Video-recording the Eyedrop Instillation Techniques of Glaucoma Patients

Purpose@#To analyze eye drop instillation by glaucoma patients using video-recording. @*Methods@#Glaucoma patients who had applied eye drops to both eyes for more than 1 month were enrolled. Patients who did not self-instill eye drops, those with best-corrected visual acuities of 0.01 or less, and patients requiring glaucoma surgery, were excluded. The patients were requested to instill their eye drops as usual, and this was video-recorded. Patients completed questionnaires exploring their usual instillation methods and the videos were viewed. The correctness of instillation (10 steps) was evaluated. We used the survey and imaging data to explore whether each step was performed correctly, and whether the patients were conscious of their instillation behaviors. We explored whether the survey responses and the video data were consistent. @*Results@#Fifty-four patients were enrolled. Of the 10 steps, washing hands before instillation (9.3%), blocking the tear duct (9.3%), gently shaking the bottle (11.1%), and wiping away excessive eye drops with tissue (11.1%) were the steps that were most commonly poorly performed (as revealed by the videos). The mismatches between the survey and actual performances were greatest in the following order: Wiping away excessive eye drops with tissue (66.7%), delivering a single drop accurately into the eye (59.3%), and closing the eye to allow of absorption (57.4%). @*Conclusions@#Great proportion of glaucoma patients instill eye drops incorrectly revealed by video recording. Careful education on how to instill eye drops is required. It may be difficult to detect problems regarding eye drop instillation only by asking questions.

Methodology and Rationale for Ophthalmic Examinations in the Seventh and Eighth Korea National Health and Nutrition Examination Surveys (2017–2021)

This report provides a detailed description of the methodology for ophthalmic examinations according to the Korea National Health and Nutrition Examination Survey (KNHANES) VII and VIII (from 2017 to 2021). The KNHANES is a nationwide survey which has been performed since 1998 in representatives of whole Korean population. During the KNHANES VII and VIII, in addition to the ophthalmic questionnaire, intraocular pressure measurement, visual field test, auto refractometry, axial length and optical coherence tomography measurements were included. This new survey will provide not only provide normative and pathologic ophthalmic data including intraocular pressure, refractive error, axial length, visual field and precise measurement of anterior segment, macula and optic nerve with optical coherence tomography, but also a more accurate diagnosis for major adult blindness diseases, including age-related macular degeneration, diabetic retinopathy, glaucoma, and other ocular diseases, for the national Korean population.

Changes in the Glaucoma Diagnosis during the Last 10 years: Health Insurance Review and Assessment Service Data 2010-2019

Purpose@#We determined the current status of glaucoma diagnoses in Korea and trends in the change over the past 10 years using data from the Health Insurance Review and Assessment Service. @*Methods@#The glaucoma diagnostic code was collected from the disease subclass statistics of the medical statistical information disclosed in the Healthcare Bigdata open system, and the number of health insurance patients who were billed for medical care benefit costs from 2010 to 2019 with the glaucoma diagnosis code was collected. Data were collected for each diagnostic code by dividing it by year, age group, and gender, and then changes in the current status of glaucoma diagnosis per 100,000 people were analyzed by age group. A joinpoint regression analysis was used to determine the increasing and decreasing trends for each diagnostic code and whether the trend changed during the study period. @*Results@#The number of health insurance patients who received treatment with the glaucoma diagnostic code in 2019 compared to 2010 increased by 120.3% and 109.5% per 100,000 people covered by medical care. This increasing trend has slowed as of 2015. Suspected glaucoma, primary open-angle glaucoma, and primary angle-closure glaucoma showed an increasing trend, while glaucoma secondary to eye trauma and glaucoma secondary to drugs declined markedly. No significant trend in glaucoma secondary to eye inflammation was detected, and glaucoma secondary to other eye disorders and unspecified glaucoma tended to increase. Other glaucoma diagnoses decreased from 2010 to 2012 and then increased. @*Conclusions@#The number of patients who underwent glaucoma treatment among all health insurance patients increased significantly from 2010 to 2019. Despite the overall increasing trend, eye trauma and drug-induced secondary glaucoma have markedly decreased.

