A Case of Eagle's Syndrome after Blunt Neck Trauma / 대한이비인후과학회지

Eagle's syndrome has various symptoms at cervico-facial lesion. Recently, we have experienced a case of Eagle's syndrome that developed after a blunt neck trauma. A 51-year-old man presented with a click sound when he turned his head to the right. The symptom had developed after a traffic accident that occurred 2 months ago. Physical examination revealed a long styloid process that was easily palpable and burging out into the right tonsillar fossa. Radiologic examination did not reveal any presence of fracture on stylohyoid complex including stylohyoid ligament. We underwent a transoral resection of styloid process and released a stylohyoid ligament. The patient immediately experienced a relief of the symptom following the operation. It might be elucidated that the patient had an elongated styloid process and that the neck trauma had developed due to the dislocation or pseudoarticulation between stylohyoid ligament and the hyoid bone. Transoral resection of styloid process released pseudoarticulation and relieved the symptom.

The Objective Change of the Eyelid after Upper Blepharoplasty

PURPOSE: To evaluate the morphological changes in the external eyes after upper blepharoplasty. METHODS: Twenty-six eyes of 13 patients undergoing upper blepharoplasty from May 2002 to May 2003 were selected. All surgeries were performed by one surgeon. MRD1, MRD2, interpalpebral fissure height, and levator function test were each measured twice, and the averages were calculated. Likewise, significant changes were checked before and after the operation. The subjects were divided into two groups. For group A (n=12), a double line suture was stitched at the levator aponeurosis, which was directly superior to the tarsal plate. In group B (n=14) the suture was stitched at a levator aponeurosis 3 mm superior to tarsal plate. The delta levator function (postoperative mean levator function minus preoperative mean levator function) measurements were calculated and compared between the two groups. RESULTS: The MRD1 was 2.04+/-0.75 (mean+/-SD) before the operation, and 2.0+/-0.81 after the operation. MRD2 was 5.23+/-0.75 before the operation, 5.35+/-0.54 after operation. Interpalpebral fissure height was 7.27+/-0.38 before the operation and 7.35+/-0.63 after the operation. There were no statistically significant factors before and after the operation in MRD1, MRD2 and interpalpebral fissure height. The levator function was 14.04+/-1.80 before versus 16.19+/-1.58 after. This increase was statistically significant (p<0.01, Wilcoxon signed ranks test). The delta levator function was 1.58+/-0.90 for group A and 1.96+/-1.36 for group B. CONCLUSIONS: After upper blepharoplasty, the measurement of levator function increased significantly.

A Modified Iris Repair Technique and Capsular Tension Ring Insertion in a Patient with Coloboma with Cataracts

PURPOSE: We describe our successful experience using a capsular tension ring (CTR) and iris repair during cataract surgery in a patient with bilateral coloboma. METHODS: A 67-year-old woman had no history of trauma, but had zonular deficiency and inferonasal iris defects in both eyes. An extracapsular cataract extraction and intraocular lens (IOL) scleral fixation was performed in the left eye. A CTR was implanted in the right eye through a sclerocorneal incision. After the IOL was placed centrally in the capsular bag, two paracenteses were made at the limbus (5 o'clock and 7 o'clock). A long, straight needle was passed through the 7 o'clock paracentesis site into a angled, blunt tipped 27 gauge needle inserted from the 5 o'clock paracentesis. The two needles were pulled out at 5 o'clock. After inserting the long needle into the blunt tipped needle at 7 o'clock, both were passed back through the 7 o'clock paracentesis site. The needles were pulled out again at the 5 o'clock paracentesis site tied. Equal tension was used to tie both sides. RESULTS: Visual acuity improved to 20/20 in the right eye. CONCLUSIONS: Both capsular tension ring implantation and iris repair was successfully performed at the time of cataract surgery in a coloboma patient, which resulted in improvements in visual function and cosmesis.

