The Effects of the Scleral Suture in 23-Gauge Transconjunctival Sutureless Vitrectomy

PURPOSE: To evaluate the effects of scleral suture for the sclerotomy wound leakage and the clinical outcomes in 23-gauge transconjunctival sutureless vitrectomy with fluid-air exchange. METHODS: A retrospective, comparative chart review of 75 eyes of 75 patients who underwent 23-gauge transconjunctival vitrecomy with fluid air exchange was performed. The patients were divided into 2 groups according to the scleral suture used at the end of the operation, sclera-sutured group and sutureless group. The amount of intraocular gas remnants was measured to compare the degree of sclerotomy wound leakage and the postoperative intraocular pressure (IOP) and reoperation rate were analyzed. RESULTS: The mean IOP on postoperative day 1, 7 and 14 was 15.5 +/- 4.0 mm Hg in the sclera-sutured group and 15.8 +/- 6.2 mm Hg in the sutureless group, without statistical difference (p = 0.874). The percentage of intraocular gas remnants in eyes on postoperative day 1 was significantly higher in the sclera-sutured group (92.9 +/- 9.7%) than in the sutureless group (82.4 +/- 16.2%; p = 0.002) as well as on postoperative days 7 and 14. The reoperation rate was not statistically significantly different between the sclera-sutured group (6.5%) and sutureless group (9.1%; p = 0.683) CONCLUSIONS: In the cases of 23-gauge sutureless vitrectomy with fluid-air exchange, the scleral suture may be effective to prevent the sclerotomy wound leakage and maintain the intraocular gas longer, but there was no statistically significant difference in the final success rate between the 2 groups. However, as more intraocular gas remained in the sclera-sutured group than in the sutureless group statistically, the scleral suture should be considered in cases that require long-term gas tamponade.

Association between serum vitamin D and depressive symptoms among female workers in the manufacturing industry

BACKGROUND: Vitamin D has been known to maintain the body's balance of calcium and phosphorus as well as skeletal health. There has been increasing emphasis on the importance of vitamin D as recent studies have been reporting the specific functions of vitamin D in the cerebral nervous system and the association between the level of serum vitamin D and depressive symptoms. However, there is currently a paucity of research investigating the association between serum vitamin D and depressive symptoms in Korean subjects. Consequently, this study has aimed to determine the level of serum vitamin D and explore the association between serum vitamin D and depressive symptoms in Korean female workers. METHOD: A medical examination, questionnaire, anthropometric measurements, and a blood test were conducted between February 3 and March 7, 2014 in 1054 subjects among female workers in the manufacturing industry who underwent physical examinations in a university hospital. From this data, we identified the level of serum vitamin D and investigated the association between serum vitamin D deficiency and depressive symptoms. RESULTS: The average serum vitamin D level of the 1054 subjects was 9.07 +/- 3.25 ng/mL, and the number of subjects in the serum vitamin D deficiency group with less than 10 ng/mL was 721 (68.4 %). The odds ratio of the depressive symptom group with a CES-D score of 16 or above being in the deficiency group with a serum vitamin D level less than 10 ng/mL was found to be 1.55 (95 % CI = 1.15-2.07). CONCLUSION: 68.4 % of female workers in the manufacturing industry were in the deficiency group with serum vitamin D levels less than 10 ng/mL. Additionally, we identified an association between serum vitamin D deficiency and depressive symptoms. In the future, if serum vitamin D deficiency is checked regularly in workers, we expect to achieve better outcomes in managing their depressive symptoms.

Clinical Manifestation of Juvenile Idiopathic Arthritis Associated Uveitis in Korea

