Acquired von willebrand syndrome in patients with Philadelphia-negative myeloproliferative neoplasm

Background@#Acquired von Willebrand syndrome (AVWS) has not been investigated in Korean patients with Philadelphia chromosome-negative myeloproliferative neoplasm. @*Methods@#This study analyzed the prevalence at diagnosis and clinical features of AVWS in patients with essential thrombocythemia (ET), polycythemia vera (PV), prefibrotic/early primary myelofibrosis (pre-PMF), or overt PMF (PMF) diagnosed between January 2019 and December 2021 at Chungam National University Hospital, Daejeon, Korea. AVWS was defined as below the lower reference limit (56%) of ristocetin cofactor activity (VWF:RCo). @*Results@#Sixty-four consecutive patients (36 with ET, 17 with PV, 6 with pre-PMF, and 5 with PMF;30 men and 34 women) with a median age of 67 years (range, 18‒87 yr) were followed for a median of 25.1 months (range, 2.6‒46.4 mo). AVWS was detected in 20 (31.3%) patients at diagnosis and was most frequent in ET patients (41.4%), followed by patients with pre-PMF (33.3%) and PV (17.6%) patients. VWF:RCo was negatively correlated with the platelet count (r=0.937; P =0.002). Only one episode of minor bleeding occurred in a patient with ET and AVWS. Younger age (＜50 yr) [odds ratio (OR), 7.08; 95% confidence interval (CI), 1.27‒39.48; P =0.026] and thrombocytosis (＞600×10 9 /L) (OR, 13.70; 95% CI, 1.35‒138.17; P =0.026) were independent risk factors for developing AVWS. @*Conclusion@#AVWS based on VWF:RCo was common in patients with ET and pre-PMF, but less common in patients with PV in the Korean population. Clinically significant bleeding is rare in these patients.

Predictive role of absolute lymphocyte count in daratumumab-treated patients with relapsed/ refractory multiple myeloma

Background/Aims@#Daratumumab has shown an encouraging antitumor effect in patients with multiple myeloma (MM), and was known to alter the immune properties by off-targeting immunosuppressive cells. Here, we aimed to evaluate the change in absolute lymphocyte count (ALC) as a surrogate marker for predicting survival outcomes of patients treated with daratumumab. @*Methods@#Between 2018 and 2021, the medical records of patients with relapsed/refractory MM (RRMM) treated with daratumumab monotherapy at 10 centers in South Korea were reviewed. We collected the ALC data at pre-infusion (D0), day 2 after the first infusion (D2), and prior to the third cycle of daratumumab therapy (D56). @*Results@#Fifty patients who were administered at least two cycles of daratumumab were included. Overall response rate was 54.0% after two cycles of daratumumab treatment. On D2, almost all patients experienced a marked reduction in ALC. However, an increase in ALC on D56 (ALCD56) was observed in patients with non-progressive disease, whereas failure of ALC recovery was noted in those with progressive disease. Patients with ALCD56 > 700/μL (n = 39, 78.0%) had prolonged progression- free survival (PFS) and overall survival (OS) than those with ALCD56 ≤ 700/μL (median PFS: 5.8 months vs. 2.6 months, p = 0.025; median OS: 24.1 months vs. 6.1 months, p = 0.004). In addition, ALCD56 >700/μL was a significant favorable prognostic factor for PFS (hazard ratio [HR], 0.22; p = 0.003) and OS (HR, 0.23; p = 0.012). @*Conclusions@#Increase in ALC during daratumumab treatment was significantly associated with prolonged survival outcomes in patients with RRMM. The ALC value can predict clinical outcomes in patients treated with daratumumab.

