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.

The Efficacy of Photodynamic Therapy With Verteporfin for Polypoidal Choroidal Vasculopathy: Retrospective Multi-Center Case Study

PURPOSE: To evaluate the efficacy of photodynamic therapy (PDT) with verteporfin for polypoidal choroidal vasculopathy (PCV) in Korean patients. METHODS: Clinical data of patients who were treated with PDT for PCV and followed up for more than 6 months were collected from 14 hospitals around the country. The changes in the best corrected visual acuity, angiographic outcome, retinal thickness measured by optical coherence tomography (OCT), and adverse effects of treatment were evaluated. RESULTS: Eighty six patients (86 eyes) were recruited (male: 75.6%, age: 65.9+/-8.3 years, mean follow-up: 14.8+/-10.2 months). The mean logMAR visual acuity at baseline was 0.55+/-0.32 and did not show any statistically significant difference from the final mean logMAR visual acuity (0.53+/-0.54) (p=0.639). The mean treatment session number of PDT was 2+/-1.2. Visual acuity stabilized or improved in 70.9% of patients. Visual acuity improved by more than 2 lines in 33 eyes (38.4%) and worsened by more than 2 lines in 21 eyes (24.4%) of patients. Vascular leakage decreased in 62.5% of patients in fluorescein angiography and polypoidal lesions disappeared or were reduced in 57.3% of patients in indocyanine green angiography. There was no systemic adverse effect of PDT, but increased subretinal hemorrhage after PDT occurred in 10 eyes (11.6%). CONCLUSIONS: In polypoidal choroidal vasculopathy, photodynamic therapy with verteporfin is safe and effective for preserving visual acuity and reducing vascular leakage and retinal thickness.

Photodynamic Therapy for Chronic Central Serous Chorioretinopathy: Multicenter Study of 65 Cases

PURPOSE: To determine the effect of photodynamic therapy (PDT) on patients with chronic central serous chorioretinopahty (CSC). METHODS: This was a retrospective multicenter study. We collected demographic and ophthalmic data for patients with chronic CSC who were treated with PDT from 16 institutions in Korea. The best corrected visual acuity (BCVA), ophthalmoscopic finding and optical coherence tomography at baseline and follow-up visits were compared longitudinally. RESULTS: Sixty-five eyes of 65 patients were recruited. Males (51 patients, 78.5%) outnumbered females (14 patients, 21.5%). The mean age was 46.4+/-10.0 years of age (28~69). By 1 month, mean BCVA improved from 0.47 to 0.37 (logarithm of the minimum angle of resolution) (P <0.01). This BCVA increased throughout 6 months. Subretinal fluid resolved partially or completely in 89.1% of the patients. Central macular thickness (CMT) decreased from 303.4 to 168.7 micrometer. The amount of change in CMT after PDT was correlated to the female sex and prePDT CMT. At 3 months after PDT, the amount of change in BCVA was significantly related to that of change of CMT (p <0.05). Adverse events were reported in 4 cases, however, most were mild. CONCLUSIONS: PDT was effective and safe for treating chronic CSC.

Photodynamic Therapy for Choroidal Neovascularization Secondary to Age-Related Macular Degeneration

PURPOSE: To investigate the effects of repeated photodynamic therapy (PDT) for subfoveal choroidal neovascularization secondary to age-related macular degeneration (AMD) in Korean patients. METHODS: Clinical data of patients who were treated with repeated (3 times or more) PDT for subfoveal choroidal neovascularization secondary to AMD and followed up for more than 6 months were collected from 17 hospitals around the country. Visual outcomes at 12 and 24 months, follow-up were compared between subtypes of choroidal neovascularization. The factors related to final visual prognosis and PDT-related adverse effects were evaluated. RESULTS: 244 patients (244 eyes) were recruited (male: 60%, age: 67.7+/-9.1 years). The portion of patients with predominantly classic, minimally classic, and occult without classic choroidal neovascularization was 57%, 13%, and 24%, respectively and that of patients with visual improvements or less than moderate visual loss at 24 months follow-up were 28%, 38%, 30% and 47%, 56%, and 65%, respectively. Baseline visual acuity and age were significantly related to the final visual prognosis (p<0.05). PDT-related adverse events developed in 15 (6.1%) patients, but most were mild and transient. CONCLUSIONS: Repeated PDT for subfoveal choroidal neovascularization secondary to AMD has effects comparable to those of previous prospective, controlled trials without any significant safety concerns in Korea.

