Peripapillary Retinal Nerve Fiber Layer Thicknesses Did Not Change in Long-term Hydroxychloroquine Users

PURPOSE: To evaluate changes in the peripapillary retinal nerve fiber layer (RNFL) thicknesses using spectral-domain optical coherence tomography (SD-OCT) in hydroxychloroquine (HCQ) users. METHODS: The medical records of HCQ users were retrospectively reviewed. In these HCQ users, an automated perimetry, fundus autofluorescence photography, and SD-OCT with peripapillary RNFL thickness measurements were performed. The peripapillary RNFL thicknesses were compared between the HCQ users and the control groups. The relationships between the RNFL thicknesses and the duration or cumulative dosage of HCQ use were analyzed. RESULTS: This study included 77 HCQ users and 20 normal controls. The mean duration of HCQ usage was 63.6 ± 38.4 months, and the cumulative dose of HCQ was 528.1 ± 3.44 g. Six patients developed HCQ retinopathy. Global and six sectoral RNFL thicknesses of the HCQ users did not significantly decrease compared to those of the normal controls. No significant correlation was found between the RNFL thickness and the duration of use or cumulative dose. The eyes of those with HCQ retinopathy had temporal peripapillary RNFL thicknesses significantly greater than that of normal controls. CONCLUSIONS: The peripapillary RNFL thicknesses did not change in the HCQ users and did not correlate with the duration of HCQ use or cumulative doses of HCQ. RNFL thickness is not a useful biomarker for the early detection of HCQ retinal toxicity.

Frequency and Clinical Characteristics of Hydroxychloroquine Retinopathy in Korean Patients with Rheumatologic Diseases

This study aimed to evaluate the frequency and clinical characteristics of hydroxychloroquine (HCQ) retinopathy in Korean patients with rheumatologic diseases. We retrospectively reviewed medical records of 310 patients taking HCQ. Ophthalmic examinations included spectral-domain optical coherence tomography (SD-OCT), automated visual field test, and fundus autofluorescence. The severity of retinopathy was categorized as early, moderate, or severe, and the location was categorized as parafoveal, pericentral, or mixed pattern. Among 310 patients, 9 patients (2.9%) were diagnosed as HCQ retinopathy. Among the patients with HCQ use ≥ 5 years (n = 174), the frequency was 5.2%. Only 1 (11.1%) of the 9 patients was symptomatic. The mean daily dose per kilogram of real body weight of the 9 patients was 5.6 mg, and only 3 had used 6.5 mg or more. Four of the 9 patients had severe HCQ retinopathy. Six of the 9 patients showed pericentral or mixed pattern of retinal damage. Consequently, the frequency of HCQ retinopathy in Korean patients was not low, especially when administered at a high cumulative dose and for a long duration. Screening of HCQ retinopathy by the recommended guidelines that include SD-OCT seems useful and should be done to detect retinal damage earlier in patients with chronic exposure to HCQ.

Ultrawide-field Fluorescein Angiography for Evaluation of Diabetic Retinopathy

PURPOSE: To investigate the advantages of ultrawide-field fluorescein angiography (FA) over the standard fundus examination in the evaluation of diabetic retinopathy (DR). METHODS: Ultrawide-field FAs were obtained in 118 eyes of 59 diabetic patients; 11 eyes with no DR, 71 eyes with nonproliferative diabetic retinopathy (NPDR), and 36 eyes with proliferative diabetic retinopathy (PDR), diagnosed by the standard method. The presence of peripheral abnormal lesions beyond the standard seven fields was examined. RESULTS: Ultrawide-field FA images demonstrated peripheral microaneurysms in six (54.5%) of 11 eyes with no DR and all eyes with moderate to severe NPDR and PDR. Peripheral retinal neovascularizations were detected in three (4.2%) of 71 eyes with NPDR and in 13 (36.1%) of 36 eyes with PDR. Peripheral vascular nonperfusion and vascular leakage were found in two-thirds of eyes with severe NPDR and PDR. CONCLUSIONS: Ultrawide-field FA demonstrates peripheral lesions beyond standard fields, which can allow early detection and a close evaluation of DR.

