Implications of Central Corneal Thickness-corrected Intraocular Pressure in Normal-tension Glaucoma with Reduced Central Corneal Thickness

Purpose@#Reduced central corneal thickness (CCT) is a risk factor for glaucoma progression and can impact intraocular pressure (IOP) measurement. Therefore, we investigated the glaucoma progression pattern and associated risk factors among individuals with normal-tension glaucoma (NTG) and reduced CCT. @*Methods@#This retrospective study enrolled 187 eyes of 187 NTG patients with an open angle and a baseline IOP < 20 mmHg, adjusted for CCT. Reduced CCT was defined as < 500 µm thickness in both eyes. Patients with a history of corneal disease or surgery affecting CCT were excluded. We used Goldmann tonometry to measure baseline and CCT-corrected IOP (ccIOP; [IOP - [CCT - 545]/50 × 2.5]). The participants were divided into progressing and stable subgroups. @*Results@#The mean CCT was 481.2 ± 17.5 µm and the mean follow-up period was 6.3 ± 2.5 years. The baseline IOP and ccIOP were 13.7 ± 2.4 and 16.6 ± 2.5 mmHg, respectively. The average visual field progression rate was -0.79 ± 1.26 dB/yr. Of the participants, 47 (26.6%) and 140 (73.4%) were in the progressing and stable group, respectively. Participants in the progressing group were older, had a higher baseline ccIOP, and had a higher proportion of pseudophakia than those in the stable group. Multivariate analysis showed that baseline ccIOP was a significant risk factor. @*Conclusions@#Individuals presenting with NTG and reduced CCT had a relatively stable glaucoma progression rate. However, glaucoma progression was associated with old age, pseudophakia, and high baseline IOP in individuals with reduced CCT. In particular, the only significant factor associated with glaucoma progression was ccIOP. Therefore, ccIOP is a clinically significant factor in individuals with NTG and reduced CCT.

Effect of Phacoemulsification Cataract Surgery on the Clinical Outcomes of Advanced Glaucoma Patients

Purpose@#To identify the clinical outcomes of cataract surgery in patients with advanced glaucoma. @*Methods@#A retrospective chart review of open-angle glaucoma patients who underwent cataract surgery and were followed-up for 1 year was conducted. Advanced glaucoma was defined as a mean deviation (MD) 0.05). Both groups evidenced VA improvements at 1 year postoperatively and the visual field (VF) indices did not differ from those before surgery. The numbers of antiglaucoma medications used decreased after surgery, but the decrease was significant only in the advanced glaucoma group (p = 0.030). @*Conclusions@#The advanced and mild-to-moderate glaucoma groups evidenced similar IOP and VF changes after cataract surgery. The VA improved and the number of antiglaucoma medications decreased. Our findings suggest that cataract surgery for patients with advanced glaucoma may afford similar clinical outcomes compared to other less severe glaucoma groups.

Retinal Thickness and Its Interocular Asymmetry Between Parkinson’s Disease and Drug-Induced Parkinsonism

Background@#Drug-induced parkinsonism (DIP) is common, but diagnosis is challenging.Although dopamine transporter imaging is useful, the cost and inconvenience are problematic, and an easily accessible screening technique is needed. We aimed to determine whether optical coherence tomography (OCT) findings could differentiate DIP from Parkinson’s disease (PD). @*Methods@#We investigated 97 de novo PD patients and 27 DIP patients using OCT and [ 18 F] N-(3-fluoropropyl)-2b-carbon ethoxy-3b-(4-iodophenyl) nortropane (FP-CIT) positron emission tomography. We compared peripapillary retinal nerve fiber layer thickness (pRNFLT) and macular retinal thickness (mRT) between PD and DIP patients as well as interocular differences in the pRNFLT and the mRT. Asymmetric index (%) for retinal thickness (AIRT) was calculated to measure the interocular differences between pRNFLT and mRT. The correlation between AIRT and total striatal specificon-specific binding ratio asymmetry index (SNBRAI) was investigated in PD and DIP patients. @*Results@#No significant differences in pRNFLT and mRT values were observed between PD and DIP patients (all Pvalues > 0.090). The mean SNBRAI was significantly higher in PD than in DIP (P = 0.008) patients; however, AIRT did not differ between PD and DIP patients in pRNFLT and mRT (all P values > 0.100). SNBRAI did not correlate with AIRT of pRNFL or mRT in PD and DIP patients (all P values > 0.060). @*Conclusion@#Our study showed no benefit of retinal thickness and interocular asymmetry measurements using OCT for distinguishing PD from DIP in the early stages. Additional investigations are needed for confirmation.