Visual Acuity Prediction with the Illuminated Near Card in Cataract Patients

PURPOSE: To determine the accuracy of predicting potential visual acuity in cataract using the illuminated near card (INC). METHODS: Thirty-nine eyes (34 patients) having cataract were studied prospectively by comparing the postoperative distance Snellen acuity to the visual acuity (VA) obtained preoperatively using the INC viewed through a pinhole. RESULTS: The INC predicted postoperative acuity within two Snellen lines in 20 of 39. The accuracy between predicted and achieved acuities was follows: 61.5% in patients with a preoperative acuity of better than 0.3, 53.8% of better than 0.1, 50.0% of better than 0.05 and 28.6% of worse than 0.05. The disparity between INC results and postoperative VA was 3.89 lines (cortical opacity, nucleosclerosis, subcapsular opacity), 2.48 lines (cortical and subcapsular opacity), 2.08 lines (cortical opacity, nucleosclerosis), 1.8 lines (nucleosclerosis only), 3.3 lines (nucleosclerosis, subcapsular opacity), 1.6 lines (subcapsular opacity) and 3.0 lines (the others). CONCLUSIONS: The INC is easy to use and is a fast and accurate measurement instrument for predicting postoperative VA after cataract operation.

Comparison of Scleral Tunnel and Clear Cornea Incision in Phacoemulsification Combined with Pars Plana Vitrectomy

PURPOSE: To compare the results of two different incision METHODS: scleral tunnel vs clear cornea in cases phacoemulsification and posterior chamber intraocular lens implantation combined with pars plana vitrectomy. METHODS: Between August 2003 and August 2005, 61 eyes with cataract and vitreoretinal diseases were treated by phacoemulsification combined with pars plana vitrectomy and PC-IOL implantation. Preoperative demographic data and postoperative best-corrected visual acuity (BCVA), astigmatism change, and complications were analyzed. RESULTS: The mean age of patients in the scleral tunnel incision (Group 1) and clear corneal incision (Group 2) was 57.09+/-13.72 and 58.83+/-11.83 years respectively. Diabetes mellitus was the most common underlying disease resulting in vitreous opacity. Vision improved in 82% of Group 1 and 78% of Group 2. There was a significant difference in the postoperative astigmatic changes between Group 1 and 2 (1.37+/-1.13D vs 0.78+/-0.67D). No discernible differences such as recurrent vitreous hemorrhage, inflammation in anterior chamber, increased intraocular pressure or iris changes were noted between the two groups. CONCLUSIONS: Although there was no difference in the postoperative BCVA, two different incision methods yielded significant different postoperative astigmatic changes.

Comparison of the Clinical Diagnosis of Diabetic Macular Edema with Diagnosis by Retinal Thickness Analyzer

PURPOSE: To evaluate the correlation between diabetic macular edema diagnosed with stereoscopic slit-lamp and retinal thickness analyzer (RTA). METHODS: Diabetic macular edema diagnosed with stereoscopic slit-lamp was compared to indices of RTA in 50 eyes of 32 persons which were diagnosed clinically with diabetic retinopathy. RESULTS: From stereoscopic slit-lamp results, diabetic macular edema was present in 39 of 50 eyes, and absent in 11 of 50. Foveal average thickness out of the RTA indices was 209.7+/-58.5 micrometer from observing diabetic macular edema clinically and 199.4+/-47.3 micrometer from not observing diabetic macular edema clinically. Statistically significant differences were found in average foveal thickness between the 2 groups (p=0.013). CONCLUSIONS: RTA appears to serve as a useful and sensitive tool for the diagnosis of diabetic macular edema.

Neovascularization in Branch Retinal Vein Occlusion Combined with Arterial Insufficiency

The aim of this study is to elucidate the association of neovascularization in branch retinal vein occlusion (BRVO) combined with major arterial insufficiency (MAI), compared with BRVO alone. The authors retrospectively reviewed the charts, color photographs, and fluorescein angiograms of 304 patients (308 eyes) who had BRVO from 1990 to 2002 at Hanyang University hospital. Patients with BRVO combined with MAI and patients with BRVO alone were differentiated by angiographic appearance. Of the 308 eyes, 12 (3.9%) had neovascularization, all of which were in the 56 eyes of the MAI group for which the neovascularization rate was 21.4%. Neovascularization in BRVO was more strongly associated with the non-perfusion caused by MAI, rather than with the extent of the non-perfusion area that originated from retinal capillary obstruction. MAI is considered as a risk factor for neovascularization and hence could be a prognostic factor.