Retinopathy of Prematurity in Infants Born before 25 Weeks Gestation in a Korean Single Neonatal Intensive Care Unit: Incidence, Natural History and Risk Factors

As younger preterm infants are able to survive, more extremely preterm infants are at risk of developing retinopathy of prematurity (ROP). To investigate the incidence, progression and risk factors of ROP in extremely preterm infants in Korea, the medical records of infants born before 25 weeks gestation were retrospectively reviewed. The criteria for laser treatment agreed with type 1 ROP as defined by the Early Treatment for Retinopathy of Prematurity study. Of the 121 infants included in the analysis, 119 (98.4%) infants developed any stage ROP, including 78 infants (64.5%) with type 1 ROP. The mean postmenstrual age (PMA) at the onset of any ROP and type 1 ROP were 33.5 and 36.1 weeks, respectively. All but one infant developed type 1 ROP after 31 weeks PMA. Univariate analysis showed that duration of total parenteral nutrition and onset of any ROP (PMA) were associated with the development of type 1 ROP. In conclusion, this study shows high incidence of ROP in extremely preterm infants and suggests that, although current screening protocols are feasible for most preterm infants born before 25 weeks gestation, earlier screening before 31 weeks PMA may be necessary in infants with an unstable clinical course.

Cinical Manifestations and Prognosis of Cytomegalovirus Retinitis

PURPOSE: Cytomegalovirus (CMV) retinitis is common in patients with immunodeficient conditions caused by acquired immunodeficiency syndrome (AIDS), cytotoxic chemotherapy and immunosuppresive treatment. The purpose of this study was to assess the clinical manifestations and prognosis of CMV retinitis cases. METHODS: Thirty-one eyes of 21 patients who were diagnosed with CMV retinitis were retrospectively reviewed. The clinical manifestations and prognosis of all patients were analyzed. RESULTS: The average age of patients was 24.4+/-19.8 years. Eight patients were female and 13 patients were male. The predisposing conditions of patients were leukemia (nine patients), immunosuppressed conditions due to organ transplantation (three patients), AIDS (two patients) and other (seven patients). Eleven patients exhibited bilateral disease. The mean follow-up period was 31.3 months, and there were no differences between mean initial visual acuity (0.70+/-0.31) and mean visual acuity (0.77+/-0.20) at final visit. The major causes of visual loss were retinitis and atrophic changes involving the macula. Although retinitis was successfully treated with anti-viral agents in all cases, cataract (10 eyes, 31.3%), cystoid macular edema (four eyes, 12.5%), retinal detachment (two eyes, 6.3%), epiretinal membrane (two eyes, 6.3%) and immune recovery uveitis (two eyes, 6.3%) developed after the initial treatment. CONCLUSIONS: Although the visual prognosis of CMV retinitis was relatively good after administration of appropriate antiviral therapy, clinicians should remain alert for the development of late complications, including retinal detachment, cystoid macular edema and immune recovery uveitis.

Clinical Characteristics and Treatments of Intermediate Uveitis

PURPOSE: To investigate the clinical characteristics and treatment of intermediate uveitis under new diagnostic standards. METHODS: Medical records of patients diagnosed with pars planitis or intermediate uveitis were followed for more than 6 months, and retrospectively reviewed. RESULTS: A total of 90 patients and 117 eyes were enrolled in the study. The mean age was 40.1 years, and the mean follow-up period was 43.0 months. Thirty percent of cases were bilateral. The most common initial symptom was decreased visual acuity. Snowbank was detected in 39.3%, snowballs in 15.4%, vitritis in 96.6%, and vasculitis in 56.4%. Common complications includedcystoid macular edema (57.3%), cataracts (43.6%), and epiretinal membrane (36.8%). Therapies included topical steroids (82.9% of cases), posterior sub-Tenon steroid injection (45.3% of cases), systemic steroid administration (67.8% of cases), and immunosuppressants (28.7% of cases). Vitrectomy was performed in 11.1% of patients due to complications such as epiretinal membrane and traction retinal detachment. The mean initial and final visual acuities were 0.67 and 0.74, respectively. CONCLUSIONS: The patients in this study experienced various courses of symptoms that required different treatment plans. Future investigations may corroborate these results.

