Short-term Efficacy and Safety of Intravitreal Brolucizumab Injection for Treatment-Naive Exudate Age-related Macular Degeneration: A Multicenter Study

Purpose@#To compare short-term efficacy and safety of intravitreal brolucizumab injection with aflibercept in treatment-naive neovascular age-related macular degeneration (nAMD) patients. @*Methods@#A total of 59 eyes from 59 treatment-naive nAMD patients in three hospitals were retrospectively reviewed. Of which, 27 patients underwent intravitreal brolucizumab injections and 32 received aflibercept. After monthly consecutive three injections, best-corrected visual acuity (BCVA; in logarithm of minimal angle of resolution [logMAR]), central macular thickness (CMT), dry macula achievement rate, and intraocular inflammation (IOI) incidence were compared. @*Results@#After loading-phase treatment, BCVA was significantly increased from 0.48 ± 0.30 logMAR at baseline to 0.33 ± 0.21 logMAR at 3 months in the brolucizumab group (p = 0.002) and 0.40 ± 0.39 logMAR at baseline to 0.33 ± 0.36 logMAR at 3 months in the aflibercept group (p = 0.007). But there was no significant difference in BCVA improvement at 3 months between the two groups. CMT significantly decreased from 429.67 ± 250.59 μm at baseline to 210.67 ± 93.53 μm at 3 months in the brolucizumab group and from 346.69 ± 159.09 μm to 234.52 ± 83.42 μm in the aflibercept group (both p < 0.001). The amount of CMT reduction was significantly greater in the brolucizumab group after 3 months (p = 0.036). In typical AMD eyes, brolucizumab showed similar BCVA improvement but better CMT reduction at 3 months (p = 0.018). Dry macula achievement rate was not significantly different between the two groups. One IOI was observed in the brolucizumab group. @*Conclusions@#Intravitreal injections of brolucizumab and aflibercept showed similar anatomical and functional outcomes. But CMT reduction was greater in the brolucizumab group. One IOI was identified, which was tolerable for topical agents. These results suggest that brolucizumab could be a novel first line treatment option for treating naive nAMD patients.

Influence of Vitreoretinal Surgery on Ocular Surface Dynamics Using Keratograph 5M

Purpose@#To evaluate changes of ocular surface dynamics using Keratograph 5M for 3 months after vitreoretinal surgery. @*Methods@#Eighty-three patients were divided into three groups: phacoemulsification group, vitrectomy group, and combined group. Keratograph 5M was performed for all patients at 1 week, 1 month, and 3 months after the surgery. Ocular surface dynamics parameters measured by Keratograph 5M, including noninvasive keratograph first tear film breakup time (NifBUT), noninvasive keratograph average tear film breakup time (NiaBUT), and tear meniscus height (TMH) were compared among the three groups over time. @*Results@#The mean age of all patients (46 men and 37 women) was 62.2 ± 8.4 years. NifBUT and NiaBUT were significantly decreased at 1 week after surgery compared to those at baseline in all three groups (all p < 0.001). NifBUT and NiaBUT in the phacoemulsification group almost recovered to the preoperative level, while those in the vitrectomy group and the combined group were still significantly less than those at baseline. NifBUT and NiaBUT in the phacoemulsification group were significantly longer than those in the vitrectomy group and the combined group at 3 months. After 1 week, TMHs were significantly higher in the vitrectomy group (p = 0.001) and the combined group (p = 0.022) than in the phacoemulsification group, while TMHs were significantly less in the vitrectomy group (p = 0.010) and the combined group (p < 0.001) than in the phacoemulsification group at 3 months after surgery. @*Conclusions@#These results suggest that vitreoretinal surgery could induce alteration of ocular surface dynamics for 3 months. The vitrectomy group and the combined group showed tear film instability compared to the cataract surgery alone group. Patients who underwent vitreoretinal surgery experienced more severe dry eye syndrome symptoms than those who underwent cataract surgery. Thus, managing dry eye syndrome after vitreoretinal surgery should be considered important for patients.