Methodology and Rationale for Ophthalmic Examinations in the Seventh and Eighth Korea National Health and Nutrition Examination Surveys (2017–2021)

This report provides a detailed description of the methodology for ophthalmic examinations according to the Korea National Health and Nutrition Examination Survey (KNHANES) VII and VIII (from 2017 to 2021). The KNHANES is a nationwide survey which has been performed since 1998 in representatives of whole Korean population. During the KNHANES VII and VIII, in addition to the ophthalmic questionnaire, intraocular pressure measurement, visual field test, auto refractometry, axial length and optical coherence tomography measurements were included. This new survey will provide not only provide normative and pathologic ophthalmic data including intraocular pressure, refractive error, axial length, visual field and precise measurement of anterior segment, macula and optic nerve with optical coherence tomography, but also a more accurate diagnosis for major adult blindness diseases, including age-related macular degeneration, diabetic retinopathy, glaucoma, and other ocular diseases, for the national Korean population.

Changes in the Glaucoma Diagnosis during the Last 10 years: Health Insurance Review and Assessment Service Data 2010-2019

Purpose@#We determined the current status of glaucoma diagnoses in Korea and trends in the change over the past 10 years using data from the Health Insurance Review and Assessment Service. @*Methods@#The glaucoma diagnostic code was collected from the disease subclass statistics of the medical statistical information disclosed in the Healthcare Bigdata open system, and the number of health insurance patients who were billed for medical care benefit costs from 2010 to 2019 with the glaucoma diagnosis code was collected. Data were collected for each diagnostic code by dividing it by year, age group, and gender, and then changes in the current status of glaucoma diagnosis per 100,000 people were analyzed by age group. A joinpoint regression analysis was used to determine the increasing and decreasing trends for each diagnostic code and whether the trend changed during the study period. @*Results@#The number of health insurance patients who received treatment with the glaucoma diagnostic code in 2019 compared to 2010 increased by 120.3% and 109.5% per 100,000 people covered by medical care. This increasing trend has slowed as of 2015. Suspected glaucoma, primary open-angle glaucoma, and primary angle-closure glaucoma showed an increasing trend, while glaucoma secondary to eye trauma and glaucoma secondary to drugs declined markedly. No significant trend in glaucoma secondary to eye inflammation was detected, and glaucoma secondary to other eye disorders and unspecified glaucoma tended to increase. Other glaucoma diagnoses decreased from 2010 to 2012 and then increased. @*Conclusions@#The number of patients who underwent glaucoma treatment among all health insurance patients increased significantly from 2010 to 2019. Despite the overall increasing trend, eye trauma and drug-induced secondary glaucoma have markedly decreased.

Oral Spironolactone Treatment in Chronic Central Serous Chorioretinopathy

PURPOSE: To evaluate the effect of oral spironolactone for non-resolving chronic central serous chorioretinopathy after intravitreal bevacizumab injection.METHODS: Seventeen eyes of 17 patients with non-resolving chronic central serous chorioretinopathy after intravitreal bevacizumab injection from September 2017 to December 2018 were treated with oral spironolactone for 6 months, and changes in central macular thickness, subretinal fluid height, and best-corrected visual acuity (BCVA) were analyzed retrospectively.RESULTS: The central macular thickness decreased from 309.94 ± 105.20 µm at baseline to 259.76 ± 81.83 µm at 3 months, and 243.11 ± 61.98 µm at 6 months, which were both statistically significant (Wilcoxon signed-rank test, p = 0.016 and p = 0.001, respectively). The subretinal fluid height decreased from 138.05 ± 95.69 µm at baseline to 70.88 ± 83.13 µm at 3 months, and 54.00 ± 56.25 µm at 6 months, which were both statistically significant (Wilcoxon signed-rank test, p = 0.002 and p = 0.000, respectively). The BCVA (LogMAR) changed from 0.30 ± 0.38 at baseline to 0.35 ± 0.43 at 1 month, 0.29 ± 0.43 at 3 months, and 0.26 ± 0.40 at 6 months. The results at 6 months were statistically significant (Wilcoxon signed-rank test, p = 0.033). There were no side effects in patients treated with oral spironolactone.CONCLUSIONS: In chronic central serous chorioretinopathy, treatment with oral spironolactone significantly reduced the central macular thickness, subretinal fluid height, and the BCVA, without side effects.

