Effects of Subcutaneous Methotrexate in Patients with Refractory Uveitis and Chorioretinitis

Purpose@#Methotrexate (MTX) is an immunosuppressive agent used to treat noninfectious inflammatory eye conditions and is generally administered orally for ocular inflammatory diseases. When used in rheumatological diseases, subcutaneous administration has been reported to show higher efficacy than oral administration. Therefore, this study aimed to evaluate the effect of subcutaneous MTX in patients with refractory uveitis or choroiditis who did not respond to other immunosuppressive agents. @*Methods@#A retrospective case series study was performed between January and December 2018. Patients with uveitis or chorioretinitis who showed little to no treatment response for 6 months or more with conventional immunosuppressive agents were treated with MTX, administered subcutaneously. After 6 months of treatment, patients were evaluated to determine whether complete suppression of inflammation sustained for ≥28 days was achieved in both eyes and whether improvement can be confirmed by fluorescein angiography (FAG). @*Results@#Subcutaneous MTX treatment was performed on 18 patients: 11 had intermediate uveitis and seven had posterior uveitis. In the intermediate uveitis patient group, five patients (50% of the group excluding one patient who dropped out) showed improvement in FAG and three patients (30%) showed complete suppression of inflammation. In the posterior uveitis group, two out of seven patients (excluding two patients who dropped out) showed an improvement, two patients in the group showed little change, and one patient showed aggravation of FAG findings. @*Conclusions@#The study confirmed that in patients with uveitis or chorioretinitis who had a refractory response to treatment with other immunosuppressive agents, subcutaneous MTX showed improved treatment efficacy.

Prevalence and Progression of Stage 0 Macular Hole in Fellow Eyes of Patients with Idiopathic Full-thickness Macular Hole

Purpose@#To assess the prevalence and progression of a stage 0 macular hole in the fellow eye of patients with an idiopathic full-thickness macular hole. @*Methods@#The fellow eyes of 189 patients who underwent idiopathic full-thickness macular hole surgery were examined by biomicroscopy and spectral domain-optical coherence tomography (SD-OCT). A subset of 21 fellow eyes with a stage 0 macular hole was observed. Changes in the macular hole were evaluated by biomicroscopy and SD-OCT for an average of 29 months. @*Results@#Among the 21 eyes, 15 showed no change in perifoveal vitreous detachment (71.4%). Two eyes (9.5%) developed complete vitreofoveal separation, and one of the two developed a separation after progression to stage 1A. Among 21 eyes, 5 (23.8%) developed above stage 1A, and one of the five progressed to stage 1B after five years, which was successfully treated with vitrectomy and gas tamponade. @*Conclusions@#Perifoveal vitreous detachment in the fellow eye on SD-OCT, defined as a stage 0 macular hole, occurred at an earlier phase than stage 1A macular holes and may progress to an advanced stage. Therefore, patients who undergo macular hole surgery and have a stage 0 macular hole or perifoveal vitreous detachment in the fellow eye should be followed closely.

Prevalence and Progression of Stage 0 Macular Hole in Fellow Eyes of Patients with Idiopathic Full-thickness Macular Hole

Purpose@#To assess the prevalence and progression of a stage 0 macular hole in the fellow eye of patients with an idiopathic full-thickness macular hole. @*Methods@#The fellow eyes of 189 patients who underwent idiopathic full-thickness macular hole surgery were examined by biomicroscopy and spectral domain-optical coherence tomography (SD-OCT). A subset of 21 fellow eyes with a stage 0 macular hole was observed. Changes in the macular hole were evaluated by biomicroscopy and SD-OCT for an average of 29 months. @*Results@#Among the 21 eyes, 15 showed no change in perifoveal vitreous detachment (71.4%). Two eyes (9.5%) developed complete vitreofoveal separation, and one of the two developed a separation after progression to stage 1A. Among 21 eyes, 5 (23.8%) developed above stage 1A, and one of the five progressed to stage 1B after five years, which was successfully treated with vitrectomy and gas tamponade. @*Conclusions@#Perifoveal vitreous detachment in the fellow eye on SD-OCT, defined as a stage 0 macular hole, occurred at an earlier phase than stage 1A macular holes and may progress to an advanced stage. Therefore, patients who undergo macular hole surgery and have a stage 0 macular hole or perifoveal vitreous detachment in the fellow eye should be followed closely.

