Effect of 23-gauge Sutureless Vitrectomy & Preoperative Bevacizumab on Results of Diabetic Vitrectomy

PURPOSE: To investigate the results of 23-gauge sutureless vitrectomy and preoperative bevacizumab in diabetic retinopathy cases. METHODS: A total of 212 eyes received pars plana vitrectomy by a single surgeon for proliferative diabetic retinopathy and were followed up for at least 6 months. The change of visual acuity and operative complications among the 20-gauge vitrectomy (group I, 86 eyes), 23-gauge vitrectomy (group II, 30 eyes), and 23-gauge vitrectomy with preoperative intravitreal bevacizumab (IVB) injection (group III, 96 eyes) were retrospectively analyzed. RESULTS: One month postoperatively, visual improvement was better in groups II and III than in group I. Three months postoperatively, visual improvement was better in group III than in groups I and II. Six months postoperatively, visual improvement in group III was better than in group I, but there was no significant difference between group II and III. Intraoperative retinal breaks and postoperative vitreous hemorrhage were less common in group III than in groups I and II. CONCLUSIONS: In patients with proliferative diabetic retinopathy, 23-gauge sutureless vitrectomy showed faster visual recovery compared with 20-gauge vitrectomy, and vitrectomy with preoperative bevacizumab had less intraoperative and postoperative complications than vitrectomy without preoperative bevacizumab.

Leber's Idiopathic Stellate Neuroretinitis with Peripapillary Serous Retinal Detachment

PURPOSE: To report a patient with Leber's idiopathic stellate neuroretinitis accompanying peripapillary sensory retinal detachment detected with optical coherence tomography. CASE SUMMARY: A 26-year-old woman complained of visual disturbance in her right eye for several months. Her best corrected visual acuity was 0.5 in the right eye and 0.9 in the left eye. A relative afferent papillary defect was present in the right eye. Severe disc swelling with retinal hemorrhage and stellate macular exudates were observed in the right eye. Fluorescein angiography revealed optic disc leakage. There appeared to be no leakage from the other retinal vessels or from the retinal pigment epithelium. OCT revealed outer nuclear-plexiform layer fluid accumulation in the papillomacular region. Eight weeks after steroid treatment, the best corrected visual acuity in the right eye had improved to 0.7, and the optic disc edema had improved. The OCT showed that the fluid in the outer nuclear-plexiform layer space had largely been absorbed.

The 23-Gauge Sutureless Vitreoretinal Surgery in Previously Vitrectomized Eyes

PURPOSE: To investigate the incidence and risk factors of major complications including postoperative hypotony after 23-gauge transconjunctival sutureless vitrectomy in previously vitrectomized eyes. METHODS: The authors retrospectively reviewed medical records of 52 eyes, which underwent 23-gauge transconjunctival sutureless vitrectomy of previously vitrectomized eyes by a single surgeon. Major outcomes were postoperative hypotomy (<6 mmHg), intraoperative sclera shrinkage during sclerotomy,and other postoperative complications. Multiple logistic regression analysis was performed that included 212 eyes with primary vitreoretinal surgery in order to validate secondary vitreoretinal surgery as a significant risk factor of postoperative hypotony. RESULTS: Postoperative hypotony occurred in 4 eyes (7.7%) out of 52 eyes that underwent a second vitrectomy. The odds ratio of the second vitreoretinal surgery (OR=1.15, p=0.283) was not significant by multiple logistic regression analysis that included age, sex, axial length of globe, and the number of surgeries as the independent variables. Choroidal detachment occurred in one eye but disappeared three days later. The intraocular pressure was normalized within one week in all cases. Scleral shrinkage during sclerotomy occurred in five eyes (9.6%), and there were no other major complications, such as endophthalmitis. CONCLUSIONS: A 23-gauge transconjunctival sutureless vitrecomy of previously vitrectomized eyesshowed a 7.7% incidence of postoperative hypotony and favorable prognosis.

