Double-Layered Conjunctival Autograft and Amniotic Membrane Transplantation to Treat Restrictive Esotropia and Hypotropia

PURPOSE: To report a case of double-layered conjunctival autograft and amniotic membrane transplantation for the effective treatment of esotropia and hypotropia after removal of the recurrent pterygium. CASE SUMMARY: A 58-year-old male who had pterygium surgery of the right eye twice presented with diplopia on right gaze for 3 months. At the first visit, he had orthotropia in the primary position and right esotropia of 12 prism diopters (PD) on right gaze with limited abduction of -1 in the right eye. Fourteen months later, deviation was aggravated by esotropia of 30 PD and 12 PD of right hypotropia in the primary position at distance, and esotropia of 35 PD and 12 PD of right hypotropia at near with limited abduction of -2 and supraduction of -3 in the right eye. The patient complained of diplopia at all gazes and demonstrated chin-up posture. The conjunctival edge was recessed near the medial canthus and fornix, preventing conjunctival autograft after removal of subconjunctival scar tissue. Thus, 5 mm right medial rectus recession and additional half-sized conjunctival autograft were performed after amniotic membrane transplantation. The patient than showed no diplopia and orthotropia at both distance and near, with limited adduction of -1 in the right eye. He experienced no recurrence during 7 months of follow-up. CONCLUSIONS: To prevent poor epithelial regeneration and dehiscence of graft in the patients with severe restrictive strabismus and very extensive conjunctival defect, double-layered conjunctival autograft and amniotic membrane transplantation may be effective for the treatment of severe esotropia and hypotropia.

Traumatic Dislocation of Posterior Chamber Phakic Intraocular Lens into the Berger's Space

No abstract available.

Effect of Electrocauterization on the Inflammation of the Conjunctiva in Experimental Animal Model

PURPOSE: Recently, conjunctivochalasis repair surgery using electrocauterization has been gaining popularity. However, patients with electrocauterized conjunctivoplasty tend to complain of more postoperative pain than patients undergoing simple excision with suturing. Therefore, we investigated the effects of electrocauterization on inflammation of the conjunctiva using an experimental animal model and compared these with the effects of simple excision with suturing. METHODS: Ten New Zealand white rabbits underwent cauterization in the right eyes and excision and suturing in the left eyes. For each eye, we excised or electrocauterized the inferior bulbar conjunctiva, 1 mm in width and 6 mm in length, 2 mm from the limbus. A fine-needle electrode was inserted subconjunctivally, and electrocauterization was performed. In the contralateral eye, the corresponding area was excised and re-approximated with 10-0 nylon sutures. Sutures were removed after 14 days. Tissue samples were obtained at 21 days post-procedure, and inflammatory cells were counted in five randomly selected fields (x200) on hematoxylin-eosin stained slides. Tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta concentrations in tears were measured using enzyme linked immunosorbent assays. RESULTS: All cauterized eyes demonstrated smooth surface healing without scarring after 5 days, whereas sutured eyes presented with mild edema with some scarring until the suture was removed. The number of inflammatory cells was significantly greater in sutured eyes compared with cauterized eyes (p = 0.035, Mann-Whitney U-test) at 21 days post-procedure. Tear TNF-alpha and IL-1beta concentrations at 21 days were similar in both groups. CONCLUSIONS: Electrocauterization for conjunctivoplasty seems to be advantageous in terms of inflammation compared with simple suturing and excision.

Effect of Age and Early Intervention with a Systemic Steroid, Intravenous Immunoglobulin or Amniotic Membrane Transplantation on the Ocular Outcomes of Patients with Stevens-Johnson Syndrome

PURPOSE: This retrospective observational case series of fifty-one consecutive patients referred to the eye clinic with acute-stage Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) from 1995 to 2011 examines the effect of early treatment with a systemic corticosteroid or intravenous immunoglobulin (IVIG) on the ocular outcomes in patients with SJS or TEN. METHODS: All patients were classified by age (18 years) and analyzed by treatment modality and early intervention with systemic corticosteroids (< or =5 days), IVIG (< or =6 days), or amniotic membrane graft transplantation (AMT) (< or =15 days). The main outcomes were best-corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR) and ocular involvement scores (OIS, 0-12), which were calculated based on the presence of superficial punctate keratitis, epithelial defect, conjunctivalization, neovascularization, corneal opacity, keratinization, hyperemia, symblepharon, trichiasis, mucocutaneous junction involvement, meibomian gland involvement, and punctal damage. RESULTS: The mean logMAR and OIS scores at the initial visit were not significantly different in the pediatric group (logMAR = 0.44, OIS = 2.76, n = 17) or the adult group (logMAR = 0.60, OIS = 2.21, n = 34). At the final follow-up, the logMAR and OIS had improved significantly in the adult group (p = 0.0002, p = 0.023, respectively), but not in the pediatric group. Early intervention with IVIG or corticosteroids significantly improved the mean BCVA and OIS in the adult group (p = 0.043 and p = 0.024, respectively for IVIG; p = 0.002 and p = 0.034, respectively for corticosteroid). AMT was found to be associated with a significantly improved BCVA or OIS in the late treatment group or the group with a better initial OIS (p = 0.043 and p = 0.043, respectively for BCVA; p = 0.042 and p = 0.041, respectively for OIS). CONCLUSIONS: Our findings suggest that patients with SJS or TEN who are aged 18 years or less have poorer ocular outcomes than older patients and that early treatment with steroid or immunoglobulin therapy improves ocular outcomes.

