The Effect of Intravitreal Bevacizumab Injection before Trabeculectomy in Patients with Neovascular Glaucoma

PURPOSE: To evaluate the efficacy of preoperative intravitreal bevacizumab injection (IVBI) and prognostic factors of surgical success in neovascular glaucoma patients, who underwent trabeculectomy. METHODS: A total of 58 patients (58 eyes) diagnosed with neovascular glaucoma who underwent trabeculectomy between 2003 and 2013 were enrolled in this retrospective study. Trabeculectomy with mitomycin C was performed between 2003 and 2006 and additional preoperative IVBI with the above mentioned technique was performed between 2007 and 2013. To evaluate the efficacy of preoperative IVBI, the patients were divided into the preoperative IVBI group and control group. Best corrected visual acuity (BCVA) and intraocular pressure (IOP) were measured from preoperative to postoperative 12 months. To evaluate the prognostic factors related to surgical success, the following was investigated: age, lens status, preoperative IVBI, time interval between preoperative IVBI and trabeculectomy, previous vitrectomy and, postoperative complications. RESULTS: Trabeculectomy with mitomycin C only was performed in 26 eyes and additional preoperative IVBI was performed in 32 eyes. Surgical success was 81.3% in the IVBI group and 57.7% in the control group at postoperative 6 months (p = 0.012), and 78.1% in the IVBI group and 50.0% in the control group at postoperative 12 months (p = 0.021). Statistically significant IOP reduction effect was observed in the IVBI group (p = 0.048), and reduced anti-glaucoma eye drop usage was observed in the IVBI group (0.4) compared with 0.8 in the control group (p = 0.040). Postoperative hyphema (hazard ratio [HR] = 2.872, p = 0.044) and preoperative IVBI (HR = 0.280, p = 0.030) were considered risk factors for surgical failure in univariate analysis, however, only preoperative IVBI was statistically significant in multivariate analysis (p = 0.046). CONCLUSIONS: In neovascular glaucoma patients, preoperative IVBI before trabeculectomy is a good prognostic factor of surgical success and shows benefit in lowering the IOP and reducing anti-glaucoma eye drop usage at postoperative 1 year.

Clinical Features of Posterior Capsule Rupture during Phacoemulsification Performed by Novice Ophthalmologists

PURPOSE: To report the related factors of posterior capsule rupture and the difference of postoperative visual prognosis after phacoemulsification by analyzing clinical features of the surgery performed by ten novice ophthalmologists. METHODS: We retrospectively evaluated electronic medical records of 326 patients (412 phacoemulsification cases) who underwent surgery by novice ophthalmologists certified by the Board of Ophthalmology after a resident training program. RESULTS: The number of cataract surgeries performed by each surgeon within the ophthalmology fellowship period (6 months - 2 years) ranged from 16 to 75 eyes, and perioperative posterior capsule ruptures occurred in 64 of 412 eyes (15.5%). Factors such as age, sex, laterality, axial length and clinical courses were not related to the rate of posterior capsule rupture. Nucleosclerosis was significantly related to the posterior capsule rupture rate and was especially higher in the group with a grade higher than five compared to that in the groups with a grade less than 5 based on the Lens Opacities Classification System III (p = 0.033). Factors of surgeon's subspecialty, nucleofractis method, and period between residency and the fellowship were not related to the posterior capsule rupture rate, except when considering anesthetic methods. The posterior capsule rupture rate was less frequent in the retrobulbar surgery group than the topical surgery group (p = 0.046). Postoperative visual outcomes were significantly different at postoperative day one and one month (p = 0.023, 0.022, respectively) but not at postoperative two months (p = 0.059). CONCLUSIONS: Phacoemulsifications performed by novice ophthalmologists showed a statistically significant difference in posterior capsule rupture rate between nucleosclerosis and anesthesia groups. Postoperative visual outcome differed at postoperative day one and one month but not after two months postoperatively.