A Case of Intraoperative Floppy Iris Syndrome in a Patient Using Tamsulosin

PURPOSE: To report a case of Intraoperative Floppy Iris Syndrome (IFIS) experienced during pars plana vitrectomy and phacoemulsification in a patient using tamsulosin, which is a selective alpha 1 adrenergic antagonist. CASE SUMMARY: A 77-year-old male who had used tamsulosin for the previous month for prostate cancer visited our clinic with left visual disturbance, that had developed a week earlier. The best-corrected visual acuity of the left eye was 0.02 and both pupils showed incomplete mydriasis. Pars plana vitrectomy and phacoemulsification with PCL implantation were performed on his left eye to correct a left cataract and retinal vein occlusion with vitreous hemorrhage. Phacoemulsification idenfied a billowing iris and progressive pupillary constriction. Therefore, we administered an intracameral epinephrine injection and applied an iris hook. The procedure was completed successfully without any complications. The best-corrected visual acuity of the left eye was good as at 0.9, and iris depigmentation and atrophy were checked two months postoperatively in the right eye, which had not had any previous surgical history. CONCLUSIONS: A detailed medical history taking is essential because IFIS may raise the risk of intraoperative complications, such as posterior capsule rupture, especially when the small pupil is small. Safe procedures must be planned with cessation of tamsulosin at least a week preoperatively.

Tractional Retinal Detachment After Intravitreal Bevacizumab (Avastin(R)) Injection in Proliferative Diabetic Retinopathy

PURPOSE: To report two cases of tractional retinal detachment after intravitreal bevacizumab injection. CASE SUMMARY: (Case 1) A 48-year-old female with insulin-dependent diabetes mellitus and a high HbA1c level came to our clinic for fundus evaluation. The best corrected visual acuity (BCVA) was 1.0 in the right eye and funduscopic examination of the right eye revealed proliferative diabetic retinopathy with preretinal hemorrhage and a mild fibrovascular proliferative membrane around the optic disc. Intravitreal bevacizumab injection (1.25 mg) was performed before starting panretinal photocoagulation (PRP) to prevent macular edema after PRP. Three days after the injection, visual acuity decreased to 0.3 and funduscopic findings showed tractional retinal detachment. Vitrectomy was performed and visual acuity recovered to 1.0 four months after operation. CONCLUSIONS: Intravitreal bevacizumab injection may cause tractional retinal detachment in poorly controlled insulin-dependent diabetes mellitus patients with fibrovascular proliferative membranes.

Sclerotomy-related Retinal Breaks in Vitrectomy for Proliferative Diabetic Retinopathy: 20- vs 23-Gauge Systems

PURPOSE: To compare the rate of intraoperative sclerotomy-related retinal breaks (SRRB) between 20- and 23-gauge vitrectomy for proliferative diabetic retinopathy (PDR). METHODS: Medical records of 62 consecutive eyes of 54 patients who underwent 20-gauge pars plana vitrectomy (PPV) and 63 consecutive eyes of 55 patients who received 23-gauge transconjunctival sutureless vitrectomy were retrospectively reviewed. RESULTS: Three (4.8%) out of 62 eyes in the 20-gauge group had SRRB and 1 (1.6%) eye developed retinal detachment at 4 months postoperatively, while 2 (3.2%) out of 63 eyes in the 23-gauge group had SRRB and 1 (1.6%) eye developed retinal detachment at 3 months postoperatively. CONCLUSIONS: There were no significant differences in the rates of sclerotomy-related retinal breaks and sclerotomy-related retinal detachments between 20-gauge PPV and 23-gauge PPV for PDR.

Partial Fluid-Air-Exchange at the End of 23 Gauge Sutureless Vitrectomy to Prevent Postoperative Hypotony

PURPOSE: To evaluate the efficacy and safety of partial fluid air exchange at the end of 23-gauge transconjunctival sutureless vitrectomy to prevent postoperative hypotony. METHODS: Fifty-five eyes in 49 consecutive patients who underwent partial fluid air exchange at the end of 23-gauge sutureless vitrectomy by a single surgeon at Gil Hospital between August 2007 and February 2008 were recruited for this study. Intraocular pressure (IOP), visual acuity and post-operative complications were evaluated. RESULTS: Surgical indications included proliferative diabetic retinopathy (n=31), epiretinal membrane (n=9), nondiabetic vitreous hemorrhage (n=5), vitreous opacities (n=3), and others (n=7). Two eyes showed hypotony (<6 mmHg) on postoperative day 1 and resolved within a week without any supplemental procedures. Other complications included choroidal detachment in 1 eye, hyphema in 1 eye, and transient IIOP in 2 eyes. In 38 eyes in which combined cataract surgery was performed, air bubble-related complications including iris capture by the IOL in 3 eyes (7.9%) and opacification of the posterior capsule in 11 eyes (28.9%) occurred. No case of retinal detachment or endophthalmitis was observed. The final best corrected visual acuity was 20/40 or better in 14 eyes (25.5%). CONCLUSIONS: The partial fluid air exchange shows promise as an effective and safe procedure for prevention of postoperative hypotony after sutureless vitrectomy. Air bubble-related complications after combined cataract surgery can be avoided by several techniques.