Risk Factors for Diffuse Diabetic Macular Edema as Classified by Optical Coherence Tomography

PURPOSE: Recently diffuse diabetic macular edema has been morphologically classified by optical coherence tomography. This study was conducted to examine the difference of risk factors of the classified types of diffuse macular edema. METHODS: The subjects included 93 people who were diagnosed with non-insulin dependent diabetes. We diagnosed the presence of diabetic macular edema with slit lamp fundus examination and used OCT for the classification of diffuse macular edema. We examined the differences in epidemiological risk factors in non-diabetic macular edema patients after diabetic macular edema patients were examined with fluorescein angiography to confirm diffuse macular edema. RESULTS: Diabetic macular edema was classified into 4 types using OCT. Compared with patients without macular edema, sponge-like macular edema - related epidemiological risk factors included diabetic nephropathy, cystoid macular edema was related to HbA1c, serous macular detachment was related to treatment of diabetes by insulin, and posterior hyaloid raction was related to diastolic blood hypertension. CONCLUSIONS: In the present study, differences in epidemiological risk factors were related to the occurrence of a type of diffuse macular edema.

The Expression of TGF-beta Isoform mRNA in the Cataract Lens Epithelial Cell

PURPOSE: Transforming growth factor (TGF)-beta is recognized as being associated with cataractogenesis. We quantitated the mRNA expression of TGF-beta isoforms in cataractous crystalline lens to determine the effect of the isoforms on cataractogenesis. METHODS: With lens epithelial cells from thirty eyes in thirty patients, the mRNA expressions of TGF-beta1, beta2 and beta3 were quantitated by real-time SYBR Green polymerase chain reaction and the results were compared according to cataract type and presence of diabetes mellitus. RESULTS: Each isoform mRNA of TGF-beta was expressed: TGF-beta3 in all 30 eyes, TGF-beta1 in 29 eyes (96.7%), with the exception being one diabetic senile cataract, and TGF-beta2 in 9 eyes. The amount of TGF-beta1 mRNA expression was significantly lower in the diabetic cataracts than in the non-diabetic cataracts (P=0.056). CONCLUSIONS: TGF-beta was associated with cataractogenesis. It is significant that the expression of TGF-beta2 mRNA was decreased in all cataracts. The decrease of TGF-beta1 mRNA expression was more meaningful in the diabetic cataracts than in the non-diabetic cataracts.

Surgical results of Vitrectomy for Diabetic Macular Heterotopia

PURPOSE: This study aimed to investigate visual prognosis and postoperative complications of vitrectomies for macular heterotopia, and compare it with that of tractional macular detachment. METHODS: Medical records of 10 eyes which had undergone pars plana vitrectomy for diabetic macular heterotopia and 21 eyes which for diabetic tractional macular detachment in the 202 patients who had been diagnosed as proliferative diabetic retinopathy at Pusan Paik hospital from January, 1995 to december, 1998 were reviewed to study their clinical features, complications, visual outcome. RESULTS: Final postoperative improved visual acuity was documented in 70% of patients with macular heterotopia and 38% of patients with tractional macular detachment (P>0.05). Postoperative vitreous hemorrhage and cataract developed in 20% and 10% of patients with macular heterotopia and 19% and 10% of patients with tractinal macular detachment. Patients with macular heterotopia experienced retinal detachment and macular hole. Patients with tractional macular detachment experienced increased IOP, neovascular glaucoma and phthisis. CONCLUSIONS: Although we could not revealed statistical significance, the surgical results of vitrectomy for diabetic macular heterotopia was better than that of diabetic tractional macular detachment and in the view of vision and complications, diabetic macular heterotopia was more favorable.

