Comparison of the Efficacy between Time and Spectral Domain Optical Coherence Tomography for the Identification of Vitreomacular Interface

PURPOSE: To compare the efficacy of time domain (TD) and spectral domain (SD) optical coherence tomography (OCT) in determining vitreomacular interface (VMI). METHODS: VMIs were evaluated with TD and SD OCT images crossing the fovea horizontally in 69 eyes (mean age 52.7 +/- 15.4 years) and were classified as follows: (1) no vitreomacular separation (VMS), (2) incomplete VMS, and (3) unknown. RESULTS: In TD OCT, no VMS was observed in 2 eyes (2.9%), incomplete VMS in 2 eyes (2.9%), and unknown in 65 eyes (94.2%). In SD OCT, no VMS was observed in 31 eyes (45.0%), incomplete VMS in 13 eyes (18.8%), and unknown in 25 eyes (36.2%). In 31 eyes with no VMS on SD OCT, 29 eyes (93.5%) presented unknown on TD OCT (p<0.0001). In 13 eyes with incomplete VMS on SD OCT, 2 eyes (15.4%) showed incomplete VMS and 11 eyes (84.6%) showed unknown on TD OCT (p<0.0001). TD OCT was also non-informative in all 25 eyes with unknown on SD OCT. CONCLUSIONS: SD OCT allows better visualization of VMI than TD OCT, especially in patients with no VMS.

Spontaneous Resolution of Intravitreal Steroid-Induced Bilateral Cytomegalovirus Retinitis

A 73-year-old woman underwent vitrectomy and intravitreal triamcinolone acetonide (IVTA) of the right eye and cataract surgery with IVTA of the left eye, for bilateral diabetic macular edema. The patient presented with visual loss in both eyes three-months postoperatively. The fundoscopic examination revealed white-yellow, necrotic peripheral lesions in the superotemporal quadrant of both eyes. Although bilateral acute retinal necrosis was suspected, azotemia resulting from diabetic nephropathy limited the use of acyclovir. Antiviral treatment was not started. A sample of the aqueous humor for polymerase chain reaction (PCR) analysis was obtained. One week later, the PCR results indicated the presence of cytomegalovirus (CMV). Since the retinal lesions did not progress and did not threaten the macula, the patient was followed without treatment for CMV. The retinal lesions progressively regressed and completely resolved in both eyes by six months of follow-up. Patients with IVTA-induced CMV retinitis may not require systemic treatment with ganciclovir.

Hereditary and Clinical Features of Retinitis Pigmentosa in Koreans

There has been no report about hereditary and clinical features of retinitis pigmentosa (RP) in Koreans. To evaluate these, data were collected from 365 RP patients including age, gender, visual acuity (VA), spherical equivalent (SE) of refractive errors, funduscopic findings, color vision test, visual field score (VFS) obtained from Goldmann perimetry, and the inheritance patterns from pedigrees. Simplex RP was the most common inheritance pattern (61.9%); followed by autosomal recessive RP (17.3%), autosomal dominant RP (12.1%) and X-linked recessive RP (8.8%). Myopia was the most common refractive errors (77.5%) including 16.1% of high myopia. The most common cataract type was posterior subcapsular cataract (25.8%). Observed retinal findings included changes of retinal pigment epithelium (88.8%), bony spicule-like pigmentation (79.7%), attenuation of retinal vessel (76.2%), waxy disc pallor (12.6%), golden ring around optic disc (2.2%), epiretinal membrane (0.8%) and cystoid macular edema (0.5%). Corrected VA and refractive errors did not show any significant difference between the inheritance patterns. VFS was significantly worse in autosomal recessive RP than in autosomal dominant RP. Color vision defect was noted in 66.1% on Hardy-Rand-Rittlers color vision test. In conclusion, Korean RP patients have the indigenous hereditary and clinical features as well as the ordinary ones.

Repeatability and Agreement of Macular Thickness Measurement Using Time and Spectral Domain OCT in Diabetic Macular Edema