Volumetric Splenomegaly in Patients With Polycythemia Vera

Background@#Non-palpable splenomegaly in patients with polycythemia vera (PV) has seldom been addressed. In this retrospective study, we evaluated non-palpable, volumetric splenomegaly defined based on age- and body surface area (BSA)–matched criteria in patients with PV diagnosed according to the 2016 World Health Organization diagnostic criteria. @*Methods@#Patients with PV who underwent abdominal computed tomography (CT) and who had palpable splenomegaly at diagnosis from January 1991 to December 2020 at Chungnam National University Hospital were enrolled. The spleen volume of each patient was determined by volumetric analysis of abdominal CT and adjusted for the patient’s age and BSA. Then the degree of splenomegaly was classified as no splenomegaly, borderline volumetric splenomegaly, overt volumetric splenomegaly, or palpable splenomegaly. @*Results@#Of the 87 PV patients enrolled, 15 (17.2%) had no splenomegaly, whereas 17 (19.5%), 45 (51.7%), and 10 (11.5%) had borderline volumetric, overt volumetric, and palpable splenomegaly, respectively. The degree of splenomegaly did not affect the cumulative incidence of thrombotic vascular events (10-year incidence: 7.7%, 0%, 22.3%, and 50.7%, respectively, P = 0.414). By contrast, splenomegaly tended to adversely affect myelofibrotic transformation (10-year cumulative incidence: 0%, 0%, 7.1%, and 30.3%, respectively, P = 0.062). Moreover, the cumulative incidence of myelofibrotic transformation was significantly higher in patients with overt volumetric or palpable splenomegaly than those with no or borderline volumetric splenomegaly (10-year incidence: 0% vs. 10.3%, respectively; 15-year incidence: 0% vs. 26.3%, respectively, P = 0.020). Overall survival (OS) differed among patients with different degrees of splenomegaly (15-year OS: 100%, 78.6%, 71.7%, and 51.9%, respectively, P = 0.021). @*Conclusion@#The degree of splenomegaly, including volumetric splenomegaly, based on ageand BSA-matched reference spleen volumes at diagnosis reflects disease progression in PV patients. Therefore, volumetric splenomegaly should be evaluated at the time of diagnosis and taken into consideration when predicting the prognosis of patients with PV.

Myelofibrotic and leukemic transformation in 2016 WHO-defined Philadelphia-negative myeloproliferative neoplasm

Background@#Information on myelofibrotic and leukemic transformations in Korean Philadelphia chromosome-negative myeloproliferative neoplasms (Ph ‒ MPNs) is limited. @*Methods@#This study retrospectively analyzed transformations in patients diagnosed with essential thrombocythemia (ET), polycythemia vera (PV) prefibrotic/early primary myelofibrosis (pre-PMF), or overt primary myelofibrosis (PMF) based on the 2016 World Health Organization criteria between January 1996 and December 2020 at Chungam National University Hospital, Daejeon, Korea. @*Results@#A total of 351 patients (144 with ET, 131 with PV, 45 with pre-PMF, and 31 with PMF;204 men and 147 women) with a median age of 64 years (range, 15‒91 years) were followed for a median of 4.6 years (range, 0.2‒24.8 years). The 10-year incidence of overt myelofibrosis was higher in pre-PMF than in ET (31.3% and 13.7%, respectively; P =0.031) and PV (12.2%; P =0.003). The 10-year incidence of leukemic transformation was significantly higher in PMF than in ET (40.0% and 7.9%, respectively; P =0.046), pre-PMF (4.7%; P =0.048), and PV (3.2%; P =0.031). The 5-year incidence of leukemic transformation was higher in patients with secondary myelofibrosis (SMF) than in those with PMF (19.0% and 11.4%, respectively; P =0.040). The 5-year overall survival of patients with SMF was significantly worse than that of patients with pre-PMF (74% and 93%, respectively; P =0.027) but did not differ from that of patients with PMF (57%; P =0.744). @*Conclusion@#The rates and clinical courses of myelofibrotic and leukemic transformations in Korean patients with Ph ‒ MPN did not differ from those in Western populations.