Foveal Reattachment After Scleral Buckling vs Vitrectomy for Macula-Off Retinal Detachment

PURPOSE: To compare the time course of foveal reattachment after successful surgery for macula-off retinal detachments by scleral buckling or pars plana vitrectomy (PPV). METHODS: We retrospectively examined, using optical coherence tomography (OCT), the cross-sectional retinal images of 28 patients who underwent scleral buckling or PPV for macula-off retinal detachment and whose retinas reattached upon binocular stereoscopic indirect ophthalmoscopy within 4 weeks postoperatively. All eyes underwent clinical examination and OCT scan of the macula at 6 weeks after surgery. If subretinal fluid persisted, repeated OCT was obtained at every 1~2 months until no abnormality was seen on OCT. Demographic data, including detachment characteristics, was also analyzed. RESULTS: On postoperative OCT examination 6 weeks after surgery, complete foveal reattachments were detected in 14 patients (73.7%) in the PPV group (n=19), significantly higher than 3 (33.3%) patients in the buckling group (n=9). Foveal reattachment took a mean 8.31+/-5.25 weeks in the PPV group and a mean 20.89+/-11.37 weeks in the buckling group. CONCLUSIONS: Foveal reattachment after macula-off retinal detachment occurred faster after PPV than after buckle surgery.

Cataract and Refractive Surgery in ; a Survey of KSCRS Members From 1995~2006

PURPOSE: This purpose of this report was to study trends in cataract and refractive surgeries conducted during the past twelve years and to compare results to previous reports from the ASCRS and New Zealand (NZ) in order to forecast future medical services. METHODS: We surveyed members of the Korean Society of Cataract and Refractive Surgery (KSCRS) every year from 1995 to 2006, and studied changes in cataract and refractive surgeries (RS). RESULTS: The duration of hospitalization has been gradually decreasing to the point that a one day hospitalization following surgery has become common. The rate of topical anesthesia use has significantly increased since 1998. Sutureless incision methods are now commonly practiced. The use of acryl IOL as an optic material has been gradually increasing for cataract surgeries. KSCRS members showed an interest in the special intraocular lenses as multifocal IOL. While Excimer laser PRK was the most popular refractive surgery during the first stage, KSCRS members increasingly prefer LASIK to the Excimer laser PRK. Regression of the corrected visual acuity, dry eye, night halo, and flashes were the most common complications following refractive surgeries. Medical disputes related to PRK and LASIK have been gradually increasing throughout the study period. CONCLUSIONS: We confirm that the KSCRS practice styles for cataract and RS are similar to those of the ASCRS and NZ. We infer a world-wide trend from the comparison of these three societies.

A Case of Atypical Miller Fisher Sndrome

PURPOSE: To report one case of atypical Miller Fisher syndrome with spontaneous recovery. METHODS: A 44-year-old woman was visited our clinic complaining of diplopia for 2 days. She has irregular medication history for thyroid dysfunction, and there was no antecedent respiratory or gastrointestinal infection. The best corrected visual acuity of both eyes was 20/20. She showed bilateral proptosis and limitation of abduction and supraduction, mild blepharoptosis of left eye and esotropia of 30 prism diopter (PD). RESULTS: Thyroid fuction test, orbital CT and electromyography were normal. Cerebrospinal fluid (CSF) analysis revealed albuminocytologic dissociation. Steroid pulse therapy was started promptly, but there was no improvement. Extraocular movement and diplopia gradually improved after 4 weeks of onset. and spontaneously recovered completely after 2 months. CONCLUSIONS: We reported a case of atypical Miller Fisher syndrome that completely and spontaneously recovered within 2 months., and represented normal findings by every examination such as orbital CT, thyroid function test, electromyography and CSF analysis.