PURPOSE: To evaluate the repeatability of macular thickness measurements using time domain (TD) OCT and spectral domain (SD) OCT in diabetic macular edema. METHODS: In 42 eyes of 42 patients with diabetic macular edema, three consecutive macular measurements were performed with TD OCT and SD OCT, and measurements for macular thickness and total macular volume obtained by the two OCTs were compared. The within-subject standard deviation (Sw), coefficient of variation (CVw), and intraclass correlation coefficient (ICC) were calculated to assess repeatability, with agreement between measurements assessed with Bland Altman plots. The correlations were also evaluated via the Pearson's correlation coefficient. RESULTS: The Sw of TD OCT and SD OCT for foveal thickness, total macular volume were 29.67 micrometer/16.44 micrometer, 1.26 mm3/0.23 mm3, respectively, and were significantly lower in SD OCT. The ranges of the respective CVw and ICC values were 1.10-2.78%, 0.78~0.96 for TD OCT, and 0.29~0.94%, 0.92~0.99 for SD OCT. The SD OCT showed better repeatability for macular thickness measurements (all p< or =0.001). The 95% limits of agreement for foveal and total macular volume were 88.9 micrometer, 2.4 mm3, respectively. The Pearson's correlation coefficients of macular thickness and total macular volume between the two OCT methods were statistically significant (p=0.88-0.99). CONCLUSIONS: Although both OCTs proved reliable for macular thickness measurements in diabetic macular edema, SD OCT shows better repeatability than TD OCT. Although macular thickness measurements obtained from the two OCTs cannot be used interchangeably, there were statistically significant correlations between measurements obtained using the two OCTs.

Four Cases of Pars Plana Vitrectomy for Treatment of Symptomatic Lamellar Macular Holes

PURPOSE: To report the results of pars plana vitrectomy for the treatment of symptomatic lamellar macular holes. CASE SUMMARY: Pars plana vitrectomy with epiretinal membrane (ERM) and internal limiting membrane (ILM) stripping was performed for the treatment of lamellar holes in four patients who complained of vision loss or metamorphopsia. In three out of four patients, fluid-gas exchange with 14% C3F8 was performed and patients were instructed to maintain aprone position for 7 days after surgery. Postoperatively, the improvement of visual acuity, foveal contour, and disappearance of metamorphopsia were achieved in three patients. However, full-thickness macular hole (FTMH) developed in one patient after vitrectomy. Repeated fluid-gas exchange was performed and the patient was instructed to maintain a prone position, however, the FTMH did not close. CONCLUSIONS: In patients with visual loss or metamorphopsia, vitrectomy with ERM and ILM stripping appears to be a beneficial treatment. FTMH developed after surgery in one patient, therefore further study is needed to elucidate the prognostic factors for the development of FTMH.

Best Disease With Old-age Onset Misdiagnosed as Chronic Central Serous Chorioretinopathy: A Case Report

PURPOSE: To report a case of Best's disease with old-age-onset with unusual clinical features. CASE SUMMARY: A 68-year-old woman with a six-month history of using oral steroids complained of decreased vision in both eyes. Fundus examination revealed a circular area of macular elevation measuring approximately 1.5 disc diameter size in both eyes. Optical coherence tomography (OCT) showed serous retinal detachment, but pigment epithelial detachment was seen only on fluorescein angiography and indocyanine green angiography. The patient received a diagnosis of chronic central chorioretinopathy with choroidal neovascularization. Photodynamic therapy (PDT) and intravitreal bevacizumab (IVB) injections were prescribed as treatment, but were ineffective. For a definitive diagnosis, we performed an electro-oculogram (EOG) and the result was abnormal with an Arden ratio below 1.5 in both eyes. A final diagnosis of Best's disease was established. Spectral domain OCT findings at the last visit showed a clearly visible RPE split and a low reflective space between the split RPE layers, as well as a high reflectivity corresponding to the subretinal material. CONCLUSIONS: We report a case of Best's disease with old-age onset with unusual clinical features and abnormal EOG findings. Spectral domain OCT was helpful in evaluating the disease. Treatment with PDT and IVB was not effective.

Effects and Prognostic Factors of Intravitreal Bevacizumab Injection on Choroidal Neovascularization from Age-Related Macular Degeneration

PURPOSE: To investigate the effects and prognostic factors related to intravitreal injection of bevacizumab on patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration. METHODS: The medical records of patients who received 3 consecutive intravitreal injections of bevacizumab (1.25 mg/0.05 ml, 6 weeks interval) for subfoveal choroidal neovascularization secondary to age-related macular degeneration and followed up for more than 12 months were reviewed (a total of 31 eyes; male, 20; mean age, 72.3+/-7.5 years). Baseline best corrected visual acuity, foveal thickness, and total macular volume were compared with those after 1, 4, and 12 months. The therapeutic effects were investigated with regard to factors such as age, sex, initial visual acuity, lesion size, subtypes of choroidal neovascularization, pigment epithelial detachment, submacular hemorrhage, and previous history of photodynamic therapy. RESULTS: Initial visual acuity (logMAR), foveal thickness, and total macular volume were 0.74+/-0.49, 320+/-88 microm and 9.50+/-2.99 mm3, respectively. Visual acuity improved to 0.68+/-0.61 (p=0.012), and foveal thickness and total macular volume decreased to 218+/-69 microm and 6.32+/-0.71 mm3 (p<0.001), respectively, at 12 months. Visual improvement was achieved less often in patients who were 75 years or older and who had lesions 3 disc areas or greater and relatively good initial vision at 12 months. CONCLUSIONS: Intravitreal bevacizumab injection has beneficial effects for patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration with regard to function and anatomy. However, it should be noted that visual improvement may be limited in older patients with larger lesions and good initial vision.