Thrombotic and hemorrhagic events in 2016 World Health Organization-defined Philadelphia-negative myeloproliferative neoplasm

Background/Aims@#Recent changes in the diagnostic criteria for myeloproliferative neoplasms (MPNs) and increasing patient numbers necessitate updating of the data on vascular events in patients with such disorders. @*Methods@#In this single-center study, thrombotic and hemorrhagic events were retrospectively analyzed in patients diagnosed with essential thrombocythemia (ET), polycythemia vera (PV) prefibrotic/early primary myelofibrosis (pre-PMF), or PMF, based on the 2016 World Health Organization diagnostic criteria. @*Results@#Of a total of 335 consecutive patients (139 ET, 42 pre-PMF, 124 PV, and 30 PMF patients; 192 males and 143 females) of median age 64 years (range, 15 to 91), 112 (33.4%) experienced a total of 126 thrombotic events before diagnosis, at the time of diagnosis, or during follow-up over a median of 4.6 years (range, 0.1 to 26.5). Cerebrovascular thrombosis (18.8%) was the most common initial event, followed by coronary heart disease (10.1%) and splanchnic (1.5%) and peripheral thrombosis (1.5%). Arterial thrombosis was more common than venous thrombosis (31.3% vs. 2.1%, respectively; p = 0.001). Thrombosis was most frequent in PV patients (39.5%), followed by patients with pre-PMF (38.1%), ET (30.9%), and PMF (13.3%). Of the 112 patients who experienced thromboses, 53 (47%) and 39 (33.9%) had thrombotic events before and at the time of MPN diagnosis, respectively. Twenty-seven patients (8.1%) experienced 29 hemorrhagic events, of which gastrointestinal bleeding (n = 20) was the most common. @*Conclusions@#Most thrombotic events occurred before or at the time of diagnosis, and the prevalence of arterial thrombosis was markedly higher than that of venous thrombosis in patients with MPN.

Fecal Microbiota Transplantation for Treating Steroid-Refractory Acute Graft-versus-Host Disease of the Gut / 대한내과학회지

Restoring the microbiota via fecal microbiota transplantation (FMT) can be an effective treatment for steroid-refractory acute graft-versus-host disease (GVHD) of the gut. Here, we report two adult patients who underwent FMT to treat steroid-refractory acute GVHD of the gut. The first patient was a 43-year-old man who underwent allogeneic hematopoietic stem cell transplantation (HSCT) with cells from a matched sibling donor. The second patient was a 70-year-old woman who underwent haplo-identical HSCT with cells from her son. Gut GVHD developed at 7 and 4 weeks after HSCT, respectively. After undergoing FMT, the clinical symptoms improved; the first patient had a complete response and the second patient had a partial response. Microbial analyses using RNA gene sequencing showed that a diverse fecal microbiome was recovered by 4 weeks after FMT. FMT should be considered an effective therapeutic option for managing steroid-refractory acute GVHD of the gut.

Thrombotic and hemorrhagic events in 2016 World Health Organization-defined Philadelphia-negative myeloproliferative neoplasm

Background/Aims@#Recent changes in the diagnostic criteria for myeloproliferative neoplasms (MPNs) and increasing patient numbers necessitate updating of the data on vascular events in patients with such disorders. @*Methods@#In this single-center study, thrombotic and hemorrhagic events were retrospectively analyzed in patients diagnosed with essential thrombocythemia (ET), polycythemia vera (PV) prefibrotic/early primary myelofibrosis (pre-PMF), or PMF, based on the 2016 World Health Organization diagnostic criteria. @*Results@#Of a total of 335 consecutive patients (139 ET, 42 pre-PMF, 124 PV, and 30 PMF patients; 192 males and 143 females) of median age 64 years (range, 15 to 91), 112 (33.4%) experienced a total of 126 thrombotic events before diagnosis, at the time of diagnosis, or during follow-up over a median of 4.6 years (range, 0.1 to 26.5). Cerebrovascular thrombosis (18.8%) was the most common initial event, followed by coronary heart disease (10.1%) and splanchnic (1.5%) and peripheral thrombosis (1.5%). Arterial thrombosis was more common than venous thrombosis (31.3% vs. 2.1%, respectively; p = 0.001). Thrombosis was most frequent in PV patients (39.5%), followed by patients with pre-PMF (38.1%), ET (30.9%), and PMF (13.3%). Of the 112 patients who experienced thromboses, 53 (47%) and 39 (33.9%) had thrombotic events before and at the time of MPN diagnosis, respectively. Twenty-seven patients (8.1%) experienced 29 hemorrhagic events, of which gastrointestinal bleeding (n = 20) was the most common. @*Conclusions@#Most thrombotic events occurred before or at the time of diagnosis, and the prevalence of arterial thrombosis was markedly higher than that of venous thrombosis in patients with MPN.