Effect of ROCK Inhibitor on the Expansion and Wound Healing of Human Corneal Endothelial Cell

PURPOSE: To investigate the effect of ROCK inhibitor Y27632 on the human corneal endothelial cell proliferation in vitro and in vivo. METHODS: Using corneal endothelial cells isolated and cultured from human donor cornea, we compared the effect of Y27632 (10 microM) on the proliferation in vitro by flow cytometry analysis. For the evaluation of the effect of Y27632 (10 mM) in vivo, corneal thickness and wound area were analyzed for the corneal endothelial wound rabbit model induced by transcorneal freezing. RESULTS: Ki67 positive cells were increased in the Y27632 group (9.1 +/- 4.1%) than the control group (8.0 +/- 5.9%), whereas annexin V positive cells in the Y27632 group (2.9 +/- 1.0%) were decreased compared to the control group (4.2 +/- 2.2%). However these were not statistically significant. Wound area after Y27632 application in animal model is concerned, the control group showed significant smaller area (45.6 +/- 0.6 mm2) compared to the Y27632 group (49.3 +/- 0.8 mm2; p = 0.029, Mann-Whitney U test), however, these were not significantly different from the baseline. Corneal thickness was not different between the two groups. CONCLUSIONS: Different from other reports for the effect of Y27632, no significant effect on the proliferation in vitro and wound healing in vivo, regarding human corneal endothelial cell, were found in this study.

A Comparative Study of the Effect of Fibrin Glue versus Sutures on Clinical Outcome in Patients Undergoing Pterygium Excision and Conjunctival Autografts

PURPOSE: To compare the effect of using fibrin glue or 10-0 nylon sutures on the clinical outcome of patients undergoing pterygium excision and conjunctival autografting. METHODS: We retrospectively reviewed the medical records of 52 eyes from 46 patients who underwent pterygium excision and conjunctival autografting and were followed up for more than 3 months. The operation duration, postoperative inflammation, complications, and recurrence rates were compared between groups of 20 patients (22 eyes) for whom fibrin glue was used (fibrin glue group) and 26 patients (30 eyes) for whom suturing was performed with 10-0 nylon (suture group) in pterygium excision and conjunctival autografting. RESULTS: The operation duration was 27.71 (5.22) minutes in the fibrin glue group and 43.30 (8.18) minutes in the suture group (p = 0.000). Seven days after the operation, the fibrin glue group showed milder conjunctival inflammation than the suture group (p = 0.000). Postoperative complications and corneal recurrence rates were not statistically different between the two groups. CONCLUSIONS: The use of fibrin glue in pterygium excision with conjunctival autografting is likely to be a more effective, safer procedure than suturing.

Asymptomatic Cervical or Thoracic Lesions in Elderly Patients who Have Undergone Decompressive Lumbar Surgery for Stenosis