PURPOSE: To investigate the incidence and clinical characteristics of juvenile idiopathic arthritis (JIA)-associated uveitis in Korea and to identify the risk factors for developing uveitis and poor visual outcome. METHODS: We performed a retrospective chart review of 149 patients who were diagnosed as JIA between January 2001 and December 2012. Patients were classified based on the International League of Associations for Rheumatology (ILAR) criteria and the incidence and clinical course of uveitis according to each subtype was investigated. We also evaluated the risk factors for poor prognostic outcomes. RESULTS: The present study included 79 males and 70 females and the mean age was 7.42 +/- 3.82 years. In 13 patients (8.6%), uveitis manifested evenly among JIA subtypes, including 5 patients with oligoarthritis type, 4 patients with polyarthritis rheumatoid negative type, and 4 patients with systemic type. Anti-nuclear antibody (ANA) was detected more in the uveitic group (46.13%). The characteristics of uveitis were acute (85%), bilateral (85%), and anterior uveitis (92%). Chronic uveitis occurred in only 2 patients who had uveitis at an early age (mean age of 5 years) and had severe anterior chamber reaction at presentation. Poor visual outcome was associated with band keratopathy and posterior synechiae preceded by the chronic uveitis. CONCLUSIONS: JIA-associated uveitis occurred evenly in each subtype. Uveitis was increased in the presence of ANA. Most uveitis showed good visual outcomes but in cases of early uveitis onset and with severe anterior chamber reaction at presentation the risk of chronic uveitis increased resulting in poor visual outcomes.

Neovascular Glaucoma Due to Branch Retinal Vein Occlusion Combined with Branch Retinal Artery Occlusion

Branch retinal artery occlusion (BRAO) and branch retinal vein occlusion (BRVO) rarely cause neovascular glaucoma (NVG). A 58-year-old woman with hypertension and type 2 diabetic mellitus complained of progressive visual loss in her right eye for the previous 3 months. At initial examination, visual acuity was 20 / 63 in the right eye. Angle neovascularization was observed and the intraocular pressure (IOP) was 30 mmHg in her right eye. Fundus examination and fluorescein angiography showed BRAO combined with BRVO. We immediately injected intravitreal and intracameral bevacizumab in her right eye. The next day, we performed scatter photocoagulation in the nonperfusion area. One month later, visual acuity was 20 / 20 in her right eye and the IOP was 17 mmHg with one topical antiglaucoma agent. The neovascularization had regressed completely. We report a case of unilateral NVG which was caused by BRAO with concomitant BRVO and advise close ophthalmic examination of the iris and angle in BRVO with BRAO.

Long-Term Changes in Visual Acuity and Foveal Thickness after Vitrectomy for Idiopathic Epiretinal Membrane

PURPOSE: To evaluate the clinical outcomes of visual acuity and foveal thickness after vitrectomy for an idiopathic epiretinal membrane (ERM). METHODS: We retrospectively reviewed the records of 62 patients (62 eyes) with ERM who had been treated with vitrectomy between 2004 and 2009. Visual acuity and central macular thickness from optical coherence tomography imaging were obtained preoperatively and at every postoperative follow-up visit. RESULTS: Mean preoperative visual acuity and central macular thickness were 0.495 +/- 0.292 log MAR and 414.645 +/- 95.528 microm, respectively. Mean visual acuity and central macular thickness 1 month after surgery were 0.389 +/- 0.373 log MAR and 341.484 +/- 73.676 microm, respectively. Visual acuity improved within 9 months and central macular thickness significantly decreased 12 months after surgery. Most of the changes in visual acuity and central macular thickness took place during the first 3 months. The only parameter which was significantly correlated with final visual acuity was preoperative visual acuity (0.635) (p < 0.001). CONCLUSIONS: Visual acuity and central macular thickness improved 12 months months after vitrectomy in patients with idiopathic ERM. Preoperative visual acuity had a significant correlation with final visual acuity.

The Changes in Central Macular Thickness after Cataract Surgery in Patients with Diabetic Retinopathy

PURPOSE: To evaluate the changes in central macular thickness (CMT) and incidence of macular edema (ME) after cataract surgery in diabetic patients compared with non-diabetic patients using optical coherence tomography (OCT). METHODS: The records of 138 diabetic patients and 34 non-diabetic patients who underwent cataract surgery were retrospectively reviewed. The diabetic group was divided into 5 groups according to severity of diabetic retinopathy. The diabetic group was also divided into 2 groups depending on prior panretinal photocoagulation history. The changes in CMT were examined using OCT before cataract surgery and 1 week, 1-, 2- and 6-months after surgery in diabetic and non-diabetic patients. RESULTS: The incidence of ME in the diabetic group and non-diabetic group was 19.6% and 2.9% respectively. The increased amount of CMT (DeltaCMT) was significantly greater in the diabetic group compared with the non-diabetic group during the observation period (p < 0.05). The DeltaCMT of eyes without a history of panretinal photocoagulation was statistically greater compared to the eyes with a history of panretinal photocoagulation at 1-, 2- and 6-months after cataract surgery (p = 0.005, 0.002, 0.008, respectively). CONCLUSIONS: The DeltaCMT and incidence of ME were significantly greater in the diabetic group compared with the non-diabetic group. Additionally, the incidence of ME was significantly greater depending on severity of diabetic retinopathy in the diabetic group.

