Healthcare Utilization and Treatment Patterns in Diabetic Macular Edema in Korea: a Retrospective Chart Review

BACKGROUND: Limited data exist on real-world treatment patterns for diabetic macular edema (DME) in Korea. In this study, we investigated DME treatment patterns from 2009 to 2014 and the impact of baseline treatment on healthcare resource utilization and visual acuity (VA) outcomes. METHODS: A retrospective cohort chart review of DME patients treated at 11 hospital ophthalmology clinics between January 1, 2012 and December 31, 2013 was conducted. We collected data on demographics, healthcare resource utilization (clinic visits, treatment visits, and visits for ocular investigations), distribution of DME treatments, and VA. RESULTS: Overall, 522 DME patients (men, 55.2%; mean age, 59 years; mean HbA1c [n = 209], 8.4%) with 842 DME eyes were evaluated. For all treatments, healthcare resource utilization was significantly higher during the first 6 months versus months 7–12, year 2, or year 3 (P ≤ 0.001), but was highest for patients whose first treatment was an anti-vascular endothelial growth factor (VEGF) treatment (visits/quarter; anti-VEGF, 1.9; corticosteroids, 1.7; laser, 1.4). Use of macular laser therapy decreased (44% to 8%), whereas use of anti-VEGF injections increased (44% to 69%) during the study period. However, VA improvement was not commensurate with healthcare resource utilization of anti-VEGF treatment (mean VA gain, 2.7 letters). CONCLUSION: A trend toward increasing use of intravitreal anti-VEGF injections for DME treatment was observed in Korea. However, the frequency of dosing and monitoring was lower in clinical practice versus major clinical trials, which may have led to the less-than-favorable improvements in visual outcomes.

Results of the 2015 Questionnaire Survey of the Korean Retina Society: Current Trends in the Treatment of Vitreoretinal Diseases

PURPOSE: To report the results of the 2015 questionnaire survey of current trends and practice patterns in the treatment of vitreoretinal diseases, which was conducted by the Korean Retina Society (KRS). METHODS: In October 2015, members of the KRS participated in a survey of current trends and practice patterns in the treatment of vitreoretinal diseases. This survey was comprised of 68 multiple choice and dichotomy questions. RESULTS: One hundred eleven (41%) members participated in this survey. Most respondents (42%) had begun their vitreoretinal subspecialty ≤7 years previously, 32% had practiced for 8-15 years, and 26% for 16 years or more. The preferred primary treatment for newly diagnosed wet-type age-related macular degeneration was ranibizumab or aflibercept, and most clinicians (68%) favored a pro re nata regimen. Seventy percent of respondents treated injection-related endophthalmitis using a combination of immediate vitrectomy and intravitreal antibiotic injection. Bevacizumab was the most commonly (78-87%) preferred first-line therapy for macular edema (ME) secondary to central retinal vein occlusion or branch retinal vein occlusion. When ME did not respond to anti-vascular endothelial growth factor treatment, most respondents (91%) switched patients to dexamethasone implant or triamcinolone acetonide. Eighty-four percent of the respondents performed scleral buckling during retinal detachment surgery in fewer than 40% of cases. Also, most respondents (96%) prescribed an antibiotic eye drop after, or before and after intravitreal drug injection. CONCLUSIONS: This survey reflected the recent trends and practice patterns in the treatment of vitreoretinal diseases in Korea.

The Effect of Gas Tamponade with Vitrectomy in Lamellar Macular Hole

PURPOSE: To investigate the effect of gas tamponade with vitrectomy for lamellar macular hole. METHODS: This study included 18 eyes of 18 patients with lamellar macular hole who reported visual acuity loss or distorted vision. All patients underwent vitrectomy, epiretinal membrane removal and internal limiting membrane peeling. Intravitreal gas tamponade was performed only in 8 eyes of 8 patients. The patients were divided into 2 groups: 8 eyes in the gas tamponade with vitrectomy group and 10 eyes that did not receive gas tamponade in the control group. The best-corrected visual acuity (BCVA) and appearance based on optical coherence tomography (OCT) were obtained retrospectively. RESULTS: Epiretinal membranes were observed in all cases. Average visual acuity of the gas tamponade group improved from log MAR 0.50 +/- 0.24 to log MAR 0.25 +/- 0.14 (p = 0.041). In the control group, average visual acuity improved from log MAR 0.53 +/- 0.36 to log MAR 0.32 +/- 0.28 (p = 0.041), however, no significant difference was observed in visual acuity between the 2 groups (p = 0.584). Anatomical closure or normalized foveal contour after surgery was confirmed in 6 of 8 eyes in the gas tamponade group and in 7 of 10 eyes in the control group. No significant difference between the 2 groups was observed (p = 1.00). CONCLUSIONS: Gas tamponade combined with vitrectomy for lamellar macular hole did not affect postoperative anatomical and functional recovery.