Chroidal Circulation in Central Serous Chorioretinopathy using Indocyanine Green Angiography

Fluorescein angiography(FAG)has been used to identify retinal circulation, but it has limitations to detect any other ocular circulations. Recently new technology developed indocyanine green angiography(ICGA), which allows better enhanced imaging of the ocular structures, such as choroid and other subretinal structure as compared with FAG. The authors investigated the characteristic findings of ICGA in central serous chorioretinopathy, comparing with those of FAG finding. After performing ICGA and FAG in 74 patients(74 eyes)with acute forms of central serous chorioretinopathy, as follows, arterial filling, leaking pattern. ICGA study showed presumed choroidal hyperpermeability in the 42 eyes(56.7%), which are no leak on the FAG. ICGA study showed focal hyperfluorescence detected by FAG, corresponding to presumed choroidal hyperpermeability in 65 eyes(87.8%). Delayed choroidal filling areas were showed in ICGA(49 eyes, 66.2%). ICGA study showed presumed choroidal hyperpermeability in the 32 eyes(43.2%)corresponding leak noted on the FAG. Numbers of hyperfluorescent lesion was two in 40 eyes(54.1%)on the ICGA. Most of focal leaking areas were located in superonasal area. In central serous chorioretinopathy the authors suggest that choroid is the primary pathologic focus, the choroidal circulatory dysfunction and vascular hyperpermeability can be assumed to be a causative role in structural abnormality of the retinal pigment epithelium. In conclusion we think that the ICGA is effective method for diagnosis and treatment of the central serous chorioretinopathy.

The Surgical Outcome of Cataract Exraction After Pars Plana Vitrectomy

This study aimed to investigate the frequent intraoperative and postoperative complications and visual outcome of phacoemulsification or extracapsular cataract extraction after vitrectomy. The authors reviewed the medical records of 30 paitients who had undergone pars palana vitrectomy and followed by cataract extraction from January, 1996 to January, 1998, and had been followed up for 3 months or longer. Associated retinal diseases included complication of diabetic retinopathy (11 cases,36.7%), vitreous hemorrhage from branch retinal vein occlusion (6 cases, 20.0%), proliferative vitreoretinopathy (4 cases,13.3%). Mean interval between two operations was 21.0 months. The most commom intraoperative complication was anterior chamber depth fluctuation (4 cases).In a few cases,we had radial tear (3 cases) in lens capsule or miosis (2 cases). The most common early postoperative complication was corneal edema and late complication was posterior capsular opacity.Postoperative visual acuity remained still or improved in 28 cases (93.37%) at postoperative 3 months. In conclusion cataract extraction after vitrectomy may be performed safely with few complications. Visual outcome was favarable but was mainly dependent on previous vitreoretinal patholgy.

The Clinical Study of Retinal Detachment Associated with B ranch Retinal Vein Occlusion

The branch retinal vein occlusion is the second most common retinal vascular disease after diabetic retinopathy. Complications such as macular edema, retinal neovascularization, vitreous hemorrhage, epiretinal membrane may be associated. But, the retinal detachment may occur rarely in BRVO patients. We studied the clinical features of retinal detachment associated with branch retinal vein occlusion. We reviewed the medical records of 15 retinal detachment patients associated with branch retinal vein occlusion. Mean age was 54.7 years old and 10 patients(66.7%) were female. Hypertension was associated in 13cases(86.7%). The duration between the development of BRVO and the development of retinal detachment was shorter than 4 years in all cases and shorter than 2 years in 9 cases(60.0%). Retinal break was identified in 14 cases(93.3%), among which 13 cases(92.2%) were located inside the lesion of branch vein occlusion. The epiretinal membrane was frequently combined 8 cases(53.3%). The preoperative laser photocoagulation was done in 4 cases(26.7%). The primary surgical procedures included scleral buckling in 8 cases(53.3%), pars plana vitrectomy in 6 cases(40.0%), and scleral buckling with pars plana vitrectomy in 1 case(6.7%). Three cases(20.0%) required reoperations. The postoperative complications included the progression of cataract in 6 cases(40.0%), iatrogenic retinal tear in 3 cases(20.0%), epiretinal membrane in 2 cases(13.3%), and proliferative vitreoretinopathy in 1 case(6.7%). The anatomic retinal reattachment was achieved in 14 cases(93.5%) and the visual recovery in 11 cases(73.3%).