Late-onset Endophthalmitis Caused by Streptococcus Cristatus after Trabeculectomy

Purpose@#To report a case of late-onset bleb-associated endophthalmitis caused by streptococcus cristatus (S. cristatus) after trabeculectomy.Case summary: A 59-year-old woman presented with left ocular pain and visual disturbance. She had undergone trabeculectomy of the left eye 2 years ago. At the initial visit, she was only able to count fingers from the left eye. Whitish thin bleb, conjunctival injection, and inflammation were observed in the left anterior chamber, and the fundus could not be visualized. Despite administering topical and systemic antibiotics, the chamber reaction worsened, and hypopyon and inflammatory membrane were noticed the next day. Vitrectomy with phacoemulsification and intravitreal antibiotic injection was performed, and the intravitreal antibiotic injections were repeated over the next two days. Bacterial culture of vitreous fluid showed a growth of S. cristatus 5 days after the surgery, and inflammation improved after 7 days. One month later, she was still only able to count fingers from the left eye, but there were no signs of endophthalmitis. @*Conclusions@#Postoperative endophthalmitis after glaucoma filtering surgeries caused by S. cristatus has not been reported previously from Korea. To the best of our knowledge, this is the first Korean case of late-onset bleb-associated endophthalmitis caused by S. cristatus. If gram-positive cocci are grown in samples from the patients with endophthalmitis after trabeculectomy, resident oral microflora such as S. cristatus should be considered as the causative pathogen.

A Novel Pathogenic RS1 Variant (c.362delA) in a Korean Patient With Late-onset X-linked Retinoschisis

No abstract available.

Short-term Surgical Outcomes of Rectus Muscle Plication and Resection in Intermittent Exotropia

PURPOSE: To evaluate the efficacy and safety of medial rectus muscle plication compared to resection, coupled with antagonist muscle recession, as treatments for intermittent exotropia (IXT). METHODS: We retrospectively reviewed the charts of IXT patients treated by a single surgeon and followed-up for at least 6 months between September 2016 and February 2017. The patients were divided into three groups: a bilateral lateral rectus muscle recession (BLR) group, a unilateral lateral rectus recession with medial rectus plication (R&P) group, and a unilateral lateral rectus recession with medial rectus resection (R&R) group. Serial changes in ocular alignment at 4–24 weeks after surgery were compared among the groups. In addition, the operative times were assessed. RESULTS: We included 119 patients (mean age 6.65 ± 2.79 years). The preoperative exodeviation was 29.81 ± 7.31 prism diopters (PDs) and did not differ among the groups. The R&P group exhibited significantly less postoperative deviation than the BLR group. The operative time was significantly less for the R&P group (25.77 ± 9.29 minutes) than the R&R group (28.97 ± 5.74 minutes). The success rates were identical among groups at 6 months; no severe adverse events were recorded apart from one case of dellen that improved after application of a topical agent. CONCLUSIONS: Plication may reduce the risk for anterior segment ischemia to a level lower than the risks associated with other procedures, and also facilitate reoperation if necessary. We found that R&P took less time but had success rate similar to BLR and R&R. Thus, medial rectus muscle plication for IXT patients is a valuable alternative procedure when the external rectus muscle requires strengthening.

Simultaneous Recording of Flash Electroretinography and Visual Evoked Potential in Vitreous Hemorrhage with Diabetic Retinopathy

PURPOSE: To determine whether the simultaneous recording of photopic electroretinography (ERG) and flash visual evoked potential (VEP) can predict the postoperative outcome in diabetic cases where massive vitreous hemorrhage precludes fundus observation. METHODS: The photopic ERG and flash VEP were recorded simultaneously on 20 eyes of 20 normal subjects, and 23 eyes of 23 patients who were diagnosed with Grade IV vitreous hemorrhage d/t diabetic retinopathy. Of the 23 patients, fellow eyes were diagnosed with proliferative diabetic retinopathy and they underwent pars plana vitrectomy after the test. Three groups were analyzed the responses of photopic ERG and flash VEP. Best corrected visual acuity was also checked before and after the surgery. After the 8 weeks after the vitrectomy, two groups were formed, based on the outcome of surgery and these two groups were analyzed the preoperative response of photopic ERG and flash VEP. RESULTS: When comparing the groups between proliferative diabetic retinopathy and normal eyes, Grade IV vitreous hemorrhage and fellow eyes, there was a statistically significant (p < 0.05) difference in a wave amplitude, a wave implicit time, b wave amplitude, b wave implicit time of photopic ERG and P2 peak time of flash VEP. In addition, a wave amplitude of photopic ERG showed the best predictive ability (area under receiver operating characteristic [AUROC] curve value of 0.88) when comparing improved visual acuity group to the unimproved visual acuity group. CONCLUSIONS: Simultaneous recordings of photopic ERG and flash VEP showed the decreased function of retina and optic pathway on eyes with vitreous hemorrhage precluding inspection of the fundus. In addition, preoperative photopic ERG and flash VEP can safely predict the outcome of vitrectomy in dense vitreous hemorrhage of diabetics.