Correlation between Seasons, Climatic Factors and Acute Angle Closure Attack Incidence

PURPOSE@#To investigate seasonal variations in the incidence of acute primary angle closure (PAC) attack and to identify climatic factors associated with the frequency of angle closure attack.@*METHODS@#A retrospective analysis of proven cases of acute PAC attack from hospital records over a 10-year period from January 2009 to December 2018 at a tertiary hospital. The study was performed to identify and analyze sex, age on diagnosis, onset timing of symptoms. And then, compared the seasonal occurrence rates and analyzed the correlation between climatic factors and occurrence frequency.@*RESULTS@#A total of 227 patients of 227 eyes were diagnosed as acute PAC attack. There were 57 men and 170 women, mean age was 67.0 ± 9.1 years and the highest rate was in the 60s (38.3%). There was a statistically significant increase of acute angle closure attack incidence in women in winter (p = 0.002). In the case of climate factors, there was a negative correlation with the average temperature and the sunshine time (r = −0.657, p = 0.030; r = −0.583, p = 0.046, respectively). There was no significant correlation with the average humidity and the rate of sunshine (r = −0.288, p = 0.364; r = 0.021, p = 0.948, respectively).@*CONCLUSIONS@#Acute PAC glaucoma occurred more frequently in winter. Especially in women, it seems to be more affected by seasonal changes. Acute PAC attack incidence was associated with mean temperature, sum of hours of sunshine.

The Incidence of Increased Intraocular Pressure and Clinical Course in Traumatic Hyphema

PURPOSE@#This study aimed to investigate the incidence of increased intraocular pressure (IOP) and the clinical course of traumatic hyphema.@*METHODS@#We retrospectively reviewed the medical records of traumatic hyphema patients from March 2016 to January 2019. Based on whether the IOP exceeded 21 mmHg, the patients were divided into two groups: increased IOP (IIOP) hyphema grade, and intraocular damage. We compared the two groups based on sex, age, cause of trauma, IOP, visual acuity, follow-up period, and hyphema grade. The IIOP group was also divided into two groups: treatment continuation and treatment termination. We compared the two groups on the same aforementioned basis.@*RESULTS@#Of the 181 eyes, 53 (29.3%) were in the IIOP group. The initial IOP (p < 0.001), hyphema grade (p < 0.001), rebleeding incidence (p = 0.011), and intraocular damage (p = 0.027) were statistically significant between the two groups. The treatment continuation group for IIOP had 11 (20.8%) eyes, and the age (p = 0.029) and intraocular damage (p = 0.010) were statistically different from the treatment termination group.@*CONCLUSIONS@#The incidence of increased IOP was 29.3%. Continuous treatment was needed in 20.8% of the increased IOP cases, and the age and intraocular damage were related.

Loss of Reflex Tearing after Maxillary Orthognathic Surgery Case Report and Literature Review

PURPOSE@#To report a case of unilateral loss of reflex tearing after double-jaw surgery with anatomy and mechanism.CASE SUMMARY: A 32-year-old woman complained of a 3-year history of loss of tearing in her left eye. She had undergone double-jaw surgery 3 years prior to correct her malocclusion. In orbital computed tomography (CT) images, there were no specific findings, with the exception of a fractured left pterygoid plate, possibly caused by the double-jaw surgery. The tear break-up times of both eyes were similar, with non-specific findings on slit lamp examination. We diagnosed loss of reflex tearing due to pterygopalatine ganglion injury based on her history, physical examination and orbital CT findings.@*CONCLUSIONS@#Nerve damage due to artificial fracture may occur during double-jaw surgery and may result in loss of reflex tearing, thus, pre-operative evaluation of basic lacrimal secretion and a reflex tearing test are important. Once the loss of reflex tearing due to nerve injury occurrs, orbital CT scans are needed for diagnosis. Ophthalmologist examination is necessary to confirm the mechanism of loss of reflex tearing and changes in the anatomical structure.