STUDY DESIGN: A retrospective study. PURPOSE: To evaluate the prevalence and risk factors of asymptomatic cervical or thoracic lesions in elderly patients who have undergone surgery for lumbar spinal stenosis. OVERVIEW OF LITERATURE: Concurrent multiple spinal lesions have been reported in many studies with a varied prevalence, and described the characteristics of the disease and its treatment options. However, the cervical or thoracic lesions without apparent symptoms in patients with symptomatic lumbar stenosis had not been evaluated. METHODS: A total of 101 elderly patients (aged 65 or more), who had undergone surgery for lumbar spinal stenosis from January 2005 to December 2005, were enrolled in this study. All patients underwent lumbar magnetic resonance imaging (MRI) along with T2-weighted cervical and thoracic sagittal MRI prior to surgery. The concurrent cervical or thoracic lesions were classified according to the disease entity, and the severity of the lesions was graded from grade 0 (no lesion) to grade 4 (any lesion compressing the cord with a signal change). The prevalence of concurrent cervical and thoracic lesions was then analyzed. In addition, the risk factors for the development of concurrent lesions were evaluated, and the risk factors affecting the severity of the concurrent lesion were analyzed individually. RESULTS: Seventy-seven (76.2%) and 30 (29.7%) patients had a concurrent cervical and thoracic lesion, respectively. Twenty-six patients (25.7%) had both a cervical and thoracic lesion. There was a positive correlation between the symptom duration of lumbar stenosis and the prevalence of both cervical (p = 0.044) and thoracic (p = 0.022) lesions. CONCLUSIONS: The incidence of asymptomatic cervical or thoracic lesions is apparently high in elderly patients who have undergone surgery for lumbar spinal stenosis, particularly in those with longer symptom duration. This highlights the need for a preoperative evaluation of the cervical and thoracic spine in these patients.

Initial Experience With 20-Gauge Transconjunctival Sutureless Vitrectomy Using Conventional Instruments

PURPOSE: To describe a transconjunctival sutureless technique for pars plana vitrectomy using conventional 20-gauge instruments. METHODS: We performed transconjunctival sutureless pars plana vitrectomy (TSV) using conventional 20-gauge instruments in 36 eyes of 35 patients. We made 20-gauge transconjunctival beveled sclerotomies using microvitreoretinal (MVR) blades and used traditional 20-gauge instruments for the operations. RESULTS: Eighty-three (81.4%) of 102 sclerotomies self-sealed without the need for sutures. The sutureless rate was even higher in the last one-third of the patients: 32 (94.1%) of 34 sclerotomy sites were sutureless. No serious complications were observed in our series, including postoperative hypotony, wound leakage, or endophthalmitis. CONCLUSIONS: The 20-gauge TSV technique is safe and can be utilized for almost all vitreoretinal diseases, without incurring additional cost for new instruments.

A Case of Complete Recovery of Visual Loss Associated With Electroconvulsive Therapy

PURPOSE: To report a case of complete recovery within 1 day of cortical blindness associated with electroconvulsive therapy (ECT). CASE SUMMARY: A 15-year-old girl, who had no ophthalmologic disease, complained of bilateral visual loss immediately after ECT. At the first ophthalmologic examination, best corrected visual acuity was 0.03 in both eyes. Findings of anterior segment and fundus, movement of external ocular muscles, and pupillary light reflex were normal. Visual field examination showed generalized reduction of sensitivity and increased fixation loss in both eyes. Optical coherence tomography revealed no abnormalities. Electroretinography was normal, and a slightly prolonged latency of P100 was noted in the right and left flash visual evoked potentials. Without any specific treatment, the patient's vision improved gradually after 18 hours of ECT and was recovered completely, with vision of 1.0 in both eyes the next day. There were no abnormalities in visual evoked potentials or the visual field. CONCLUSIONS: Transient visual loss can occur after ECT, because of cortical blindness by transient cerebral ischemia, and can be recovered completely without specific treatment.

Histopathological Changes by Low-Power-Long-Duration and High-Power-Short-Duration Subthreshold Laser Treatment in the Rabbit Retina

PURPOSE: To compare histopathological and apoptotic changes of ophthalmoscopically similar subthreshold laser burns made by a low power-long duration (LD) and a high power-short duration (SD) subthreshold laser treatment. METHODS: Ophthalmoscopically invisible subthreshold laser burns with a 3.0 mm spot size were made using an 810 nm diode laser on the rabbit retina. Lasers were applied for 60 seconds in the LD group, and 1 second in the SD group. Laser power was adjusted to achieve ophthalmoscopically invisible burns just below the threshold. The rabbits were sacrificed at 6, 12, 24, and 72 hours, 1, 2, and 4 weeks after laser treatment. The eyes were processed for light microscopic examination using hematoxylin and eosin (H&E), toluidine blue, and TdT-dUTP terminal nick-end labeling (TUNEL) staining. Eyes were also processed for electron microscopic examination. RESULTS: The changes in the retina were different between the two groups. The LD group showed abundant TUNEL positive cells in all the retinal layers at 6 hours after laser treatment, and distinct histological changes in the outer nuclear layer. Conversely, in the SD group, apoptosis did not occur and histological alteration in the outer nuclear layer was minimal. CONCLUSIONS: Subthreshold laser treatment for 1 second reduced damage of the inner retinal layer and did not result in apoptosis in the neurosensory retina while maintaining a similar effect on the RPE and its adjacent region.

