Effectiveness of Inferior Oblique Myectomy in Unilateral Superior Oblique Palsy Depending on Magnitude of Hyperdeviation

Purpose@#To evaluate surgical outcome and effectiveness of inferior oblique (IO) myectomy on unilateral superior oblique palsy (SOP) as a primary treatment. @*Methods@#This study is a retrospective review of the medical records of 99 patients who had undergone IO myectomy due to SOP as a first-line treatment. Sixty-five patients with hyperdeviation of 15 prism diopters (PD) or less were categorized into group 1, 22 patients with hyperdeviation between 16 PD to 20 PD into group 2, and 12 patients with hyperdeviation higher than 20 PD into group 3. Preoperative hyperdeviation, postoperative hyperdeviation, and improvement of head tilting were then compared between the 3 groups. Surgery was determined to be successful when the post-op residual hyperdeviation is less than 5 PD, or when the improvement of hyperdeviation and head tilting was noted, for the patients who had preoperative deviation less than 5 PD, and without hypercorrection. @*Results@#All groups showed significant improvement of hyperdeviation, and the amount of correction was larger in group with larger preoperative hyperdeviation. 80.3%, 95.0%, and 90.9% of patients showed improvement of head tiling and success rate was 87.7%, 77.3%, and 50.0% in group 1, 2, and 3 respectively. Group 1 and 2, group 2 and 3 had no significant difference in success rate but only group 1 and 3 had significant difference. @*Conclusions@#Considering success rate with improvement of head position, self-titrating and possibility of overcorrection, IO myectomy could be an effective option as a first-line surgical treatment for unilateral SOP with hyperdeviation of 20 PD or less. However, due to a 50% success rate in patients with hyperdeviation larger than 20 PD, a secondary operation must be considered following IO myectomy, or a two-muscle procedure must be considered as a primary treatment.

Superior Oblique Atrophy on Magnetic Resonance Imaging with Clinical Features in Unilateral Superior Oblique Palsy

Purpose@#To investigate the correlation of superior oblique (SO) atrophy of magnetic resonance imaging (MRI) with clinical features including surgical success in unilateral SO palsy. @*Methods@#This study was a retrospective review of the records of 38 patients who had undergone inferior oblique (IO) myectomy due to SO palsy between January 2017 and March 2019 at our hospital. The patients with more than a 40% decrease of cross-section areas using preoperative orbital MRI were categorized into the atrophic group (16 patients). We compared surgical outcomes between the atrophic and non-atrophic groups. @*Results@#Preoperative IO over-action and vertical deviation showed no significant difference, but the excyclotorsion in paralytic eyes were more frequent in the atrophic group and the surgical success (62.5% vs. 95.5%), and the degree in improvement of vertical deviation (7.17 ± 5.19 prism diopters [PD] vs. 11.05 ± 5.59 PD) was significantly lower in the atrophic group. The degree of SO atrophy showed a weak correlation with the degree of improvement of hypertropia or diopter differences of bilateral head tilting. @*Conclusions@#SO atrophy, detected using preoperative MRI of unilateral SO palsy patients did not show a definite correlation with clinical features except for excyclotorsion in paralytic eyes but did show a clinically significant correlation with surgical outcomes. Preoperative MRI can therefore be used for predicting surgical outcomes of IO myectomy in unilateral SO palsy patients.

Effects of Orbital Decompression on Lamina Cribrosa Depth in Patients with Graves' Orbitopathy

PURPOSE: We sought to investigate the effects of Graves' orbitopathy (GO) and orbital decompression on lamina cribrosa depth (LCD) using spectral-domain optical coherence tomography. METHODS: Forty eyes that underwent orbital decompression to relieve compressive optic neuropathy or correct disfiguring exophthalmos in the context of GO were included. Subjects were imaged with spectral-domain optical coherence tomography before surgery and at 1 and 3 months after surgery, at which the examiner measured the LCD (distance from the anterior surface of the lamina cribrosa to the Bruch membrane opening line) and peripapillary retinal nerve fiber layer thickness. Subjects were divided into two groups—a muscle-dominant group composed of patients who had extraocular muscle enlargement on preoperative orbital computed tomography scan and a fat-dominant group composed of patients who did not show extraocular muscle enlargement on preoperative orbital computed tomography scan—and subgroup analysis was performed. Preoperative and postoperative intraocular pressure, exophthalmos, LCD, and retinal nerve fiber layer thickness were evaluated. RESULTS: At baseline, LCD was remarkably shallower in the muscle-dominant group than in the fat-dominant group (95% confidence interval, p = 0.007). In the muscle-dominant group, LCD showed no definite change after surgery. However, the fat-dominant group showed temporary posterior displacement of the lamina cribrosa at 1-month postoperation that was reversed to baseline at 3 months postoperation (95% confidence interval, p < 0.01). CONCLUSIONS: The lamina cribrosa was anteriorly displaced preoperatively, and its position was nearly unchanged after the surgery, especially in association with extraocular muscle enlargement. An enlarged extraocular muscle could reduce the pressure-relieving effect of orbital decompression around the scleral canal in patients with GO.