Relationship between Location and Size of Pituitary Adenoma and Visual Field Change

PURPOSE: To evaluate the relationship between the location and size of pituitary adenoma and visual field change. METHODS: Fifty-two patients were diagnosed with pituitary adenoma and underwent tumor resection at the Department of Neurosurgery in our hospital between July 1999 and July 2004. Among them, we retrospectively studied that location and size of pituitary adenoma as related to visual field changes in 29 patients who had credible perimetry results and no other ophthalmologic problems that caused visual field changes. We obtained the information about the size and location of pituitary adenoma using MRI, and performed ophthalmologic examination such as perimetry and fundus examination. RESULTS: There were no visual field changes in 18 patients. The visual field changes observed were as follows; bitemporal hemianopsia in 4 patients who had inferior involvement of optic chiasm; scotoma in one eye and temporal hemianopsia in the other eye in 2 patients who had lateral and inferior involvement; bitemporal superior quadranopsia in 2 patients who had anterior and inferior involvement; and 3 patients showed visual field changes, but they had no optic nerve involvement of pituitary adenoma. The size of adenoma was not exactly related to visual field changes. CONCLUSIONS: These results indicate that visual field changes can be influenced by the location and size of pituitary adenoma.

Photodynamic Therapy with Verteporfin for Anterior Segment Neovascularization in Neovascualr Galucoma

PURPOSE: To evaluate photodynamic therapy (PDT) with verteporfin for iris and angle neovascularization in eyes with neovascular glaucoma. METHODS: We treat a patient who had neovascular glaucoma with iris and angle neovacularization and showed reduction of intraocular pressure (IOP) and the obliteration of neovascularization after PDT. PDT was performed following the treatment parameters used in age-related macular degeneration. The laser was directed at the anterior chamber angle and iris surface using a Goldmann three-mirror contact lens. Follow-up examination was performed 1, 2, 3, 5, 7, and 8 weeks after PDT, and included visual acuity, IOP, and iris fluorescein angiography (7 weeks after PDT). RESULTS: Two months after PDT, we observed a reduction of IOP and the improvement of iris fluorescein leakage. IOP diminished considerably after 1 week, and showed subsequent tendency toward stabilization without additional antiglaucoma medicine. CONCLUSIONS: Photodynamic therapy can be used safely and effectively in the early phase of neovascular glaucoma to achieve the obliteration of iris and angle neovascularization and induce IOP reduction.

The Factors Related with Epithelial Healing after Vitrectomy for Proliferative Diabetic Retinopathy

PURPOSE: To evaluate the factors that contribute to protraction of epithelial damage after vitrectomy for proliferative diabetic retinopathy (PDR). METHODS: We retrospectively studied factors that may be related to protraction of epithelial damage and recovery time after epithelial damage in 76 eyes of 66 patients who underwent vitrectomy for PDR in our hospital between August 2003 and August 2004. The 76 eyes in this study were divided into two groups: 17 eyes (22.4 %) with epithelial damage persisting for more than 14 days after vitrectomy (protracted group) and 59 eyes (77.6 %) without epithelial damage or signs of epithelial damage that disappeared in less than 13 days after vitrectomy (non-protracted group). We compared factors that may be related to protraction of epithelial damage and recovery time from epithelial damage between the two groups. RESULTS: The average recovery time from epithelial damage was 45.7+/-26.6 days in the protracted group and 2.6+/-2.4 days in the non-protracted group. Intraoperative epithelial debridement significantly delayed epithelial healing in the protracted group (P<0.05). The level of BUN, insulin use, and epithelial defect during surgery were correlated with the duration of epithelial damage (P<0.05). CONCLUSIONS: Our results show that protracted recovery from epithelial damage after vitrectomy for PDR is correlated with impaired renal function, the method of treatment, and epithelial debridement. Therefore, particular attention should be paid to corneal epithelial damage in patients with these factors.