Clinical Outcomes of Nasolacrimal Probing and Silicone Intubation in Patients with Congenital Nasolacrimal Duct Obstruction

PURPOSE: To investigate the efficacy and factors affecting the success rates of nasolacrimal probing and silicone intubation (SI) in patients with congenital nasolacrimal duct obstruction (CNLDO). METHODS: We retrospectively reviewed the medical records of patients including 69 eyes of 59 patients who received probing and 61 eyes of 49 patients who received SI. In patients with probing, the age, sex, and history of conservative treatment were analyzed in the success and failure groups, and a success rate comparison was conducted by dividing these values into postnatal group 1 ( 12 months, the success rate of probing was lower than in patients 12 months.

The Effect of Bilateral Medial Rectus Resection for Recurrent Intermittent Exotropia

PURPOSE: The purpose of this study was to investigate the effect of bilateral medial rectus muscle resection on the treatment of recurrent intermittent exotropia. METHODS: A retrospective chart analysis was conducted for 25 patients who underwent bilateral medial rectus resection for recurrent exotropia over 20 prism diopters (PD) between January 2009 and August 2015. The medial rectus was resected from 4.0 to 6.5 mm by 0.5 mm according to the deviation angle. The postoperative angle of deviation was checked at 1 day, 1 week, 3 months, 6 months, and 1 year postoperatively to investigate the amount of corrected deviation per resected muscle. RESULTS: The average preoperative deviation angle was 27.20 ± 5.02 PD exodeviation and the mean resection was 5.10 ± 0.79 mm of the medial rectus. The postoperative angle deviation was 10.68 ± 5.50 PD esodeviation at 1 day. The incidence of esodeviation tended to decrease over time. At 1 year, the postoperative angle deviation was 1.16 ± 7.54 PD esodeviation. The overcorrection rate was 84% at 1 day postoperatively but decreased to 24% at 1 year with a success rate of 68%. The corrected deviation angle per millimeter was 7.53 ± 1.22, 7.75 ± 2.16, 6.27 ± 1.74, 5.50 ± 1.54, and 5.56 ± 1.58 PD/mm at 1 day, 1 week, 3 months, 6 months, and 1 year after surgery, respectively. The dose effect per millimeter decreased over time. The corrected deviated angle per millimeter remained constant regardless of the amount of medial rectus muscle resection at 1 year postoperatively(p=0.939). CONCLUSIONS: Bilateral medial rectus resection for recurrent exotropia over 20 PD tended to overcorrect at first; however, after 1 year, the mean angle of deviation was 1.16 ± 7.54 PD esodeviation. Bilateral medial rectus resection is an effective surgical method for the treatment of recurrent exotropia over 20 PD.

The Correlation between Preoperative En Face Optical Coherence Tomography and Postoperative Visual Prognoses in Idiopathic Epiretinal Membranes