Supermaximal Recession and Resection in Large-Angle Sensory Exotropia

In cases of extropia with an exodeviation angle over 50 prism diopter (PD), a 3- or 4-muscle surgery is a rational option. But, in patients with sensory exotropia, there is usually a strong preference for a monocular procedure to avoid surgery on the single seeing eye. Thus, we confined surgery to visually poor eyes, and performed a medial rectus muscle resection with a mean of 10.3 mm (range, 9-11 mm) and a lateral rectus muscle recession with a mean of 12.8 mm (range, 10-14 mm) in 4 adult sensory exotropia patients who had a mean deviation of 82.3 PD (range, 75-90 PD). The mean postoperative angle of exodeviation was 2.0 PD (range, ortho-8 PD). The limitation on abduction was not disfiguring. Other expected disfigurements, such as narrowing of the palpebral fissure or enophthalmos, were not conspicuous. The mean follow-up period was 4.5 months (range, 3-7 months). In large-angle sensory exotropia, instead of additive surgery on the seeing eye, supermaximal medial rectus resection and lateral rectus recession only on the visually poor eye is a clinically feasible surgical option.

Subretinal Fluid Collection in Patient With Non-Arteritic Anterior Ischemic Optic Neuropathy: A Case Report

PURPOSE: To report a patient with non-arteritic anterior ischemic optic neuropathy with submacular fluid and peripapillary swelling. CASE SUMMARY: A 53-year-old patient visited our clinic complaining of acute visual loss in the right eye which began two days previously. The patient had no clinical history of ocular pain on eye movement. A relative afferent pupillary defect was observed in the right eye. Fundoscopic examination showed optic disc edema and an elevated macular lesion (1 disc diameter). Fluorescein angiography (FAG) revealed blocking by serous detachment in the peripapillary area in the early phase and peripapillary leakage in the late phase. Spectral domain optical coherence tomography (SD-OCT) showed submacular fluid and peripapillary swelling. Intravenous steroid injection was administrated. After five days of treatment, visual acuity improved to 0.2; one month later, visual acuity was 0.5. subretinal fluid absorption was observed with remaining lipid deposits. CONCLUSIONS: In non-arteritic anterior ischemic optic neuropathy, submacular fluid accumulation can occur due to destruction of retinal glial cells. Accumulation of submacular fluid can induce sudden visual loss and may predict visual prognosis. The macular area requires careful evaluation in non-arteritic anterior ischemic optic neuropathy patients.

Multifocal Visual Evoked Potential in Normal Subjects

PURPOSE: To introduce the clinical utility of multifocal visual evoked potential (mfVEP) and to assess the waveform from normal Korean subjects. METHODS: mfVEP with 4 channel recording was performed using the RETIscan(R) system (Roland Consult, Wiesbaden, Germany) for 25 eyes of 25 normal subjects. Amplitudes and implicit times were obtained from ring-shaped 6 areas and 4 sectors. To investigate the false-positive ratio of the examination, stimuli were given with one-half of the CRT monitor completely covered and the results were compared. RESULTS: Amplitudes of P1, N2 were larger in the central 10degrees area than other areas (p<0.001). Amplitudes were reduced and implicit times were prolonged on peripheral areas. P1 amplitudes were larger in the inferior field. Waves with large amplitudes by noise were recorded in 13.7% of covered areas. CONCLUSIONS: mfVEP is useful tool to detect local optic nerve damage and rule out the non-organic cause of visual field defect. However, mfVEP results are difficult to interpret due to noise and poor patient cooperation. Standardization of mfVEP is necessary for its application.

A Case of Candida Parapsilosis Keratitis With Atypical Presentation

PURPOSE: To report a case of Candida parapsilosis keratitis with atypical presentation demonstrated by subepithelial white dot deposits without peripheral inflammatory reaction. CASE SUMMARY: A 45-year-old woman with Stevens-Johnson syndrome had used topical corticosteroid and bandage contact lens due to recurrent epithelial defect and keratitis. Multiple subepithelial white dot deposits were revealed on the central corneal area without surrounding inflammation. The corneal lesion was improved after epithelial debridement with topical antibiotics and steroid eyedrops. A few months later, however, the corneal lesion recurred. Smear cytology was performed, and yeast-formed fungi and pseudohyphae were found. C. parapsilosis was identified in the culture study. Therefore, the topical steroid was withdrawn and 0.15% topical Amphotericin was applied. The corneal lesion improved and corneal opacity did not progress. CONCLUSIONS: The case reported in this study is C. parapsilosis keratitis with multiple subepithelial white dot deposits without typical presentations of fungal kertitis. Although no typical infectious indication was evident, infection should be suspected in patients who show abnormal corneal lesion under immunosuppressive treatment.