Comparision of Clinical Findings between Phakic Retinal and Pseudophakic Retinal Detachment

We reviewed our medical records of primary retnal detachment(239 patients, 243 eyes) to compare the clincal findings of phakic retinal detachment(206 eyes) and pseudophakic retinal detachment(37 eyes). Pseudophakic retinal detachment was more common in male(73.0%) than in female(27.0%) and occurred more frequently in aged 60 years or more than phakic retinal detachment(10.4%)(P<0.001). Associated ocular finding such as high myopia(35.0%), peripheral retinal degeneration(23.3%0, retinal tear in fellow eye(5.8%) were more commonly seen in phakic retinal retinal detachment. Rupture of posterior capsule(40.5%), high myopia(18.9%), small pupil(13.5%) were associate with pseudophakic retinal detachment. In pseudophakic retinal detachment, more than 3 quadrant retinal detachment(73.0%) and macular involvement(78.4%) were more common than in phakic retinal detachment(P<0.01), but atropic hole(29.7%), or 2 or more retinal break(10.8%) were less common than in phakic retinal detachment(P<0.01) where the success rate of first operation(59.5%) and the overall success rate(81.1%) were lower in paeudophakic retinal detachment than phakic retinal detachment. The degree of visual recovery was nearly equal between two.

The Clinical Study of Macular Hole Retinal Detachment Associated with Peripheral Retinal Hole

Most of the macular hole retinai detachinents are limited to the perimacular area. Therefore, we must look for the peripheral retinal hole when the macular hole retinal detachment extends beyond equator. And the principle of operation should be on the peripheral retinal hole rather than macular hole. Authors studied the clinical feature of macular hole retinal detachment associated with the peripheral retinal hole. Among the 39 macular hole retinal detachment patients, peripheral hole was found in 12 patients (30.7%). Sex distribution was the same and mean age was 55.9 years old. Retinal detachment was not diagnosed for more than I month in 7 cases (58.4%). Nine cases (75.0%) were extensive retinal detachments extending beyond 3 quardrants. Nine cases (75.0%) had one peripheral hole and most of peripheral holes were found on the ternporal side. Associated diseases were cataract (5 cases, 38. 5%) and high myopia (5 cases, 38.5%). In 4 cases (33.3%) hole was found on the opposite side. Among the 12 macular hole retinal detachment patients, 11 operations were performed with the technique of gas injection and scleral buckling which lead to successful attachment in 5 cases (41.7%). Among the 7 cases in which reoperations were needed, 3 cases (42.9%) were recurred in 3 months. In 8 cases (66.7%) there were improvements of post-operative visual acuity.

A Case of Giant Retinal Tear in Atopic Dermatitis

Retinal detachments occuring in atopic dermatitis patients are usually associated with tears of peripheral retina or nonpigmented epithelium of the ciliary body or retinal dialysis. It has been considered relatively rare, however, its clinical reports have been increasing recently. We experienced a case of atopic dermatitis with retinal detachment of right eye caused by giant retinal tear and retinal tear of left eye in 23-year-old male, we could obtain successful result by treating his right eye with scleral buckling procedure and intravitreal gas injeciton.

Hemorrhagic Retinopathy Associated with Sexual Activity

A 70 year old male patient experienced a sudden visual acuity decrease in his left eye below 0.1 with preretinal, retinal and subretinal hemorrhage after excessive sexual activity. Four months later, his vision improved in the affected eye without any treatment. Eight months later, there was an area of organized sugbretinal hemorrhage remained around vascular arcade. We report this case with case review.

Characteristics of Retinal Detachment in Pseudophakic Eyes

To evauate the clinical characteristics of pseudophakic retinal detachments, 20 eyes were reviewed retrospectively. We identified the following characteristics of pseudophakic retinal detachment ; age in period of 40 (35%) and 60(30%), male(65%), rupture of posterior capsule (intraoperative and YAG laser capsulotomy)(50%). 15(75%) of the 20 pseduophakic retinal detachment eyes occured within 24months from the time of cataract surgery. Within 6 months after cataract surgery, the incidence of retinal detachment after posterior capsule rupture was higher than after uncomplicated cataract surgery, but there was no statistical significance. Retinal breaks were not detected in 7 eyes(35%). Retinal breaks were principally located in the upper quadrant in 6 eyes, horsehoe tear and atropic hole were most commonly encountered. More than 3 quadrant retinal detachment was observed in 80% of patients at the time of presentation and macular detachment, in 75%, Anatomic success rates were 85%. All of the failures were due to proliferative vitreoretinopathy.