Treatment of Exposed Hydroxyapatite Orbital Implants Wrapped with a Synthetic Dura Substitute

PURPOSE: To describe cases of exposed hydroxyapatite (HA) implants wrapped with the synthetic dura substitute Neuro-Patch treated via simple Neuro-Patch removal. METHODS: The medical records of seven patients who experienced exposure of their HA implant were reviewed. All patients had been enucleated and implanted with HA wrapped with Neuro-Patch. For treatment, Neuro-Patch was removed to the greatest extent possible. After applying local anesthesia with lidocaine, blunt dissection was performed to separate the conjunctiva and Neuro-Patch via the site of exposure. Pressure was applied to the remaining Neuro-Patch with forceps and removed with scissors. RESULTS: Neuro-Patch was visible at the area of exposure in all patients. No surgery beyond initial Neuro-Patch removal was necessary in six of the seven patients. In five cases, the exposed area began to heal rapidly after Neuro-patch removal without primary closure of the defect. In one case, the Neuro-Patch material and all necrotic tissue was removed aggressively due to inflammation around the orbital implant. Lastly, an infection was noted in one case, prompting complete removal of the Neuro-Patch–wrapped HA implant. CONCLUSIONS: Wrapping material may hinder implant vascularization. Exposure of HA in wrapped implants can be successfully treated by a simple removal procedure if detected and managed early.

Anti-N-methyl-D-aspartate Receptor Encephalitis in a Patient with Thyroid Eye Disease

No abstract available.

Comparison of Central Corneal Thickness Measured by Swept-source Optical Coherence Tomography and Ultrasound Pachymetry

PURPOSE: To analyze and compare ultrasound pachymetry (USP) with a more recently adopted device, the intra ocular lens (IOL) master 700, which are both used to measure central corneal thickness. METHODS: The central corneal thickness was measured in 24 eyes of 12 glaucoma patients and in 83 eyes of 42 normal patients. First, the IOL master 700 was used to measure the central corneal thickness, followed by measurements taken using USP later. The results were analyzed using a paired t-test. We analyzed the agreement and the correlations between the two test devices by using Bland-Altman plots and the Pearson correlation test. To evaluate the reproducibility, measurements with the IOL master 700 were taken twice for a few normal patients within a small time interval. RESULTS: Via the IOL master 700, the thickness of the central cornea showed a high reproducibility and repeatability, demonstrating 2.7 ± 1.7 µm for the test-retest variability, 6.78% for the coefficient of variation, and 0.997 for the intraclass correlation value. The mean measurements using USP and the IOL master 700 are 554.4 ± 37.4 µm and 551.1 ± 37.1 µm, respectively, showing that the IOL master 700 measured significantly smaller values than USP with a p-value < 0.001. The deviations between the two methods are scattered throughout the 95% confidence interval. According to the Pearson correlation test, the measured values of the two test devices were found to have a highly positive correlation (r = 0.977, p < 0.0001). CONCLUSIONS: This study demonstrated that the central corneal thickness (CCT) measured via the IOL master was significantly thinner than that of USP, and the two test devices had a high correlation and good agreement. The CCT value measured via the IOL master 700 also exhibited high reproducibility.

A Case of Double Fovea Artifact Detected with Spectral-domain Optical Coherence Tomography

PURPOSE: In the present study, a case of double fovea artifact on spectral-domain optical coherence tomography (SD-OCT) was reported. CASE SUMMARY: A nine-year-old male presented with blurred vision of both eyes. His best corrected visual acuity (BCVA) was 20/20 in both eyes, and complete ophthalmologic evaluation including fundus examination and fundus photography revealed no abnormality in both eyes. He underwent SD-OCT imaging with the Cirrus HD-OCT. The Macular Cube 512 × 128 protocol of his right eye revealed an unusual pseudo-duplication of the fovea in the vertical meridian. The same protocol in his left eye also rendered a pseudo-duplication of two foveas in the vertical and horizontal meridians on the retinal thickness map. Re-examination with the same OCT system and protocol was performed two weeks later after the patient received counseling on fixation during the examination, and it revealed normal contour of the fovea in both eyes. CONCLUSIONS: Double fovea artifact seen in SD-OCT is a rare artifact that can possibly lead to misdiagnosis and inappropriate clinical treatment. Since the artifact was resolved with better fixation of the patient, repeating the scan with better patient compliance is necessary when such an artifact is encountered.

