Regression of Choroidal Neovascularization in a Choroideremia Patient after Intravitreal Bevacizumab Injection: A Case Report

PURPOSE: To report the first domestic case of choroidal neovascularization in a choroideremia patient treated with intravitreal bevacizumab injection. CASE SUMMARY: A 29-year-old male presented with a sudden decline in vision in the left eye. Fundus examination revealed areas of choriocapillaries and retinal pigment epithelium atrophy with macular hemorrhage. Fluorescein angiogram revealed vascular hyperfluorescence in the juxtafoveal area. Neurosensory detachment around the macula and increased central macular thickness was also observed using optical coherence tomography. Upon the diagnosis of choroideremia with choroidal neovascularization, the patient was treated with 1.25 mg intravitreal bevacizumab. Visual acuity improved after four injections of intravitreal Bevacizumab with improvement in both detachment and fluorescein leakage. CONCLUSIONS: In patients with choroideremia presenting sudden decline in vision, ophthalmologists should detect for possible choroidal neovascularization. The results from the present study show that judicious use of intravitreal Bevacizumab may be effective in such cases. Further studies with a large sample size and sufficiently long follow-up periods are required.

A Case of Macular Hole after Exposure to Tattoo Removal by Q-Switched Neodymium:YAG Laser

PURPOSE: To report a case of a macular hole resulting from accidental exposure to tattoo removal by the Q-Switched Nd:YAG laser, which was treated successfully by vitrectomy and silicone oil infusion. CASE SUMMARY: A 33-year-old man presented with decreased visual acuity after accidental exposure to a Q-Switched Nd:YAG laser. According to fundus examination, vitreous hemorrhage and macular edema were observed. After 21 days, a macular hole had developed which was treated by standard pars plana vitrectomy and gas tamponade. Unfortunately, closure was not obtained on the first attempt. Therefore, a second attempt using silicone oil infusion was performed. Four months after the initial visit, BCVA had increased to 20/50, and anatomical occlusion was achieved. CONCLUSIONS: The authors of the present study experienced an unusual case of macular hole developed from the Q-Switched Nd:YAG laser used to remove a tattoo. A satisfactory visual acuity was achieved after silicone oil infusion despite failure in the first surgery.

Development and Evaluation of the Quick Anaero-system-A New Disposable Anaerobic Culture System / 대한진단검사의학회지

BACKGROUND: We developed a new disposable anaerobic culture system, namely, the Quick anaero-system, for easy culturing of obligate anaerobes. METHODS: Our system consists of 3 components: 1) new disposable anaerobic gas pack, 2) disposable culture-envelope and sealer, and 3) reusable stainless plate rack with mesh containing 10 g of palladium catalyst pellets. To evaluate the efficiency of our system, we used 12 anaerobic bacteria. We prepared 2 sets of ten-fold serial dilutions of the 12 anaerobes, and inoculated these samples on Luria-Bertani (LB) broth and LB blood agar plate (LB-BAP) (BD Diagnostic Systems, USA). Each set was incubated in the Quick anaero-system (DAS Tech, Korea) and BBL GasPak jar with BD GasPak EZ Anaerobe Container System (BD Diagnostic Systems) at 35-37degrees C for 48 hr. The minimal inoculum size showing visible growth of 12 anaerobes when incubated in both the systems was compared. RESULTS: The minimal inoculum size showing visible growth for 2 out of the 12 anaerobes in the LB broth and 9 out of the 12 anaerobes on LB-BAP was lower for the Quick anaero-system than in the BD GasPak EZ Anaerobe Container System. The mean time (+/-SD) required to achieve absolute anaerobic conditions of the Quick anaero-system was 17 min and 56 sec (+/-3 min and 25 sec). CONCLUSIONS: The Quick anaero-system is a simple and effective method of culturing obligate anaerobes, and its performance is superior to that of the BD GasPak EZ Anaerobe Container System.

