Aqueous Misdirection Syndrome after Laser Iridotomy in a Patient with Intermediate Uveitis

Purpose@#We report a case of aqueous misdirection syndrome triggered by pilocarpine use after laser iridotomy, which was treated by pars plana vitrectomy and phacoemulsification.Case summary: A 48-year-old female patient presented with sudden-onset right eye pain and decreased vision. The patient had presented to another institute with similar symptoms 20 days prior; she had been diagnosed with acute angle closure. Laser iridotomy was performed, followed by administration of pilocarpine twice daily. In the right eye, visual acuity was hand motion, and intraocular pressure was 31 mmHg. The laser iridotomy site was located at the 11 o’clock position; microcysts, anterior chamber cells, corneal endothelium precipitates, and glaukomflecken were observed. The anterior chamber was shallow due to forward movement of the lens and iris. Despite the application of atropine and pressure-lowering eyedrops, anterior chamber shallowing continued along with a progressive myopic shift of -4.5 diopters. Therefore, the patient was diagnosed with aqueous misdirection syndrome. Pars plana vitrectomy was performed, followed by phacoemulsification, intraocular lens insertion, and posterior capsulotomy. During surgery, vitreous inflammation, a peripheral snowball, and an anterior hyaloid inflammatory membrane were observed, indicating the presence of intermediate uveitis. @*Conclusions@#The administration of miotics after laser iridotomy, intraocular inflammation, and uveitis can lead to aqueous misdirection syndrome. Effective treatment of aqueous misdirection syndrome involves controlling inflammation and performing surgery.

A Case of Primary Hodgkin Lymphoma in the Orbit

PURPOSE: Hodgkin lymphoma involving the orbit and ocular adnexal tissue is very rare and usually appears in the form of a metastatic tumor at the end stage of the disease. Primary Hodgkin lymphoma in the orbit has not been previously reported, and herein we report a case of primary Hodgkin lymphoma occurring in the bilateral orbit. CASE SUMMARY: A 64-year-old male presented with a left lower eyelid mass that increased in size over 2 years. The patient had no specific past medical history or family history except diabetes. During the physical examination, a fixed mass was gently palpated in the left lower eyelid. Mild upgaze limitation was observed during extraocular muscle movement examination in both eyes. Orbital computed tomography and magnetic resonance imaging showed soft tissue masses involving the bilateral inferior rectus muscle and left lower eyelid. The patient was diagnosed with nodular sclerosing Hodgkin lymphoma after pathological examination following incisional biopsy. The patient was transferred to the oncology department for tumor staging. Positron emission tomography showed no involvement of other organs except both orbits. After systemic chemotherapy and radiation therapy, the patient was under observation for 14 months without ophthalmic and systemic complications or recurrence. CONCLUSIONS: The authors present a case of primary nodular sclerosing Hodgkin lymphoma that occurred in the orbit. After systemic chemotherapy and radiation therapy, the patient was in good general condition.

Surgical Outcomes of Balanced Deep Lateral and Medial Orbital Wall Decompression in Korean Population: Clinical and Computed Tomography-based Analysis

PURPOSE: To evaluate the clinical outcomes of balanced deep lateral and medial orbital wall decompression and to estimate surgical effects using computed tomography (CT) images in Korean patients with thyroid-associated ophthalmopathy (TAO). METHODS: Retrospective chart review was conducted in TAO patients with exophthalmos who underwent balanced deep lateral and medial orbital wall decompression. Exophthalmos was measured preoperatively and postoperatively at 1 and 3 months. Postoperative complications were evaluated in all study periods. In addition, decompressed bone volume was estimated using CT images. Thereafter, decompression volume in each decompressed orbital wall was analyzed to evaluate the surgical effect and predictability. RESULTS: Twenty-four patients (48 orbits) with an average age of 34.08 ± 7.03 years were evaluated. The mean preoperative and postoperative exophthalmos at 1 and 3 months was 18.91 ± 1.43, 15.10 ± 1.53, and 14.91 ± 1.49 mm, respectively. Bony decompression volume was 0.80 ± 0.29 cm3 at the medial wall and 0.68 ± 0.23 cm3 at the deep lateral wall. Postoperative complications included strabismus (one patient, 2.08%), upper eyelid fold change (four patients, 8.33%), and dysesthesia (four patients, 8.33%). Postsurgical exophthalmos reduction was more highly correlated with the deep lateral wall than the medial wall. CONCLUSIONS: In TAO patients with exophthalmos, balanced deep lateral and medial orbital wall decompression is a good surgical method with a low-risk of complications. In addition, deep lateral wall decompression has higher surgical predictability than medial wall decompression, as seen with CT analysis.

Deep Anterior Lamellar Keratoplasty Using Irradiated Acellular Cornea with Amniotic Membrane Transplantation for Intractable Ocular Surface Diseases

PURPOSE: To report the clinical outcomes of deep anterior lamellar keratoplasty (DALK) when sterile gamma-irradiated acellular corneal tissues (VisionGraft) are used in combination with amniotic membrane transplantation (AMT) for intractable ocular surface diseases. METHODS: The medical records of fifteen patients who had DALK with AMT were retrospectively reviewed. Indications for surgery included ocular burn, bacterial keratitis, herpes simplex virus keratitis, corneal opacity with Stevens-Johnson syndrome, Mooren's ulcer, idiopathic myxoid degeneration of corneal stroma, and recurrent band keratopathy. DALK was performed using partial-thickness acellular corneal tissue and a temporary amniotic membrane patch was added at the end of the operation. RESULTS: All cases that underwent DALK with AMT became epithelialized within 2 postoperative weeks. Twelve patients showed favorable outcomes without graft rejection, corneal opacification, or neovascularization. The other three grafts developed corneal opacification and neovascularization, and required additional penetrating keratoplasty (PK). Unlike the results of previous PKs, there were no graft rejections and the graft clarity was well-maintained in these three cases for at least 8 months after PK. CONCLUSIONS: DALK using sterile acellular corneal tissues in combination with AMT may be a good therapeutic strategy for treating intractable ocular surface diseases because of lowered immune rejection, fibroblast activation, and facilitation of epithelialization. Furthermore, DALK can help stabilize the ocular surface, prolong graft survival, and may allow better outcomes when combined with subsequent PK.