Prognostic Factors of Anatomical Success in Scleral Buckling for High Myopic Rhegmatogenous Retinal Detachment

PURPOSE: To assess the prognostic factors associated with anatomical success of scleral buckle (SB) for rhegmatogenous retinal detachment (RRD) in high myopia patients. METHODS: The medical records of RRD in highly myopic eyes treated with SB from January 2009 to December 2013 were reviewed retrospectively. Cases with history of intraocular surgery including phacoemulsification and vitrectomy were excluded. Correlations between anatomical success and the parameters of age, sex, preoperative visual acuity, axial length, presence of large tear, presence of horseshoe tear, the number of tears, involved fovea, and extent of detachment were analyzed. RESULTS: This study included 80 eyes of 80 patients. Average age and axial length were 32.3 ± 13.4 and 26.753 ± 0.961 mm, respectively. Sixty-nine eyes (86.3%) were reattached following primary surgery. Univariate analysis revealed that age (p = 0.011), presence of large tear (p = 0.002), and presence of horseshoe tear (p = 0.044) were correlated with anatomical success after SB. Based on multivariate logistic regression analysis, age was the sole independent prognostic factor (odds ratio = 1.086, 95% confidence interval = 1.022~1.154, p = 0.004). CONCLUSIONS: A younger age is associated with a higher rate of primary anatomical success of SB for RRD in highly myopic eyes. In young, highly myopic patients with RRD, SB should be considered as the primary procedure.

Two Cases of Acute Spontaneous Resolution in Macula-Off Rhegmatogenous Retinal Detachment

PURPOSE: To report 2 cases of acute spontaneous resolution of rhegmatogenous retinal detachment (ASRRRD). CASE SUMMARY: (Case 1) A 28-year-old male presented with acute visual loss in his left eye for 5 days. The best corrected visual acuity was 10/200 in the left eye and fovea-off retinal detachment with retinal break at the 11-o'clock location was observed. The retina was reattached after 5 days without any treatment. Prophylactic barrier photocoagulation was performed around the break and 3 months after ASRRRD visual acuity improved to 20/30. (Case 2) A 19-year-old male was referred with a history of blurry vision and visual disturbance in his right eye. He underwent a cataract surgery due to traumatic cataract in his right eye 3 years prior. The best corrected visual acuity was 10/200 in the right eye and fovea-off retinal detachment with retinal break at the 10:30-o'clock location was observed. The retina reattached spontaneously after 5 days. Prophylactic barrier photocoagulation was performed around the break and 3 months after ASRRRD visual acuity improved to 20/30. CONCLUSIONS: It would be better to check the status of fundus and the visual acuity before the surgery in the cases of rhegmatogenous retinal detachment in young age.

Accuracy of Predictive Refraction in Combined Vitrectomy-Cataract Surgery for Epiretinal Membrane and Macular Hole

PURPOSE: To evaluate the accuracy of predictive refraction and the factors influencing the predictability in combined vitrectomy and cataract surgery. METHODS: We retrospectively investigated patients who received combined vitrectomy and cataract surgery for idiopathic epiretinal membrane (ERM) and macular hole (MH), followed up for a minimum of 6 months. Preoperative refraction, target refraction, postoperative refraction, predictive refraction error (target refraction - postoperative refraction), accuracy of predictive refraction error (predictive refraction error was within +/-0.5 diopter), intraocular pressure, axial length, central macular thickness, and tools that were used for intraocular lens power calculation (A-scan and IOL master) were assessed by analyzing medical records. RESULTS: A total of 176 eyes (including 132 idiopathic ERM cases and 44 MH cases) were included in this study. The accuracy of predictive refraction error was 60.8% at 6 months and there was no difference between the idiopathic epiretinal membrane group (59.8%) and the macular hole group (63.6%). There was no significant difference in predictive refraction error according to axial length and tools (IOL master vs A-scan). Predictive refraction error correlated positively with preoperative refraction (r = 0.227; p = 0.002). In the ERM group, predictive refraction error correlated negatively with both preoperative central macular thickness and the change in central macular thickness between, before, and 6 months after surgery (r = -0.211; p = 0.015 and r = -0.241; p = 0.005). CONCLUSIONS: The accuracy of predictive refraction error was approximately 60% in combined vitrectomy and cataract surgery. Postoperative refraction appeared to be myopia relative to target refraction with higher preoperative myopia and thicker preoperative central macular thickness. Hence, the intraocular lens power should be determined considering the above factors.