Fecal Microbiota Transplantation for Treating Steroid-Refractory Acute Graft-versus-Host Disease of the Gut / 대한내과학회지

Restoring the microbiota via fecal microbiota transplantation (FMT) can be an effective treatment for steroid-refractory acute graft-versus-host disease (GVHD) of the gut. Here, we report two adult patients who underwent FMT to treat steroid-refractory acute GVHD of the gut. The first patient was a 43-year-old man who underwent allogeneic hematopoietic stem cell transplantation (HSCT) with cells from a matched sibling donor. The second patient was a 70-year-old woman who underwent haplo-identical HSCT with cells from her son. Gut GVHD developed at 7 and 4 weeks after HSCT, respectively. After undergoing FMT, the clinical symptoms improved; the first patient had a complete response and the second patient had a partial response. Microbial analyses using RNA gene sequencing showed that a diverse fecal microbiome was recovered by 4 weeks after FMT. FMT should be considered an effective therapeutic option for managing steroid-refractory acute GVHD of the gut.

Helicobacter pylori testing in a population of Korean patients with pernicious anemia

No abstract available.

Comparison of Exodrift between Natural Group and Postoperative Group in Intermittent Exotropia Patients

PURPOSE: To compare the exodrift between unilateral lateral rectus (ULR) recession and observation groups in moderate angle intermittent exotropia (IXT). METHODS: A retrospective study was performed in 769 patients who were diagnosed with IXT from 2005 to 2015. Seventy-six patients were enrolled in this study that presented with IXT of 20 to 25 prism diopters (PD) on their first visit and were observed for more than 6 months without or after operation. The observation group (group 1) was composed of 29 patients who had regular examination without operation. The surgery group (group 2) was composed of 47 patients with ULR recession that were observed for deviation changes since surgery. RESULTS: The mean age was 71.8 ± 22.0 months at first visit in group 1 and 91.1 ± 18.9 months before surgery in group 2 (p < 0.01). The distant exodeviation was 22.9 ± 2.5 PD at first visit in group 1 and 22.9 ± 2.4 PD before surgery in group 2 (p = 0.89). During follow-up, mean exodrift was 0.6 ± 9.0 PD in group 1 and 10.0 ± 7.4 PD in group 2 (p < 0.01). Exodrift up to postoperative 6 months in group 2 was 3.2 ± 4.0 PD and exodrift from postoperative 6 months to 2 years in group 2 was 7.1 ± 6.9 PD. More exodrift was noticed after post-operative 6 months (p = 0.04). CONCLUSIONS: Comparing the exodrift between the groups in moderate angle IXT, patients in the observation group showed less exodrift. Patients who had a ULR recession presented more exodrift after postoperative 6 months. Even though they were orthotropic at postoperative 6 months when the operation was thought to be stabilized, an increase in exodrift after postoperative 6 months could not be excluded.