The Effect of Postoperative Intranasal Steroid in Endonasal Dacryocystorhinostomy

PURPOSE: Endonasal dacryocystorhinostomy (DCR) has been performed commonly in patients with chronic epiphora due to nasolacrimal duct obstruction. The most frequent cause of DCR failure is obstruction of the osteotomy site due to inflammation and granuloma. We used postoperative nasal steroid spray to suppress inflammation, and growth of granuloma, and to increase the success rate. METHODS: Between November 2002 and August 2003, 48 patients (55 eyes) underwent endonasal DCR in Hanyang University Guri Hospital. The patients were classified into two groups: those who took nasal steroid spray and those who did not. RESULTS: Thirteen cases showed recurrent epiphora. The total success rate of endonasal DCR was 76.4% (42/55). The success rate of the steroid group at 83.9% (26/31), was higher than that of the non-steroid group at 66.7% (16/24), but the difference was not statistically significant (P=0.20, x2 test). CONCLUSIONS: The nasal steroid spray failed to increase the patency rates in endonasal DCR.

The Clinical Characteristics of Stress Line and the Corrleation with Diabetes Mellitus

PURPOSE: To find the incidence of the stress line, its mechanism, the clinical features and the relationship with diabetes mellitus, and to compare with the results of the other studies. METHODS: A prospective study with 60 consecutive eyes of the 51 patients who had phacoemulsification with IOL (Alcon AcrySof Model MA60BM in 20 eyes and Allergan Sensar Model AR40 in 40 eyes) implantation from October 2002 to March 2003. The presence of stress lines was noted at the end of the operation and at the first and second months after the operation. The linear posterior capsular opacifications(PCOs) were noted during the average 6-month follow-up period. RESULTS: Stress lines were observed 40 eyes (66.6%) among the total 60 eyes. Among the 19 diabetic eyes, 15 (78.9%) had the stress lines. The stress lines were significantly related with the hardness (P = 0.109) and PCO (P = 0.002). CONCLUSIONS: The stress lines didn't influence vision but could be channels to the PCO having an effect on vision. Especially, among the diabetic eyes, stress lines had a significant relationship with the PCOs.

Hypertensive Optic Neuropathy Related to Chorioretinal Lesions

PURPOSE: To investigate the relationship between chorioretinal lesions and papilledema in patients with hypertensive optic neuropathy. METHODS: We analyzed the angiographic findings of 142 patients (284 eyes) who had been diagnosed with hypertensive chorioretinal disease in the ophthalmic outpatient department of our hospital, from March 2001 to December 2003. We classified hypertensive ocular disorders to either the optic disc edema group or the non-optic disc edema group. RESULTS: There were 34 patients with hypertensive optic neuropathy. With an analysis of color photo and angiographic findings, a significant correlation of optic disc edema was seen in Elschnig's spot, prominent watershed zone, and retinal hemorrhage. CONCLUSIONS: Hypertensive optic neuropathy was significantly related to retinal hemorrhage, Elschnig's spot, and prominent watershed zone. We should carefully observe the patients who have these lesions.

A Clinical Study in Transscleral Fixation of Foldable Intraocular Lenses

PURPOSE: To evaluate the results and complications of transscleral fixation of the foldable intraocular lens(IOL). METHODS: We performed a retrospective review of the medical records of 26 patients who had undergone transscleral fixation of acrylic three-piece foldable IOL from January 2002 to April 2004 in our hospital. There were 5 eyes with aphakia, 2 with idiopathic lens subluxation, 3 with trauma, 5 with dislocation or opacification of IOL, and 11 with complicated cataract surgery. RESULTS: The mean age of the patients was 70.6 years (range, 47~87 years). The range of preoperative best corrected visual acuity (BCVA) was from light perception to 0.6. The mean preoperative refraction and mean preoperative target refraction were 2.0 +/- 6.51D (-8.5~13D) and -0.45 +/- 0.70D (-3.75~0.39D), respectively, in spherical equivalent. The mean preoperative corneal astigmatism was -1.0 +/- 0.65D (-0.25~-2.5D). The postoperative BCVA ranged between 0.02 and 1.0, and the mean refractive error was -0.66 +/- 1.15D (-3.3~1.75D) at the last follow-up visit. The mean corneal astigmatism was -1.55D +/- 1.67 (-9~-0.25D) at the last follow-up visit (p=0.99, paired t-test). CONCLUSIONS: Transscleral fixation of the foldable IOL through small incision results in fewer complications, due to the large incision and the shorter time, and therefore, instantly improved visual acuity.