Clinical Features of Posterior Capsule Rupture during Phacoemulsification Performed by Novice Ophthalmologists

PURPOSE: To report the related factors of posterior capsule rupture and the difference of postoperative visual prognosis after phacoemulsification by analyzing clinical features of the surgery performed by ten novice ophthalmologists. METHODS: We retrospectively evaluated electronic medical records of 326 patients (412 phacoemulsification cases) who underwent surgery by novice ophthalmologists certified by the Board of Ophthalmology after a resident training program. RESULTS: The number of cataract surgeries performed by each surgeon within the ophthalmology fellowship period (6 months - 2 years) ranged from 16 to 75 eyes, and perioperative posterior capsule ruptures occurred in 64 of 412 eyes (15.5%). Factors such as age, sex, laterality, axial length and clinical courses were not related to the rate of posterior capsule rupture. Nucleosclerosis was significantly related to the posterior capsule rupture rate and was especially higher in the group with a grade higher than five compared to that in the groups with a grade less than 5 based on the Lens Opacities Classification System III (p = 0.033). Factors of surgeon's subspecialty, nucleofractis method, and period between residency and the fellowship were not related to the posterior capsule rupture rate, except when considering anesthetic methods. The posterior capsule rupture rate was less frequent in the retrobulbar surgery group than the topical surgery group (p = 0.046). Postoperative visual outcomes were significantly different at postoperative day one and one month (p = 0.023, 0.022, respectively) but not at postoperative two months (p = 0.059). CONCLUSIONS: Phacoemulsifications performed by novice ophthalmologists showed a statistically significant difference in posterior capsule rupture rate between nucleosclerosis and anesthesia groups. Postoperative visual outcome differed at postoperative day one and one month but not after two months postoperatively.

A Case of Phoma glomerata Keratitis Occurred in Recurrent Herpes Simplex Keratitis Cicatrix

PURPOSE: To report a case of Phoma glomerata keratitis occurring in recurrent herpes simplex keratitis cicatrix. CASE SUMMARY: A 63-year-old male patient was admitted to our hospital with complaints of abrupt visual deterioration and ocular pain in his left eye. He was treated for recurrent herpes simplex keratitis in the same eye 12 years prior. Because central desmatocele was observed as a result of advanced corneal stromal melting, Gram staining, Potassium Hydroxide (KOH) mount, and culture were performed in corneal scrape specimens. On microbiological evaluation, a Phoma species was detected and Phoma glomerata was diagnosed using DNA sequencing method. Two consecutive amniotic membrane transplantations were performed with topical antifungal agents. The lesion was not improved when using topical amphotericin B and natamycin eyedrops, thus fluconazole eyedrops were used additionally. The corneal infection was resolved with central thick opacification. CONCLUSIONS: In the present case, herpetic keratitis was the main underlying causative factor because the patient had no past history of trauma. When diverse appearances of keratitis occur in herpes simplex keratitis patients, clinicians need to consider the concurrence of fungal infection, especially Phoma glomerata, a rare fungal organism.

A Case of Beauveria Bassiana Keratitis Confirmed by Gene Sequencing

PURPOSE: To report a case of Beauveria bassiana keratitis that was confirmed by gene sequencing. CASE SUMMARY: A 70-year-old man presented to our hospital with complaints of ocular pain and deterioration of the visual acuity in his left eye after injury caused by a wood branch one week previously. Visual acuity in the left eye was 20/400 at the time of the first visit. Slit lamp examination showed a central 0.7 x 2.5-mm-sized epithelial defect surrounded by cellular infiltration in the stroma. Scraping of the corneal lesion for microbiological examinations was performed. Initial Gram stain, potassium hydroxide (KOH) mount, and culture were negative. However, fungal hyphae were observed on a KOH mount of the repeated corneal scraping specimen, and a Beauveria species was suspected based on the culture. Beauveria bassiana was confirmed using a MicroSEQ(R) D2 large-subunit ribosomal DNA fungal sequencing kit. Natamycin eye solution was initially instilled bihourly (every two hours), but the persistent epithelial defect and progressive stromal melting finally resulted in a descemetocele. Temporary and permanent amniotic membrane transplantations were performed, and amphotericin B eye solution was administered bihourly (every two hours). The ulcerous lesion gradually improved with no evidence of recurrence. CONCLUSIONS: Recently, cases of fungal keratitis have been increasing. Therefore, molecular diagnosis methods such as gene sequencing can be helpful in diagnosis and in improving the prognosis of fungal keratitis caused by rare fungi, as we found in this case.