Therapeutic Effect of Steroids in Patients with Non-arteritic Anterior Ischemic Optic Neuropathy

PURPOSE: To investigate the effect of steroid treatment (intravenous injection, oral) in patients with non-arteritic anterior ischemic optic neuropathy (NAION). METHODS: From January, 2005 to December, 2016, 41 patients who were diagnosed with NAION and observed for more than 6 months were included in this study. The treatment was decided based on patient's choice after explaining the advantages and disadvantages of steroid therapy. The patients were divided into three groups (intravenous steroid injection, oral steroid, no treatment). Initial visual acuity, final visual acuity, degree of visual field defect, fluorescein angiography, visual evoked potential and brain magnetic resonance imaging were analyzed by chart review. RESULTS: The chief complaints of the 41 NAION patients at the first visit were decreased visual acuity (n = 24), visual field defect (n = 10), no symptoms (n = 4), diplopia (n = 2), and floaters (n = 1). The distribution of the patients according to steroid administration method was 15 patients with intravenous steroid injection, 14 patients with oral steroid and 12 patients with no treatment. The improvement in visual acuity was greatest in intravenous steroid injection (87%), oral steroid (43%) and no treatment (33%) in that order. CONCLUSIONS: In a retrospective comparison of treatment effects after explaining the advantages and disadvantages of steroid therapy in patients with NAION, the intravenous steroid injection group showed 87% improvement in visual acuity and an odds ratio of 5.5 (95% confidence interval [CI] 1.05–28.88, p-value 0.04), while the oral steroid group showed 43% improvement and an odds ratio of 1.5 (95% CI 0.30–7.43, p-value 0.62). The steroid treatment group showed better visual acuity improvement than the no treatment group, and the intravenous steroid injection group showed 5.5 times greater improvement in visual acuity compared to the no treatment group.

Euglycemic Diabetic Ketoacidosis When Reducing Insulin Dosage in Patients Taking Sodium Glucose Cotransporter 2 Inhibitor / 이화의대지

Sodium glucose cotransporter 2 (SGLT2) inhibitor has been recently reported of diabetic ketoacidosis due to accumulation of ketone bodies in patients with severe dehydration caused from such like diarrhea even though the patient had normal glucose level. This is a case of ketoacidosis in normal glucose level as production of ketone bodies is stimulated in liver with increased secretion of glucagon by stimulation of α cells in pancreas due to increase of lipolysis caused from reducing insulin and by SGLT2 inhibitor among patients who are under concurrent insulin and SGLT2 inhibitor. Thus, insulin dosage reduction requires caution in order to control blood glucose level on combined treatment of SGLT2 inhibitor in a patient who is administering insulin because the patient may be caused ketoacidosis in normal blood glucose level.

Central Retinal Vein Occlusion in Young Healthy Patients and the Role of Thrombophilia in Pathogenesis

PURPOSE: We report two young patients who developed central retinal vein occlusion (CRVO) without any systemic disease, and various thrombophilia tests were performed to determine the etiology. CASE SUMMARY: Two young patients, a 22-year-old female and a 23-year-old male, who had acute vision loss were diagnosed with nonischemic CRVO via fluorescein angiography. They had no other disease and no common risk factors for CRVO. We performed various tests to determine the thrombophilic risk factors and discovered a transient decrease in protein S antigen and protein C antigen in the female and male patients, respectively. CONCLUSIONS: CRVO in young patients without systemic disorders may have different mechanisms in the pathology and thus additional laboratory tests to determine thrombophilic disorders are necessary.

A Case of a Corneal Stromal Penetrating Injury via an Ejected Needle during Stromal Hydration

