PE test were included in the analysis. A 2.5% ophthalmic solution of phenylephrine hydrochloride was instilled at the superior conjunctival fornix in the ptotic eye. After 10 minutes of instillation, the patients' eyelid heights were evaluated. Underlying systemic diseases were examined based on previous medical history, a blood test, neurologic examination, and radiologic imaging findings. RESULTS: Twenty-six of 44 patients who underwent a PE test showed positive results. Fourteen (53.8%) patients with positive PE test had systemic disease, and 2 (11.2%) patients had systemic disease with negative PE test. In the positive PE test group, the associated systemic disease frequency was remarkably high (p = 0.004). Myasthenia gravis (MG) was found more frequently in the positive PE test group than in the negative PE test group (p = 0.031). After 6 months, the interpalpebral fissure height increased by 2.20 mm in the positive PE test group and 2.38 mm in the negative PE test group. Patients receiving medication treatment experienced an increase in interpalpebral fissure height of 2.00 mm in the positive PE test group and 2.50 mm in the negative PE test group. In patients undergoing observation alone, the interpalpebral fissure height increased by 1.50 mm in the positive PE test group and 0.80 mm in the negative PE test group. There was no significant difference in treatment methods (respectively, p = 0.147, p = 0.228 and p = 0.112). CONCLUSIONS: The PE test can be considered to help with differential diagnosis when examining patients with mild to moderate ptosis. If the PE test is positive, underlying comorbidity including MG should be considered.

Three Cases of Esotropia after Cosmetic Botulinum Toxin A Use in the Eyelid

PURPOSE: We report three cases of esotropia after botulinum toxin A injection in the eyelid for esthetic purposes. CASE SUMMARY: Esotropia was observed in three patients presented with diplopia after botulinum toxin A application in the eyelid for esthetic purposes. (Case 1) A 51-year-old woman developed diplopia, mild ptosis and hyperemia in both eyes after periocular cosmetic use of botulinum toxin A 6 weeks before. In the primary position, the angle of esotropia was 10 prism diopters (PD) at distance and 6 PD at near. She had slightly limited abduction and mild ptosis on both eyes. (Case 2) A 50-year-old woman developed diplopia after botulinum toxin A injection in the upper eyelid 15 days prior. In primary position, the angle of esotropia was 18 PD at distance and 12 PD at near. She had slightly limited abduction and mild ptosis in both eyes. (Case 3) A 40-year-old woman was examined with diplopia after botulinum toxin A injection in the crow's feet and lower lid 6 days earlier. In primary position, the angle of esotropia was 30-35 PD at distance and 18 PD at near. She had slightly limited abduction. Prism glasses were prescribed for patients in case 1 and case 3. All three patients were resolved in symptoms of diplopia, gaze limitation and ptosis after 1 or 2 months. CONCLUSIONS: Botulinum toxin A could spread out from the lateral canthus to both lateral rectus muscles and cause a transient paresis of the muscles. This was presented as esotropia and the mild abduction deficits on both eyes. We suggest that patients presenting with diplopia should be asked if they have a history of injection of botulinum toxin A and patients should be fully informed about the complications of botulinum toxin A before injection.

A Case of Joubert Syndrome Accompanied with Retinal Abnormality

PURPOSE: Joubert syndrome is a rare disorder which affects the cerebellum and the brain stem. Herein, we report a case of Joubert syndrome accompanied with retinal abnormality. CASE SUMMARY: A 9-year-old female visited our hospital with chief complaints of low vision in both eyes, nystagmus, and lack of gaze movement. The best-corrected visual acuity in her right eye was 20/80 and in the left 20/80 and heterotropia was not observed. She appeared to have incomplete total color blindness on the color vision test. The anterior segment test showed no abnormal findings other than diffuse pigmentation and degeneration of the peripheral retina, vascular attenuation, and pale optic disc in both eyes on fundus examination. The patient showed overall developmental delay and decreased muscle tension, but genetic and congenital metabolic disease tests were normal. The molar tooth sign of the midbrain, defect in the lower part of the cerebellum and dilatation of the fourth ventricle were observed on magnetic resonance imaging. CONCLUSIONS: Appropriate evaluation of retinitis pigmentosa and visual function should be performed in Joubert syndrome patients.