Differentiations of Retinal Detachment and Vitreous Membrane Using Color Doppler Imaging

In eyes with media opacity and equivocal ultrasonographic findings, we can differenciate retinal detachment from vitreous membrane using color doppler imaging(CDI), which allows the display of blood flow characteristics on conventional ultrasonography. The authors performed high resolution Bscan ultrasonography and color doppler imaging simultaneously in 31 eyes with opacity of ocular media, and their intraoperative characteristics and post operative results were evaluated. In 30 eyes with retinal detachment or vitreous membrane, 7 eyes(23%) had equivocal ultrasonographic findings and needed color doppler imaging. Nine eyes(75%) had positive color signal in 12 eyes with retinal detachment, whereas 3 eyes negative. 17 eyes(94%) had negative color signal in 18 eyes with vitreous membrane, 1 eye with proliferative diabetic retinopathy had positive. In conclusion, color doppler imaging is a useful diagnostic method in differentiating retinal detachment from vitreous membrane.

The Management of Giant Retinal Tear by use of Perfluorodecalin(DK-line(R) and Silicone Oil

Recently, various types of perfluorocarbon liquids are used to treat the retinal detachment due to giant tear. The authors treated 3 cases of giant retinal tear with perfluorodecalin and silicone oil. After pars plana vitrectomy, posterior retinal flap was unfolded by injection of perfluorodecalin and exchanged it for silicone oil subsequently. Silicone oil was removed after 4 weeks. Endophotocoagulation and scleral buckling were taken in all cases, and lensectomy for normal lens in 1 case. After the close observation for 6 months or more, retina was reattached successfully in 2 of 3 cases. Because of proliferative vitreoretinopathy, reinjection of silicone oil was needed in 1 case. Perfluorodecalin and silicone oil were useful materials to reattach the folded retinal flap of giant retinal tear.

Clinical Analysis of the Hemispheric Retinal Vein Occlusion

Hemispheric retinal vein occlusion(HSRVO) involves the venous return from approximately one-half of the retina and have characteristics of both central retinal vein occlusion and branch retinal vein occlusion. We have clinically analized in 20 patients that were classified as the HSRVO from June 1988 to December 1993 in the aspect of spheric distribution of diseased retina, sex, age, associated systemic diseases, ocular sequale. The patients were comprised of 6 males and 14 females. The average age was 57.5 years. There were no significant differences in superior and inferior spherical distribution. The most common associated systemic disease was hypertension(40%) and the next was diabets mellitus(20%). As sequle, macula edema in 9 cases and retinal neovascularization and vitreal hemorrhage in 5 cases were found. But iridis rubeosis or neovascular glaucoma was not found. Clinically, HSRVO is closer to branch retinal vein occlusion than central retinal vein occlusion.

Macular Ischemia in Temporal Branch Retinal Vein Occlusion: Fluorescein angiographic classification and Visual prognosis

There have been various report about visual prognosis in branch retinal vein occlusion according to location and size of occluded vessel, status of perifoveal capillary ring, presence of retinal ischemia and hypertension. We therefore sought to determine prognostic indicators of BRVO by observing retrospectively the natural course of the BRVO with macular ischemia. To do that, we devide 63 eyes with BRVO into groups according to the macular perfusion status on high-quality fluorescein angiography. The patients without broken capillary ring exhibited better initial, final visual acuity and visual improvement. The patients with the extent of macular ischemia under 90degree exhibited better initial and final visual acuity but same visual improvement. There were no statistically significant difference in visual prognosis according to the status of perifoveal capillary ring, extent of macular ischemia and presence of hypertension.

Surgical Result of Vitrectomy in Ocular Trauma

We reviewed 49 patients(50 eyes) who had undergone pars plana vitrectomy for the traumatized eyes during the last 4 years. We divided patients into 4 groups according to the characteristics of ocular injuries-anterior segment Injury, posterior penetrating injury, intraocular foreign body and blunt injury. We analyzed surgical results and compared surgical outcomes according to timing of vitrectomy performed(within 2 weeks VS more than 2 weeks after trauma). Anatomical success was achieved in 36 eyes(72.0%) and functional success was achieved in 23 eyes(46.0%). The main causes of functional and anatomical failure were macular pucker and phthisis bulbi respectively. The anatomical and functional success rates were higher when vitrectomy was performed within 2 weeks after trauma. In posterior penetrating injury group, however, anatomical success rate was lower when vitrectomy was performed more than 2 weeks after trauma. The frequency of retinal detachment was higher when vitrectomy was performed more than 2 weeks after trauma. In cases of intraocular foreign body, retinal detachments were developed in all patients after vitrectomy performed more than 2 weeks after trauma. If vitrectomy is required for patients with ocular injury, we suggest vitrectomy within 2 weeks after frauma for better chance to perserve the globe and for salvaging vision.