Clinical Result of Planned Posterior Continuous Curvilinear Capsulorrhexis in Adult Patients

PURPOSE: Following planned posterior continuous curvilinear capsulorrhexis (PCCC) during cataract surgery in adults, we evaluated the clinical effects of visual acuity and prevention of posterior capsule opacity. METHODS: The clinical results were studied retrospectively by comparing 43 eyes of 43 patients who underwent cataract surgery with PCCC (the experimental group) and 46 eyes of 31 patients who underwent cataract surgery without PCCC (the control group). Preoperative and postoperative best corrected visual acuities (BCVAs) of patients were measured. BCVA (using log MAR) and the occurrence of posterior capsule opacity were closely monitored in both groups preoperatively, two months postoperatively, and at each group's final visit (14.6 months postoperatively for the experimental group and 15.7 months for the control group). One-piece plate intraocular lens was used in cataract surgery. RESULTS: Preoperative BCVA was lower in the control group but not significantly. The 2-month mean postoperative BCVA showed improvement in vision in both the control and experimental groups. In both groups, the BCVA was decreased at the final examination compared with the 2-month postoperative BCVA, and significant differences between the two groups were not observed. Under slit lamp examination, anterior hyaloid opacity was observed in 13 of 43 eyes that underwent PCCC. The decrease in BCVA in 13 eyes with anterior hyaloid opacity was significantly different (p < 0.05) compared with the 2-month postoperative BCVA. CONCLUSIONS: Considering the effort and operation skills required for PCCC, the clinical benefits are negligible. Since cataract surgery with PCCC can cause reduced vision due to anterior hyaloid opacity, side effects should be disclosed before PCCC is performed.

Comparison of 1% Prednisolone and 0.1% Bromfenac Solutions for Preventing Macular Edema after Cataract Surgery

PURPOSE: To compare the clinical effectiveness of 1% Prednisolone acetate ophthalmic solution and 0.1% Bromfenac sodium hydrate ophthalmic solution on prevention of cystoid macular edema after cataract surgery. METHODS: A retrospective chart review of 349 patients who received phacoemulsification with intraocular lens implantation in Severance Hospital from July 2013 to January 2016 was performed. In these patients, 192 eyes received 1% Prednisolone acetate ophthalmic solution, and 157 eyes were treated with topical 0.1% Bromfenac sodium hydrate ophthalmic solution. The incidence and severity of cystoid macular edema (CME) were evaluated by retinal foveal thickness on optical coherence tomography for patients who showed best corrected visual acuity (BCVA) less than 0.5 (log MAR ≥ 0.3). RESULTS: There was no significant difference between the two groups in age (p = 0.708), sex (p = 0.977), or the side of operated eye (p = 0.443). The two groups showed BCVA 0.04 ± 0.09 (Steroid group) and 0.03 ± 0.07 (nonsteroidal anti-inflammatory drug [NSAID] group) at 1 month after the surgery and the difference was not significant (p = 0.947). One eye in the topical steroid group had cystoid macular edema, and 3 eyes in the steroid group showed elevated intraocular pressure (IOP) over 30 mm Hg. There were no IOP elevations or macular edema in the NSAID group. CONCLUSIONS: The results showed that 0.1% Bromfenac sodium hydrate ophthalmic solution had a similar effect to 1% Prednisolone acetate ophthalmic solution on preventing CME after cataract surgery. This indicates that topical NSAID can be considered along with topical steroids in order to prevent CME after cataract surgery.