A Case of Fusarium Keratitis Treated with Moxifloxacin 0.5% Ophthalmic Solution

PURPOSE: To report a case of fusarium keratitis treated with only moxifloxacin 0.5% ophthalmic solution (Vigamox(R), Alcon Laboratories, Inc., Ft Worth, TX, USA). CASE SUMMARY: A 37-year-old healthy male patient experienced a right eye injury due to grain 7 days prior to presentation at our hospital with visual disturbance and ocular pain. A 2.7 x 4.3 mm sized corneal epithelial defect with irregular featherlike midstromal infiltration was observed, and slit lamp examination revealed a dry, rough texture. Thus a smear and culture were performed. Moxifloxacin 0.5% ophthalmic solution (Vigamox(R)) and lubricant were applied for treatment. Three days after using the eye solution, all clinical features improved. Seven days later, Fusarium species was identified in culture. CONCLUSIONS: As standard treatment for Fusarium, the authors of the present study used an antifungal agent. Although hyphae were detected in culture, the use of only moxifloxacin 0.5% ophthalmic solution (Vigamox(R)) result in a satisfactory result and improvement in clinical features.

Phialemonium obovatum Keratitis after Penetration Injury of the Cornea

Phialemonium keratitis is a very rare case and we encountered a case of keratitis caused by Phialemonium obovatum (P. obovatum) after penetrating injury to the cornea. This is the first case report in the existing literature. A 54-year-old male was referred to us after a penetration injury, and prompt primary closure was performed. Two weeks after surgery, an epithelial defect and stromal melting were observed near the laceration site. P. obovatum was identified, and then identified again on repeated cultures. Subsequently, Natacin was administered every two hours. Amniotic membrane transplantation was performed due to a persistent epithelial defect and impending corneal perforation. Three weeks after amniotic membrane transplantation, the epithelial defect had completely healed, but the cornea had turned opaque. Six months after amniotic membrane transplantation, visual acuity was light perception only, and corneal thinning and diffuse corneal opacification remained opaque. Six months after amniotic membrane transplantation, visual acuity was light perception only, and corneal thinning and diffuse corneal opacification remained.

Tectonic Deep Anterior Lamellar Keratoplasty in Impending Corneal Perforation Using Cryopreserved Cornea

We report a case of tectonic corneal transplantation for impending corneal perforation to preserve anatomic integrity using cryopreserved donor tissue. An 82-year-old woman exhibiting impending corneal perforation suffered from moderate ocular pain in the left eye for one week. After abnormal tissues around the impending perforation area were carefully peeled away using a Crescent blade and Vannas scissors, the patient received tectonic deep anterior lamellar keratoplasty using a cryopreserved cornea stored in Optisol GS(R) solution at -70degrees C for four weeks. At six months after surgery, the cornea remained transparent and restored the normal corneal thickness. There were no complications such as corneal haze or scars, graft rejection, recurrent corneal ulcer, and postoperative rise of intraocular pressure. Cryopreserved donor lamellar tissue is an effective substitute in emergency tectonic lamellar keratoplasty, such as impending corneal perforation and severe necrotic corneal keratitis.

Opacification of the Optic of an Akreos Adapt Intraocular Lens

A 60-year-old diabetic patient transferred to our retina clinic for a regular follow-up for diabetic retinopathy. He had uneventful cataract surgery at the time of pars plana vitrectomy in the right eye due to diabetic retinopathy at a private ophthalmologic hospital. Six months after the surgery, neovascular glaucoma with hyphema developed in the right eye and an Ahmed valve was implanted at our hospital. Ten months after cataract surgery, we found opacification of the intraocular lens (IOL) which was causing significant visual disturbance. At the time, the best corrected visual acuity (BCVA) in the right eye was hand motion. The IOL was explanted 45 months after the operation. Five months after explantation, the BCVA was 0.06. Unfortunately, pathologic analysis was not performed. Patient-related factors such as an anterior chamber reaction caused by hyphema might have been responsible for the opacification. To our knowledge, there are no previous reports of opacification of the Akreos Adapt IOL.