Clinical Features and Prognosis of HLA-B27 Positive and Negative Anterior Uveitis in a Korean Population

Clinical features and prognosis of HLA-B27 positive anterior uveitis (AU) were assessed compared with HLA-B27 negative AU in a Korean population, based on the medical records of AU patients seen at a university hospital. Twenty-seven HLA-B27 negative, idiopathic AU patients (group I) and 55 HLA-B27 positive AU patients (group II) were studied. HLA-B27 positive group was further divided into 29 with associated systemic disease (seronegative spondyloarthropathy) (group IIA) and 26 without associated systemic disease (group IIB). Significantly more severe anterior chamber inflammation in terms of anterior chamber cells (P=0.006) and hypopyon formation (P=0.034) was observed with higher frequency of AU attacks (P=0.007) in the HLA-B27 positive group than in the HLA-B27 negative group. Systemic/periocular steroids were required in significantly more patients in the HLA-B27 positive group than in the HLA-B27 negative group (P=0.015). However, no significant differences were observed for final ocular and visual outcomes between these two groups. Associated systemic disease made no significant difference in the clinical features and prognosis in the HLA-B27 positive AU patients. In conclusion, despite more severe inflammation and a higher recurrence rate, HLA-B27 positive AU shows similar good final ocular and visual outcomes compared to HLA-B27 negative, idiopathic AU in a Korean population.

Photodynamic Therapy for Choroidal Neovascularization Secondary to Age-Related Macular Degeneration

PURPOSE: To investigate the effects of repeated photodynamic therapy (PDT) for subfoveal choroidal neovascularization secondary to age-related macular degeneration (AMD) in Korean patients. METHODS: Clinical data of patients who were treated with repeated (3 times or more) PDT for subfoveal choroidal neovascularization secondary to AMD and followed up for more than 6 months were collected from 17 hospitals around the country. Visual outcomes at 12 and 24 months, follow-up were compared between subtypes of choroidal neovascularization. The factors related to final visual prognosis and PDT-related adverse effects were evaluated. RESULTS: 244 patients (244 eyes) were recruited (male: 60%, age: 67.7+/-9.1 years). The portion of patients with predominantly classic, minimally classic, and occult without classic choroidal neovascularization was 57%, 13%, and 24%, respectively and that of patients with visual improvements or less than moderate visual loss at 24 months follow-up were 28%, 38%, 30% and 47%, 56%, and 65%, respectively. Baseline visual acuity and age were significantly related to the final visual prognosis (p<0.05). PDT-related adverse events developed in 15 (6.1%) patients, but most were mild and transient. CONCLUSIONS: Repeated PDT for subfoveal choroidal neovascularization secondary to AMD has effects comparable to those of previous prospective, controlled trials without any significant safety concerns in Korea.

Incidence and Risk Factors of Retinopathy of Prematurity in Extremely Low Birth Weight and Very Low Birth Weight Infants