Novel Findings of Polypoidal Choroidal Vasculopathy via Optical Coherence Tomography Angiography

PURPOSE: To introduce novel findings of polypoidal choroidal vasculopathy (PCV) via optical coherence tomography angiography (OCTA) METHODS: This study is a retrospective chart review of 16 patients (16 eyes) with PCV. OCTA (Avanti RTVue XR) findings were evaluated and selected for analysis after agreement by two retina specialists . RESULTS: Twenty one polyps in 16 eyes (16 patients) with PCV were included in this study. The mean patient age was 67 years (13 men and three women). The shape of polypoidal lesions on OCTA at initial were halo (five polyps), rosette (seven polyps), and vascular network (nine polyps). Eight months after anti-vascular endothelial growth factor treatment, in a total of four eyes, seven polyps could be followed up completely, the two halo type polypoidal lesions changed to rosette and vascular network type. The lesions of three rosette and two vascular network type lesions did not change in shape. In addition, the size of the polypoidal lesions (one among two halo types, two among three rosette types, and two among two vascular network types) decreased, but one halo type did not change and one rosette type increased in size on OCTA. CONCLUSIONS: En-face OCTA enabled us to categorize novel types of PCV with polypoidal lesions.

Macular Edema after Gabapentin

No abstract available.

High Dose Intravitreal Bevacizumab for Refractory Pigment Epithelial Detachment in Age-related Macular Degeneration

PURPOSE: Intravitreal anti-vascular endothelial growth factor (anti-VEGF) is the first choice of treatment for age-related macular degeneration. However, quite a few eyes treated using conventional dose anti-VEGF (CDAV) have persistent pigment epithelial detachment (PED) on optical coherence tomography. This study investigated the efficacy and safety of high dose anti-VEGF (HDAV) for refractory PED. METHODS: In this retrospective study, 31 eyes of neovascular age-related macular degeneration patients with persistent PED findings despite six or more intravitreal injections of CDAV (bevacizumab 1.25 mg or ranibizumab 2.5 mg) were analyzed. Changes in visual outcome, central foveal thickness, and PED height were compared before and after HDAV (bevacizumab 5.0 mg) for these refractory PED cases. RESULTS: The mean age of patients was 67.7 years. The number of CDAV injections was 12.1. The number of HDAV injections was 3.39. Best-corrected visual acuity in logarithm of the minimum angle of resolution before and after HDAV was 0.49 and 0.41 (p < 0.001), respectively. Central foveal thickness before and after HDAV was 330.06 and 311.10 µm (p = 0.125), respectively. PED height before and after HDAV was 230.28 and 204.07 µm (p = 0.014), respectively. There were no serious adverse reactions in all the eyes. CONCLUSIONS: Increasing the dose of bevacizumab in refractory PED may be a possible treatment option.

Management of Acute Submacular Hemorrhage with Intravitreal Injection of Tenecteplase, Anti-vascular Endothelial Growth Factor and Gas

PURPOSE: To evaluate the visual and anatomical outcomes for neovascular age-related macular degeneration with submacular hemorrhage after intravitreal injections of tenecteplase (TNK), anti-vascular endothelial growth factor (VEGF) and expansile gas. METHODS: This study was a retrospective clinical case series following 25 eyes of 25 patients. All patients received a triple injection using 0.05 mL TNK (50 µg), 0.05 mL anti-VEGF and 0.3 mL of perfluoropropane gas. Retreatment with anti-VEGF was performed as needed. Preoperative and postoperative best-corrected visual acuity and central retinal thickness were analyzed. RESULTS: The mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved significantly from 1.09 ± 0.77 at baseline to 0.52 ± 0.60 at 12 months (p < 0.001). The mean central retinal thickness also improved significantly from 545 ± 156 at baseline to 266 ± 107 at 12 months (p < 0.001). A visual improvement of 0.3 logarithm of the minimum angle of resolution unit or more was achieved in 15 eyes (60%). During the 12 postoperative months, an average of 4.04 intravitreal anti-VEGF injections was applied. CONCLUSIONS: A triple injection of TNK, anti-VEGF, and a gas appears to be safe and effective for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration.