A Case of Acute Retinal Necrosis Following Herpes Simplex Virus (HSV) Encephalitis

PURPOSE: To report a case of unilateral acute retinal necrosis (ARN) following herpes simplex virus (HSV) encephalitis. CASE SUMMARY: A 19-year-old man previously diagnosed with HSV encephalitis presented with a headache and visual loss in his left eye. On the initial visit, slit-lamp examination showed conjunctival injection and inflammatory cells (3+) in the anterior chamber of the left eye. Funduscopic examination showed optic disc swelling, multiple yellow-whitish spots in the peripheral retina and retinal vascular sheathing. After the patient was diagnosed with ARN, intravenous acyclovir (1,500 mg/m2/day) was administered. Because retinal detachment and multiple retinal breaks were found during the treatment period, the authors performed barrier laser treatment in the peripheral retina. At that time, no retinal necrosis was observed in the patient's right eye. The retinal lesions regressed, and no new retinal lesion was observed in the left eye, during the follow-up period. CONCLUSIONS: We report a case of ARN in a patient with HSV encephalitis. Ophthamologist should perform a thorough ophthalmic examination in a patient diagnosed with HSV encephalitis.

Evaluation of Changes of Macular Thickness in Diabetic Retinopathy after Cataract Surgery

PURPOSE: To assess the macular thickness changes after cataract surgery in diabetic patients using optical coherence tomography (OCT). METHODS: We retrospectively reviewed the records of 104 diabetic patients who underwent cataract surgery. We examined the changes of macular thickness using OCT before cataract surgery and 1 week, 1-, 2- and 6-months after surgery. The central subfield mean thickness (CSMT) was used to evaluate macular edema which was defined as an increase of CSMT (DeltaCSMT) > 30% from the baseline. The association between prior laser treatment or severity of diabetic retinopathy and macular thickness were also analyzed. RESULTS: Macular edema occurred in 19 eyes (18%) from the diabetic group and 63% of macular edema developed at 1 month after surgery. Thirteen (68%) out of 19 eyes with macular edema showed the resolution of macular edema by 6 months after surgery without treatment. DeltaCSMT of eyes without a history of laser treatment was statistically greater compared to eyes with a history of laser treatment in at 1- and 2-months after surgery, but was not different than eyes who had laser treatment at 6-months after surgery. The severity of diabetic retinopathy was not significantly correlated to macular edema, but there was statistical difference when patients who had a history of prior laser treatment were excluded. CONCLUSIONS: The incidence of macular edema after cataract surgery in diabetic patients was 18%. Its peak incidence was at 1 month post surgery and it resolved spontaneously in 68% of patients by 6 months post surgery. Prior laser treatment might prevent postoperative macular edema until 2 months after cataract surgery in diabetic patients. However, macular edema did not affect the severity of diabetic retinopathy.

Comparison of the Natural Course and Intravitreal Triamcinolone Treatment for Macular Edema with Branch Retinal Vein Occlusion

PURPOSE: To evaluate the natural course of eyes with decreased visual acuity associated with macular edema secondary to branch retinal vein occlusion (BRVO) and to compare the visual outcome and macular thickness with those of eyes treated with intravitreal triamcinolone acetonide injection (IVTA). METHODS: We reviewed the medical records of patients with macular edema secondary to BRVO who were followed-up for 12 months. We evaluated the best corrected visual acuity (BCVA) and macular thickness of the patients who had no treatment for macular edema (natural course group) and compared them with those of patients who had been treated with IVTA (treatment group). RESULTS: A total of 29 eyes (29 patients) in the natural course group and 27 eyes (27 patients) in the treatment group were enrolled. The BCVA of the natural course group improved in a slow but steady manner and showed a statistically significant difference at 12 months. The treatment group did not show any improvement in BCVA throughout the follow-up period. Therefore, BCVA significantly improved in the natural course group after six months compared to that in the treatment group. Macular thickness showed a statistically significant reduction in three months in the natural course group and in one month in the treatment group. CONCLUSIONS: Although IVTA was effective in reducing macular edema in branch retinal vein occlusion at one month after administration, the natural course group had a superior outcome and more improved macular thickness after six months.