PURPOSE: To investigate the correlation between en face optical coherence tomography and improvements in the postoperative prognoses of idiopathic epiretinal membranes. METHODS: The medical records of 59 epiretinal membrane patients who had epiretinal membrane peeling between January 2005 and January 2016, and were followed up for > 12 months, were retrospectively reviewed. The preoperative en face images were divided into four sections involving three circular areas (6,000 µm diameter circle, 3,000 µm diameter circle, and 1,000 µm diameter circle) and one square (6,000 × 6,000 µm). The surface area where no epiretinal adhesion was present was quantified by measuring the number of black pixels using image-editing software (Adobe Photoshop CS6, Adobe Systems, San Jose, CA, USA). Then the correlations among the value of black pixels, preoperative and postoperative visual acuities, and central retinal thickness were analyzed. RESULTS: The best-corrected visual acuity (BCVA) was significantly increased after epiretinal membrane peeling (p < 0.001), and the central retinal thickness was significantly decreased (p < 0.001). As the number of black pixels in the circles and the square in the en-face images increased, the postoperative BCVA significantly increased (r = 0.645, p < 0.001; r = 0.590, p < 0.001, respectively). CONCLUSIONS: As the nonadhesive surfaces of the epiretinal membrane and the retina in preoperative en face images became wider, the increments of the BCVA after surgery were greater. Therefore, en face optical coherence tomography can be used to predict prognosis after epiretinal membrane peeling.

Analysis of Microorganisms and Antibiotics Susceptibility in Dacryocystitis

PURPOSE: This article analyzes the microorganisms and antibiotics susceptibility in dacryocystitis. METHODS: In this study, patients who were diagnosed with acute and chronic dacryocystitis with nasolacrimal duct obstruction were selected and underwent endoscopic endonasal dacryocystorhinostomy. Cultures were obtained from the lacrimal sac during operation from January 2008 to January 2016, and were used to analyze the microorganisms and antibiotics susceptibility. RESULTS: The 67 patients, 9 were diagnosed with acute dacryocystitis and 58 were diagnosed with chronic dacryocystitis. Among them, 64 cases showed bacterial growth (95.5%). The most frequently detected bacteria was Staphylococcus epidermidis (S. epidermidis) (33.8%), followed by Staphylococcus aureus (S. aureus) (25.4%) and Enterobacter aerogenes (18.3%). S. epidermidis had the most powerful resistance to ciprofloxacin compared to the other bacteria (58.3%, p = 0.02). Except for S. epidermidis and S. aureus, the other bacteria responded to ciprofloxacin and gentamycin. CONCLUSIONS: As a causative microorganism of dacryocystitis, S. epidermidis is becoming more prominent, and it is thought that S. epidermidis may be resistant to quinolones (i.e., broad-spectrum antibiotics). This resistance might be increasing the percentage of present S. epidermidis when viewed as a causal pathogen in dacryocystitis.

A Typical Case of IgG4-related Ophthalmic Disease Satisfying Diagnostic Criteria

PURPOSE: In the present study, a case of IgG4-related ophthalmic disease which met the 2015 IgG4-related ophthalmic disease diagnostic criteria is reported and literature review performed. CASE SUMMARY: A 51-year-old female presented with both upper eyelid swelling, redness, and a palpable mass. Eye movements were normal and exophthalmos was not observed. Facial computed tomography showed both lacrimal gland hypertrophy. The patient underwent left anterior orbitotomy with incisional biopsy. Immunostained biopsy showed the ratio of IgG4+ to IgG+ cells was 50% and the mean number of IgG4-positive plasma cells was approximately 150 per high-power field. Hematological examination showed elevated serum IgG4 concentrations of 6,930 mg/dL, however, other organs were not involved. The patient satisfied the diagnostic criteria for IgG4-related ophthalmic disease. The patient was given an oral steroid and immunosuppressant and the symptoms improved. CONCLUSIONS: IgG4-related ophthalmic disease is currently receiving increased attention. The authors of the present study report a case of IgG4-related ophthalmic disease which met the 2015 IgG4-related ophthalmic disease diagnostic criteria.