Two Cases of Recurrent Enterococcus Faecalis Endophthalmitis after Cataract Surgery

PURPOSE: To report 2 cases of recurrent Enterococcus faecalis (E. faecalis) endophthalmitis after uneventful phacoemulsification and posterior chamber intraocular lens (IOL) implantation. CASE SUMMARY: Case 1: A healthy, 75-year-old female presented with a sudden visual loss and ocular pain 2 days after phacoemulsification and IOL implantation. After successful treatment with intravitreal antibiotics injection, the infection was apparently cleared. At 1 month after the initial presentation, recurrent endophthalmitis occurred and was resolved with vitrectomy, silicon oil tamponade, and intravitreal antibiotics injection. Two months after vitrectomy, the silicone oil was removed and the patient's final visual acuity improved to 20/400 5 months later. Case 2: A healthy, 74-year-old female presented with a sudden visual loss 2 days after phacoemulsification and IOL implantation. After successful treatment with intravitreal antibiotics injection, the infection was apparently cleared. One month later, recurrent endophthalmitis occurred and was resolved with vitrectomy, posterior capsulotomy, and intravitreal antibiotics injection. Forty days later, the patient had a similar relapse. The infection resolved with IOL explantation, silicon oil tamponade, and repeated intravitreal antibiotics injections. E. faecalis was identified at the first and recurrent episode. Vancomycin and ceftazidime were used for each intravitreal administration. Silicone oil removal and IOL scleral fixation were performed and the patient's final visual acuity was 20/40 5 months later. CONCLUSIONS: Close monitoring for recurrences is recommended in endophthalmitis due to E. faecalis after phacoemulsification even after a successful initial treatment.

Myopic Shift and Cataract Change after Lens Sparing Vitrectomy in Patients with Idiopathic Epiretinal Membrane in Their 5th and 6th Decade

PURPOSE: To determine the myopic shift and cataract change after lens sparing vitrectomy (LSV) in patients with idiopathic epiretinal membrane (ERM) in their 5th and 6th decade of life. METHODS: The medical records of patients undergoing LSV for idiopathic ERM from 2008 to 2012 were reviewed. Patients with previous intraocular surgery, preoperative significant cataract, under 40 or over 60 years of age and a follow-up period of less than 6 months were excluded. The change in refractive errors, visual acuity, and cataract grade were evaluated for 6 months after LSV as well as the correlation between myopic shift and cataract change at 6 months after LSV. RESULTS: Twenty-eight eyes were included in this study. The cataract status worsened by 1.07 levels, myopia progressed by 3.13 diopters (p < 0.001), and uncorrected visual acuity (log MAR) decreased from 0.73 to 0.98 (p = 0.022) at 6 months after LSV. Additional cataract surgery was performed in 22 eyes (78.6%) at 13.6 months on average during the follow-up period (average 16.9 months). In 6 eyes (21.4%) having myopic change below 1.0 diopters, crystalline lens was preserved for 36 months after vitrectomy. Conversely, 22 eyes (78.6%) with myopic change over 1.5 diopters required cataract surgery. Therefore, myopic change over 1.5 diopters could be a major postoperative change predicting the necessity for cataract surgery (p < 0.001). CONCLUSIONS: LSV for ERM caused a significant myopic shift and cataract changes in patients in their 5th and 6th decade of life and additional cataract surgery was required in 78.6% of patients within 3 years after vitrectomy. The myopic shift over 1.5 diopters at 6 months after vitrectomy could be a major postoperative change predicting the necessity for cataract surgery.