The Results of Nation-Wide Registry of Age-related Macular Degeneration in Korea

PURPOSE: To evaluate the incidence and clinical features of age-related macular degeneration (AMD) in Korea. METHODS: Web-based (www.armd-nova.or.kr) registration was conducted for AMD patients aged 50 or more who were newly diagnosed by retinal specialists in Korea from August 20, 2005 to August 20, 2006. Patient data including ophthalmologic examination, fundus photography, fluorescein angiogram and/or indocyanin green angiogram (ICG), past medical history, behavioral habit, combined systemic diseases were up-loaded. RESULTS: Among finally enrolled 1,141 newly diagnosed AMD patients, 690 patients (60.5%) were male and 451 patients (39.5%) were female. The average age of AMD patients was 69.7+/-8.0. Early AMD was observed in 190 patients and 951 patients had late AMD. Classic choroidal neovascular membrane (CNVM) was observed in 18.6% of exudative AMD patients and 63.4 % had occult CNVM. Subfoveal CNVM was observed in 80.4% of the patients with CNVM. Among the 580 exudative AMD eyes that performed indocyanin green angiography (ICG), 184 eyes (31.7%) had polypoidal choroidal vasculopathy (PCV) and 36 eyes (6.2%) showed retinal angiomatous proliferation (RAP). Age, male gender, smoking, diabetes and hypertension significantly increased the risk of the AMD among Koreans. CONCLUSIONS: Because of the low rate of participation by retinal specialists, definite incidence of AMD was not obtainable. However, the estimated 1-year AMD incidence in the Pusan area of Korea is at least 0.4%. In contrast to Western people, 31.7% of exudative AMD cases were revealed to be PCV and 6.2% were revealed to be RAP. This discrepancy between ethnic groups should be considered in the diagnosis and treatment modality selection of Korean AMD patients.

Methotrimeprazine-induced Corneal Deposits and Cataract Revealed by Urine Drug Profiling Test

Two schizophrenic patients who had been taking medication for a long period presented with visual disturbance of 6-month duration. Slit-lamp examination revealed fine, discrete, and brownish deposits on the posterior cornea. In addition, bilateral star-shaped anterior subcapsular lens opacities, which were dense, dust-like granular deposits, were noted. Although we strongly suspected that the patient might have taken one of the drugs of the phenothiazine family, we were unable to obtain a history of medications other than haloperidol and risperidone, which were taken for 3 yr. We performed a drug profiling test using urine samples and detected methotrimeprazine. The patient underwent surgery for anterior subcapsular lens opacities. Visual acuity improved in both eyes, but the corneal deposits remained. We report an unusual case of methotrimeprazine-induced corneal deposits and cataract in a patient with psychosis, identified by using the urine drug profiling test.

Intraocular Foreign Body of a Vitreous Cutter Tip Fragment

PURPOSE: To report a case of intraocular foreign body of a vitreous cutter tip fragment. CASE SUMMARY: A 60-year-old women was referred by her ophthalmologist with a two-day history of visual disturbance in her right eye. She had undergone pars plana vitrectomy, barrier laser and C3F8 gas injection due to pseudophakic rhegmatogenous retinal detachment in our retinal service center four months previously. Slit-lamp biomicroscopy of her right eye showed cornea stromal edema with Descemet membrane folding. Gonioscopic examination revealed a metallic foreign body in the direction of the 6-o'clock anterior chamber angle. Anterior chamber irrigation with successful removal of the metallic foreign body using intraocular foreign body forceps was performed. The removed intraocular foreign body was a vitrectomy cutter tip fragment 20 gauge in size and 3 mm in length. After surgery, the corneal stromal edema disappeared and her visual acuity in the right eye recovered. CONCLUSIONS: Intraoperative breakage of vitreous cutter tips can occur and cause toxic ocular tissue reaction. Care should be taken against vitreous cutter tip breakage during vitrectomy.