Use of Video-oculography in the Diagnosis of Superior Oblique Myokymia

PURPOSE: Superior oblique myokymia is intermittent spontaneous contractions of the superior oblique muscle presenting as rapid and small-amplitude intorsions and depressions of the eye. The authors report a case of superior oblique myokymia that was objectively and quantitatively diagnosed with slit lamp examination and video-oculography and completely resolved with medical treatment. CASE SUMMARY: A 44-year-old woman presented with a seven-year history of intermittent oscillopsia which continued for few seconds. She had no history of head trauma or systemic ocular disease, and the anterior segment and fundus examination were unremarkable. Right eye intorsion lasting for a few seconds as detected by slit lamp examination. Eye movements were recorded using video-oculography, which showed a torsional nystagmus of 5 to 10 degrees with 2 to 5 vertical components in the right eye. Based on these findings, the patient was diagnosed with superior oblique myokymia. The patient was prescribed topical timolol ophthalmic solution, one drop twice per day, but the symptoms persisted. Timolol ophthalmic solution was stopped and replaced with carbamazepine, 200 mg twice a day, which resolved her symptoms. CONCLUSIONS: Slit lamp examination and video-oculography can be used as objective and quantitative diagnostic tools in order to confirmed a diagnosis and lead to proper treatment.

Characteristics of the Gray Optic Disc Crescent and Associated Factors

PURPOSE: To investigate the characteristics of the gray optic disc crescent and associated factors. METHODS: We retrospectively reviewed stereo fundus photographs of 590 glaucoma patients and 273 non-glaucoma patients. An experienced investigator evaluated the presence or absence of the gray crescent (a crescent-shaped, slate-gray pigmentation on the periphery of the neuroretinal rim) which is entirely inside the scleral crescent. Correlations with age, gender, refractive error, disc diameters, and the presence of glaucoma or peripapillary atrophy were also analyzed. RESULTS: Out of 863 patients, the gray crescent was observed in 166 patients and was found in 19.0% of glaucoma patients and 19.8% of non-glaucoma patients. The gray crescent was most often located temporally (30.1%) and most frequently occurred within only 1 quadrant (63.9%). The prevalence of the gray crescent was not correlated with refractive error (p = 0.61) or the occurrence of glaucomatous optic neuropathy (p = 0.25), but was significantly related to peripapillary atrophy (p < 0.001) and the horizontal diameter of the optic disc (p = 0.001). CONCLUSIONS: The gray optic disc crescent is a common finding within a glaucomatous or non-glaucomatous eye and factors significantly related to occurrence of the gray crescent include peripapillary atrophy and the horizontal diameter of the optic disc. Patients with gray crescent require special attention when the optic disc is examined.

Contemplation of the Surgical Normogram of Lateral Rectus Recession for Exotropia Associated with Superior Oblique Palsy

PURPOSE: To suggest a surgical normogram for lateral rectus recession in exotropia associated with unilateral or bilateral superior oblique muscle palsy (SOP). METHODS: We retrospectively reviewed the charts of 71 patients with exotropia who were successfully corrected over one year. Each patient had undergone unilateral or bilateral rectus recession associated with uni- or bilateral inferior oblique (IO) 14 mm recession, using a modified surgical normogram for lateral rectus (LR) recession, which resulted in 1 to 2 mm of reduction of LR recession. We divided all patients into 2 groups, the 34 patients who had undergone LR recession with unilateral IO (UIO) recession group and the remaining 37 patients who had undergone LR recession with bilateral IO (BIO) recession group. Lateral incomitancy was defined when the exoangle was reduced by more than 20% compared to the primary gaze angle. The surgical effects (prism diopters [PD]/mm) of LR recession were compared between the two groups using the previous surgical normogram as a reference (Parks' normogram). RESULTS: The mean preoperative exodeviation was 20.4 PD in the UIO group and 26.4 PD in the BIO group. The recession amount of the lateral rectus muscle ranged from 4 to 8.5 mm in the UIO group and 5 to 9 mm in the BIO group. Lateral incomitancy was noted as 36.4% and 70.3% in both groups, respectively (p = 0.02). The effect of LR recession was 3.23 +/- 0.84 PD/mm in the UIO group and 2.98 +/- 0.62 PD/mm in the BIO group and there was no statistically significant difference between two the groups (p = 0.15). CONCLUSIONS: Reduction of the LR recession by about 1 to 2 mm was successful and safe to prevent overcorrection when using on IO weakening procedure, irrespective of the laterality of SOP.

