Prognosis of Ocular Injury Caused by Wasp Sting: Case Reports

PURPOSE: In the present study, the prognosis of ocular injury caused by a wasp sting was evaluated in two cases: Case 1 was treated by anterior chamber irrigation and Case 2 was simultaneously treated by anterior chamber irrigation and vitrectomy. CASE SUMMARY: Both patients had unilateral damage and complained of severe eye pain and blurred vision. Severe corneal edema, conjunctival injection, marked anterior chamber inflammatory reaction and the wasp sting through the cornea at the anterior chamber were observed in both cases. In Case 1, anterior chamber irrigation was performed, however, corneal edema was not recovered. Six months after the wasp sting, phthisis was observed. In Case 2, anterior chamber irrigation and vitrectomy were simultaneously performed, corneal edema decreased and epithelial healing occurred. Four months after the wasp sting, the eyeball was stable, but there was no wave on the electroretinogram. CONCLUSIONS: Unlike the ocular damage resulting from a bee sting, the ocular damage from a wasp sting causes severe toxic reactions and results in poor prognosis. Aggressive treatment including vitrectomy is necessary shortly after wasp sting injury to save both the vision and eyeball.

Rocuronium Bromide Inhibits Inflammation and Pain by Suppressing Nitric Oxide Production and Enhancing Prostaglandin E2 Synthesis in Endothelial Cells / 대한배뇨장애요실금학회지

PURPOSE: Rocuronium bromide is a nondepolarizing neuromuscular blocking drug and has been used as an adjunct for relaxation or paralysis of the skeletal muscles, facilitation of endotracheal intubation, and improving surgical conditions during general anesthesia. However, intravenous injection of rocuronium bromide induces injection pain or withdrawal movement. The exact mechanism of rocuronium bromide-induced injection pain or withdrawal movement is not yet understood. We investigated whether rocuronium bromide treatment is involved in the induction of inflammation and pain in vascular endothelial cells. METHODS: For this study, calf pulmonary artery endothelial (CPAE) cells were used, and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, Western blot, nitric oxide detection, and prostaglandin E2 immunoassay were conducted. RESULTS: Rocuronium bromide treatment inhibited endothelial nitric oxide synthase and suppressed nitric oxide production in CPAE cells. Rocuronium bromide activated cyclooxygenase-2, inducible nitric oxide synthase and increased prostaglandin E2 synthesis in CPAE cells. CONCLUSIONS: Rocuronium bromide induced inflammation and pain in CPAE cells. Suppressing nitric oxide production and enhancing prostaglandin E2 synthesis might be associated with rocuronium bromide-induced injection pain or withdrawal movement.

A Case of Dengue Fever with Macular Involvement

PURPOSE: To report a case of Dengue fever with bilateral macular edema and retinitis. CASE SUMMARY: A 31-year-old female was referred to our clinic with blurred vision. The patient had visited Bali, Indonesia approximately 2 weeks prior. Dengue fever was diagnosed at the Division of Infectious Disease because the patient's serum dengue virus antibodies test was positive for dengue viral IgM antibodies. The patient's best corrected visual acuity was 0.4 in the right eye and 0.6 in the left eye. Slit lamp examination showed inflammatory cells in the vitreous but not in the anterior segment of both eyes. Fundus examination showed thickening of the retina in both eyes as well as a splinter retinal hemorrhage in left eye. Fluorescein angiography revealed hyperfluorescence of the venule in the perifoveal vascular network of the left macula, and indocyanine green angiography showed early diffuse hyperfluorescence in both eyes. Standard automated perimetry showed an overall reduction of the visual field and an increase in scotoma in both eyes. At 1 week after the initial visit, the macular edema had not improved and the patient's vision had deteriorated, especially in left eye. To improve the macular edema and ocular inflammation, a subtenon triamcinolone acetonide injection in the left eye was administered. At 5 weeks after treatment, corrected visual acuity improved to 1.0 in both eyes. Ocular findings, such as macular edema and intraretinal hemorrhage were resolved. The patient did not complain of any remaining discomfort. However, standard automated perimetry revealed that a pericentral scotoma was still present in left eye. CONCLUSIONS: In the present study, the authors report a case of bilateral macular edema and retinitis at the posterior pole after dengue infection. The patient demonstrated a relatively positive response to steroid therapy in the left eye and to conservative treatment in the right eye.