The Clinical Course of the Idiopathic Epiretinal Membrane After Surgery

PURPOSE: To evaluate the clinical course of visual acuity and foveal thickness in the idiopathic epiretinal membrane (ERM) after a vitrectomy with the use of triamcinolone. METHODS: We retrospectively reviewed the records of 30 patients (30 eyes) with ERM that were treated by vitrectomy from 2004 to 2008. Visual acuity and foveal thickness from optical coherence tomography imaging was obtained preoperatively and at every postoperative follow-up visit. RESULTS: Visual acuity improved by two or more lines of vision in 30%, 50%, 60%, and 70%, and stayed the same within +/-1 line in 47%, 50%, 40%, and 30% at one month, three months, five months, and seven months after surgery. Twenty-three percents of the subjects deteriorated by two or more lines of vision within one month after surgery. None of the subjects had reduced vision three months after surgery. Foveal thickness decreased significantly after surgery. The mean thickness was 409.7+/-107.9 microm before surgery and 288.6+/-66.1 microm seven months after surgery. Parameters which were significantly correlated with the final visual acuity included preoperative visual acuity (0.683), preoperative foveal thickness (0.544), and final foveal thickness (0.643) (p<0.005). CONCLUSIONS: Foveal thickness and visual acuity improved until seven months after the vitrectomy in patients with idiopathic ERM. Preoperative visual acuity, foveal thickness, and final foveal thickness had a significant correlation with the final visual acuity.

Retinal Nerve Fiber Layer Thickness Analysis in Early Glaucoma

PURPOSE: To investigate the difference between superior and inferior peripapillary retinal nerve fiber layer (RNFL) thickness in early glaucoma patients who have RNFL defect in either superior quadrant or inferior quadrant and to determine if it can be useful to detect early glaucomatous change. METHODS: Eighty eight patients with early glaucoma who have RNFL defect in either the superior quadrant or the inferior quadrant as confirmed by red free photograph (40 eyes with normal standard automated perimetry and 48 eyes with early glaucomatous visual field loss) were divided into the superior RNFL defect group and the inferior RNFL defect group. The average RNFL thickness was measured in the superior and inferior quadrants using optical coherence tomography and the thickness differences between the superior and the inferior quadrants (S-I difference) were compared among early glaucoma eyes and 59 normal controls. Then, discriminative power of the S-I difference was assessed by area under ROC (AUROC). RESULTS: The average thickness of the RNFL showed a statistically significant difference between early glaucoma eyes and normal controls (P<0.05). S-I differences of the superior RNFL defect group and inferior RNFL defect group in preperimetric patients and in early perimetric patients were -20.5+/-16.4 micrometer and 15.0+/-14.2 micrometer, -24.0+/-17.2 micrometer and 18.4+/-16.7 micrometer, respectively, which were significantly greater than that of the normal control group (-8.2+/-17.1 micrometer). AUROC of S-I difference in the superior and inferior defect groups of preperimetric patients were 0.691, 0.872, respectively. CONCLUSIONS: The difference in RNFL thickness between the superior and inferior quadrants (S-I difference) in early glaucoma patients was larger than in normal controls. We expect that this parameter of RNFL analysis using OCT can be useful in detecting early glaucoma.

Upper Eyelid Retraction After Periorbital Trauma

We report four unusual cases of upper eyelid retraction following periorbital trauma. Four previously healthy patients were evaluated for unilateral upper eyelid retraction following periorbital trauma. A 31-year-old man (Case 1) and a 24-year-old man (Case 2) presented with left upper eyelid retraction which developed after blow-out fractures, a 44-year-old woman (Case 3) presented with left upper eyelid retraction secondary to a periorbital contusion that occurred one week prior, and a 56-year-old man (Case 4) presented with left upper eyelid retraction that developed 1 month after a lower canalicular laceration was sustained during a traffic accident. The authors performed a thyroid function test and orbital computed tomography (CT) in all cases. Thyroid function was normal in all patients, CT showed an adhesion of the superior rectus muscle and superior oblique muscle in the first case and diffuse thickening of the superior rectus muscle and levator complex in the third case. CT showed no specific findings in the second or fourth cases. Upper eyelid retraction due to superior complex adhesion can be considered one of the complications of periorbital trauma.