Internal Limiting Membrane Peeling Using 0.025% Brilliant Blue G During Vitrectomy

PURPOSE: To evaluate 0.025% brilliant blue G (BBG) for staining the internal limiting membrane (ILM) during vitrectomy. METHODS: In a retrospective, non-comparative clinical case series, we analyzed consecutive 111 patients who underwent pars plana vitrectomy and removal of the ILM after staining using BBG solution. BBG was dissolved and diluted with balanced salt solution at a concentration of 0.025% and then sterilized by filtering through a 0.22 microm millipore filter. The prepared BBG solution was injected into the vitreous cavity over the macula after removal of the vitreous and excessive solution was removed immediately. RESULTS: The ILM was successfully removed without use of additional adjuvant in all cases. Mean best corrected visual acuity (log MAR) was significantly improved from 0.80 +/- 0.44 at baseline to 0.40 +/- 0.39 at 6 months postoperatively (p < 0.001). One case each of endophthalmitis and diabetic papillopathy developed. The relationship when using BBG solution was not identified as complications were not observed in the other patients who underwent vitrectomy using the same BBG solution on the same day. One idiopathic epiretinal membrane patient had visual acuity loss more than 2 lines. During the follow-up period, other complications suspected to be associated with the use of BBG solution were not observed. CONCLUSIONS: A BBG solution (0.025%) was effective in staining the ILM for removal. Complications associated with the use of BBG solution were not observed.

Myopic Shift and Cataract Change after Lens Sparing Vitrectomy in Patients with Idiopathic Epiretinal Membrane in Their 5th and 6th Decade

PURPOSE: To determine the myopic shift and cataract change after lens sparing vitrectomy (LSV) in patients with idiopathic epiretinal membrane (ERM) in their 5th and 6th decade of life. METHODS: The medical records of patients undergoing LSV for idiopathic ERM from 2008 to 2012 were reviewed. Patients with previous intraocular surgery, preoperative significant cataract, under 40 or over 60 years of age and a follow-up period of less than 6 months were excluded. The change in refractive errors, visual acuity, and cataract grade were evaluated for 6 months after LSV as well as the correlation between myopic shift and cataract change at 6 months after LSV. RESULTS: Twenty-eight eyes were included in this study. The cataract status worsened by 1.07 levels, myopia progressed by 3.13 diopters (p < 0.001), and uncorrected visual acuity (log MAR) decreased from 0.73 to 0.98 (p = 0.022) at 6 months after LSV. Additional cataract surgery was performed in 22 eyes (78.6%) at 13.6 months on average during the follow-up period (average 16.9 months). In 6 eyes (21.4%) having myopic change below 1.0 diopters, crystalline lens was preserved for 36 months after vitrectomy. Conversely, 22 eyes (78.6%) with myopic change over 1.5 diopters required cataract surgery. Therefore, myopic change over 1.5 diopters could be a major postoperative change predicting the necessity for cataract surgery (p < 0.001). CONCLUSIONS: LSV for ERM caused a significant myopic shift and cataract changes in patients in their 5th and 6th decade of life and additional cataract surgery was required in 78.6% of patients within 3 years after vitrectomy. The myopic shift over 1.5 diopters at 6 months after vitrectomy could be a major postoperative change predicting the necessity for cataract surgery.

Internal Limiting Membrane Peeling Using 0.025% Brilliant Blue G During Vitrectomy

PURPOSE: To evaluate 0.025% brilliant blue G (BBG) for staining the internal limiting membrane (ILM) during vitrectomy. METHODS: In a retrospective, non-comparative clinical case series, we analyzed consecutive 111 patients who underwent pars plana vitrectomy and removal of the ILM after staining using BBG solution. BBG was dissolved and diluted with balanced salt solution at a concentration of 0.025% and then sterilized by filtering through a 0.22 microm millipore filter. The prepared BBG solution was injected into the vitreous cavity over the macula after removal of the vitreous and excessive solution was removed immediately. RESULTS: The ILM was successfully removed without use of additional adjuvant in all cases. Mean best corrected visual acuity (log MAR) was significantly improved from 0.80 +/- 0.44 at baseline to 0.40 +/- 0.39 at 6 months postoperatively (p < 0.001). One case each of endophthalmitis and diabetic papillopathy developed. The relationship when using BBG solution was not identified as complications were not observed in the other patients who underwent vitrectomy using the same BBG solution on the same day. One idiopathic epiretinal membrane patient had visual acuity loss more than 2 lines. During the follow-up period, other complications suspected to be associated with the use of BBG solution were not observed. CONCLUSIONS: A BBG solution (0.025%) was effective in staining the ILM for removal. Complications associated with the use of BBG solution were not observed.