Aflibercept Treatment for Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy Refractory to Anti-vascular Endothelial Growth Factor

PURPOSE: To report the results of switching treatment to vascular endothelial growth factor (VEGF) Trap-Eye (aflibercept) in neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) refractory to anti-VEGF (ranibizumab and bevacizumab). METHODS: This is a retrospective study involving 32 eyes from 29 patients; 18 were cases of neovascular AMD and 14 were cases of PCV. The best-corrected visual acuity (BCVA) and central macular thickness (CMT) of spectral-domain optical coherence tomography were evaluated. RESULTS: BCVA and CMT improved from 0.58 to 0.55 (p = 0.005) and from 404 to 321 microm (p < 0.001), respectively, after switching to aflibercept. The 14 eyes that received 6 or more aflibercept injections remained stable at 0.81 to 0.81 and 321 to 327 microm (p = 1.0, 0.29), respectively, after 3 aflibercept injections. The 10 eyes that received 3 or more bevacizumab injections after 3 or more aflibercept injections worsened, from 0.44 to 0.47 and from 332 to 346 microm (p = 0.06, 0.05), respectively. The results showed similar improvement of BCVA and CMT in neovascular AMD and PCV. CONCLUSIONS: Aflibercept seems to be effective for improvement and maintenance of BCVA and CMT for neovascular AMD and PCV refractory to anti-VEGF. Switching from aflibercept back to bevacizumab treatment may not be a proper strategy.

Sterile Inflammation after Intravitreal Injection of Aflibercept in a Korean Population

PURPOSE: To report the frequency and clinical features of sterile inflammation after intravitreal aflibercept injection in a Korean population. METHODS: A single-center, retrospective study was performed in patients who received intravitreal aflibercept from July 2013 through January 2015. RESULTS: A total of four cases of post-injection sterile inflammation were identified from 723 aflibercept injections in 233 patients. Patients presented 1 to 13 days after intravitreal aflibercept injection (mean, 5 days). The mean baseline visual acuity was 20 / 60, which decreased to 20 / 112 at diagnosis but ultimately recovered to 20 / 60. Three cases had inflammatory cells in the anterior chamber (mean, 2.25+; range, 0 to 4+), and all cases had vitritis (mean, 3+; range, 2+ to 4+). No patients had pain. Only one patient underwent anterior chamber sampling (culture negative) and injection of antibiotics. Three of four patients were treated with a topical steroid, and all experienced improvement in their symptoms and signs of inflammation. CONCLUSIONS: The overall incidence of sterile inflammation after intravitreal aflibercept injection in a Korean population was 4 of 723 injections (0.55%), or 4 of 233 patients (1.79%). Sterile inflammation after intravitreal aflibercept injection typically presents without pain, and the visual outcomes are generally favorable.

A Case of Ocular Toxocariasis Successfully Treated with Albendazole and Triamcinolon

We present a case of ocular toxocariasis treated successfully with oral albendazole in combination with steroids. A 26-year-old male visited the authors' clinic with the chief complaint of flying flies in his right eye. The fundus photograph showed a whitish epiretinal scar, and the fluorescein angiography revealed a hypofluorescein lesion of the scar and late leakage at the margin. An elevated retinal surface and posterior acoustic shadowing of the scar were observed in the optical coherence tomography, and Toxocara IgG was positive. The patient was diagnosed with toxocariasis, and the condition was treated with albendazole (400 mg twice a day) for a month and oral triamcinolone (16 mg for 2 weeks, once a day, and then 8 mg for 1 week, once a day) from day 13 of the albendazole treatment. The lesions decreased after the treatment. Based on this study, oral albendazole combined with steroids can be a simple and effective regimen for treating ocular toxocariasis.