Stratus OCT, SWAP, Matrix FDT in Preperimetric Glaucoma

PURPOSE: To evaluate the peripapillary retinal nerve fiber layer (RNFL) thickness with optical coherence tomography (OCT) in normal subjects and preperimetric glaucoma patients, as well as compare the results of OCT, short wavelength automated perimetry (SWAP), frequency doubling technology perimetry (FDT) in preperimetric glaucoma patients. METHODS: Thirty-six eyes of 36 preperimetric glaucoma patients who have definitive localized RNFL defects in disc photograph and normal standard visual field, as well as 35 eyes of 35 normal subjects, were enrolled in this study. We compared the peripapillary RNFL thickness between the two groups using Stratus OCT. Stratus OCT, FDT, and SWAP results in preperimetric glaucoma group were also compared. RESULTS: Compared with normal controls, peripapillary RNFL thickness, including the average, superior, and inferior quadrant, was significantly low (P<0.05) in the preperimetric glaucoma group, 93.40+/-11.16 micrometer, 118.33+/-21.17 micrometer, and 108.72+/-16.76 micrometer respectively. In preperimetric glaucoma group, functional and structural abnormalities were found in 55.6% with Stratus OCT, 31.4% with SWAP, and 79.4% with Matrix FDT. CONCLUSIONS: Statistically significant reduction of RNFL thickness was revealed in the preperimetric glaucoma group, and Matrix FDT was the most sensitive test for detecting early glaucomatous change, followed by Stratus OCT, and SWAP.

The Effects of Riluzole and Trolox in Transient Retinal Ischemia

PURPOSES: To evaluate the effect of riluzole (water soluble vitamin E, antioxidant) and trolox(glutamatergic neurotransmission antagonist) in transient retinal ischemia. METHODS: The effects of two drugs were investigated in a gerbil model of retinal ischemic injury. Retinal ischemia was induced by clipping both common carotid arteries for 15 minutes. In group I (10 eyes), 10 gerbils received an intraperitoneal injection of the saline, and in group II (10 eyes), riluzole was injected 30 minutes before ischemia and 30 minutes after the end of the ischemic insult and once daily during the recovery period. In group III (10 eyes), trolox was injected and in group IV (10 eyes), riluzole and trolox were injected in a same manner. Electroretinograms were recorded before ischemia and after 1 hour, 2 days, and 7days of reperfusion. Retinas were harvested for histopathology (hematoxyline-eosin staining and Tdt-dUTP terminal nick-end labeling method). RESULTS: Ischemia for 15 minutes caused reduction of a- and b- waves of the electroretinogram. Treatments with riluzole or trolox significantly enhanced the recovery of the reduced a-and b-waves after reperfusion. Combined treatment with riluzole and trolox also enhanced the recovery of the reduced a-and b-waves, but synergistic effect was not observed. Riluzole and trolox also prevented or attenuated ischemia induced cell death (necrosis and apoptosis). CONCLUSIONS: Riluzole and trolox acted in vivo as a potent neuroprotective agents against transient retinal ischemic model. Therefore, riluzole and trolox may be a major drug for use in the protection against retinal ischemic injury.

polypoidal Choroidal Vasculopathy

No Abstract Available.

The Effect of Intrav it real Injection of tPA and C3F8 Gas in Submacular Hemorrhage

This study was designed to evaluate the efficacy of intravitreal injection of tPA &C3F8 gas in submacular hemorrhage. Fourteen patients with sub-macular hemorrhage received an intravitreal injection of tPA &C3F8 gas and maintained face down position for 2 weeks. We investigated the feature of blood absorption, the correlation between underlying disease, hemorrhage size, duration and visual outcome. Underlying disease seemed to be a prognostic factor related to final visual acuity. Patients with choroidal rupture had better visual prognosis than those with age-related macular degeneration. The duration between the formation of submacular hemorrhage and treatment was correlated with final visual acuity, however, it was not sta-tisticallly significant. We have shown that submacular hemorrhage could be displaced by tPA and C3F8 gas injection in our most cases. In 7 of total 14 cases, visual acuity improved. The result suggests that this technique may be good for the initial treatment if done in appropriate timing in cases of submacular hemorrhage due to its simplicity and it can achieve relatively good results.