Neurotrophic Corneal Ulcer Development Following Cataract Surgery with a Limbal Relaxing Incision

A 60-year-old man with bilateral corneal opacity underwent cataract extraction surgery involving the use of a limbal relaxing incision in his left eye. He had lower lid ectropion and lagophthalmos in both eyes. Eleven days after the surgery, a slit-lamp examination revealed a neurotrophic corneal ulcer with a punch-out epithelial defect and rolled edges at the center of the pre-existing corneal opacity. The patient was treated with sodium hyaluronate, autologous serum, and oral doxycycline. Six weeks after the surgery an improvement in corneal sensation was observed and the neurotrophic corneal ulcer subsequently healed over the course of one year. In this report, we present a case of neurotrophic keratitis that occurred after performing cataract surgery concurrent with a limbal relaxing incision. As such, we suggest that limbal relaxing incisions should be performed cautiously in patients with causative risk factors for corneal hypesthesia.

A Validation and Reliability Study of the Korean Version of National Eye Institute Visual Function Questionnaire 25

PURPOSE: To translate and evaluate the reliability and validity of the Korean version of the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ-25). METHODS: Two bilingual ophthalmologists independently translated the original English version of the NEI-VFQ-25 into written Korean. A panel of the Korean Retina Society reviewed the translations to form a single reconciled forward translation of the Korean version of the NEI-VFQ-25. Another ophthalmologist back-translated this first draft into English. Both the first draft and back-translated draft were edited by a professional translator. To evaluate the correlation and validity, results between the original NEI-VFQ-25 and the Korean version, completed by the bilingual participants, were compared. RESULTS: The Korean version of the National Eye Institute Visual Functioning Questionnaire-25 was developed by translation, back-translation, and expert supervision. Results from 23 bilingual participants between the original NEI-VFQ-25 and the Korean version were compared and showed statistically significant correlation, with a Spearman's correlation coefficient of 0.4 or greater. The Kolmogorov-Smirnov test results showed no statistically significant differences between the two questionnaires. CONCLUSIONS: Translation and validation of the Korean version of the NEI-VFQ-25 was achieved.

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.

A Case of Miller Fischer Syndrome With Optic Nerve Involvement

PURPOSE: To report an extremely rare case of optic nerve involvement in Miller-Fisher syndrome. CASE SUMMARY: A 74-year-old woman presented to our clinic with decreased visual acuity in both eyes. Such symptoms started 1 month prior to her visit, after sudden onset of left-side motor power weakness and dysphasia. Following the initial symptoms, our patient consecutively experienced worsening dysphagia, ptosis, and lateral gaze limitation. We confirmed the diagnosis as Miller Fischer syndrome with a positive anti-GQ1b antibody serology. She received immunoglobulin treatment for 5 days in other departement. She visited our clinic due to continuing diplopia, decrease of visual acuity and gait disturbance. On initial examination, the corrected visual acuity was 0.5 in both eyes. Ptosis of both eyelids, esodeviation, limitation in ocular movement was noted. The fundoscopic examinations revealed relatively pale optic disc. There was decrease in color vision in both eyes. The visual evoked potential test showed low amplitude and delayed latency in P100 wave in both eyes. Two months after her initial visit to our department her symptoms started to improve, and after 4 months all the initial problems resolved completely and her corrected visual acuity checked out to be 0.8 in both eyes and VEP abnormality was recovered. CONCLUSIONS: It is extremely uncommon for Miller Fisher syndrome to involve the optic nerve. We present such a case of a 74-year-old woman whose symptoms improved 4 months after its first attack with treatment.

Orbital Apex Syndrome with Nasal Type Natural Killer(NK)/T-cell Lymphoma of Sphenoid and Ethmoid Sinus

PURPOSE: To report a case of nasal-type NK/T cell lymphoma occurring in the sphenoid and ethmoid sinuses of an orbital apex syndrome patient. CASE SUMMARY: A 61-year-old male patient visited our hospital for the impairment of vision in the right eye for the previous month, and for right-side blepharoptosis, pain around the eyeball, and limitation of extraocular movement in the right eye for three days earlier. In MRI (magnetic resonance image) and CT (computed tomography), shades with vague boundaries were observed in the right sphenoid and ethmoid sinuses, and open biopsy and decompression were performed for the lesions. After the surgery, the vision of the right eye increased, and improvement was observed in the right blepharoptosis, the pain around the eyeball, and in the limitation of motility of the extraocular muscle in the right eye. The patient was diagnosed with nasal type NK/T cell lymphoma in biopsy, and radiotherapy and chemotherapy were performed.