Effect of Triamcinolone on Angiogenesis-related Factors of Cultured Retinal Pigment Epithelial Cells

PURPOSE: To examine the effects of triamcinolone on angiogenesis related factors in cultured human retinal pigment epithelial cells. METHODS: Human retinal pigment epithelial cells were exposed to triamcinolone, cultured in a hypoxic environment, and expression and production of VEGF and PEDF were subsequently tested by RT-PCR and Western blot. Angiogenesis was measured via a tube formation assay using ECV 304 cells and with a migration assay using human dermal microvascular endothelial cells. RESULTS: Expression and production of VEGF and PEDF were tested by RT-PCR and Western blot, respectively. VEGF abundance was reduced while that of PEDF was unchanged in triamcinolone exposed retinal pigment epithelial cells cultured in hypoxic environment compared with cells with no treatment in hypoxic environment (p<0.05). Tube formation and cell migration were reduced by triamcinolone (p<0.05). CONCLUSIONS: These results suggest that triamcinolone affects the secretion of angiogenesis-related factors and suppresses neovascularization.

Vitrectomy as a Substitute for PRP on the High-risk PDR Patients

PURPOSE: This research is to evaluate the effectiveness of vitrectomy on early vision recovery compared to that of panretinal photocoagulation for the high-risk proliferative diabetic retinopathy (PDR) patients. METHODS: A retrospective chart review of 84 high-risk PDR patients (100 eyes) who had undergone panretinal photocoagulation or vitrectomy under the diagnosis the high-risk PDR and followed up at least 12 months. Authors divided them into two different groups; one with who received PRP, and another with vitrectomy. We investigated both groups' vision change every 3, 6, and 12 months after the treatment. RESULTS: The Vitrectomy group patients showed higher percentage of vision improvement and lower percentage of vision decrease (p< or =0.05) than the PRP group patients in 3rd and 6th month. Macular edema decreased in the Vitrectomy group and increased in the PRP group in the 3rd month. Need for additional surgery due to complication showed 26% in the PRP group, and 12% in the Vitrectomy group. CONCLUSIONS: We conclude the vitrectomy is more efficient method than PRP for high-risk PDR patients who are in need of early vision recovery.

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.

Expression of Angiogeneis-related Factors in Retinal Pigment Epithelial Cells under Hypoxia

PURPOSE: To elucidate the mechanism of neoangiogenesis of human retinal pigment epithelium (HRPE) under hypoxia. METHODS: HRPE cells were cultured for 2 and 24 hours in a hypoxic chamber. Expression and production of the angiogenic factor, vascular endothelial growth factor (VEGF) and the anti-angiogenic factor, pigment epithelium-derived factor (PEDF) were analyzed by RT-PCR and Western blot, respectively. Neoangiogenesis was induced by adding culture supernatant harvested from cells exposed to hypoxic conditions. Neoangeogenesis was measured with a tube formation assay that uses ECV 304 cells and with a migration assay that uses human dermal microvascular endothelial cells. RESULTS: Competitive RT-PCR showed that the expression of the PEDF gene in HRPE cells under hypoxic state decreased compared to normoxic state (p<0.01) but the expression of the VEGF gene increased (p<0.01) when exposed to hypoxic conditions. These results corresponded to those of the Western blot analysis which revealed a significant increase of VEGF production (p<0.01) and a decrease of PEDF production (p<0.01). Moreover, the tube formation and migration assays demonstrated that angiogenesis was increased by exposure to hypoxic stress. Taken together, HRPE cells under hypoxic stress produce more VEGF and less PEDF, which lead to neoangiogenesis. CONCLUSIONS: These results suggest that the subretinal neovascularization that occurs under hypoxic stress might be caused by an imbalance of angiogenesis-related factors in HRPE cells.

Stem Cell Transplantation in Retinitis Pigmentosa Patients

PURPOSE: This study was to evaluate the effect of stem cell transplantation into the sub-retinal space in retinitis pigmentosa (RP) patients for improving their visual acuity. RP is a progressive hereditary disease that leads to the blindness, and there is no reliable treatment for recover the disease until now. METHODS: The author transplanted mesenchymal stem cell extracted from umbilical cord blood into the sub-retina of four RP patients recommended by Korea RP association, and checked the changes of their visual acuity and electroretinograms. RESULTS: There was no obvious improvement in their visual acuity and elecroretinograms compared with preoperative state. Two patients, however, experienced slight improvements of their color sense and peripheral visual fields, and slight decrease of photophobia. Although there were no any obvious complications in relation to the stem cell transplantation, surgical procedures developed complications such as vitreous hemorrhage and retinal detachment. CONCLUSIONS: Mesenchymal stem cell derived from umbilical cord blood could not improve visual acuity and electroretinogram of RP patients.