A Case of Idiopathic Central Serous Chorioretinopathy in a 12-year-old Male Treated with Bevacizumab

A 12-year-old male presented with a chief complaint of a 1-month-history of decreased visual acuity in his right eye. The patient had no past history of steroid use or other systemic diseases. On fundus examination, which included fluorescent angiography (FAG) and optical coherence tomography (OCT), the patient was diagnosed with idiopathic central chorioretinopathy, whose clinical course was monitored without any specific treatments. At the time of admission, the best-corrected visual acuity was 0.5 in the right eye and 1.0 in the left eye. On fundoscopy, a serous detachment of 1 disc diameter in size was observed in the posterior pole. According to the FAG and the OCT, serous neurosensory detachment was present. After two months of monitoring the clinical course, the best corrected visual acuity in the right eye was 0.8, and there was improvement of neurosensory retinal detachment. However, OCT detected recurrence after five months, and the corrected visual acuity was decreased to 0.6. Bevacizumab was then injected into the vitreous cavity. Complete resolution of the subretinal fluid resulted eight months later, and the corrected visual acuity improved to 1.0.

The Results of Nation-Wide Registry of Age-related Macular Degeneration in Korea

PURPOSE: To evaluate the incidence and clinical features of age-related macular degeneration (AMD) in Korea. METHODS: Web-based (www.armd-nova.or.kr) registration was conducted for AMD patients aged 50 or more who were newly diagnosed by retinal specialists in Korea from August 20, 2005 to August 20, 2006. Patient data including ophthalmologic examination, fundus photography, fluorescein angiogram and/or indocyanin green angiogram (ICG), past medical history, behavioral habit, combined systemic diseases were up-loaded. RESULTS: Among finally enrolled 1,141 newly diagnosed AMD patients, 690 patients (60.5%) were male and 451 patients (39.5%) were female. The average age of AMD patients was 69.7+/-8.0. Early AMD was observed in 190 patients and 951 patients had late AMD. Classic choroidal neovascular membrane (CNVM) was observed in 18.6% of exudative AMD patients and 63.4 % had occult CNVM. Subfoveal CNVM was observed in 80.4% of the patients with CNVM. Among the 580 exudative AMD eyes that performed indocyanin green angiography (ICG), 184 eyes (31.7%) had polypoidal choroidal vasculopathy (PCV) and 36 eyes (6.2%) showed retinal angiomatous proliferation (RAP). Age, male gender, smoking, diabetes and hypertension significantly increased the risk of the AMD among Koreans. CONCLUSIONS: Because of the low rate of participation by retinal specialists, definite incidence of AMD was not obtainable. However, the estimated 1-year AMD incidence in the Pusan area of Korea is at least 0.4%. In contrast to Western people, 31.7% of exudative AMD cases were revealed to be PCV and 6.2% were revealed to be RAP. This discrepancy between ethnic groups should be considered in the diagnosis and treatment modality selection of Korean AMD patients.

Effects of Triamcinolone Acetonide in Cultured Trabecular Meshwork Cells

PURPOSE: To investigate the effect of triamcinolone acetonide (TA) on the survival, nitric oxide (NO) production, and migration of cultured human trabecular meshwork (TM) cells. METHODS: After exposure to TA, indomethacin, and dexamethasone for 2 days, the survival and nitrite production of the primarily cultured human TM cells were assessed with MTT and Griess assays respectively. The effect of co-exposure to the NO donor, sodium nitroprusside, was also assessed. A migration assay was done to evaluate the effect of TA on the activity of TM cells. RESULTS: Cellular survival increased after exposure to TA at low concentration but decreased at high concentration. TA decreased the production of NO significantly (p<0.05). Exposure to indomethacin and dexamethasone revealed similar results. TA reversibly inhibited the migration of TM cells. CONCLUSIONS: TA decreases the production of NO and inhibits the migration of TM cells. TA at high concentration decreases cellular survival accompanied with decreased NO production. These effects of TA on TM cells may result in the elevation of intraocular pressure.