The Effect of Mitomycin C Concentration in Endonasal Dacryocystorhinostomy

PURPOSE: We applied mitomycin C in different concentrations and times into osteotomy site during surgery to observe its effects and compare the success rates between two groups. METHODS: Fifty-three patients (53 eyes) who presented with chronic epiphora symptoms underwent endonasal dacryocystorhinostomy (DCR) and silicon tube intubation in our hospital between november, 2002 and january, 2004. In group A, mitomycin C at 0.25 mg/ml was applied into the osteotomy site for 3minutes during the operation, in group B mitomycin at 0.5 mg/ml was applied for 5 minutes. Success was defined as the absence of any epiphora symptoms and good passage by punctum irrigation test. RESULTS: The primary success rate of endonasal DCR was 83% (44/53). 78.1% (25/32) in group A, and 90.4% (19/21) in group B. Three failed patients were reoperated and applied at the same concentration and the same duration as previously. The total success rate was 88.7% (47/53) ; 84.4% (27/32) in group A, 95.2% (20/21) in group B. However the difference of success rates between the two groups was not significant statistically (P=0.384, Fisher's exact test). CONCLUSIONS: The success rate of mitomycin C at 0.25 mg/ml for 3 minutes application was not significantly different from that of mitomycin C at 0.5 mg/ml for 5 minutes.

The Effect of Intravitreal Triamcinolone Acetonide on Intraocular Pressure

PURPOSE: To evaluate the effect of a single intravitreal injection of 4.0 mg/0.1ml triamcinolone acetonide on intraocular pressure (IOP). METHODS: Retrospective studies were conducted by reviewing the charts of 26 eyes of 24 patients that were followed up for 16 weeks after intravitreal triamcinolone injection. The IOPs before and after triamcinolone injection were measured with Goldmann applanation tonometer. RESULTS: Within 16 weeks after intravitreal triamcinolone acetonide injection, 23 of 26 eyes (88.5%) demonstrated an increment in IOP of 5 mmHg or greater, and 6 of 26 (23.1%) had an increment of 10 mmHg or greater. The mean duration of the increase in IOP of 5 mmHg or greater was 5.5 weeks (standard deviation=4.4), and the mean time to reach maximum IOP was 6.6 weeks (standard deviation=4.4). The difference between the mean pre-injection IOP (14.12 mmHg, n=26) and the maximum post-injection IOP (24.65 mmHg, n=26) was statistically significant (P<0.001). All eyes that needed treatment responded to topical glaucoma medication. CONCLUSIONS: An increment in IOP is a common complication after a single intravitreal injection of 4.0 mg/0.1ml triamcinolone acetonide and despite this serious increment in IOP, it was controlled by topical glaucoma medication.

The Morphological Change of Iris and Ciliary Body in the Korean Fetal Eyes according to Gestational Age

PURPOSE: This study was performed to investigate the morphological change of the iris and ciliary body of human eyes during fetal period. METHODS: Under the Registry of Congenital malformation, fetuses were supplied by the Department of Pathology of Seoul National University. We selected 81 eyes enrolled with the gestational age between 8 and 40 weeks, and examined under light microscope. RESULTS: The development of iris and ciliary body began from 12 weeks. During the gestational age 15-18 weeks, marginal sinus and the fold of iris and ciliary body were formed. At the gestational age 18 weeks, the iris sphincter located in front of marginal sinus was certainly distinguished, and the vessels of ciliary body formed. During the gestational age 19-22 weeks the minor folds of ciliary body were formed between the original it. During the gestational age 23-27 weeks marginal sinus was being diminished and dilator muscle was seen. During the gestational age 28-30 weeks the dilator muscle of iris was certainly developed and the longitudinal and circular muscle of ciliary body were distinguished. During the gestational age 34-40 weeks the adultlike appearance of the iris and ciliary body became apparent. CONCLUSIONS: The mesenchymal cells located in the anterior rim of optic cup began to develop after the gestational age 12 weeks. If the develpment of the iris and ciliary body was arrested around the gestational age 15-22 weeks, the congenital malformation of the iris and ciliary body could appear.