Repeatability and Agreement of Macular Thickness Measurement Using Time Domain OCT and Spectral Domain OCT in Normal Subjects

PURPOSE:To compare the repeatability and agreement of macular thickness measurements using time domain (TD) optical coherence tomography (OCT) and spectral domain (SD) OCT in normal subjects. METHODS: Thirty-four normal subjects were included. Three consecutive macular measurements were taken with TD OCT and SD OCT. Total and regional macular thickness and total macular volume obtained by the two OCTs were compared. Within-subject standard deviation (Sw), coefficient of variation (CVw), and the intraclass correlation coefficient (ICC) were calculated to evaluate repeatability. The agreement was examined with Bland Altman plots. The correlation was also evaluated with Pearson correlation coefficients and multiple regression analysis. RESULTS: Sw for foveal thickness, total macular thickness, and total macular volume were 11.53 microm, 7.58 microm, and 0.48 mm3 for TD OCT and 6.69 microm, 2.55 microm, and 0.09 mm3 for SD OCT, respectively. The values for SD OCT were consistently lower, and this result was statistically significant. The range of the respective CVw and ICC values were 1.10~2.78% and 0.78~0.96% for TD OCT, and 0.29~0.94% and 0.92~0.99% for SD OCT, respectively. The SD OCT showed better repeatability for macular thickness measurements(all with p< or =0.001). The spans of 95% limits of agreement for foveal thickness, total macular thickness, and total macular volume were 67.94 microm, 29.01 microm, and 0.98 mm3, respectively. The Pearson correlation coefficient of foveal thickness, total macular thickness, and total macular volume between the two OCT's was statistically significant. CONCLUSIONS: Although both OCTs are reliable for macular thickness measurements, SD OCT shows better repeatability compared with TD OCT. Although macular thickness measurements obtained from the two OCTs can not be used interchangeably due to low agreement by different standards of measurement, there was a statistically significant correlation between the two OCT's.

Comparison of Effects of Intravitreal Triamcinolone and Bevacizumab in the Treatment of Diabetic Macular Edema

PURPOSE: To compare the effect of an intravitreal injection of triamcinolone acetonide with bevacizumab in the treatment of diabetic macular edema (DME). METHODS: For this study, the medical records of patients with diabetic macular edema, who received intravitreal triamcinolone injection (IVTA) or intravitreal bevacizumab injection (IVB), were reviewed. Best corrected visual acuity (BCVA), central macular thickness (CMT) and total macular volume (TMV) were evaluated before injection and at 1 week, 1 month, 2 months, 3 months, and 6 months after injection. The adverse events, such as increased intraocular pressure, and progression of cataract, were also reviewed. RESULTS: A total of 72 eyes from 72 patients, (IVTA: 40 eyes, IVB: 32 eyes) were included in this study. In the IVTA group, BCVA improved significantly at 1 week after injection and was maintained until 3 months after injection. In the IVB group, BCVA improved significantly at 1 week after injection and was maintained until 2 months after injection. In the IVTA group, CMT and TMV decreased significantly at 1 week after injection and were maintained until 3 months after injection, while in the IVB group CMT and TMV were maintained until 2 months after injection. The IVTA group showed significantly better results in visual improvement, CMT and TMV reduction compared to the results of the IVB group, from 1 month to 3 months after injection. In the IVTA group, intraocular pressure increased to more than 25 mmHg in 12.5% of patients during the follow-up period. CONCLUSIONS: While the functional and anatomical improvements are achieved by both IVTA and IVB for diabetic macular edema, the effect of IVTA is more prominent with longer duration than IVB.