PURPOSE: To evaluate the risk factors and prevalence of retinopathy of prematurity (ROP) in extremely low birth weight (ELBW) infants and very low birth weight (VLBW) infants. METHODS: All babies were screened for ROP at a postconceptional age of 31 weeks or at 4 weeks of chronological age. We divided the infants into two groups according to birth weight < 1000 g (ELBW) and 1000~1500 g (VLBW), to compare the incidence of ROP and photocoagulation, and to retrospectively evaluate the risk factors. RESULTS: Three hundred eight consecutive infants were included in the data analysis. The incidences of ROP were 70.5% (79/112) in ELBW infants and 36.7% (72/196) in VLBW infants (p<0.0001). 31 of 79 ELBW infants (39.2%) and 17 of 72 VLBW infants (23.6%) had undergone photocoagulation (p<0.0001). Among the various risk factors, mechanical ventilation (p=0.039) and surfactant (p<0.000) were the independent risk factors associated with ROP in all infant groups by logistic regression analysis. In the ELBW group, however, surfactant injection was the only factor independently associated with ROP (p=0.008). The use of surfactant, the only risk factor in ELBW infants, was attributed with the initiation of ROP. However, it did not act as an aggravating factor. CONCLUSIONS: ELBW was associated with a higher incidence of ROP and laser photocoagulation. The results of this study emphasize that more special attention is needed for immature infants when ventilators and surfactants are used.

Visual Prognosis of Culture-Proven Bacterial Endophthalmitis

PURPOSE: To evaluate the factors contributing to the visual outcome of patients with culture-proven bacterial endophthalmitis. METHODS: We reviewed medical records of all eyes with infectious endophthalmitis between January 1996 and June 2005. The causative bacteria were identified in 18 of 90 eyes, for which we evaluated their clinical features and factors influencing their visual prognosis. RESULTS: Bacterial endophthalmitis occurred after cataract surgery in 6 of 18 eyes, after trabeculectomy or glaucoma implant surgery in 4 eyes, after trauma in 3 eyes, after intravitreal triamcinolone injection in 1 eye, and after endogenous endophthalmitis in 4 eyes. The culture results were similar between gram positive and gram negative organisms. Final vision was 0.1 or better in 6 of the 18 eyes. Final visual acuities showed statistically significant correlation with causative organisms (p=0.018). CONCLUSIONS: For effective management of bacterial endophthalmitis and prediction of prognosis, we recommend thorough bacterial culture. Also, further investigation with a large population is needed.

Clinical Features of Punctate Inner Choroidopathy in Korea

PURPOSE: To characterize the clinical presentation and visual prognosis of punctate inner choroidopathy in Korean patients. METHODS: Eleven patients (seventeen eyes) with punctate inner choroidopathy (PIC) and four (six eyes) with multifocal choroiditis with panuveitis (MCP) were analyzed retrospectively. RESULTS: The mean age of the PIC patients was 32.2 +/- 9.3 years and the mean refractive error was -4.79 +/- 3.18 diopters. In all PIC eyes, fundus photographs showed multiple yellowish white punctate lesions and punched-out scars at the level of the inner retina and choroid. There was no significant difference between the mean initial visual acuity (0.67 +/- 0.40) and the mean final visual acuity (0.56 +/- 0.41). The major cause of visual deterioration was choroidal neovascularization (CNV) which developed in 4 eyes. In PIC, the lesions were located in the more posterior retina and the incidence of CNV was higher than in MCP. CONCLUSIONS: PIC affects young women with moderate myopia and shows the characteristic chorioretinal lesion. Although the eye with PIC usually maintains stable vision after initial attack, CNV may cause complications and significant visual loss.

The Results of Posterior Subtenon Steroid Injection in Uveitis Patients

PURPOSE: Locally administered corticosteroids have been widely used in the treatment of inflammatory eye disease. The main purpose of this study is to analyze the treatment effects and the complications of posterior subtenon steroid injection in uveitis patients. METHODS: Retrospective study was performed on 36 eyes of 32 patients diagnosed as uveitis and treated with subtenon steroid injection. RESULTS: Sixty eight consecutive injections of triamcinolone were performed, and the mean follow-up duration was 6.9 months (1~28 months). Visual acuity was improved in 28 (88%) of 32 patients, and mean time to improvement was three weeks after the injection. Intraocular pressure was increased (>21 mmHg) in 10 eyes (31%) of 10 patients, with mean onset of three weeks after the initial injection. The increased pressures was not controlled by medical treatment and additional filtration surgery was needed in 2 eyes (6%). Cataracts were newly developed or worsen in 5 eyes (15.6%) of 4 patients and 2 eyes underwent cataract surgery. CONCLUSIONS: Although a postrerior subtenon steroid injection effectively improved visual acuity in most uveitis patients, side effects, such as the increased intraocular pressure or cataract were developed. The complication rate as well as treatment effect should be taken into consideration when using this treatment method.