Postoperative Visual Recovery and Complications of Vitrectomy in Terson's Syndrome

PURPOSE: To investigate the visual recovery and complications of vitrectomy in Terson's syndrome. METHODS: A retrospective study was carried out on 11 eyes in 9 patients who had undergone pars plana vitrectomy for Terson's syndrome from October 2004 to June 2006. The factors assessed were age, gender, presence of hypertension, type of intracranial hemorrhage, preoperative and final visual acuity, time interval from intracranial hemorrhage (ICH) to vitrectomy, and any intraoperative and postoperative complications. RESULTS: The average age of the subjects and the Interval from ICH to vitrectomy were 43.0+/-11.0 years and 3.25+/-3.48 months respectively. Binocular involvement was found in two of the nine patients, and fundus findings were severe vitreous opacity in all cases, while sub-ILM hemorrhage at the posterior pole was seen in five eyes. Intraoperative retinal break was recorded at the 10 o'clock sclerotomy site in five eyes, and four of these five eyes were associated with sub-ILM hemorrhage. One patient underwent a scleral buckling operation four months postoperatively due to rhegmatogenous retinal detachment associated with a retinal tear at the 2 o'clock sclerotomy site. Visual acuity improved in all cases postoperatively, and the final visual acuity was over 0.6 in seven eyes. CONCLUSIONS: We can expect from early surgery a relatively good prognosis of visual acuity and prevention of complications. Due to the possibility of retinal breaks at the sclerotomy sites, we should keep in mind that cautious handling of intraocular instrument and complete removal of vitreous base may be necessary.

Postoperative Visual Recovery and Complications of Vitrectomy in Terson's Syndrome

PURPOSE: To investigate the visual recovery and complications of vitrectomy in Terson's syndrome. METHODS: A retrospective study was carried out on 11 eyes in 9 patients who had undergone pars plana vitrectomy for Terson's syndrome from October 2004 to June 2006. The factors assessed were age, gender, presence of hypertension, type of intracranial hemorrhage, preoperative and final visual acuity, time interval from intracranial hemorrhage (ICH) to vitrectomy, and any intraoperative and postoperative complications. RESULTS: The average age of the subjects and the Interval from ICH to vitrectomy were 43.0+/-11.0 years and 3.25+/-3.48 months respectively. Binocular involvement was found in two of the nine patients, and fundus findings were severe vitreous opacity in all cases, while sub-ILM hemorrhage at the posterior pole was seen in five eyes. Intraoperative retinal break was recorded at the 10 o'clock sclerotomy site in five eyes, and four of these five eyes were associated with sub-ILM hemorrhage. One patient underwent a scleral buckling operation four months postoperatively due to rhegmatogenous retinal detachment associated with a retinal tear at the 2 o'clock sclerotomy site. Visual acuity improved in all cases postoperatively, and the final visual acuity was over 0.6 in seven eyes. CONCLUSIONS: We can expect from early surgery a relatively good prognosis of visual acuity and prevention of complications. Due to the possibility of retinal breaks at the sclerotomy sites, we should keep in mind that cautious handling of intraocular instrument and complete removal of vitreous base may be necessary.

Endogenous Aeromonas Hydrophila Endophthalmitis in an Immunocompromised Patient

PURPOSE: To report a case of endogenous endophthalmitis due to Aeromonas hydrophila in a patient with distal common bile duct carcinoma and biliary sepsis. METHODS: A 72-year-old woman with distal common bile duct carcinoma, obstructive jaundice, diabetes mellitus, and hypertension had a 1-day history of blurred vision, redness, and eye discharges in the right eye. An ophthalmic examination showed no light perception vision, increased intraocular pressure, severe corneal edema, severe anterior chamber reaction, exudative membranes on the anterior lens surface, and severe vitreal reaction. There was no ocular history of trauma, infection, or surgery in either eye. RESULTS: Under the impression of endogenous bacterial endophthalmitis, immediate intraocular cultures and intravitreal antibiotic injections were performed, but the anterior chamber reaction, and the ultrasonogram findings were deteriorated. Evisceration was undertakened because of extrusion of the intraocular contents, and Aeromonas hydrophila was isolated by intraocular culture. CONCLUSIONS: Endogenous endophthalmitis due to Aeromonas hydrophila is rare, but has a rapid clinical course and a poor prognosis, despite of prompt diagnosis and management.

Clinical Features of Refractive Accommodative Esotropia according to the Age of Onset

PURPOSE: To examine the difference of clinical features according to age of onset of refractive accommodative esotropia. METHODS: We retrospectively analyzed the medical record of 52 cases of refractive accommodative esotropia for more than 12 months of follow-up from March, 2000 to December, 2003. The factors we compared were gender, age of first ocular examination, interval from age of onset to first glasses, preoperative refractive error, amount of deviation corrected with hyperopic glasses, stereopsis and associated ocular conditions. RESULTS: Cases were grouped according to age of onset. Fourteen (27%) patients were less than 2 years old., 32 (62%) were between 2 to 4 years old, and 6 (11%) were between 4 to 6 years old 6. the group less than 2 years old showed lower levels of preoperative refractive error than the group more than 2 years old. The younger the age of onset, the lager the deviation angle without hyperopic glasses. There were no differences according to age of onset in gender, interval from age of onset to first glasses, stereopsis, anisometropia or amblyopia. CONCLUSIONS: In refractive accommodative esotropia, the younger the age of onset is, the lager the deviation angle without hyperopic glasses and the greater the deviation can be corrected with hyperopic glasses.