PURPOSE: We report a case of a horizontally penetrating injury of corneal stroma via an ejected irrigating needle during stromal hydration in cataract surgery. CASE SUMMARY: A 79-year-old woman presented with decreased visual acuity in her right eye. Her best corrected visual acuity in the right eye was 0.3. The cataract score of her right eye was nuclear opacity 3, cortical opacity 1−2, and posterior subcapsular opacity 1. She underwent phacoemulsification using a clear corneal approach while under topical anesthesia, and an intraocular lens was successfully implanted in the bag. A plastic syringe with an irrigating needle was used to hydrate the corneal stroma at the clear cornea site. As a result of the increased pressure applied to the connection between the syringe and irrigating needle, the loosened irrigating needle was forcefully ejected toward the corneal endothelium, horizontally penetrating the stroma without injuring the corneal epithelium. On the 1st postoperative day, her right eye exhibited a visual acuity of 0.5, astigmatism of −1.25 diopter (D) cyl., corneal edema with Descemet's folds, and insignificant scarring of the corneal endothelium. Three weeks after surgery, the visual acuity was 0.9, the astigmatism was −0.50 D, and any other abnormalities such as corneal opacity were no longer present. CONCLUSIONS: Despite a penetrating needle injury through the corneal endothelium and stroma, the corneal wound healing process did not result in corneal opacity or worsened astigmatism. To prevent sequela due to an ejected irrigating needle, operators and assistants should be actively aware of tight locking between the needle and syringe.

Extramedullary Relapse of Multiple Myeloma Presenting as Mechanical Small Bowel Obstruction: A Case Report / 대한내과학회지

Plasmacytoma in patients with multiple myeloma usually develops in the advanced stage of the disease. We report herein an atypical case of extramedullary relapse of multiple myeloma that presented as mechanical obstruction of the small bowel in a patient who had achieved complete remission after chemotherapy. A 75-year-old man was diagnosed with multiple myeloma 25 months previously and treated with a bortezomib-containing chemotherapy regimen. He presented for evaluation of abdominal pain. A circumferential mass resulting in mechanical ileus was observed by abdominal computed tomography. Biopsy after surgical resection confirmed the diagnosis of plasmacytoma. The patient was subsequently treated with thalidomide-containing chemotherapy, but he died of disease progression after 6 months. We suggest careful observation of unusual relapses of multiple myeloma in patients who have achieved complete remission after antimyeloma therapy.

The Efficacy and Safety of Platinum/Vinorelbine as More Than Second-Line Chemotherapy for Advanced Non-small Cell Lung Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: There is no regimen that is strongly recommended for more than second-line treatment. We investigated the efficacy and safety of platinum/vinorelbine as more than second-line treatment. MATERIALS AND METHODS: We selected patients with advanced non-small cell lung cancer (NSCLC) who received treatment with platinum/vinorelbine at Chungnam National University Hospital from August 2001 to December 2013. The primary end point was the response rate, and secondary end points were progression-free survival (PFS), overall survival (OS), and toxicity. RESULTS: Thirty-five patients were enrolled. Response rate was 22.9% (complete response, 0 patients [0%]; partial response, eight patients [22.9%]; stable disease, 10 patients [28.6%]; progressive disease, 14 patients [40.0%]). A significantly higher response rate was observed for patients who had responded to previous chemotherapy than for those who did not (34.8% [8/23] vs. 0% [0/12], p=0.020). The median PFS was 4 months (range, 1 to 21 months). Patients with adenocarcinoma and non-smokers had a significantly longer PFS than patients with non-adenocarcinoma and smokers (5 months vs. 2 months, p=0.007; 4.5 months vs. 2 months, p=0.046, respectively). The median OS was 10 months (range, 1 to 41 months). Patients with good performance status and non-smokers had a significantly longer OS than patients with poor performance status and smokers (14 months vs. 4 months, p=0.02; 18.5 months vs. 6 months, p=0.049, respectively). The main serious adverse event (grade 3 or 4) was neutropenia (15 events, 13.3%) in a total of 113 cycles. CONCLUSION: Platinum/vinorelbine was effective as more than second-line chemotherapy, and the toxicity was tolerable, in patients with advanced NSCLC.