The Study of Prognostic Factors after Vitrectomy for Posterior Segment Metallic Foreign Bodies

PURPOSE: To evaluate the clinical results and prognostic factors that predict final visual outcome in eye with posterior segment metallic foreign body(FB) managed by primary pars plana vitrectomy. METHODS: Twenty-nine patients with posterior segment FBs managed by pars plana vitrectomy were reviewed retrospectively. To determine prognostic factors for visual outcomes, variables including ocular findings at presentation, initial visual acuity(VA), location, size and weight of FBs, site of entrance, location of intraretinal lesion, mechanisms of injury and FB removal time were compared with final visual acuity. RESULTS: After a mean follow up of 19.2 months, 15 eyes(52%) achieved VA of 20/40 or better and 5 eyes(17%) showed decreased VA compared to the initial VA. Prognostic factors for the final VA of 20/40 or better included the weight of FBs less than 20 mg, negative findings of retinal detachment and endophthalmitis. Prognostic factors for the final VA of 20/200 or less included the size of FBs more than 4mm, the weight of FBs more than 20 mg, intraretinal FBs, nonhammering as the mechanism of injury. CONCLUSIONS: The predictors of the final VA were the size, the weight and the location of FBs, mechanisms of injury, preoperative negative findings of retinal detachment and endophthalmitis. These factors will be helpful for planning surgery and predicting the prognosis.

Simultaneous Phacoemulsification, Pars Plana Vitrectomy, Intraocular Foreign Body Extraction, and Intraocular Lens Implantation

PURPOSE: To evaluate the effectiveness of simultaneous phacoemulsification, pars plana vitrectomy, the removal of posterior intraocular foreign body(IOFB), and primary intraocular lens implantation(IOL). METHODS: Simultaneous phacoemulsification, pars plana vitrectomy, the removal of posterior IOFB, and primary IOL implantation were performed in 10 eyes of 10 patients with ocular perforation and traumatic cataract due to posterior IOFB. The results showed no retinal detachment and endophthalmitis based on retrospective analysis. RESULTS: The follow-up period ranged from 3 to 45months(mean 19.6 months). In 8 eyes(80%), the final visual acuity was better than 0.9 but in remaining 2 eyes, it was less than 0.5 due to postoperative retinal detachment. There were enlargement of posterior capsule rupture and vitreous prolapse into anterior chamber in 2 cases, and lens dislocation into the vitreous cavity in 1 case during phacoemulsification. IOL was implanted into the bag in 4 eyes and into the ciliary sulcus without scleral fixation in remaining 6 eyes. CONCLUSIONS: Simultaneous phacoemulsification, pars plana vitrectomy, the removal of IOFB, and primary IOL implantation is a relatively safe operation. It provides rapid rehabilitation of the visual acuity and helps to save time and money in selected patients without the large posterior capsule rupture, retinal detachment, endophthalmitis and injury of macula and center of cornea due to IOFB.

Combined Surgery of Vitrectomy, Phacoemulsification and Intraocular Lens Implantation in Patients with Vitreous Hemorrhage Caused by Branch Retinal Vein Occlusion Patients

PURPOSE: To evaluate the effect of vitrectomy, phacoemulsification and posterior intraocular lens implantation in patients with branch retinal vein occlusion (BRVO) associated with vitreous hemorrhage. METHODS: We performed vitrectomy, phacoemulsification and posterior intraocular lens implantation in 38 patients with BRVO associated with vitreous hemorrhage. The age distribution was 44 to 82 years old (mean 61.8 years old) and the duration of follow up was 6 to 48 months (mean 16.7 months). Patientswere divided into 3 groups according to intraoperative fundus findings. Patients had only vitreous hemorrhage in group 1, vitreous hemorrhage with fibrovascular proliferations in group 2, and vitreous hemorrhage with retinal breaks in group 3. The number of eyes were 27, 8, and 3 respectively. RESULTS: The improvement of visual acuity up to 2 lines on the chart was found in 37 eyes (97.4%) after the surgery and the final visual acuity of 0.5 or better was achieved in 28 eyes (73.7%). Final corrected visual acuity was 0.5 or better in 85.1% in group 1, in 50.0% in group 2 and in 33.3% in group 3. The percentage of final visual acuity of 0.5 or better was statistically higher in group 1 than goup 2 and group 3 (p=0.036). Only one patient who developed retinal detachment had a decrease of final visual acuity. CONCLUSIONS: The results of this study suggest that combined vitrectomy, phacoemulsification and posterior intraocular lens implantation are relatively effective procedures for patients with BRVO associated with vitreous hemorrhage.