Spectral Domain Optical Coherence Tomography Findings of Butterfly Shaped Pigment Dystrophy

PURPOSE: The butterfly-shaped pigment dystrophy is an extremely rare autosomal dominant retinal disorder. The authors present a case of butterfly-shaped pigment dsytrophy not reported previously in Korea. CASE SUMMARY: A 45-year-old man had bilateral blurred vision for 2 years. His visual acuity was 0.2 in the right eye, and 0.3 in the left and was uncorrected. Funduscopically, yellow pigment deposits were present at the level of retinal pigment epithelium (RPE) in the central macula of both eyes. Fluorescein angiography (FA) revealed a central, dark, butterfly-shaped lesion surrounded by a region of hyperfluorescence, Spectral domain optical coherence tomography (OCT) showed thick elevation of the RPE with hyperreflectivity and disruption of the inner and outer segment (IS/OS) interface of the photoreceptors. The patient had normal color vision, visual field and electroretinograms and reduced electrooculograms. CONCLUSIONS: In general, butterfly-shaped pigment dystrophy is known to have good visual prognosis. However, in some cases the disease can be a chronic progressive disorder with secondary involvement of the photoreceptors, as exemplified this patient. The authors anticipate more detail regarding the natural course of this disease will be obtained through spectral domain OCT.

Prediction of Refractive Error in Combined Vitrectomy and Cataract Surgery With One-Piece Acrylic Intraocular Lens

PURPOSE: To compare the predicted and actual refractive errors of hydrophilic, one-piece, C-flex(R)570C (C-flex) intraocular lens (IOL) implantation in simultaneous vitrectomy and lens extraction in various conditions. METHODS: One hundred fifty-nine eyes of patients who had lens extraction between March 2004 and September 2005 were enrolled in a retrospective study. Group 1 had lens extraction and IOL implantation, and Group 2 had lens extraction and IOL implantation with vitrectomy. IOL calculation was done with axial length and keratometry measurements. The actual and predicted refractive errors were compared at 1 and 6 months postoperatively. The factors influencing the postoperative refractive outcomes were analyzed. RESULTS: The mean refractive predictive error (i.e., the actual minus predicted spherical equivalent) was +0.19+/-0.39 D (Diopter) and -0.26+/-0.45 D at 1 and 6 months postoperatively (all: p0.05). CONCLUSIONS: Refractive errors in combined surgery showed myopic shift of -0.50 D and -0.32 D at 1 and 6 months postoperatively compared with C-flex IOL implantation alone. With the hyperopic tendency of IOL and myopic tendency of vitrectomy, the combined surgery made postoperative refractive errors near emmetropia.

Progressive Outer Retinal Necrosis Combined with Vitreous Hemorrhage in a Patient with Acquired Immunodeficiency Syndrome

PURPOSE: To describe an unusual case of rapidly progressive outer retinal necrosis (PORN) with vitreous hemorrhage in a 41-year-old woman with acquired immunodeficiency syndrome (AIDS), who had retinitis developed from what was probably varicellar-zoster virus combined with cytomegalovirus (CMV) and herpes simplex type 1,2, as proven by the polymerase chain reaction restriction fragment length polymorphism method (PCR-RFLP). METHODS: This study is a case report detailing clinical follow-up and an aqueous humor test by PCR-RFLP. RESULTS: The deep, white retinal lesions coalesced and progressively expanded in a circumferential manner, with sparing of the perivascular retina. However, retinal and vitreous hemorrhages, unusual findings for PORN, could be noted around the optic nerve. Varicellar-zoster virus (VZV), cytomegalovirus (CMV), and herpes simplex types 1,2 (HSV-1,2) were detected in the aqueous humor by PCR. CONCLUSIONS: PORN has been described as a variant of necrotizing herpetic retinopathy, occurring particularly in patients with AIDS. Although the etiologic agent has been reported to be VZV, concurrent or combined etiologic agents can include HSV-1, HSV-2, and CMV in AIDS patients. Therefore, combined antiviral therapy with acyclovir and ganciclovir could be more reasonable as an initial therapy.