Diagnostic and Prognostic Implications of Spine Magnetic Resonance Imaging at Diagnosis in Patients with Multiple Myeloma / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The aim of this study is to determine the diagnostic and prognostic role of baseline spinal magnetic resonance imaging (MRI) in patients with multiple myeloma. MATERIALS AND METHODS: We enrolled patients newly diagnosed with multiple myeloma from 2004-2011 at a single center. Abnormal MRI findings that were not detected in radiographs have been analyzed and categorized as malignant compression fractures or extramedullary plasmacytoma. The bone marrow (BM) infiltration patterns on MRI have been classified into five categories. RESULTS: A total of 113 patients with a median age of 65 years (range, 40 to 89 years) were enrolled in the study. Malignant compression fractures not detected in the bone survey were found in 26 patients (23.0%), including three patients (2.6%) with no related symptoms or signs. Extramedullary plasmacytoma was detected in 22 patients (19.5%), including 15 (13.3%) with epidural extension of the tumor. Of these 22 patients, 11 (50.0%) had no relevant symptoms or signs. The presence of malignant compression fractures did not influence overall survival; whereas non-epidural extramedullary plasmacytoma was associated with poor overall survival in the multivariate analysis (hazard ratio, 3.205; 95% confidence interval [CI], 1.430 to 9.845; p=0.042). During the follow-up for a median of 21 months (range, 1 to 91 months), overall survival with the mixed BM infiltrative pattern (median, 24.0 months; 95% CI, 22.9 to 25.1 months) was shorter than those with other patterns (median 56 months; 95% CI, 48.9 to 63.1 months; p=0.030). CONCLUSION: These results indicate that spine MRI at the time of diagnosis is useful for detecting skeletal lesions and predicting the prognosis in patients with multiple myeloma.

Response: The Biochemical Prognostic Factors of Subclinical Hypothyroidism (Endocrinol Metab 2014;29:154-62, Myung Won Lee et al.)

No abstract available.

A Case of Posner-Schlossman Syndrome with Retinal Arterial Tortuosity in a Young Male

PURPOSE: To report a case of Posner-Schlossman syndrome with retinal arterial tortuosity in a young male. CASE SUMMARY: A 15-year-old male presented to our department with a halo in his left vision. Best corrected visual acuity was 0.6 and intraocular pressure was 59 mm Hg in the left eye. Slit lamp examination revealed corneal edema, keratic precipitate, deep anterior chamber, anterior chamber cell (1+) and open angle. Fundus examination revealed increased cup/disc (C/D) ratio and retinal arterial tortuosity. After treatment with anti-glaucomatic eyedrops, steroid eyedrops, and nonsteroidal anti-inflammatory drug (NSAID) eyedrops, intraocular pressure decreased to 15 mm Hg and C/D ratio decreased. CONCLUSIONS: Posner-Schlossman syndrome can occur even at an early age and must be included in the differential diagnosis of glaucoma in pediatric patients. Additional studies should be conducted regarding the association between retinal arterial tortuosity and Posner-Schlossman syndrome.

Discriminating Between Normal and Glaucomatous Eyes Using the Modified ISNT Rule

PURPOSE: To evaluate the diagnostic ability of the modified ISNT rule (disc rim thickness of the smaller of inferior and superior > the larger of nasal and temporal) for normal and glaucomatous eyes compared to the classic ISNT rule (disc rim thickness of inferior > superior > nasal > temporal). METHODS: Color stereo optic disc photographs of 113 normal subjects and 108 open angle glaucoma patients with early and moderate stage were morphometrically evaluated. The classic ISNT rule and the modified ISNT rule were assessed by masked evaluation of disc photographs at the 3, 6, 9 and 12 o'clock positions. RESULTS: Among normal subjects, 58 of 113 eyes (51.3%) were normal and in open angle glaucoma patients, 104 of 108 eyes (96.3%) were abnormal with the classic ISNT rule. Among normal subjects, 98 of 113 eyes (94.2%) were normal and in open angle glaucoma patients, 102 of 108 eyes (94.4%) were abnormal with the modified ISNT rule. The modified ISNT rule was more accurate than the classic ISNT rule in terms of Cohen's Kappa analysis used for discriminating between normal and glaucomatous eyes. CONCLUSIONS: The modified ISNT rule is useful for differentiating between normal and glaucomatous optic nerves and easily applied in clinical practice.