Management of choroidal neovascularization following laser photocoagulation for central serous chorioretinopathy

Little is known about the natural history and management of choroidal neovascularization (CNV) which developed as a complication of laser photocoagulation for central serous chorioretinopathy (CSC). We experienced two patients with CNV which developed after laser treatment for CSC. Submacular membranectomy was performed on both cases after the confirmation of subretinal CNV with optical coherence tomography. One patient received photodynamic therapy for recurrent CNV. The vision of both patients has been improved over 6 months of follow up. These cases suggest that active intervention, including submacular surgery, improves the visual prognosis of this condition.

The Relation between Idiopathic Macular Hole and Perifoveal Vitreous Detachment

PURPOSE: To determine the relation between the pathogenesis of idiopathic macular hole and perifoveal vitreous detachment using OCT scan. METHODS: On 28 eyes with idiopathic macular hole stage 1,2,3 which was graded according to using the classification described by Gass and on 123 eyes from the normal contrast group, OCT scan were performed to obtain axial views of the vitreoretinal interface in the posterior pole. The incidence of perifoveal vitreous detachment was assessed. RESULTS: 18 of the 28 eyes (64.2%) from the macular hole group and 15 of the 123 eyes (12.1%) from the normal contrast group had perifoveal vitreous detachment on OCT scan. The difference was statistically significant (p<0.05).There was no statistically significant difference on the incidence of perifoveal vitreous detachment according to stage of macular hole. CONCLUSIONS: These results led to the conclusion that there is a significant relation between the pathogenesis of macular hole and the papillofoveal traction.

The Effect of LASIK on the Retina in Patients with High Myopia

PURPOSE: To investigate the effect of LASIK on the peripheral retina in patients with high myopia. SUBJECT AND METHOD: The difference between preoperative and postoperative retinal findings was investigated in 454 high myopic eyes underwent LASIK. RESULT: At postoperative 6 month, we did not observe any change in the preoperative retinal findings. CONCLUSION: From the above results, it is concluded that there is no significant effect of LASIK on the retina in patients with high myopia, at postoperative 6 month.

Sensitivity of CD95-induced apoptosis in different proliferative status of human retinal pigment epithelial cells

It is known that CD95 (APO-1/Fas) is expressed on the cell surface, and apoptotic cell death can be induced by the CD95 ligation in the cultured, proliferating human retinal pigment epithelial (RPE) cells. However, little is known about CD95 on the non-proliferating RPE cells. In this study, human RPE cells were cultured up to 4 weeks after they reached the confluence, to simulate the non-proliferating RPE cells in situ. There was no significant difference in CD95 expression on the cell surface between the predominantly proliferating, preconfluent cells and predominantly non-proliferating, postconfluent cells in flow cytometric assays. However, unlike proliferating cells, no cellular death occurred in the predominantly non-proliferating cells after the treatment of agonistic anti-CD95 antibody with cycloheximide, pretreated with interferon-gamma. Our results suggest that the CD95/CD95L system probably plays a physiologic role in vivo to remove the abnormal, proliferating RPE cells, and factors other than the surface expression of CD95 may determine the sensitivity to the CD95 signals.