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.

Comparison of Vitreolytic Effect in Rabbit Eyes: Plasmin, Hyaluronidase, and Their Mixtures

PURPOSE: The aim of the present study was to quantify and compare the vitreolytic effect of plasmin, hyaluronidase, and a combination of the two. METHODS: Thirty-six rabbits were randomized into 3 groups: (A) twelve rabbits had an intravitreal injection of plasmin 1 U with hyaluronidase 10 U/0.1 mL into the right eye, (B) twelve rabbits had an injection of plasmin alone (1 U/0.1 mL), and (C) twelve rabbits had an injection of hyaluronidase alone (10 U/0.1 mL). The left eye of each rabbit was used as control, which was injected with 0.1 mL phosphate buffered saline (PBS). The eyes were enucleated 1 hour and 24 hours after injection. The volume of fluid-type vitreous and gel-type vitreous was measured with a micropipette using the melting point as the difference. Statistical analysis was performed and light microscopy was used to assess potential damage to the retinal tissue. RESULTS: The volume of remaining gel-type vitreous was measured as 52.5%, 60.3%, 59.2%, and 76.5% after 1 hour enucleation and as 44.6%, 56.7%, 56.1%, and 74.7%, after 24 hours enucleation in group A, B, C, and control group, respectively. Group A, B, and C showed statistically significant differences against the control group. Group A (plasmin with hyaluronidase) showed less remaining gel-type vitreous volume than a single injection of plasmin or hyaluronidase alone. CONCLUSIONS: Intravitreal injection of plasmin with hyaluronidase showed more vitreolytic effect than a single injection of plasmin or hyaluronidase alone. The enzyme may be useful in liquefying the vitreous, and may be a useful biochemical adjunct to vitrectomy.

Measurement and Analysis of Serous Fluid in Central Serous Chorioretinopathy using OCT

PURPOSE: To evaluate the correlation between the degree of serous fluid and best corrected visual acuity at the first visit in central serous chorioretinopathy using optical coherence tomography. METHODS: Retrospective analysis was performed for 30 eyes of 30 patients with central serous chorioretinopathy. Cross-sectional retinal images through the center of the fovea were obtained from all eyes by optical coherence tomography. The height, sectional area, and the tangent of theta (tan theta) were estimated. They were statistically analyzed and correlated with best corrected visual acuity. RESULTS: Mean (+/-SD) height of serous fluid was 341.40+/-120.60 micrometer, mean (+/-SD) sectional area was 0.55+/-0.29 mm2, and mean (+/-SD) tan theta was 0.22+/-0.04. The correlation coefficients between best corrected visual acuity at the first visit and sectional area were r=-0.740 (P=0.001). CONCLUSIONS: Optical coherence tomography is useful for the quantitative evaluation of serous neurosensory retinal detachment and estimating visual acuity in central serous chorioretinopathy.

The Structure of the Internal Limiting Membrane Removed by Vitrectomy Using Tissue Plasminogen Activator

PURPOSE: This study evaluated the effect of tissue plasminogen activator (TPA) on adhesion between the internal limiting membrane and the vitreous cortex in patients with diabetic macular edema. METHODS: This retrospective study included 14 eyes of 14 patients with diabetic macular edema without posterior vitreous detachment. The fourteen eyes were divided into two groups. In the first group, vitrectomy and internal limiting membrane (ILM) removal were performed after intravitreal TPA 0.1 cc (50 ug) injection the day before vitrectomy and in the second group, vitrectomy and ILM removal were performed without previous injection of TPA. We observed the ILM using electron microscopy and verified the effects of the TPA. RESULTS: Spontaneous posterior vitreous detachment occurred in 3 of 7 eyes in the first group. Internal limiting membranes removed by vitrectomy showed a smooth surface in 4 of 7 eyes in the first group and in 1 of 7 eyes in the second group. Seven eyes of the first group and 6 eyes of the second group revealed decreased foveal thickness and increased visual acuity 90 days postoperatively. CONCLUSIONS: Preoperative intravitreal TPA injection was helpful for achieving posterior vitreous detachment and for decreasing possible postoperative complications involving in remnant vitreous cortex in patients with diabetic macular edema.