A Case of Recurrent Schneiderian Papilloma of the Lacrimal Sac Invading the Nasal Cavity

A 44-year-old man presented with a history of chronic epiphora, discharge from the right eye, and a palpable mass in the medial canthal area. Irrigation of the lacrimal system revealed bloody discharge. Orbital magnetic resonance imaging (MRI) showed a well-defined heterogeneous enhanced mass filling the lacrimal sac and upper nasolacrimal duct (NLD). A wide excision and surgical biopsy were performed. Histopathology showed the tumor to be an exophytic Schneiderian papilloma with moderate to severe dysplasia. Three months later, the mass was found to be invading the nasal cavity through the NLD. Endoscopic histopathological evaluation confirmed that it was identical to the originally identified papilloma.

A Case of Radiation Retinopathy of Left Eye After Radiation Therapy of Right Brain Metastasis

A 37-year-old female, who had received modified radical mastectomy for cancer of her right breast, presented with decreased visual acuity in the left eye after radiation therapy for the management of the metastasis to her right brain 14 months ago. After ocular examination, we diagnosed her as radiation retinopathy. At the time of the first visit, the corrected best visual acuity was 0.4 in the left eye, and fundus examination revealed cotton wool spots and cystoid macular edema (CME). The findings in the right eye were normal except for cotton wool spots in the superior major arch. Fluorescein angiography (FA) showed marked telangiectasia and microaneurysms in her left eye but tiny microaneurysms in her right eye. Subsequent optical coherent tomography (OCT) showed CME. We injected intravitreal triamcinolone acetonide (TA). Two weeks after treatment, the visual acuity was improved to 0.6 and the retinal thickness was decreased. Three months later, the visual acuity in the left eye was dropped to 0.3 due to the recurrence of CME, so we injected intravitreal TA again. Five months later, visual acuity was improved to 0.5 and OCT revealed the improvement of CME. The incidence of radiation retinopathy is higher in the side nearer to radiation, but careful radiation blocking is also required on the opposite side of irradiation site considering the possibility of radiation retinopathy and careful observation is required on both sides of the eyes when performing fundus examination.

Upper Eyelid Reconstruction Using the Medpor(R) Sheet and Median Forehead Flap

PURPOSE: To report the upper eyelid reconstruction with median forehead flap and Medpor(R) sheet implant following full-thickness eyelid defect resulting from tumor resection. CASE SUMMARY: A 65-year-old woman was examined at our hospital for a recurrent mass on the right upper eyelid. A wide tumor excision with a 3 mm margin and an eyelid reconstruction procedure were performed after a frozen section biopsy revealed a malignancy. The full-thickness eyelid defect was reconstructed with a median forehead flap as a substitute for skin and muscle and a Medpor(R) sheet substituted for tarsal plate was sutured with a lower conjunctiva flap for posterior lamella. The histopathology diagnosis of the lesion showed a well-differentiated squamous cell carcinoma. The lower conjunctiva was separated at 2 weeks after surgery, and then the median forehead flap detached from the upper eyelid skin at 8 weeks after surgery. One year postoperatively, there was no evidence of a wound infection and an exposure of the Medpor(R) sheet. The eyelid had a good cosmetic contour and the movement of the eyelid during blinking was natural. CONCLUSIONS: The use of a Medpor(R) sheet as a substitute for a tarsal plate in reconstructive procedures of the upper eyelid defect shows cosmetic and functional success.

A Case of Traumatic Optic Nerve Injury due to Gunshot

PURPOSE: There have been no reports of optic nerve injuries caused by gunshot in Korea. We describe such an injury and report the treatment outcomes. CASE SUMMARY: A patient visited our hospital complaining of visual disturbance after her right zygomatic bone had been shot with an airgun during a suicide attempt in September 2006. A visual acuity test, pupillary light reflex test, fundus examination, skull X-ray, and computed tomography (CT) were performed. At the initial examination, the right eye had no light perception. The pupillary light reflex test revealed an afferent pupillary defect, and the fundus examination showed central retinal artery occlusion. The skull X-ray and computed tomography revealed a fracture of the right medial and lateral orbital walls as well as a partial injury to the medial rectus muscle. In addition, right retrobulbar hemorrhage and metallic foreign bodies were observed in the right orbit. Under general anesthesia, disinsertion of the superior and lateral rectus muscles was performed, and the metallic foreign bodies in the right orbit were removed. The surgical incision was then closed. A Krimsky prism test performed 7 days after surgery revealed an approximately 15 prism diopters of exodeviation of the right eye. CONCLUSIONS: We report a case of optic nerve injury caused by a gunshot.