Screening Examination for Retinopathy of Prematurity with Dual Parameter Protocol

So far most screening protocols for retinopathy of prematurity (ROP)have used a single parameter such as chronological age or postconceptional age. We attempted to test a screening protocol for ROP using dual parameter, chronological age and postconceptional age, to determine whether it could reduce the number of screening examinations safely.We retrospectively reviewed medical records of 23 infants (43 eyes)who had undergone laser treatment for threshold ROP.Mean gestational age at birth was 28 weeks and mean birth weight was 1055 gms.The mean age at which the study infants reached threshold ROP was 10 weeks in chronological age and 38 weeks in postconceptional age.Screening examinations as early as chronological age of 7 weeks or postconceptional age of 35 weeks could detect all threshold ROP while reducing the number of unnecessary early examinations.

Experimental Retianl Vein Occlusion in Albino Rats

The retinal vein occlusion is one of the most common, vision-threatening retinal diseases, and the establishment of animal model in rats will be of great help for further study. We occluded retinal veins with rose bengal dye injection followed by argon green laser photocoagulation in albino rats and confirmed the occlusion of veins with fluorescein angiography one hour after photocoagulation. We occluded half of an all of major retinal veins in 12 eyes, respectively. After 1-2 weeks of follow-up, histologic examinations were done. Eyes which underwent occlusion of all major retinal veins showed severe retinal atrophy and preretinal neovas-cularization developed in two eyes. Eyes which underwent occlusion of half of retinal veins showed relatively less damage and the number of retinal ganglion cells was significantly reduced in occluded area than that in control area (P=0.0033), which might represent the ischemic damage of inner retina. We expect that it will be possible to establish an animal model of retinal vein occlusion in albino rats using this method.

Experimental Exudative Retinal Detachment in Albino Rats

To establish animal model of exudative retinal detachment in Sprague Dawley albino rats and to elucidate the possible role of retinal vein in the induction of exudative retinal detachments, rose bengal photosensitive dye was injected intravenously and argon laser was applied. In group A(10 eyes), laser was applied on intervascular retinal areas linearly. In group B (12 eyes), laser was applied on major retinal veins. In group C(4 eyes), laser was applied on major retinal arteris. In group D(3 eyes), laser was applied on major retinal veins without rose bengal dye and in group E(26 eyes), only the rose bengal dye was perfused. And in group F(3 eyes), normal eyes were fixed for negative controls. Exudative bullous retinal detachment occurred only in group B and these resutls were confirmed in histological examinations. In control groups (D and E), tissue injuries were not found. In conclusion, exudative retinal detachment could be induced by occlusion of retinal veins in albino rats and the abnormalities of retinal venous blood flow were required for the induction of exudative retinal detachment.

Effect of Ascorbic Acid on Experimental Retinal Vein Occlusion

The retinal vein occlusion is one of the most common vision-threatening retinal diseases, and both the hemi-central and central retinal vein occlusion might induce severe visual loss. There have been many studies on the role of abnormally produced oxygen free radicals and excitatory amino acids in the mechanism of ischemic retinal injury. Many free radical scavengers, such as superoxide dismutase (SOD), catalase, and EGB 761 were reported to reduce the extent of ischemic retinal injury in animal experiments. Ascorbic acid is also a well-known free radical scavenger, but its in vivo therapeutic effects on retinal ischemia has not been studied, yet. We induced experimental retinal vein occlusion in 48 albino rat eyes; half of major veins in 24 eyes (group A) and total veins in 24 eyes (group B), with rose bengal dye injection followed by argon-green laser photocoagulation. The occlusion of veins was confirmed with fluorescein angiography. We injected ascorbic acid intraperitoneally just after venous occlusion in 12 eyes for each group. Rats were sacrificed after I week (group A) or 2 weeks (group B) following experiment and histological examination was done. In both groups, inner retina was less damaged than outer retina. The density of retinal ganglion cells was reduced to a less degree in eyes of rats treated with ascorbic acid in group A(P=0.0318). These data support the idea that the reactive free adicals are involved in the mechanism of ischemic retinal injury and thus the ascorbic acid may attenuate the ischemic retinal damage.