Risk Factors of Retinal Detachment after Acute Retinal Necrosis

PURPOSE: Retinal detachment (RD) complicated in acute retinal necrosis (ARN) is difficult to be treated and a main cause of blindness. The factors associated with RD in ARN were investigated. METHODS: Patients with ARN who were diagnosed and treated from Jan, 2008 to Dec, 2012 were reviewed retrospectively. The eyes were classified into the group I without RD, and the group II with RD. Early vitrectomy, history of ARN in the other eye, extent of necrosis, symptom duration and intravitreal injection of anti-viral drug were evaluated. RESULTS: Of 22 eyes of 20 patients, 11 eyes were included in each group. Symptom duration of 8.0 days in the group I was shorter than 15.8 days in the group II (p = 0.005). There were no macular involvement at initial exam in the group I and 5 eyes (45%) in the group II (p = 0.017). Five eyes (45%) in the group I and 0 eye (0%) in the group II had history of ARN in the other eye (p = 0.017). Six eyes (55%) in the group I and 1 eye (9%) in the group II underwent early vitrectomy (p = 0.031). Age, baseline visual acuity, and intravitreal injection of antiviral agent were not related to RD (p = 0.294-0.699). CONCLUSIONS: Broader necrosis and longer symptoms duration were related to occurrence of RD. Correlation of Lower risk of RD with ARN history in the other eye would result from earlier diagnosis and treatment. Early vitrectomy seems to be effective to prevent RD in ARN.

Inflammatory Cytokines in the Vitreous of Rabbits after Photocoagulation Using Pattern Scanning and Conventional Laser

PURPOSE: To compare concentration of cytokines in the vitreous of rabbit eyes after photocoagulation using a short-pulse pattern scanning laser (PASCAL) or a conventional laser. METHODS: Laser photocoagulation was performed using PASCAL (duration 0.02 seconds) in the right eyes and a conventional laser (duration 0.1 seconds) in the left eyes of 13 pigmented rabbits. To obtain ophthalmoscopically similar mild burns, power was adjusted during the photocoagulation. The rabbits were sacrificed at 1, 3 or 7 days after photocoagulation to investigate histological changes. Levels of interleukins (IL)-1beta, IL-6, IL-8 and tumor necrosis factor (TNF)-alpha in the vitreous humors of ten rabbits were measured using enzyme-linked immunosorbent assay before treatment and at 1, 3 and 7 days after photocoagulation. RESULTS: Histological changes were comparable between the two groups. IL-1beta and TNF-alpha were not detectable. IL-6 did not change significantly. IL-8 increased at day 3 and day 7, but no significant difference was observed between the two groups (p>0.05). CONCLUSIONS: When ophthalmoscopically similar mild burn intensity was achieved, conventional and PASCAL treatments of rabbit eyes caused no difference in intravitreal concentration of inflammatory cytokines.

Confocal Microscopic Changes in the Cornea 10 Years After Photorefractive Keratectomy

PURPOSE: The present study compares, using a new generation high-resolution in vivo confocal microscope, the corneas of patients who underwent photorefractive keratectomy (PRK) 10 years previously with those of healthy persons. CASE SUMMARY: A confocal microscope (Confoscan 4.0, Fortune Technology, Italy) was used to get the data from healthy volunteers and patients. Corneal cross-sectional images of the epithelium, Bowman's layer, stromal layer (anterior, middle and posterior keratocyte), Descemet's membrane, and endothelium were compared. In PRK corneas, the superficial epithelium was nearly intact and the subbasal nerve plexus was visible, but some hyperreflective areas were also found in the nerve plexus. Because of the absence of the Bowman's layer, some ECM and keratocytes were visualized in their optical section. Although anterior keratocytes showed uneven distribution with less cellularity, middle and posterior keratocytes looked unaffected. Likewise, there were no differences in the endothelium between the two groups. CONCLUSIONS: Ten years after PRK, the subbasal nerve plexus and anterior keratocytes showed histologic changes after corneal wound recovery.