A Case of Optic Neuritis in Acute Sphenoid Sinusitis

PURPOSE: We encountered a rare case of optic neuritis that developed in a sphenoid sinusitis. This case has not been reported at any of the Korean Ophthalmological Society meetings. CASE SUMMARY: A 12-year-old boy with swollen optic disc was diagnosed with optic neuritis secondary to sphenoid sinusitis, through orbit MRI (magnetic resonance imaging) and paranasal sinus CT (computed tomography). We observed the recovery of visual acuity and the improvement of papilledema after treatment. In the initial examination, the BCVA (best-corrected visual acuity) of the right eye was only hand movement. Papilledema was detected by ophthalmoscopy. Orbit MRI and paranasal sinus CT were then performed, which revealed that sphenoid sinusitis had invaded the right optic nerve. Treatment included the use of antibiotics, systemic steroid therapy, and endoscopic sinus surgery. One month after treatment, the BCVA of the right eye was 1.0 and the papilla of right eye had a normal ophthalmoscopic finding. CONCLUSIONS: Sphenoid sinusitis can be a cause of optic neuritis. The treatment of optic neuritis caused by paranasal sinusitis must include antibiotics use or endoscopic sinus surgery to remove the sinus inflammation as well as high dose steroid therapy.

A Case of Fetal Alcohol Syndrome with Esotropia

PURPOSE: Here, we report a case of an infant with fetal alcohol syndrome with esotropia who was born to a mother who consumed a large quantity of alcohol during her pregnancy. METHODS: A 1-year-old female infant visited our hospital for the main symptom of the esodeviation of the eye. The medical history of the mother and the delivery history were reviewed, and a physical examination and ophthalmic examination of the infant were performed. RESULTS: At the first examination, the patient was 15 months old, her mass was 5, 600 grams, her height was 70 cm, her head circumference was 39.5 cm, and her chest circumference was 41 cm; all the measurements were below the 3rd percentile. From the gestation age of 24 weeks, the mother consumed 1-2 bottles of sojoo every day, and the infant patient was delivered at the gestation age of 42 weeks by Cesarean section. The infant's birth weight was 1, 510 grams. Upon physical examination, her philtrum was found to be shallow, and microcephaly was detected. Upon ophthalmic examination, a refractive error +1.25 Dsph. was detected. With regard to the horizontal length of the palpebral fissure, the right and the left were 1.7 cm and 1.6 cm, respectively, which is considered short; telecanthus and esotropia were also present. CONCLUSIONS: To the best of our knowledge, this is the first reported case of fetal alcohol syndrome with accompanying esotropia.

Paralytic Exotropia from Pit Viper Snakebite

PURPOSE: The authors report their experience with four cases of paralytic exotropia from a pit viper snakebite, accompanied with a literature review. METHODS: Four patients (two males and two females) visited the emergency room in the hospital with symptoms including diplopia, limitation of eye movement, exotropia, and blepharoptosis, after being bitten by a presumed pit viper, and were treated by antivenom. RESULTS: No visual disturbance was observed in the first examination, while limitation of adduction was found in four cases in the ocular movement test. As to the type of tropia, three patients showed intermittent exotropia and the other showed exotropia. The angle of strabismus in the distance was 20~30 prism diopters (PD) while that in the near was 18~35 PD. Two cases were accompanied with blepharoptosis. Except one case which was unavailable for follow-up observation, three cases became normal in diplopia, blepharoptosis, and limitation of ocular movement between the 4th and 11th day after the snakebite. CONCLUSIONS: Neurotoxicity induced by a pit viper snakebite is rare. However, neurotoxicity including strabismus and blepharoptosis can occur because extraocular muscles have a higher ratio of nerve fibers to the extraocular muscle fibers compared with skeletal muscles.