Comparison of Evisceration with Primary Orbital Implant Surgery in Endophthalmitis and Phthisis Bulbi

PURPOSE: To evaluate the efficacy and prognosis of evisceration with primary orbital implant placement in patients with endophthalmitis and compare it to phthisis bulbi patients. METHODS: We retrospectively reviewed the medical records of patients who underwent evisceration with primary implant placement by a single surgeon from January 2005 to December 2011 at Pusan National University Hospital. Age, gender, underlying ocular disease, systemic illness, type and size of implant, follow-up period, and the causative organism were evaluated in patients with endophthalmitis. Success rates and prevalence of complications were compared between endophthalmitis and phthisis patients. RESULTS: The present study included 18 patients (18 eyes) with endophthalmitis and 23 patients (23 eyes) with phthisis. Patients in the endophthalmitis group were older than the patients in the phthisis group and no significant differences in gender, size of implant, and underlying diseases between endophthalmitis and phthisis patients were found. Sixteen endophthalmitis and 20 phthisis patients showed successful surgical outcomes with no significant differences (p = 0.31), and implant exchange rates were not significantly different between endophthalmitis and phthisis bulbi patients (p = 0.52). CONCLUSIONS: Evisceration with primary orbital implant placement in patients with endophthalmitis is a safe and effective treatment method. Comparison between endophthalmitis and phthisis showed no significant differences in success outcomes and complication rates.

Biomechanical Property of Keratoconus Measured by ORA

PURPOSE: To compare the biomechanical properties of keratoconus, keratoconus suspect, and normal subjects measured by ocular response analyzer. METHODS: A total of 72 patients were divided into 3 groups: keratoconus, suspected keratoconus, and normal control subjects. The 3 age-matched groups were evaluated according to age, sex, and visual acuity. Slit lamp examinations, Pentacam, and ocular response analyzer (ORA) examinations were performed. Mean corneal refractive power, central corneal thickness, corneal hysteresis (CH), and corneal resistance factor (CRF) were evaluated and analyzed. RESULTS: Twenty-four eyes were included in each group. The mean age was 23.8 years in keratoconus, 26.0 years in suspected keratoconus and 26.1 years in normal subject groups. Mean corneal refractive power was significantly higher in keratoconus (p < 0.001) and suspected keratoconus (p = 0.001) groups than in the normal subject group. Mean central corneal thickness showed significant differences among the 3 groups (p < 0.05). CH was significantly lower in keratoconus than suspected keratoconus (p = 0.025) and normal subject groups (p = 0.005), but showed no significant difference between suspected keratoconus and normal subject groups. CRF showed significant differences among all 3 groups (p < 0.05). CH and CRF had negative correlations with mean corneal refractive power and positive correlations with central corneal thickness. CONCLUSIONS: CH and CRF measured by ORA were significantly different between keratoconus and normal subject groups and had significant correlations with mean corneal refractive power and central corneal thickness. CRF may be a useful method to differentiate between suspected keratoconus and normal cornea patients.

Histopathologic Features of Triamcinolone Deposits in Refractory Steroid-Induced Glaucoma after Subtenon Triamcinolone Injection

PURPOSE: To report the removal of subtenon triamcinolone precipitates in patients with refractory steroid-induced glaucoma following subtenon triamcinolone injection. CASE SUMMARY: A 72-year-old male patient with diabetic retinopathy had cystoid macular edema in the right eye. The patient received a posterior subtenon injection of triamcinolone acetonide and developed intractable glaucoma one month after the injection in the right eye. Corticosteroid-deposit was excised three month after the injection. The intraocular pressure decreased to normal within one month after surgery and remained normal for seven months after surgery. A 42-year-old man with bilateral chronic recurrent anterior uveitis received a posterior subtenon triamcinolone acetonide injection in both eyes. The patient developed refractory steroid-induced glaucoma one month after the injection in the right eye. Corticosteroid-deposit was excised six months after the injection in the right eye. The patient's intraocular pressure decreased to normal within two weeks after surgery and remained normal. Light microscopy showed a fibrous capsule encapsulating an amorphous whitish material. The excised specimen with polarized light showed birefringence of triamcinolone crystals within an encapsulated cyst. CONCLUSIONS: Removal of subtenon triamcinolone acetonide precipitate may facilitate the management of patients developing increased intraocular pressure unresponsive to maximum tolerable medical therapy and should be considered before performing glaucoma filtration surgery.