Path to Diagnosis and Clinical Characteristics of Advanced Glaucoma at Initial Diagnosis: a Tertiary Single Center Experience

Purpose@#As routine health examinations become more common, many patients first diagnosed with glaucoma have advanced glaucoma. We analyzed the routes to diagnosis and the characteristics of patients initially diagnosed with advanced glaucoma. @*Methods@#We retrospectively retrieved the medical records of patients first diagnosed with advanced glaucoma in our tertiary care center. The inclusion criteria were a mean deviation (MD) less than -12 dB on the visual field test, accompanied by structural damage. All patients were classified in terms of unilateral/bilateral disease, the intraocular pressure before medication, and lens status. We divided patients into those with monocular or binocular advanced glaucoma, high- or normal-pressure glaucoma, and those who were pseudophakic or phakic. @*Results@#We included 73 patients of mean age 69.3 years. The visual field test MD was -19.6 dB. In those with binocular advanced glaucoma, incidental ophthalmic examination was the most common means of diagnosis (52.2%). Central-island visual field defects were the most common defects (54.2%). In those with monocular advanced glaucoma, glaucoma-associated symptoms most commonly triggered diagnosis (46.9%). Both superior and inferiorvisual field defects were the most common defects (42.8%). Glaucoma-associated symptoms were present in 68.2 and 22.8% of patients with high- and normal-pressure glaucoma, respectively. Central-island visual field defects were present in 43.6 and 29.4% of those with high- and normal-pressure glaucoma, respectively. @*Conclusions@#We analyzed the routes to diagnosis and the clinical characteristics of patients with advanced glaucoma. In those with binocular disease, glaucoma was most commonly diagnosed on incidental ophthalmic examination. Central-island visual field defects were the most common defects in patients with binocular and high-pressure glaucoma, and the pseudophakic group. A multi-center longitudinal study on risk factors for delayed glaucoma diagnosis is needed.

Motor Asymmetry and Interocular Retinal Thickness in Parkinson's Disease

Background@#To analyze the relationship between interocular difference of retinal thickness and motor asymmetry in Parkinson's disease (PD). @*Methods@#Prospective case-control series analyzed 62 eyes of 31 patients with PD and 62 eyes of 31 age- and sex-matched control. Ophthalmologic examinations including optical coherence tomography (OCT) scans were performed in both groups, and in the patients with PD, motor function was evaluated on the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) to determine the clinically more affected side. Peripapillary retinal nerve fiber layer thickness (pRNFLT) and macular retinal thickness (mRT) were measured in both eyes, after which the interocular asymmetry of the OCT parameters was determined. Additionally, the more and less affected sides of the UPDRS-III were evaluated using Symmetric index. @*Results@#The average and quadrant pRNFLT and mRT values between the two groups were not different, but the interocular asymmetry of the average mRT and asymmetry index of retinal thickness (AIRT) of temporal mRT were significantly higher in the PD patients than in the controls (P = 0.026 and 0.044). The sum of UPDRS-III showed a discrepancy between the more and less affected sides (P = 0.002); the calculated Symmetric index was 0.21 ± 0.19, which suggested asymmetric motor symptoms. The Symmetric index of UPDRS-III showed significant relations for interocular asymmetry of superior mRT and AIRT of average mRT (P = 0.001 and 0.008). @*Conclusion@#In the PD patients, the interocular asymmetry of mRT was larger than in the controls, and the motor symptoms were asymmetric. Additionally, the interocular asymmetry of mRT showed a significant correlation with motor-symptom laterality.