A Clinical Applications of Photopic Negative Response (PhNR) for the Treatment of Glaucoma and Diabetic Retinopathy

PURPOSE: To determine the clinical utility of using photopic negative response (PhNR) by comparing the parameters for normal, primary open angle glaucoma (POAG) and diabetic retinopathy (DR). METHODS: Electroretinography (UTAS E-3000) was performed in 12 normal, 12 POAG, and 12 DR subjects. Amplitudes and implicit times for PhNR were compared among the three groups. The mean deviation (MD) and pattern standard deviation (PSD) were evaluated using standard automated perimetry (SAP). The mean retinal nerve fiber layer (RNFL) thickness and cup-disc ratio were measured using optical coherence tomography. RESULTS: The a-waves and b-waves were not different among the three groups. However, compared to normal subjects, the PhNR amplitudes were reduced, and the PhNR implicit times were prolonged in the POAG and DR patients (p<0.001, p<0.001). The MD and RNFL thickness were correlated with the amplitudes and implicit times for the PhNR. CONCLUSIONS: PhNR may be useful for the detection of inner retinal dysfunction, which is seen in patients who have glaucoma or diabetic retinopathy.

Combined Therapy of Intravitreal Bevacizumab and Posterior Subtenon Triamcinolone Acetonide Injection in Diabetic Macular Edema

PURPOSE: To investigate the outcomes of the combined therapy of intravitreal bevacizumab (IVB) and posterior sutbtenon triamconolone acetonide (STTA) injections as compared to single injections of each in patients with diabetic macular edema (DME). METHODS: IVB injection (IVB group), STTA injection (STTA group) and combined therapy injection (combined group) were performed randomly for 90 eyes (83 patients) diagnosed with DME. Changes in central macular thickness (CMT), best corrected visual acuity (BCVA) and intraocular pressure (IOP) were compared among groups prospectively at pre-injection and one, three and six months after injection. RESULTS: Reduction of CMT and improvement of BCVA were maintained for three months after treatment in all groups, but CMT and BCVA deteriorated at six months after treatment. The combined therapy group revealed significant reductions in CMT and improvement of BCVA (p=0.003, p=0.021, respectively) for the first month compared to the single treatment group. Elevated IOPs were found in three cases and there was no endophthalmitis or retinal detachment. CONCLUSIONS: The combined therapy injection showed significant early improvements in CMT and BCVA for one month. Additionally, the combined therapy revealed similar outcomes as compared with each single treatment after three months.

Photopic Negative Response (PhNR) in Normal Subjects

PURPOSE: To evaluate the nature of photopic negative response (PhNR) in normal subjects. METHODS: The electroretinogram (ERG) waves were recorded in 52 eyes of 26 normal subjects with UTAS E-3000(R) (LKC Technologies Inc., Gaithersberg, MD, USA). Photopic cone response was obtained for analysis from a white flash with white background illumination (group 1) and a red flash with blue background illumination (group 2), after stimulations ranging from 0.007674 cd.s/m2 (-25dB) to 7.736 cd.s/m2 (5dB) with a 5dB interval. RESULTS: PhNRs were observed in all 52 eyes in group 1 stimulated with the white flash at 0.9933 cd.s/m2 (-4dB). PhNRs were also observed in all 52 eyes in group 2 at 2.4297 cd.s/m2 (0dB) after stimulation with the red flash. There was correlation between the amplitudes of PhNR and intensity of stimuli (p<0.001). Implicit times of PhNR were correlated with age in both groups, but amplitudes decreased with age in group 1. CONCLUSIONS: The amplitudes of PhNR were correlated with intensity of stimuli and age had an influence on PhNR. Standardization of examination conditions is necessary when recording PhNR.

The Effect of Intracameral Triamcinolone Acetonide Injection on the Cornea in Rabbits

PURPOSE: To evaluate the safety and effects of intracameral triamcinolone acetonide injection in rabbit corneas. METHODS: Triamcinolone acetonide in the amounts of 0.5, 1, and 2 mg was injected into the anterior chamber of rabbit eyes, and intraocular pressure, corneal thickness, and endothelial cell counts were evaluated on days 1, 3, 7, 14, and 28. Twenty-eight days after triamcinolone acetonide injection, the eyes were enucleated and examined after TUNEL staining. RESULTS: No statistically significant differences were found among control, 0.5, and 1 mg triamcinolone-injected eyes in central corneal thickness, endothelial cell density, pleomorphism, and polymegathism. There was no difference between 2 mg triamcinolone-injected eyes and control eyes for corneal thickness and cell density, but there were statistically significant differences between these two groups for pleomorphism (p<0.05) and polymegathism (p<0.05). CONCLUSIONS: The results of this study suggested that intracameral injections of 0.5~1 mg of triamcinolone acetonide are beneficial and cause no toxic effects on corneas.