A Case of Optic Neuritis Involving Optic Chiasm

PURPOSE: To report a case of optic neuritis with incongruous homonymous hemianopia involving optic chiasm. METHODS: A twenty five year old female patient complaining of decreased visual acuity in left eye for 4 days was referred from department of neurology. Best corrected visual acuity was 1.0 in the right eye and counting fingers at 20 cm in the left eye. Left afferent pupillary defect was detected. The conventional magnetic resonance image was normal, however on FLAIR image high signal intensity lesion involving left anterior portion of optic nerve, optic chiasm and both optic tract was noted. However the lesion was not easily detected on T2-weighted image. On enhanced MRI image, the lesion was partially enhanced. Visual field showed incongruous homonymous right hemianopia. VEP showed no evoked potentials in left eye stimulation by checkboard pattern and normal response in right eye stimulation. The patient had normal CSF studies and had been treated with high dose intravenous steroid. After 19 days, visual acuity and magnetic resonance image was markedly improved. RESULTS: We experienced a case of optic neuritis with incongruous homonymous hemianopia involving optic chiasm and report this case with literature review as we believe that our case is the first case in our country.

Canalicular Trephination with Lacrimal Trephine and Endoscopic DCR

PURPOSE: The purpose of this study is to evaluate surgical outcomes of canalicular trephination with lacrimal trephine and endoscopic dacryocystorhinostomy in patiens with common canalicular or canalicular obstruction. METHODS: 35 patients (38 eyes) diagnosed as common canalicular or canalicular obstruction undergoing surgery between December 1999 and August 2003. Patients have been followed up more than 5 months after surgery. RESULTS: The average age of patients was 57.3 years old and the average follow-up period was 7.1 months. The overall success rate was 92.1%. With obstructions within lower canaliculus, the success rate was 75.0%. The success rate of the cases with obstructions within upper canaliculus and upper and lower canaliculus was 100%, and the success rate of the cases with obstructions within common canaliculus was 95.2%. CONCLUSIONS: The surgical success rate of canalicular trephination with lacrimal trephine and endonasal dacryocystorhinostomy was better than canaliculodacryocystorhinostomy and this seems to be adequate as an primary procedure before Jones tube bypass surgery.

A Case of Wegener's Granulomatosis Misdiagnosed as Ocular Tuberculosis

PURPOSE: To report a case of Wegener's granulomatosis misdiagnosed as ocular tuberculosis. METHODS: A 65-year-old man who was treated with anti-tuberculosis medications as suspected pulmonary tuberculosis was referred from the department of internal medicine for visual loss over months. His initial visual acuity was counting fingers at 30 cm in the right eye and there was a chorioretinal scar involving the macula on fundus examination. At that time, we thought that the lesion was a tuberculosis-related chorioretinal scar and so he was treated with anti-tuberculosis medications. There was a recurrent bilateral anterior uveitis during three months from the initial visit. RESULTS: After 14 months, he was examined by otorhinolaryngologist due to a saddle nose deformity and Wegener's granulomatosis was diagnosed based on positive Cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) and nasal mucosal biopsy. At that time, ocular examination revealed the necrotizing scleritis in both eyes and orbital CT showed bony destruction of medial and inferior orbital wall without proptosis in both eyes. We had treated with oral cyclophosphamide and prednisone. CONCLUSIONS: We experienced a case of Wegener's granulomatosis with chorioretinal scar misdiagnosed as ocular tuberculosis. In conclusion, we should differentially diagnose Wegener's granulomatosis from suspected ocular tuberculosis.

A Case of Endogenous endophthalmitis Caused by Klebsiella Pneumoniae from Emphysematous Pyelonephritis

PURPOSE: To report a case of Klebsiella pneumoniae endogenous endophthalmitis secondary to renal or urinary tract infection such as emphysematous pyelonephritis. METHODS: A-56-year-old woman with diabetes mellitus and emphysematous pyelonephritis was reterred to us in consultation for visual loss in her right eye for 5 days. Ophthalmologic evaluation and intervention were performed. RESULTS: Culture revealed Klebsiella pneumoniae from vitreous tap of the right eye. Systemic antibiotics, intravitreous antibiotics injection and vitrectomy were performed, but the eye showed progressive worsening to phthisis. CONCLUSIONS: A high index of suspicion of Klebsiella pneumoniae endogenous endophthalmitis must be carried in patients with renal or urinary tract infection such as emphysematous pyelonephritis as well as hepatobiliary disease such as pyogenic liver abscess.