Motor Asymmetry and Interocular Retinal Thickness in Parkinson's Disease

Background@#To analyze the relationship between interocular difference of retinal thickness and motor asymmetry in Parkinson's disease (PD). @*Methods@#Prospective case-control series analyzed 62 eyes of 31 patients with PD and 62 eyes of 31 age- and sex-matched control. Ophthalmologic examinations including optical coherence tomography (OCT) scans were performed in both groups, and in the patients with PD, motor function was evaluated on the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) to determine the clinically more affected side. Peripapillary retinal nerve fiber layer thickness (pRNFLT) and macular retinal thickness (mRT) were measured in both eyes, after which the interocular asymmetry of the OCT parameters was determined. Additionally, the more and less affected sides of the UPDRS-III were evaluated using Symmetric index. @*Results@#The average and quadrant pRNFLT and mRT values between the two groups were not different, but the interocular asymmetry of the average mRT and asymmetry index of retinal thickness (AIRT) of temporal mRT were significantly higher in the PD patients than in the controls (P = 0.026 and 0.044). The sum of UPDRS-III showed a discrepancy between the more and less affected sides (P = 0.002); the calculated Symmetric index was 0.21 ± 0.19, which suggested asymmetric motor symptoms. The Symmetric index of UPDRS-III showed significant relations for interocular asymmetry of superior mRT and AIRT of average mRT (P = 0.001 and 0.008). @*Conclusion@#In the PD patients, the interocular asymmetry of mRT was larger than in the controls, and the motor symptoms were asymmetric. Additionally, the interocular asymmetry of mRT showed a significant correlation with motor-symptom laterality.

Clinicopathological Characteristics of Caruncular Tumors in Koreans

PURPOSE: To investigate the clinical characteristics and histological features of tumors in caruncles. METHODS: We conducted a retrospective chart review of 126 eyes of 126 patients who underwent incisional or excisional biopsy of conjunctival masses between March 2008 and December 2016. RESULTS: Twenty-four patients (19.0%) including 10 males and 14 females had a mass located on the caruncle. The mean age at diagnosis was 41.8 ± 13.4 years (range, 15–67 years). Most patients (75%) visited us for a cosmetically visible mass without other symptoms. The mean duration of symptoms was 73.8 ± 113.0 months (range, 1–240 months). The most common histological diagnosis was a melanocytic tumor (50%) followed by a sebaceous gland tumor (12.5%), an epidermoid cyst (12.5%), and papilloma (12.5%). The symptom duration of the melanocytic tumor was significantly longer than other types of tumors (153.6 ± 139.8 months, p = 0.025). CONCLUSIONS: Caruncular tumors accounted for 19% of all conjunctival tumors. The most common pathological diagnosis of a caruncular tumor was a melanocytic tumor, which had a characteristically long symptom duration.

Effect of Phacoemulsification on Intraocular Pressure in Healthy Subjects and Glaucoma Patients

BACKGROUND: We investigated how cataract surgery might influence long-term intraocular pressure (IOP) change in both healthy subjects and glaucoma patients. METHODS: A retrospective analysis of patients who had had clear corneal phacoemulsification with a minimum of 12 months of follow up was performed. Glaucoma patients with medically controlled open-angle glaucoma and healthy subjects with no glaucoma were included in the analysis. The change of IOP after phacoemulsification and factors associated with postoperative IOP change were investigated. RESULTS: In total, 754 eyes of 754 patients, specifically 106 patients with glaucoma and 648 patients with no glaucoma (i.e., healthy subjects) were enrolled. The phacoemulsification effected a reduction of IOP: 1.03 ± 3.72 mmHg in healthy subjects and 1.08 ± 3.79 mmHg in glaucoma patients at postoperative 1 year (P = 0.656). There were negative coefficients of IOP until 1 year of follow up (all P < 0.001), but the IOP change gradually showed a less steeply decreasing slope (correlation coefficient: −0.993), compared with those for 1 week and 1 month of follow up (correlation coefficients: −1.893 and −1.540, respectively). In the multivariate analysis, age and preoperative IOP showed significant associations with postoperative IOP change (regression coefficients: −0.034 and 0.419 respectively, all P < 0.001). CONCLUSION: Phacoemulsification resulted in IOP reduction, which effect regressed in healthy subjects and glaucoma patients over the course of long-term follow up. Therefore, long-term monitoring of IOP change is needed. In cases of higher preoperative IOP and young patients, phacoemulsification alone is a reliable option for IOP control.