Systemic lupus erythematosus presenting earlier as retinal vaso-occlusion

Retinal vascular lesions are the most common ophthalmologic manifestation of systemic lupus erythematosus (SLE), occurring in 3% to 29% of cases, generally late in the disease. More rare is the severe vaso-occlusive disease, often termed "retinal vasculitis", which includes central retinal artery occlusion, multifocal arteriolar occlusions, extensive capillary nonperfusion and central venous occlusion. Patients with SLE and raised serum concentrations of anticardiolipin antibodies (ACA) have a higher risk of developing occlusive ocular vascular disease. We report a case in which retinal involvement was an earlier manifestation of SLE in a patient without ACA.

Five Cases of Arteriovenous Adventitial Sheathotomy for Branch Retinal Vein Occlusion

PURPOSE: To report the results of arteriovenous adventitial sheathotomy for treatment of macular edema associated with branch retinal vein occlusion. METHODS: Five eyes of five patients underwent arteriovenous adventitial sheathotomy. Patient selection criteria were the best-corrected visual acuity of less than 0.1 and duration of less than 1 month. Pars plana vitrectomy was performed and 23 gauge needle, bent at the tip, was used to cut through the adventitial sheath and separate the arteriole from the underlying venule. Patients were followed postoperatively for 6 months to 1 year, with an average of 9.6 months. RESULTS: In all 5 patients, the best-corrected visual acuity improved to 0.3 to 0.9. Fluorescein angiography demonstrated reperfusion of the retina and lessening of macular edema. CONCLUSION: Arterionvenous adventitial sheathotomy may be beneficial for patients with poor vision secondary to branch retinal vein occlusion.

Treatment of Retinal Detachment occurring in Two Cases of von Hippel-Lindau Syndrome

PURPOSE: To report two cases of retinal detachment associated with von Hippel-Lindau syndrome, one case of rhegmatogenous retinal detachment combined with mild proliferative vitreoretinopathy and a case of tractional retinal detachment. METHODS: Case reports. Pars plana vitrectomy with membrane peeling and silicone oil tamponade were performed in all cases. Lens aspiration was also performed in one case. RESULTS: Successful retinal reattachment was obtained in all cases. Case 2 developed cataract and secondary glaucoma and was treated with phacoemulsification with posterior chamber lens insertion and YAG laser iridotomy. CONCLUSIONS: In two patients with retinal detachment occurring in von Hippel-Lindau syndrome, we could obtain successful retinal reattachment with stabilized visual acuity after performing pars plana vitrectomy and silicone oil injection.

Unilateral Acute Idiopathic Maculopathy: A Case of Atypical Presentation

Unilateral acute idiopathic maculopathy(UAIM)is a rare, self-limiting disorder that affects healthy young adults who experience sudden, severe visual loss. It is characterized by an exudative maculopathy with irregular margins and yellowish-white thickening at the level of the retinal pigment epithelium(RPE). The fluorescein angiographic findings characteristically demonstrate early irregular hyperfluorescence and hypofluorescence at the level of RPE lesion, followed by complete staining of the overlying neurosensory retinal detachment in the late phase. A characteristic bulls-eye pattern pigmentary changes may occur in the macula after resolution of the acute phase of the disease. We report a patient with atypical presentation of UAIM in which multifocal leaks at the RPE level on the fluorescein angiography was observed.

Comparison of Surgical Result of Vitrectomy vs Combined Phacoemulsification and Vitrectomy in Patients with Diabetic Vitreous Hemorrhage

In eyes with diabetic vitreous hemorrhage, relatively significant improvement of visual acuity has been achieved by vitrectomy.However, visual loss occurs not infrequently due to iris neovascularization or ma, one of the serious complications of vitrectomy for proliferative diabetic retinopathy.We have retrospectively studied the visual acuity and complications in 43 patients (50 eyes)who underwent only vitrectomy (group A)and in 63 patients (64 eyes)who underwent combined phacoemulsification, vitrectomy and posterior chamber intraocular lens (PCL)implantation (group B), from January of 1997 to June of 1999.The age distribution was 30 to 65 years (mean 47 years)in group A and 32 to 78 years (mean 57 years)in group B.The duration of follow up was more than 6 months.The final visual outcome showed the improvement in 84.0%, no change in 6.0%and the worsening in 10.0%in group A and the improvement in 93.7%, no change in 4.7% and the worsening in 1.6%in group B.The iris neovascularization and neovascular glaucoma occurred 10.0%in group A and 4.7%in group B but this difference was not significant statistically (p=0.271).We performed cataract operations in 30%of group A eyes postoperatively.The results of this study suggest that combined phacoemulsification, vitrectomy and PCL implantation are relatively safe and effective procedure for patients with diabetic vitreous hemorrhage.