Second Intention Healing after Shave Excision of Benign Tumors on the Lid Margin

BACKGROUND: Defects caused by excision of benign lid margin tumors are conventionally repaired by reconstructive surgery. However, second intention healing is another option for managing wounds on the lid margin. OBJECTIVE: To evaluate the effectiveness of second intention healing after a shave excision of benign tumors on the lid margin. METHODS: Lid defects following a shave excision of the lid margin tumor were allowed to heal by second intention in 25 patients (26 lesions). The epithelialzation period was calculated, and cosmetic and functional results and complications were evaluated by photographs and ophthalmological examination. RESULTS: The locations of the defects were as follows: upper lid (n=13), lower lid (n=11), and both upper and lower lids (n=1). The mean tumor size was 3.8x3.6 mm, and the mean epithelialization period by second intention was 6.1+/-1.2 weeks. Pathological examinations revealed intradermal nevus (12 cases), compound nevus (five cases), squamous papilloma (five cases), and epidermal cyst (three cases). No patients had a corneal erosion, trichiasis, or hypertrophic scar, except loss of cilia in two cases. The functional and cosmetic results were satisfactory in all patients. CONCLUSION: Healing by second intention is a safe and effective alternative to surgical reconstruction after a shave excision of benign lid margin tumors.

Medial and Lateral Canthal Tendon Laxity: An Evaluation of Patients with Involutional Entropion and Epiphora

PURPOSE: The degree of laxity of the medial and lateral canthal tendon in Korean subjects with and without involutional entropion and epiphora was evaluated in the present study. METHODS: The present study included 180 normal subjects (360 eyes), 12 patients (15 eyes) with involutional entropion, and 41 patients (58 eyes) with epiphora. The degree of laxity of the medial and lateral canthal tendon, which grades the position of the inferior punctum, was measured using the lateral and medial distraction test. RESULTS: The mean degree of medial and lateral canthal tendon laxity was 1.83/1.08 in normal subjects. A statistical difference was not observed between sexes, and the mean degree of laxity tended to be higher in older patients. The mean degree of laxity was 2.78/2.18 and 2.28/1.22 in the involutional entropion group and the epiphora group, respectively. The involutional entropion group and the epiphora group underwent endoscopic endonasal dacryocystitis (D), medial spindle procedure (M), and endoscopic endonasal dacryocystitis with the medial spindle procedure and/or the tarsal strip procedure (T). The mean degree of laxity was 1.84/1.04 in group D, 3.00/1.20 in group M, 2.33/2.00 in group D + T, 3.20/1.40 in group D + M and 3.50/2.00 in group D + T + M before surgery. CONCLUSIONS: The results from the present study may aid in the selection of a basic treatment plan for Korean patients with involutional entropion or epiphora.

Dissociated Horizontal Deviation after Traumatic Brain Injury

A 4-year-old boy visited the hospital with exotropia after brain hemorrhage caused by trauma. He had undergone decompressive craniectomy and cranioplasty 18 months prior to presentation at our hospital. An alternate prism cover test showed more than 50 prism diopters (PD) of left exotropia when he was fixing with the right eye and 30 PD of right exotropia when he was fixing with the left eye at near and far distance. On the Hirschberg test, 60 PD of left exotropia was noted in the primary position. Brain computerized tomography imaging performed 18 months prior showed hypodense changes in the right middle cerebral artery and anterior cerebral artery territories. Subfalcian herniation was also noted secondary to swelling of the right hemisphere. The patient underwent a left lateral rectus muscle recession of 7.0 mm and a left medial rectus muscle resection of 3.5 mm. Three weeks after the surgery, the Hirschberg test showed orthotropia. On alternate prism cover testing, 8 PD of left exotropia and 8 PD of right esotropia were noted at distance. We report a patient who developed dissociated horizontal deviation after right subfalcian subdural hemorrhage caused by trauma.