Long-term Intraocular Pressure Elevation after Primary Angle Closure Treated with Early Phacoemulsification

PURPOSE: To assess long-term changes in intraocular pressure (IOP) and the development of glaucoma after early phacoemulsification in acute primary angle closure. METHODS: Retrospective chart review of acute primary angle closure patients treated with phacoemulsification in attack eyes versus fellow eyes. Within a month after the angle closure attack, all subjects underwent cataract surgery and were divided into two groups: group A received cataract surgery on their attack eyes. Group B also received cataract surgery on their fellow eye after phacoemulsification of the attack eyes. Study outcomes were the prevalence of IOP rise (occurrence of IOP >21 mmHg) and the incidence of newly developed glaucoma. RESULTS: Eighty-nine eyes were included, with 62 attack eyes in group A and 27 fellow eyes in group B. Group A (14 eyes, 22.58%) had a higher cumulative rate of IOP rise than group B (3 eyes, 11.11%) at 12 months (p = 0.001). Newly developed glaucoma was not observed in group B; however, 6 patients in group A developed glaucoma during the 12-month follow-up period (p < 0.001). CONCLUSIONS: The attack eyes treated with phacoemulsification showed a significantly higher prevalence of IOP rise and newly developed glaucoma than fellow eyes that received phacoemulsification. These findings suggest that there is a possibility of IOP rise and development of glaucoma even when angle closure and successful IOP control have apparently been achieved after phacoemulsification.

Clinical Outcomes of Early Phacoemulsification after Laser Iridotomy in Acute Angle-closure Glaucoma

PURPOSE: To evaluate long-term change in intraocular pressure (IOP) in eyes undergoing laser iridotomy (LI) and early phacoemulsification after LI in patients with acute angle-closure glaucoma (AACG). METHODS: The retrospective, comparative chart review included patients with AACG, Group A who underwent only LI and Group B who underwent early phacoemulsification within 1 month after LI. Patients were followed up on day 1; week 1; and months 1, 3, 6, and 12 after LI. IOP changes were studied. RESULTS: This study included a total 99 eyes from 99 patients, 37 in group A and 62 in group B. The mean IOP were not significantly different between the two groups at the initial visit or 1 month later. However, group B showed a consistently lower mean IOP that that of group A at 3, 6, and 12 months (p= 0.003, <0.001, <0.001, respectively). The prevalence of IOP increase to greater than 21 mmHg was 3 (8.11%), 5 (13.51%), and 5 patients (13.51%) in group A and 0, 2 (5.41%), and 1 patients (1.61%) in group B at 3, 6, and 12 months, respectively. Group B showed a significantly lower prevalence of IOP increase (p = 0.050, 0.038, 0.026). CONCLUSIONS: We found that patients treated with early phacoemulsification after LI had better outcomes of well-maintained IOP compared to those undergoing LI alone. For AACG patients with coexisting cataract, early phacoemulsification after LI can be considered as a reasonable treatment to maintain IOP.

A Case of Orbital Apex Syndrome Induced by Penetrating Orbital Injury with Long-Term Results

PURPOSE: To report a case of orbital apex syndrome induced by penetrating orbital injury by a wire with the recovery process and clinical outcomes. CASE SUMMARY: A 40-year-old female visited our clinic after a penetrating orbital injury through the left inferomedial conjunctiva by a wire. The best corrected visual acuity of the left eye was 0.6, and ptosis and total ophthalmoplegia were observed. The patient showed a dilated pupil, swelling of the optic disc on fundus exam, and an inferior field defect on the automated perimetry. The computed tomography image revealed mild retrobulbar hemorrhage, but there was no orbital bony fracture. Enhancement of the optic nerve sheath was observed on the magnetic resonance image. The patient was admitted and received systemic antibiotics and steroid treatment. After 1 month, visual acuity, ptosis, and limitation in adduction were partly improved. After 3 months, depression and adduction were improved and the pupil size was normalized. However, further improvement was not observed after the one-year follow-up. CONCLUSIONS: The recovery from orbital apex syndrome was achieved until 3 months after injury. The final outcomes may depend on the mechanism and pathophysiology of the injury. Emergent diagnosis and proper management are essential to achieve optimal clinical results.