The Effect of Pre-and Intraoperative Factors Including Marginal Fibrosis On Result of Macular Hole Surgery

PURPOSE: To evaluate the pre-operative and the intra-operative factors including marginal fibrosis affecting the result of vitrectomy for macular hole. METHODS: The medical records of the patient who had been operated for idiopathic full-thickness macular hole from January 1997 to July 2000 were investigated retrospectively. RESULTS: Hole closure, as the implication of anatomical success, was seen in 28 eyes (84.8%) at 1 month after surgery and 23 eyes (69.7%) at the end of follow-up period. And the improvement of two or more Snellen line, as the implication of functional success, was seen in 17 eyes (51.5%). The smaller size of the hole was well correlated with higher rate of anatomical success (P=0.001). And there was a good correlation of higher anatomic success rate with the lack of marginal fibrosis around the hole (P=0.001). CONCLUSIONS: There must be more efforts and investigations on proper management of marginal fibrosis, which might help to improve the result of macular hole surgery.

Polymerase Chain Reaction in the Diagnosis of Infectious Endophthalmitis

PURPOSE: We evaluated the efficacy of the PCR which is known as more sensitive method than culture in the diagnosis of causal microorganisms of the infective endophthalmitis. METHODS: We used 0.3 ml of aqueous humor and 0.5 ml of vitreous sample in 3 cases of postoperative and 1 case of endogenous endophthalmitis for detecting causal microorganisms. To detect the bacteria we used universal, Gram positive and negative primers, and to detect the fungus we used fungal primer. RESULTS: Three cases of endophthalmitis, there was no bacteria in the bacterial culture for 10 days but PCR results identified causal microorganisms in all cases. CONCLUSIONS: PCR is effective in the fast and accurate diagnosis of infective endophthalmitis and especially in the culture-negative endophthalmitis.

Pneumatic Displacement of Submacular Hemorrhage with Intravitreal Injection of tPA and SF6 Gas

Submacular hemorrhage from various causes induces the irreversible damage to the retina, leading to poor visual outcome. Surgery for removal of submacular hemorrhage was performed but the general results were not satisfactory in spite of better surgical technique. We took this study to identify the effectiveness and safety of intravitreal injection of tissue plasminogen activator(tPA) and SF6 for displacement of submacular hemorrahge. Thirteen patients who have submacular hemorrhage had undergone intravitreal injection of tPA and SF6 and positioned face down for about 1 week. Postoperative complication, best corrected visual acuity, final visual acuity, amount of displacement related to the duration of submacular hemorrhage and causal diseases were checked retrospectively. The average age of the patients was 64. Six eyes(46.2%) improved visual acuity by 2 lines or more, and 2 eyes(15.4%) lost visual acuity 2 lines or more. Complications included vitreous hemorrhage in 2 eyes, increased intraocular pressure in 2 eyes. Causes were trauma in 3 eyes and age-related macular degeneration in 10 eyes. The final visual results after 5 months or longer were related with macular lesion. Complete displacement was achieved in 10 eyes, partial displacement in 4 eyes at 1 month. The authors concluded that brief prone position after intravitreal injection of tPA and SF6 is rapid and effective method for displacement of submacular hemorrhage.

The effective concentration and exposure time of mitomycin-C for the inhibition of lens epithelial cell proliferation in rabbit eyes

The proliferation of residual lens epithelial cells following cataract surgery is assumed to be a major cause of posterior capsular opacification. To assess the efficacy of mitomycin-C in preventing posterior capsular opacification, we determined the effective concentration and exposure time of mitomycin-C in inhibiting rabbit lens epithelial cell proliferation. The fourth-passaged rabbit lens epithelial cells were maintained for one day and then exposed to mitomycin-C for 1, 2, 3, and 5 minutes, respectively. There were 9 different plating concentrations of mitomycin-C with two-fold serial dilution. The maintenance of the phenotypic properties of lens epithelial cells was confirmed by continuous transcription of lambda-crystalline mRNA determined by reverse transcription-polymerase chain reaction and the polymorphism of the restriction fragment. Cell proliferation was assayed with 3H-thymidine incorporation into DNA. The fourth-passaged cells maintained the expression of lambda-crystalline mRNA, suggesting that they are phenotypically authentic lens epithelial cells. The effective concentrations and exposure time of mitomycin-C were 0.1 mg/ml for 1 minute and 2 minutes, and 0.025 mg/ml for 2 minutes. By these results, we postulated that mitomycin-C at relatively short incubation times could be clinically used for prevention of posterior capsular opacification after cataract surgery.