Lens Particle Glaucoma with Intraocular Foreign Body

PURPOSE: To report a case of acute lens particle glaucoma with an intraocular foreign body that persisted for a long duration. CASE SUMMARY: A 47-year-old man visited our clinic due to severe pain in his right eye. His uncorrected visual acuity was hand movement, and intraocular pressure (IOP) measured by a Goldmann applanation tonometer was 76 mmHg in the right eye. Severe corneal edema and floating lens materials in the anterior chamber were revealed by slit-lamp examination. An ultrasonography scan showed that the lens had dislocated into the vitreous cavity and revealed vitreous opacities. To remove lens materials and control IOP, anterior chamber irrigation and trans pars plana vitrectomy with lensectomy were performed under local anesthesia. During the operation, an intraocular foreign body was removed from the anterior chamber. Dislocated lens particles were removed by vitrectomy. After the operation, his best corrected visual acuity was 1.0, and intraocular pressure was 12 mmHg in the right eye. CONCLUSIONS: Close observation is needed in cases with lens particle glaucoma, because a long-persisting intraocular foreign body can be accompanied by lens particle glaucoma.

The Potential Role of the Retinal Acuity Meter For Predicting Visual Outcome after Cataract Surgery

PURPOSE: To investigate the accuracy and usefulness of the retinal acuity meter (RAM) in predicting visual acuity after cataract surgery. METHODS: We randomly selected 47 eyes from 43 patients who underwent cataract surgery in our clinic. Preoperative BCVA and 3 month postoperative BCVA were measured by the Snellen chart, and we recorded the preoperative visual acuity by RAM. We also grouped the patients according to diabetic retinopathy and preoperative BCVA 20/100. By comparing the expected visual acuity by RAM with actual postoperative BCVA values, we analyzed the accuracy of the RAM's predictability after surgery. The cataract types and macular disease were taken under consideration when analyzing our results. RESULTS: Of the 47 eyes in our study, the postoperative Snellen visual acuity was predictable within three lines (90.9%) in 11 eyes with diabetic retinopathy and without macular disease. In the 36 eyes without diabetic retinopathy, the postoperative Snellen visual acuity was predictable within three lines (91.6%) of the cases. In both groups, the preoperative RAM acuity and postoperative BCVA were significantly correlated (R2=0.692, R2=0.812, p<0.05). In 41 eyes with preoperative BCVA 20/100 or more, the postoperative Snellen visual acuity was highly predictable in 95.1% (R2=0.763, p<0.05). However, in 6 eyes with preoperative BCVA levels less than 20/100, the postoperative Snellen visual acuity was not predictable (66.6 %). In the patients with both nucleosclerosis and posterior subcapsular opacity and in the patients with additional cortical opacity, the postoperative BCVA differed from the preoperative RAM acuity by more than three lines on the Snellen chart. CONCLUSIONS: RAM is useful in predicting postoperative visual acuity in cataract patients, but may be unreliable in the patients with combined cataract forms or with preoperative BCVAs less than 20/100.

Anterior Fibroblastic Proliferation of Lens Epithelial Cells in Acrylic Intraocular Lens

PURPOSE: To report upon two cases of anterior capsule opacification (ACO) proliferating into the pupillary region of the anterior surface of a single piece acrylic AcrySof(R) intraocular lens (IOL) (SA60AT, Alcon Laboratories, Inc., USA). The surgical removal of the ACO was also reported. METHODS: An 80-year-old woman and a 75-year-old woman underwent phacoemulsification with implantation of a single piece foldable AcrySof(R) IOL in the posterior capsular bag. ACO proliferating from the opposite sides of the IOL along the central axis were found three months after surgery. To recover visual acuity in the 80-year-old woman's eye, ACO was surgically removed with a Sinskey hook and irrigation and aspiration system. RESULTS: The patient's visual acuity was recovered after surgical removal of the ACO. Histopathologic findings of the removed tissues revealed fibroblastic proliferation of lens epithelial cells. The ACO in 75-year-old woman's eye was not treated, as it was not associated with a visual disturbance. CONCLUSIONS: In eyes containing an AcrySof(R) IOL, clinically significant ACO proliferation into the pupillary region along the central axis can occur. Surgical removal can be beneficial for recovery of visual acuity.