Long-Term Outcome of Surgery for Intermittent Exotropia

PURPOSE: To evaluate long-term outcomes of surgery for intermittent exotropia. METHODS: The authors evaluated 78 patients who underwent surgery for intermittent exotropia and were available for a follow-up over a 5-year period. According to distant exodeviation and fusion control at the last visit, the patients were classified into either the stable group (distant exodeviation 10 PD). The recurrent group was reclassified into the clinical success group (distant exodeviation >10 PD, or =20 PD or distant exodeviation >10 PD, <20 PD with poor fusion control). We analyzed recurrence rate, success rate, and clinical outcome. RESULTS: Recurrence rate was 65.3% (n = 51), and the surgical success rate calculated as the rate of stable group and clinical success group was 73% (n = 57). The postoperative angle of exodeviation was more decreased than the preoperative angle in 93.6% of patients. When comparing postoperative with preoperative sensory function, only 2.6% of patients demonstrated worse distant fusion control grades, 66.7% of patients remained the same, 30.8% improved, and 5.1% of patients demonstrated poorer near stereopsis. The rest of patients had better or equal fusion control and stereoacuity. Age at surgery in the recurrent group was less than in the stable group (p = 0.004) and the recurrent group had worse preoperative distant fusion control (p = 0.021). Exodeviation angle of the recurrent group at postoperative 1 month, 3 months and 6 months was greater than that of the stable group (p < 0.005). CONCLUSIONS: Despite a high recurrence rate, surgery for intermittent exotropia showed a high clinical success rate and good long-term efficacy and safety in both deviation angle and sensory function.

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.

Spinal Myoclonus Developed during Cervical Epidural Drug Infusion in Postherpetic Neuralgia Patient

Postherpetic neuralgia is the most frequent complication of herpes zoster. Treatment of this neuropathic pain syndrome is difficult and often disappointing. Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Continuous epidural blockade for patients with acute zoster can shorten the duration of treatment. However, continuous epidural block has some complications such as infection, dural puncture, and total spinal and nerve damages. We report a case of myoclonus during continuous epidural block with ropivacaine, morphine, and ketamine in an acute zoster patient.

Effect of pretreatment with acetaminophen on withdrawal movements associated with injection of rocuronium: a prospective, randomized, double-blind, placebo controlled study / 대한마취과학회지

BACKGROUND: Withdrawal movement during rocuronium injection is a common, unresolved adverse effect. We aimed to investigate the effect of IV acetaminophen pretreatment on withdrawal movement during rocuronium injection. METHODS: This study enrolled 120 American Society of Anesthesiologists (ASA) I-II patients undergoing general anesthesia. They were randomly assigned to three treatment groups. After occluding venous drainage using a tourniquet on the upper arm, the saline group received 5 ml of 0.9% sodium chloride solution, the lidocaine group received 40 mg of lidocaine, and the acetaminophen group received 50 mg of acetaminophen. During injection of pretreatment drug, pain was assessed on a four-point scale. The tourniquet was released after 120 seconds and anesthesia was performed using thiopental sodium 5 mg/kg followed by rocuronium 0.6 mg/kg. The withdrawal movement was graded on a four-point scale in a double-blind manner. RESULTS: The incidence of pain on pretreatment injection in saline, lidocaine, and acetaminophen groups was 7.7%, 5.1%, and 2.5%, respectively. The incidence of withdrawal movements was 77.5% in saline group, 32.5% in lidocaine group, and 37.5% in acetaminophen group (P < 0.05). CONCLUSIONS: Acetaminophen and lidocaine reduced the incidence of withdrawal movement after rocuronium injection compared with saline.