Surgical Results Following Cataract Surgery in Diabetic Patients

The authors retrospectively evaluated 75 diabetic patients (92 eyes) who underwent cataract surgery between January 1995 and December 1997. The minimum follow up period was one year. We analysed retrospectively the final visual cuity, the incidence and risk factors of progression of diabetic retinopathy after cataract surgery. The improvement of visual acuity more than 2 lines was achieved in 81 eyes (88.0%). Seventy two eyes (78.3%) achieved the final visual acuity of more than 0.5. In moderate or severe nonproli- ferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy(PDR)groups, visual acuity improvement was less than in no or mild NPDR group (p=0.001). Progression of retinopathy occurred in 21 out of 82 eyes (25.6%)one year following surgery and was associated with presence of diabetic nephropathy (p=0.018). The rates of retinopathy progression were higher in patients with longer duration of diabetes or insulin treatment than shorter duration of diabetes, or dietary or oral hypoglycemic treatment, but differences did not reach a significant level.

Simulated Operation of Phacoemulsification, Vitrectomy and Posterior Chamber Intraocular Lens Implantation in Proliferative Diabetic Retinopathy Patients

The combined cataract operation is increasing nowadays for the achievement of early visual rehabilitation and proper visualization of the retina during vitrectomy in proliferative diabetic retinopathy (PDR). We have ret-rospectively studied visual acuity and complications in 66 consecutive patients (81 eyes)with PDR who underwent phacoemulsification,pars plana vitrectomy and posterior chamber intraocular lens (PCL) implantation from January of 1994 to June of 1997. The age distribution was 28 to 77 years old (mean 56.0 years)and the duration of follow up was 6 to 44 months (mean 12.3 months).The improvement of visual acuity up to 2 lines on the chart was found in 63 eyes (77.8%) after the surgery and the final visual acuity of 0.5 or better was achieved in 36 eyes (44.4%). Postoperatively, rubeosis iridis developed in 5 eyes(6.2%)and reoperation was done in 7 eyes (8.6%).The improvement of visual acuity was significantly higher in eyes without diabetic nephropathy (39 eyes) (p=0.001) and significantly lower in eyes using intraocular substitutes (17 eyes) (p=0.004). The results of this study suggest that combined phacoemulsification, pars plana vitrectomy and PCL implantation are relatively effective procedures for patients with PDR.

A Case of Central Serous Chorioretinopathy with Bullous Retinal Detachment

Central serous chorioretinopathy(CSC) is a retinal disorder that typically affects young and middle-aged adults. It is characterized by the accumulation of subretinal fluid at the posterior pole of the fundus, causing a circumscribed area of retinal detachment. It is essentially benign and self-limited, generally requiring no treatment. However, a few patients have permanent visual loss because of subretinal fibrosis following a nonrhegmatogenous, bullous retinal detachment with shifting subretinal fluid. The authors experienced a case of CSC with bilateral bullous retinal detachment in a 36 year old male patient. A subretinal fibrotic band developed in both maculae and permanent visual loss of both eyes occurred. We report this unusual case with literature review.

Spontaneous Separation of Epiretinal Membrane in Young Adult

In children and young adults, secondary epiretinal membranes after ocular trauma, pars planitis, ocular toxocariasis, and Coat's disease are common and spontaneous separation occurs in a relatively higher rate with improvement in visual acuity than elderly patients. In a 31-year-old man with pars planitis, diffuse epiretinal membrane in the macula became thinner during systemic and topical steroid therapy. Two years after treatment, the preretinal membrane spontaneously separated from the macula to the inferior temporal arcade, and visual acuity improved from 0.15 to 1.0. The authors reviewed the available literatures regarding the possible mechanisms for the spontaneous separation ofepiretinal membrane.

A case of Unilateral Retinal Dysplasia

Retinal dysplasia is defined as an abnormal differentiation of the retina with proliferation of its elements into resettes, folds, and gliosis. The clinical presentation is usually bilateral with a variety fo systemic abnormalities. We experienced a case of unilateral retinal dysplasia without systemic abnormalities occurring in a 2-month-old girl who underwent an enucleation of her right eye because of the possibility of retinoblastoma. We reviewed the available literatures regarding this disease.

A case of Unilateral Retinal Dysplasia

Retinal dysplasia is defined as an abnormal differentiation of the retina with proliferation of its elements into resettes, folds, and gliosis. The clinical presentation is usually bilateral with a variety fo systemic abnormalities. We experienced a case of unilateral retinal dysplasia without systemic abnormalities occurring in a 2-month-old girl who underwent an enucleation of her right eye because of the possibility of retinoblastoma. We reviewed the available literatures regarding this disease.