Intravitreal Bevacizumab Injection as Preoperative Adjuvant of Vitrectomy for Proliferative Diabetic Retinopathy

PURPOSE:The effect of preoperative intravitreal bevacizumab (Avastin(R)) injection was investigated in primary vitrectomy for severe proliferative diabetic retinopathy. METHODS: Eyes that underwent vitectomy for proliferative diabetic retinopathy were followed up at least 6 months and were reviewed retrospectively. The authors reviewed functional outcomes, complications, and operation time between preoperative bevacizumab injection (group I) and non-injection groups(group II). RESULTS: Among 93 eyes of 87 patients, the injection group consisted of 44 eyes of 41 patients and the non-injection gauge group consisted of 49 eyes of 46 patients. The mean interval between injection and vitrectomy was 5.8 days. Final visual acuity significantly improved as compared to preoperative visual acuity, and group I showed better visual acuity than group II (p=0.008). Visual acuity improved logMAR 0.2 or more in 36 eyes in group I and 43 eyes in group II (p=0.167). The average duration of postoperative vitreous hemorrhage was 1.02 days in group I, and 4.02 days in group II (p=0.2.08). Recurrence of vitreous hemorrhage was not observed in group I or in 2 eyes of group II (p=0.274). Epiretinal membrane occurred in 2 eyes of group I, and in 9 eyes of group II (p=0.031). Only a single eye in group I had neovascular glaucoma after vitrectomy (p=0.527). The operation time of group I was 64.8 minutes, which was significantly shorter than 78.1 minutes of group II (p=0.018). CONCLUSIONS: Intravitreal bevacizumab injection before vitrectomy in proliferative diabetic retinopathy facilitated removal of the fibrovascular membrane, and leads to less postoperative complications and better functional outcomes. Intravitreal bevacizumab injection before vitrectomy can be considered as an effective preoperative adjuvant.

Confocal Microscopic Findings of Transplanted Cornea 10 Years After Penetrating Keratoplasty

PURPOSE:To examine the morphological characteristics of the transplanted cornea in patients who received penetrating keratoplasty at least 10 years previously prior. CASE SUMMERY: Each layer of the transplanted cornea of patients who received penetrating keratoplasty 10 years previously prior was examined with a confocal microscope (ConfoScan 4.1, Fortune Technology, Italy). Cross-sectioned corneal images of the corneal epithelium, Bowman's layer, stromal layer, Descement's membrane, and endothelium were evaluated and compared with the normal fellow other eye. A total of three eyes from three subjects between the ages of 60 and 70 years were examined. The epithelial cells had large cell borders, and a spindle shaped, and a highly reflective nucleus. The keratocytes were highly reflective and the density of keratocytes was lower than that in the normal cornea. The regenerated nerve fibers were markedly altered, as characterized by increased nerve tortuosity, reduced branching patterns, and shorter nerve lengths. In the endothelial cell layer, a bright nucleus, a reduced ratio of hexagonal cells, and several multinuclear cells were observed. CONCLUSIONS: Even 10 years after penetrating keratoplasty, the entire transplanted cornea is morphologically different from the normal cornea.

Comparison Between 20-Gauge and 23-Gauge Vitrectomy System in Primary Vitrectomy for Rhegmatogenous Retinal Detachment