The Cellular Characteristics of the Secondary Pupillary Membrane

PURPOSE: This study was performed to investigate the cellular characteristics of the secondary pupillary membrane. METHODS: The secondary pupillary membrane was removed from the anterior lens surface during cataract extraction from 2 patients with cataract associated with uveitis. Specimen from one patient was stained with hematoxylin-eosin with flat preparation method. Specimen from the other patient cultured for 1 and 2 weeks was observed with transmission electron microscopy. RESULTS: The flat preparation showed the neovascular membrane with pigment-laden cells. The cultured cells consisted of the well preserved vascular components which had the vascular endothelial cells and pericyte and pigment-laden cells lined by basement membrane on first week of culture. The iris pigment epithelial cell which contained the pigment granules within cytoplasm and lined by basement membrane were observed on second week of culture. CONCLUSIONS: These results suggest that the secondary pupillary membrane consists of vascular membrane and pigment epithelial cell of iris which is a major component of secondary pupillary membrane and secrets extracellular matrix.

Significance of APACHE Score in Patients with a Gastrointestinal Perforation

BACKGROUND: The APACHE scoring system of the Health Care Financing Administration (HCFA) has been being used for serious patients. The scoring system is composed of acute physiologic variables and chronic disease. METHODS: Among patients who underwent emergency operations from 1992 to 1997 because of gastrointestinal perforation, we analyzed 110 cases with five kinds of diseases: duodenal ulcer perforation, small bowel perforation, perforated appendicitis, gastric ulcer perforation and colon perforation. RESULTS: The results were as follows: 1) The preoperative APACHE II scores ranged from 0 to 21. The scores of 64 cases (60.9%) were from 0 to 5. 2) There were no death in case for which pre-peration APACHE II score was from 0 to 10, 25% of the mortality occurred in cases with scores from 11 to 15, 50% in those with scores from 16 to 20, and 100% in those with scores above 21. 3) The APACHE II score decreased continuously from the 3rd to the 7th postoperative day. 4) The preoperative APACHE II scores in gastric ulcer perforation patients were significantly higher than those in duodenal ulcer perforation patients. In the cases of gastric and duodenal ulcer perforations, the APACHE II scores in patients who underwent primary closure were higher than the scores in those who underwent a more definitive operation. 5) In death cases, all of their APACHE II scores were higher at the 3rd postoperative than at the 7th postoperative day, but their APACHE III scores continuously increased postoperatively. CONCLUSIONS: It is thought that the APACHE scoring system is more reliable than clinical experience in the classification of patients by operative risk and in estinating the result and giving a prognosis. Thus, the principle of treatment should be established by estinating patient's score before the operation. Careful preoperative management is necessary for patients with scores more than 10. Because patientswith scores more than 21 have very a high mortality, operative time and method must be carefully decided. The APACHE III scoring system seems to be more sensitive than the APACHE II scoring system in predicting deaths and further investigations and clinical applications should be performed.

Sensitivity, Specificity, and Predictive Value of Optic Disc Parameters in Primary Open-Angle Glaucoma

Attempts to quantify the parameters of optic nerve head structure have been made to recognize the earliest structural abnormalities in glaucoma, and to efficiently monitor the structural changes of the optic nerve head with advancing disease. Optic disc parameters were measured in 88 normal subjects and 149 primary open-angle glaucoma patients using a computer graphic program (Adobe photoshopTM) and the photographic magnification was corrected according to Littmanns method. The sensitivity, specificity, and predictive value of optic disc parameters were calculated to discriminate between normal and glaucomatous eyes at different stages of glaucoma. Receiver operating characteristics curves were used for comparisons of different disc parameters. In the group with mild glaucomatous visual field (VF) defects (mean deviation (MD); better than -5dB, group 1), optic disc parameters did not provide greater sensitivity and specificity enough to detect early glaucomatous optic nerve head damage. In the group with moderate VF defects (MD; -6~-10dB, group 2) and advanced VF defects (MD; worse than -11dB, group 3), the minimum rim width within the 60 sector across the vertical meridian (predictive value; 84.4%, 95.9%, respectively), vertical cup to disc ratio (83.7%, 95.2%, respectively), and rim area to disc area ratio (83.7%, 95.1%, respectively) were helpful to identify the glaucomatous eyes, whereas horizontal cup to disc ratio (77.3%, 90.3%, respectively) and cup area (75.2%, 89.0%, respectively) were less helpful in this regard.