Clinical Features of Cataract Extraction with Negative-Power Intraocular Lens Implantation in High Myopia

PURPOSE: To evaluate the clinical features of high myopic eyes with cataracts implanted with negative power intraocular lenses (IOLs) at the time of cataract surgery. METHODS: A retrospective chart review was conducted of 18 eyes of 14 patients who underwent cataract surgery with negative power IOLs and 10 eyes in 9 patients with low power IOLs. We investigated axial length, IOL power, preoperative and postoperative best-corrected visual acuity (BCVA) and preoperative and postoperative spherical equivalent (SE) refractive errors. RESULTS: Mean BCVA showed significant improvement in both groups. We measured postoperative SE refraction and the difference between the mean intended and the mean achieved SE refractive errors in the negative power group (17 eyes) was +1.59 ± 1.34 D and +0.31 ± 0.50 D in the low power group. CONCLUSIONS: BCVA was significantly improved in the majority of eyes, although they had myopic macular degeneration or posterior staphyloma. However, the mean achieved postoperative SE refraction was more hyperopic than the predicted postoperative SE error. Additionally, hyperopic refractive error was greater in the negative power group than the low power group. Therefore, we recommend that postoperative hyperopic refractive error should be considered when performing cataract surgery in high myopic patients.

Comparison of the Clinical Manifestations between Acute Vogt-Koyanagi-Harada Disease and Acute Bilateral Central Serous Chorioretinopathy

PURPOSE: To compare clinical, angiographic, and optical coherence tomographic characteristics between eyes with acute Vogt-Koyanagi-Harada (VKH) disease and eyes with acute bilateral central serous chorioretinopathy (CSC), and to demonstrate distinguishing features between the two diseases in confusing cases. METHODS: The medical records of 35 patients with VKH disease and 25 patients with bilateral CSC were retrospectively reviewed. Characteristics according to slit-lamp biomicroscopy, ophthalmoscopy, fundus photography, fluorescein angiography, indocyanine green angiography, and spectral-domain optical coherence tomography were compared between the two diseases. RESULTS: Five of 35 patients (10 of 70 eyes, 14.3%) with VKH disease were initially misdiagnosed as CSC patients, and six of 25 patients (12 of 50 eyes, 24%) with bilateral CSC were initially misdiagnosed as patients with VKH disease. Pigment epithelial detachment in CSC and optic disc hyperemia in VKH disease show the highest positive predictive values of 100% for each disease. CONCLUSIONS: Optic disc hyperemia in VKH disease and pigment epithelial detachment in bilateral CSC are the most specific clinical manifestations of each disease at initial patient presentation.

Thickness in Ganglion Cell-Inner Plexiform Layer on Spectral-Domain Optical Coherence Tomography after Cataract Surgery

PURPOSE: To assess changes in ganglion cell-inner plexiform layer (GCIPL) thickness after cataract surgery using spectral-domain optical coherence tomography (OCT). METHODS: Forty-three eyes of 33 patients, who underwent cataract surgery were imaged with spectral-domain OCT before and after surgery to measure peripapillary retinal nerve fiber layer (RNFL) and GCIPL thickness, signal strength (SS), quadrant, 12 clock-hour RNFL thickness and sectoral GCIPL thickness. RESULTS: The postoperative SS, RNFL and GCIPL thickness were higher than before surgery (p < 0.05). Multivariate analysis showed that endothelial cell count and preoperative SS were significantly correlated with SS changes in RNFL parameters and preoperative SS was significantly correlated with SS changes in GCIPL parameters. Univariate analysis indicated that age was significantly correlated with RNFL thickness changes in RNFL parameters and no factor was correlated with GCIPL thickness in GCIPL parameters (p < 0.05). CONCLUSIONS: Cataracts may decrease peripapillary RNFL and GCIPL thickness measurements and SS on OCT scans. Peripapillary RNFL and GCIPL thickness measurements should be interpreted with caution in eyes with significant cataracts.

Pigmented Choroidal Metastases Masquerading as Choroidal Melanoma

PURPOSE: To report the first case of pigmented choroidal metastases without enucleation diagnosed with fine-needle aspiration biopsy. CASE SUMMARY: A 47-year-old male was referred to our clinic with a suspected diagnosis of choroidal melanoma in his left eye. Positron emission tomography-computer tomography used to evaluate systemic metastases revealed lung cancer. Pathology of the detected lung mass was primary lung neuroendocrine tumor. To differentiate choroidal metastasis and primary choroidal melanoma, we performed a fine-needle aspiration biopsy for choroidal tumors. The cytology showed results favoring metastatic atypical carcinoid and the patient was started on systemic chemotherapy. CONCLUSIONS: All pigmented choroidal tumors are not choroidal melanomas and choroidal metastases may be pigmented. The present case suggests that proper systemic evaluation and biopsy for suspected choroidal tumor could be helpful in diagnosis.