PURPOSE: The efficacy of 20-gauge and 23-gauge vitrectomy system was investigated in primary vitrectomy for rhegmatogenous retinal detachment. METHODS: Eyes that underwent primary vitrectomy without scleral buckling for the treatment of rhegmatogenous retinal detachment were followed up at least 6 months and were reviewed retrospectively. Anatomic results, functional outcomes, operation time and complications were compared between 20-gauge and 23-gauge groups. RESULTS: Among 59 eyes of 59 patients, the 20-gauge group had 29 eyes of 29 patients and 23-gauge group had 30 eyes of 30 patients. Anatomic success after a single operation was obtained in 23 eyes (79.3%) of the 20-gauge group and 28 eyes (93.3%) of the 23-gauge group. Recurrence occurred in 6 eyes (20.7%) in the 20-gauge and in 2 eyes (6.6%) in the 23-gauge group. Retinal reattachment in all of these eyes was obtained through reoperation. Visual acuity improved logMAR 0.2 or more in 19 eyes (65.5%) of the 20-gauge group and 20 eyes (66.7%) of the 23 gauge group (p=0.153, 0.215). The average operation time of the 23-gauge group was 80.2 minutes, which was significantly shorter than the 94.8 minutes of the 20-gauge group (p=0.008). Transient ocular hypertension and progression of lens opacity were the most common complications in the both groups. CONCLUSIONS: Twenty-three-gauge transconjuctival sutureless vitrectomy achieved outcomes comparable with 20-gauge vitrectomy, with significantly shorter operation time in repair of rhegmatogenous retinal detachment. It is considered as a viable alternative to 20-gauge vitrectomy in selected cases.

Clinical Results of Surgical Treatment of Acetabular Fractures according to Quality of Reduction / 대한정형외과학회잡지

PURPOSE: To analyze postoperative clinical and radiological results of displaced acetabular fractures and to determine the factors affecting the clinical results. MATERIALS AND METHODS: Clinical analysis was performed on 51 patients with displaced acetabular fractures who had been operated on and followed up for a minimum of 1 year. The mean follow-up duration after surgery was 45 months (range, 12 to 67 months). The outcome was analyzed clinically using Postel's clinical grade criteria and radiologically using Mattas roentgenographic grading system. RESULTS: There was a statistical relationship between the type of fracture patterns (Letournel classification) and the degree of immediate postoperative reduction (p<0.05). A comparison of the radiological and clinical results at the last follow-up revealed a good correlation between good or excellent radiology results and good or excellent clinical results (p<0.05). The factors affecting the clinical outcomes of the last follow-up were the type of fracture (Letournel classification), the presence or absence of a femoral head injury and the degree of immediate postoperative reduction. CONCLUSION: The results of this study suggest that the degree of reduction was closely related to the clinical result. Therefore, it is important in the surgical treatment of the acetabular fractures to classify the fractures accurately, reduce the fragments anatomically and minimize the complications.

Minimally Invasive Percutaneous Plate Fixation for Distal Tibia Shaft Fractures / 대한정형외과학회잡지

PURPOSE: To review the efficiency of the minimally invasive plate fixation technique for distal tibia shaft fractures. MATERIALS AND METHODS: Between April 1999 and March 2001, 15 patients with distal tibia fractures were treated operatively by minimally invasive percutaneous plate osteosynthesis. There were 10 men and 5 women with an average age of 51 years (range, 20 to 72 years). The patients were followed for an average of 19 months (range, 12 to 30 months). In all patients, the center of fracture was in the distal tibia and either entirely extraarticular or with minimally displaced extension into the ankle joint. The type of fracture was evaluated using the AO/OTA classification. So far as general condition of patients permitted, temporary reduction of fractures with or without passive traction or distractor was performed under intraoperative fluoroscopy. About a 2 cm to 3 cm incision was made in the metaphyseal region proximal or distal to the fracture site, and screws fixation was performed percutaneously. A clinical assessment was evaluated according to Olerud and Molander ankle score. RESULTS: All of the fractures healed with an average time of 15 weeks (range, 10 to 25 weeks). No patient had an angular deformity more than 5 degrees, or shortening of more than 1 cm. All patients had an excellent or satisfactory ankle function. Checkrein deformity was observed in one patient and superficial infections occurred in two, but no patient experienced deep infection or skin necrosis. CONCLUSION: As compared with conventional open reduction and internal plate fixation, minimally invasive percutaneous plate osteosynthesis technique was found to be an effective method of treating distal tibia fractures, because it facilitates the rehabilitation more rapid patient rehabilitation, and induces osteosynthesis with reduced of the rates of infection and nonunion.