Early Surgery for Intermittent Exotropia in Children less than 4 Years of Age

PURPOSE: To determine the result of early surgery for intermittent exotropia for children under 4 year old and the factors which affect it. METHODS: The study subjects consisted of 25 children younger than 4 years who had received surgery for intermittent Exotropia. They were followed up for more than 1 year after surgery by the Department of Ophthalmology of the Gachon Medical School, between July 1998 and December 2003. The interval from onset to initial surgery, preoperative deviation angle, dissociated vertical deviation, stereopsis, preoperative patching, type of surgery, and initial postoperative deviation angle were compared and analyzed in a retrospective manner. RESULTS: The average age of the subjects and the preoperative deviation angle were 3.2 years and 28.67+/-8.08PD respectively. The average deviation angle at postoperative year 1 was 5.60+/-8.69PD. Out of the 25 patients, 19 (76%) showed a deviation angle less than 10PD were and 4 (16%) had recurrence of exotropia. Consecutive esotropia occurred in 2 (8%). The clinical factor statistically related to results was the initial postoperative deviation angle. The group who had esophoria of more than 10 PD (18.27+/-6.18 PD) showed 93% orthophoria at postoperative year 1, which was statistically significant. CONCLUSIONS: Though a patient be under 4 years old, if their deviation angle is in progress or if non-surgical treatment is ineffective in the case when surgery is delayed, it is presumed that performing surgery at postoperative day 1 with an overcorrection of about 10 PD is preferred.

Infectious Endophthalmitis After Intravitreal Injection of Triamcinolone Acetonide

PURPOSE: We report 2 cases of infectious endophthalmitis after intravireal triamcinolone acetonide injection which was successfully treated with early vitrectomy. METHODS: A 56 year old male patient with chronic cystoid macular edema of right eye and an 84 year old female patient with diabetic macular edema of right eye (pseudophakic) eye were treated with intravireal triamcinolone acetonide injection. Four days after the injection, both the patients complained of decreased visual acuity that had been developed 1 and 2 days prior respectively. Visual acuity was hand motion, inflammatory cells, flare, fibrins and hypopyon were found in the anterior chamber. Fundus was not visible due to vitreous opacity. RESULTS: The two patients were presumed to have infectious endophthalmitis. Anterior chamber irrigation, vitrectomy, intravitreal antibiotics injection, and vitreous culture were performed. Coagulase negative staphylococcus was detected from vitreous culture, Within 1 week of the follow-up procedures, the anterior chamber and vitreous inflammation were improved and visual acuity recovered to the level attained before intravireal triamcinolone acetonide injection. CONCLUSIONS: If after intravireal triamcinolone acetonide injection, there is severely decreased visual acuity, inflammation of the anterior chamber and vitreous, flare and fibrin are detected, infectious endophthalmitis must be suspected. If diagnosed early and treated with vitrectomy, a favorable visual prognosis is expected.

2004 Survey for KSCRS Members: Current Trends in Cataract Surgery in Korea

PURPOSE: This study investigates the current situation and future trends in the field of cataract and refractive surgery in Korea. METHODS: Since 1995, the members of the Korean Society of Cataract and Refractive Surgery (KSCRS) have been surveyed annually on cataract and refractive surgery. The 2005 annual survey, consisting of 74 multiple-choice questions, was mailed in February 2005 to 364 KSCRS members. Seventy-six (20.8%) members answered. Current data were compared with those of previous annual surveys and with those of annual surveys of ASCRS (American Society of Cataract and Refractive Surgery) members. RESULTS: The duration of hospitalization has decreased annually and the use of topical anesthesia (49%) has hemained stationary. Self sealing wound construction was the main wound closure technique in phacoemulsification (66%). Acrylic intraocular lenses are the most preferred (75%) for small incisioncataract surgery. The implantation of phakic IOL was performed by 30% of respondents and interests in the value added by IOL has increased annually. CONCLUSIONS: This survey summarized current trends and changes in cataract and refractive surgery in Korea.