Prevalence and Morphologic Features of Ponticulus Posticus in Koreans: Analysis of 312 Radiographs and 225 Three-dimensional CT Scans

STUDY DESIGN: A retrospective review of three-dimensional CT scan images and radiographs. PURPOSE: To investigate the prevalence and morphologic features of ponticulus posticus in Koreans. OVERVIEW OF LITERATURE: There has been little reported on the prevalence or morphologic characteristics of ponticulus posticus in Asians, predisposing them to vertebral artery injury during screw placement in the lateral mass of the atlas. METHODS: The presence and types of ponticulus posticus were investigated on 225 consecutive cervical three-dimensional CT scans and 312 consecutive digital lateral cephalometric head radiographs. RESULTS: Various spectra of ponticulus posticus were found in 26% of the CT scans and 14% of the radiographs. CONCLUSIONS: Ponticulus posticus is a relatively common anomaly in Koreans. Therefore, the presence of this anomaly should be carefully examined for on radiographs before lateral mass screw placement. If ponticulus posticus is suspected or confirmed on radiographs, three-dimensional CT scanning should be considered before placement of lateral mass screws into the posterior arch, especially given its wide variation of size and shape.

Indirect Decompression using Segmental Screw Fixation for Cervical Myelopathy Caused by C1-2 Subluxation: Technical Note / 대한정형외과학회잡지

The main aims of surgery for severe cord compression and myelopathy caused by atlantoaxial subluxation are decompression of the spinal cord and achievement of rigid fixation and fusion. Direct decompression by resecting the bony structures that compress the spinal cord includes transoral decompression and resection of the posterior arch of the atlas. The shortcomings of these procedures are a high complication rate and a relatively low rate of union. Indirect decompression can be performed by a reduction of the subluxation and fixation without bone resection. To the best of our knowledge, there are no domestic reports on the use of indirect decompression for severe cord compression and myelopathy for atlantoaxial subluxation. We report a case of a patient that had atlantoaxial subluxation and severe myelopathy; satisfactory reduction of the subluxation and decompression with an improvement in the myelopathy symptoms was achieved by indirect decompression using segmental screw fixation.

Old Atlantoaxial Rotary Subluxation Associated with High-riding Vertebral Arteries: Arthrodesis Using C1 Lateral Mass Screws and C2 Laminar Screws: A Case Report

To the best of our knowledge, there has been no domestic report on posterior atlantoaxial fusion with segmental screw fixation using C2 laminar screws and C1 lateral mass screws for atlantoaxial subluxation. We report the result of this operation performed in a patient with old atlantoaxial rotary subluxation who required posterior fusion. We chose this technique in this patient because wire fixation was not suitable due to osteoporosis, and transarticular screw fixation and use of C2 pedicle screws were not feasible due to the peculiar bony anatomy of the axis.

Revision of Atlantoaxial Fusion using Segmental Screw Fixation: Experience in Bilateral Posterior Arch Fracture of the Atlas Complicating Atlantoaxial Halifax Clamp Fixation: A Case Report / 대한척추외과학회지

A fracture of the posterior arch of the atlas is a rare complication of Halifax clamp fixation for atlantoaxial fusion. To the best of our knowledge, there is only one case reported reporting the English literature. Revision for this condition is challenging because of the difficulty in the surgical approach, internal fixation, and fusion. We report a case of bilateral fractures and nonunion of the posterior arch of the atlas and atlantoaxial nonunion after an atlantoaxial fusion procedure using Halifax clamp fixation, which resulted in persistent atlantoaxial instability and progressive myelopathy. Segmental screw fixation was performed using C1 lateral mass screws and C2 subarticular screws, along with intraarticular and extraarticular atlantoaxial inter-facet fusion.

Atlanto-occipital Assimilation Associated with Basilar Invagination, C1-2 Instability, C2-3 Block Vertebra,and C3-4 Retrolisthesis : A Case Report / 대한정형외과학회잡지

Congenital atlanto-occipital assimilation is frequently accompanied by basilar invagination and C1-2 instability. Occipitocervical fusion is required if these conditions cause neurological symptoms. Recently posterior fusion using occipitocervical screw fixation in the extension position has been introduced for the simultaneous decompression of the cervicomedullary junction compressed by basilar invagination, a reduction of atlantoaxial subluxation, and rigid fixation. However, it is a technically demanding procedure, and there is no domestic report of an experience with this procedure. We report a case of a patient with C2-3 block vertebra and C3-4 retrolisthesis in addition to congenital atlanto-occipital assimilation, basilar invagination and C1-2 instability. The patient underwent posterior fusion using occipitocervical screw fixation in the extension position.