Intravitreal and Additional Posterior Subtenon Triamcinolone Injection in Diabetic Macular Edema

PURPOSE: To compare the effect of triamcinolone acetonide injection between intravitreal injection alone group and intravitreal injection in combintaion with posterior subtenon injection group in diabetic macular edema. METHODS: Twenty-nine eyes of 29 patients with diabetic macular edema were randomly classified into two groups. Intravitreal injection of triamcinolone acetonide 4 mg was administered to 15 eyes and posterior subtenon injection of triamcinolone acetonide 20 mg in combination with intravitreal injection was administered to 14 eyes. Best corrected visual acuity (BCVA), macular thickness measured by optical coherence tomography were assessed 1, 3, 6, and 12 months after the procedure. RESULTS: Baseline BCVA and macular thickness showed no differences between two groups. BCVA and macular thickness 1, 3, and 6 months after the procedure revealed significant improvement, but no significant differences between two groups were observed. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide alone and intravitreal inejction in combination with posterior subtenon injection were equally effective, but had no significant differences.

A Case of Corneal Ulcer Caused by Ralstonia Paucula Infection

PURPOSE: There has not been any reports of Ralstonia paucula causing any ophthalmologic disease. However, we have detected Ralstonia paucula in the lens washing agents of a corneal ulcer patient wearing contact lens. METHODS: A 26-years-old female patient was admitted to our hospital complaining of loss of visual acuity and hyperemia. Slit lamp biomicroscopy and smear culture was done to the anterior segment of the eye and the lens cleansing agent. The patient was treated with antibiotic eye drop and intravenous antibiotic medication. RESULTS: The results of both smear and culture showed the presence of Ralstonia pacula and responded well to antibiotics treatment with ceftazidime.

Epicanthoplasty Using Modified Uchida Method to Shift an Epicanthal Fold in a Superomedial Direction

PURPOSE: The presence of epicanthal fold and the absence of supratarsal fold are characteristics of Korean eyelids. There has been many surgical procedures to eliminate medial epicanthal fold but those procedures focus on the lengthening of horizontal palpebral fissure and the shortening of intercanthal distance so that the shape of eye had tendency to be sharp. The authors suggest that the supermedial shifting of epicanthal fold enhance the aesthetic result. METHODS: From Sep 2006 to May 2007, total 17 women(mean age 22) with Type III epicanthal fold underwent epicanthoplasty using author's modified Uchida method. The design for epicanthoplasty was drawn superolaterally along epicanthal fold and split V-W plasty was done to shift the epicanthal fold superomedially. Also non-incisional double-eyelid operation was underwent. RESULTS: The epicanthal fold was shifted in superomedially, intercanthal distance was shortened and double-eyelid was achieved. The patients were satisfied with the result and no major complication was noted. CONCLUSION: This method can be effective in correcting the epicanthal fold of Korean eyelid by shifting the epicanthal fold superomedially to make the shape of eye aesthetically without noticeable scar.

Wavefront Aberration Changes after the Instillation of Artificial Tear in Dry Eyes

PURPOSE: To identify the effects of artificial tear instillation on tear film changes using wavefront aberrations. METHODS: Artifical tear was instilled every 2 hours for 14 days into 20 normal eyes and 20 dry eyes. The changes in tear film using wavefront aberrations were analyzed 1 minute after the final instillation of artifical tear. RESULTS: In dry eyes, total wavefront aberration and total high order wavefront aberration decreased significantly (p<0.05). In normal eyes, total wavefront aberration and high order wavefront aberration did not decrease. CONCLUSIONS: Stabilization of the tear film after instillation of artificial tear may be responsible for the decrease of wavefront abberation in dry-eye patients.

Normal Value for Microperimetry with the Scanning Laser Ophthalmoscope

Fundus perimetry is the device that provides visualization of the fundus and the precise localization of the stimuli on it. With the increasing importance of the direct fundus perimetry for certain focal retinal morphologic abnormalities, the scanning laser ophthalmoscope[SLO]has been utilized as a system to eliminate some of the classic technical problems in fundus perimetry. The aim of this study was to evaluate the normal light sensitivity values for microperimetryusing SLO system. Thirty eyes of thirty normal subjects were examined in 60 degrees image field using stimuli of variable intensity. The maximal retinal distance point which responded to stimulus was recorded, point which responded to stimulus was recorded, and the distance[millimeter]from the fovea was calculated by the Bennett formula. The maximum distance from the fovea at the given stimulus intensity was measured as follows :0.7596 +/-0.5262millimeter at 28decibel, 2.2050 +/-0.5878millimeter at 26decibel, 3.0571 +/-0.7151millimeter at 24decibel, 4.3690 +/-1.0973millimeter at 22decibel, and 5.6557 +/-1.3458millimeter at 20decibel. In conclusion, we were able to establish the normal range of light sensitivity in Microperimery examination. It may serve as the baseline for subsequent study of retinal pathology and functional evaluation as well as its treatment.