The Effect of Antimetabolites for Inhibiting the Proliferation of Rabbit Lens Epithelial Cells in Vitro

The most common cause of blurred vision after extracapsular cataract extraction is known to be an opacification of the posterior lens capsule. The pathogenesis of posterior lens capsule opacification is primarily caused by residual lens epithelial cells. For the prevention of posterior capsular opacification, several kinds of anti-mitotic drugs is being actively investigated. But the antimitotic drugs are not clinically used due to toxicity towards the intraocular tissues. The objectives of this study is to evaluate the effect of mitomycin C and tirilazad mesylate(FREEDOX(TM)) respectively for inhibiting the proliferation of rabbit lens epithelial cells when it is administered in a short period. Lens epithelial cells from white rabbits were harvested andcultured for 4 passages. Mitomycin C was applied for 3 minutes with 0.025mg/ml and 0.05mg/ml in concentration respectively. The proliferation assay was performed by [(3)H]-thymidine uptake test. Significant decrease of lens epithelial cell proliferation appeared in both drugs.When Mitomycin-C was applied with 0.025mg/ml for 3 minutes, cell proliferation was reduced to 31.5% compared with control and in 0.05mg/ml concentration, to 12.5%. When tirilazad mesylate was applied 0.15mg/ml for 3 minutes, cell proliferation was reduced to 46.5% compared with control and in 1.5mg/ml concentration, to 7.5%. If futher investigation would show the effectives and safety of these drugs, these agents could be applied into the lens capsular bad at the time of surgery to prevent the posterior capsular opacification after cataract surgery.

Incidence and Clinical Course of Implant Exposure after Hydroxyapatite Implantation in Anophthalmic Socket

We evaluated the incidence and clinical course of exposed hydroxyapatite implants in anophthalmic sockets. We retrospectively reviewed the charts of 157 patients who underwent hydroxyapatite implantation in anopthalmic socket and were followed up for more than 4 months. The number of the exposed hydroxyapatite implants was 13 of 157 eyes (8.28%). We found that the incidence of hydroxyapatite exposure following enucleation was 1 of 54 (1.85%), while was 9 of 68 eyes (13.24%) following evisceration, and following secondary implantation was 3 of 35 eyes (8.28%). The exposure of hydroxyapatite implants following evisceration was more frequent than that of following enucleation(P=0.02). 7 of 9 eyes (77.8%) of exposed hydroxyapatite implants following evisceration was late onset which was beyond postoperative 2 months. We believe that the rate of exposure following evisceration may be greater than that of following enucleation. Enucleation could be a good procedure in view of postoperative exposure. And many cases of exposed hydroxyapatite following evixceration were late onset.

Traumatic Exotropia Following Partial Laceration of Medial Rectus Muscle

Direct trauma to extraocular muscles is usually the result of penetrating injuries. Contusion, avulsion, or laceration of the extraocular muscles may occur. We have treated a 3-year-old boy with what appeared to be nasal conjunctival laceration by scissors. The injured eye showed approximately 50 prism diopter exotropia and slight limitation of adduction of the left eye. In orbital MRI focal hemorrhage and adhesion around left medial rectus muscle was noted but the discontinuity of left medial rectus muscle was not found in orbital MRI. After 6 months, the child underwent strabismus surgery under general anesthesia. We detected that the upper portion of the left medial rectus muscle was lacerated about 25% of total width of muscle from the insertion to 4mm distal to the insertion. We performed a recession-resection procedure to the left eye. 3 month after the operation, duction movement showed no limitation. The prism and cover test at near revealed orthophoria. We suggest that a strabismus following after a periocular laceration can be accompanied with a injury of extraocular muscle.