The Effect of Polyurethane Film with Sustained Release Edxamethasone on Prevention of Experimental Fat Adherence Syndrome in Rabbits

The fat adherence syndrome(FAS) is a severe form of the restrictive strabismus resulting from the adherence of orbital tissues to the globe of extraocular muscles and their attachments, for which no successful treatment currently exists. we developed anexperimental model for the FAS in the rabbit eyes and then evaluated the effects of polyurethane film with sustained release dexamethasone on the prevention of experimental FAS. Thirty eyes of fifteen white rabbits had a fat autograft placed between the inferior rectus and the periosteum of the inferior orbital rim and then, the inferior rectus, the fat and the periosteum were sutured to create an experimental FAS. In Group I the experimental FAS was only induced as a control group. The polyurethane film with no released substance and the polyurethane film with sustained release of dexamethasone were inserted between the inferior rectus and the fat in Group II and Group III, respectively. The force required to move the eyeball superiorly 4mm, 6mm, and 8mm was measured preoperatively and 4 weeks ostoperatively. At postoperative 4 weeks the surgical dissection to evaluate the degree of the adhesion and the histologic examination were performed. A significant increase in forced duction(postop-preop) was found at all levels of ocular rotation in Group I and it means that the induction of experimental FAS was successful. Histology revealed a moderate inflammatory response with partial loss of normal adipose tissue replaced by fibrovascular tissue. Group III had significantly less restriction than Group I and Group II. Group II had less restriction than Group I, but statistically not significant. In conclusion, the use of the polyurethane film with sustained release of dexamethasone may have a role in the prevention of experimental FAS.

Indocyanine Green Angiographic Findings in Multiple Evanescent White Dot Syndrome

We examined three patients with multiple evanescent white dot syndrome(MEWDS) using confocal laser scanning indocyanine green angiography(ICGA), and observed two types of hypofluorescent lesion which were very characteristic and diagnostic by themselves. One was dot pattern, dense hypofluorescences which were detected evidently in the late phases, and some of them could be confirmed in the early phases. They clustered in the peripapillary area and dispersed sporadically to the midperiphery. The other was circular pattern, relatively lighter hypofluorescences which were evidently observed in the late phases also. They were crowded and fused in the peripapillary area or in the posterior pole and scattered to the midperiphery in a radiating pattern. These area included clinically observed white dot lesions, but were more widespread distinctively. At the recovery stages, all these hypofluorescent lesions disappeared completely. It is supposed that the former represents blocked fluorescence by inflammatory precipitates and the latter reveals circulatory disturbance in the choriocapillary or pre-capillary arteriole. Previous fluorescein angiographic and electrophysiologic studies have demonstrated the involvement of the retinal pigment epithelium(RPE) and photoreceptors in MEWDS. Our findings on ICGA suggest that the ischemic choroidal circulatory disturbance due to the inflammatory precipitates in the choroid may be the primary change and the RPE and photoreceptors may be involved secondarily.

The Evaluation of Anterior Segment Circulation after Strabismus Surgery by using Indocyanine Green(ICG) Iris Angiography

Anterior segment ischemia is a rare, but serious complication of strabismus surgery, Iris microvascular circulation in eyes with blue irides has been investigated by fluorescein iris angiorgaphy, which failed to demonstrate the iris vascular pattern in eyes with heavily pigmented irides like Oriental brown iris. Anterior segment circulation in eyes of Korean after strabismus surgery was investigated by iris angiography using indocyanine green(ICG), which highly penetrates through the pigmented tissue or hemorrhage ICG iris angiography using confocal scanning laser ophthalmolscope was performed before and after strabismus surgery in 20 eyes of 20 Koreans. Tenotomies of medial and lateral recti produced no appreciable circulatory disturbance in the iris in any patients, but there was mild delayed filling in 2 eyes of 6 eyes undergoing tenotomy of one or both vertical recti. When tenotomies of a horizontal and a vertical rectus were combined, the filling defect occurred in the region of radial vessels was observed in eyes with tenotomies of medial rectus and lateral halves of superior and inferior recti. Our study suggests that ICG iris angiography is a useful means for the evaluation of anterior segment circulation I darkly pigmented iris like Oriental brown iris. And there was the remarkable change in iris microvascular circulation only after tenotomy of multiple muscles including vertical rectus muscles.