Comparison of Effects of Intravitreal Triamcinolone and Bevacizumab in the Treatment of Diabetic Macular Edema

PURPOSE: To compare the effect of an intravitreal injection of triamcinolone acetonide with bevacizumab in the treatment of diabetic macular edema (DME). METHODS: For this study, the medical records of patients with diabetic macular edema, who received intravitreal triamcinolone injection (IVTA) or intravitreal bevacizumab injection (IVB), were reviewed. Best corrected visual acuity (BCVA), central macular thickness (CMT) and total macular volume (TMV) were evaluated before injection and at 1 week, 1 month, 2 months, 3 months, and 6 months after injection. The adverse events, such as increased intraocular pressure, and progression of cataract, were also reviewed. RESULTS: A total of 72 eyes from 72 patients, (IVTA: 40 eyes, IVB: 32 eyes) were included in this study. In the IVTA group, BCVA improved significantly at 1 week after injection and was maintained until 3 months after injection. In the IVB group, BCVA improved significantly at 1 week after injection and was maintained until 2 months after injection. In the IVTA group, CMT and TMV decreased significantly at 1 week after injection and were maintained until 3 months after injection, while in the IVB group CMT and TMV were maintained until 2 months after injection. The IVTA group showed significantly better results in visual improvement, CMT and TMV reduction compared to the results of the IVB group, from 1 month to 3 months after injection. In the IVTA group, intraocular pressure increased to more than 25 mmHg in 12.5% of patients during the follow-up period. CONCLUSIONS: While the functional and anatomical improvements are achieved by both IVTA and IVB for diabetic macular edema, the effect of IVTA is more prominent with longer duration than IVB.

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.

Short-term Effects and Side Effects of Tacrolimus for Behcet's Uveitis

PURPOSE: To investigate the clinical effects and side effects of Tacrolimus for ocular Behcet's disease. METHODS: Eight patients (male: 5, age: 35+/-7.5 (25-48) years) with Behcet's uveitis, refractory posterior uveitis unresponsive to combination treatment with cyclosporine, azathioprine, and oral steroid or significant cyclosporine-related adverse effects were recruited prospectively, and cyclosporine was switched to Tacrolimus. Visual acuity, degree of anterior chamber, and vitreous haze were compared before the conversion and three months after. Oral glucose tolerance, plasma insulin, cholesterol, creatinine, and aspartate (AST)/alanine aminotransferase (ALT) were measured to monitor systemic effects. RESULTS: Visual acuity did not change significantly after conversion to Tacrolimus. Anterior chamber (seven patients) and vitreous (four patients) inflammation were found before conversion and decreased or disappeared after conversion. Overall plasma levels of glucose, insulin, creatinine, and AST/ALT were similar before and after conversion. However, cholesterol was significantly decreased after conversion (p=0.028). One patient developed diabetes mellitus. CONCLUSIONS: Tacrolimus may be effective for Behcet's uveitis unresponsive to or intolerable of traditional treatments. In addition, periodic monitoring for side effects, such as hyperglycemia and diabetes mellitus, may be necessary.

Short Term Effects of Topical Cyclosporine and Viscoelastic on the Ocular Surfaces in Patients with Dry Eye

PURPOSE: To compare the short term effects of topical 0.05% cyclosporine (CsA) and a mixture of 0.08% chondroitin sulfate and 0.06% sodium hyaluronate (CS-HA) on dry eye ocular surfaces. METHODS: 36 patients with moderate to severe dry eye (5 mm/5 min or less with Schirmer's test or tear break up time (BUT) less than 6 seconds), were treated with topical application of CS-HA on one eye and CsA on the other 4 times a day for 6-8 weeks. BUT, Schirmer's test without anesthesia, and conjunctival impression cytology (CIC; goblet cell density, nucleus to cytoplasmic ratio, and epithelial cell morphology) were evaluated and compared between eyes before and after treatment (repeated measurement of ANOVA). RESULTS: After treatment, BUT and tear wettings were significantly prolonged in each group. Topical CsA treated eyes had greater increase in BUT (p=0.026); there was no significant difference in tear wetting (p=0.132). While the 3 parameters of CIC improved in both groups, goblet cell density was significantly higher in eyes treated with CsA (p=0.033). CONCLUSIONS: While both CS-HA and 0.05% CsA eyedrops improve ocular surfaces, topical CsA may have a better effect on enhancing tear film stability and goblet cell density.

Congenital Symblepharon Associated with No. 3 Craniofacial Cleft

PURPOSE: To report a case of congenital symblepharon associated with No. 3 craniofacial cleft. METHODS: A 40-month old girl with left eyelid lesion underwent an ophthalmologic examination at the department of ophthalmology and a face examination at the department of plastic and reconstructive surgery. RESULTS: Congenital symblepharon associated with No. 3 craniofacial cleft including bifid uvula, partial cleft lip, and coloboma of the lower medial eyelid was found. She did not have amblyopia or strabismus. A MEDLINE search of the literature revealed only one reported case of symblepharon associated with a craniofacial cleft.

Risk Factors for the Progression of Age-related Incipient Cataract

PURPOSE: To investigate risk factors for the progression of age-related incipient cataract. METHODS: Among patients who visited the authors' clinic (SNUH) from Jun 2002 to Jan 2003 for age-related incipient cataract, those meeting one of the following two criteria were recruited: 1) non-progressive group: BCVA (best corrected visual acuity) decrease by two lines or less for 5 years or more according to Snellen's chart, 2) progressive group: BCVA decrease by four lines or more in 5 years or less. Age, sex, regular exercise, smoking, drinking, anti-cataract eyedrops, duration of menopause, hormone replacement therapy, weight, height, and BMI (body mass index) were investigated by questionnaire and compared between the two groups. If both eyes met the eligibility criteria, one eye was randomly selected. RESULTS: There were not statistically significant differences regarding age, sex, anti-cataract eyedrops application, regular exercise, duration of menopause and hormone replacement therapy, smoking, drinking, weight, and height. However, the mean BMI of the progressive group was significantly higher than that of the non-progressive group (p=0.041, Student t-test). CONCLUSIONS: In patients with age-related incipient cataract, high BMI may be related to more rapid progression of incipient cataract, thus resulting in faster visual loss.

Topical Anesthesia Combined with Patient-Controlled Sedation Analgesia (PCSA) for Posterior Vitrectomy

PURPOSE: To investigate the effects of topical anesthesia combined with patient-controlled sedation analgesia for posterior vitrectomy. METHODS: All patients requiring vitrectomy from December 2003 to January 2004 at Seoul National University Hospital underwent surgery with topical anesthesia combined with patient-controlled sedation analgesia. The levels of intraoperative pain and sedation were recorded. The associations of operation time, combined vitreoretinal procedures, and age with intraoperative pain were investigated. Hemodynamic instability and respiratory depression were checked throughout the operation. RESULTS: Forty-three patients (53 eyes) underwent vitrectomy under topical anesthesia combined with patient-controlled sedation analgesia. The mean age was 51.75 +/- 13.68 years and the sex ratio was 25: 28 (male: female). The mean of VAS (visual analogue scale) was 53.61 (5 ~ 67). The level of intraoperative sedation was grade 1 (64%) or 2 (36%). No anesthesia-associated complications were found. CONCLUSIONS: In spite of relatively high VAS, there were no remarkable difficulties in performing posterior vitrectomy and appropriate levels of intraoperative sedation and cooperation were available without anesthesia-associated complications.

Correction of Lower Lid Retraction Combined with Entropion using an Ear Cartilage Graft in the Anophthalmic Socket

PURPOSE: To investigate the surgical results of an ear cartilage graft and supplemental procedures for correcting lower lid retraction combined with entropion in anophthalmic patients. METHODS: We reviewed retrospectively the medical records of 7 anophthalmic patients with lower lid retraction and entropion, who received a posterior lamellar ear cartilage graft and one or both of lateral tarsal strip or eyelash-everting procedure between March 1998 and March 2003. Preoperative and postoperative lid and socket statuses were also investigated. RESULTS: Ear cartilage grafts were performed in all 7 patients, lateral tarsal strips in 6, and eyelash-everting procedures in 5. Postoperative follow-up durations ranged from 4 to 28 months (average 12.6 months). Retractions were corrected during follow-up in all patients. There were no cases of entropion immediately after surgery. However, the eyelashes of the lower lid returned to an upright position in 4 patients, but not so severe as to touch the ocular prosthesis, and thus did not require surgical correction during follow up. CONCLUSIONS: Lower lid retraction combined with entropion in anophthalmic patients can be corrected effectively using an ear cartilage graft with selective, supplemental procedures.

Clinical Results of Modified Muscle Transposition Surgery

PURPOSE: To report the clinical experience and surgical results of modified transposition surgery, in which half-width tendons are isolated and sutured into the paralyzed extraocular muscle. METHODS: We retrospectively reviewed the medical records of 6 patients (7 eyes), who had undergone modified transposition surgery to correct severe limitation of eye movement from January 1996 to December 2001. First, we divided the half-width tendons of two rectus muscles adjacent to the paralyzed rectus muscle and disinserted the halves from the sclera. The two half-width tendons were positioned underneath of the scleral insertion of the paralyzed muscle, sutured together and then sutured to the paralyzed muscle. In the case of contracture of the antagonizing extraocular muscle, recession of the antagonist was performed. RESULTS: Five of the six patients showed deviation under 15 prism diopters at primary gaze at distance, while synergistic divergence recurred in the sixth patient. CONCLUSIONS: Modified transposition surgery as described in this paper is thought to be an effective and safe method for correction of paralytic strabismus.