Angiogenesis according to Expressive Change of Angiogenic Related Factor in Human RPE under Oxidative Stress

PURPOSE: To elucidate the mechanism of neoangiogenesis in human retinal pigment epithelium under oxidative stress. METHODS: Paraquat was added to cultured human retinal pigment epithelium (HRPE) for 72 hours to induce oxidative stress milieu. Expression and production of angiogenic factors, including vascular endothelial growth factor (VEGF) and pigment epithelial derived factor (PEDF), was checked by RT-PCR and Western blot, respectively. The induction of neoangiogenesis was monitored by both tube formation in ECV 304 cell and migration assay of human fetal dermal microvascular endothelial cells. RESULTS: Competitive RT-PCR showed that PEDF gene in paraquat-treated HRPE was expressed at a significantly lower level than in non-treated HRPE. However, Western blot showed a significant increase of VEGF production (p<0.05) and a decrease of PEDF production (p<0.05). Moreover, angiogenesis was dose-dependently increased when the various concentrations of paraquat were added to HRPE. CONCLUSIONS: Taken together, oxidative stress by addition of paraquat caused HRPE to produce more VEGF and less PEDF, thereby leading to neoangiogenesis, and suggesting that the neovascularization in age-related macular degeneration (AMD) is caused by destroying the balance of angiogenic factors in HRPE such as VEGF and PEDF; that is, in oxidative stressed HRPE, more VEGF is released and less PEDF, as compared to normal HRPE.

Effect of Oxidative Stress on the Expression of Gelatinases in Cultured RPE

PURPOSE: To evaluate the expression pattern of gelatinases in the human retinal pigment epithelial cell line ARPE-19 in response to oxidative stress. METHODS: ARPE-19 cells were exposed to paraquat for 72 hours. The cells were assayed for the mRNA expression of gelatinase A and gelatinase B by reverse transcriptase polymerase chain reaction (RT-PCR). The conditioned media were assayed for the production of gelatinases protein by Western blotting. Also, the inhibitory effect of the antioxidants against oxidative stress to the cells was evaluated. RESULTS: The gelatinase levels in the RPE cells increased under oxidative stress compaired with the control (p<0.05). Also, the levels decreased when the cells were incubated with the antioxidant N-acetylcysteine (NAC). CONCLUSIONS: Oxidative stress upregulates gelatinase expression in ARPE-19 cells.

A Case of Tubeculous Neuroretinitis

OBJECTIVE: Tuberculosis is a chronic infection caused by Mycobacterium tuberculosis that can appear throughout the entire body; however, intraocular tuberculosis is rare. We report a case of tuberculous neuroretinitis accompanied by periphlebitis. METHODS: A 17-year-old female was referred with the diagnosis of retinal vasculitis. In the fundus of her right eye, an edematous disc, serous detachment of the macula, multiple hard exudates, and vascular sheathing around the veins were noted. Also, she had no direct light reflex in her right eye. Although her chest X-ray showed no abnormalities, the Tuberculin test was positive; therefore, the condition was diagnosed with a neuroretinitis accompanied by periphlebitis caused by Mycobacterium tuberculosis. RESULTS: High-dose steroid treatment decreased peripapillary edema but did not improved visual acuity. Treatment with antituberculosis medicine resulted in the recovery of her visual acuity and in fundus changes. CONCLUSIONS: Ocular tuberculosis commonly appears as perivasculitis; however, it can cause a visual disturbance by invading the retina and optic nerve simultaneously.

Ahmed Valve Implantation for Refractory Glaucoma following Pars Plana Vitrectomy

PURPOSE: To evaluate the effectiveness of Ahmed valve implantation for refractory glaucoma following pars plana vitrectomy. METHODS: Seventeen eyes of 15 patients suffering from secondary glaucoma following pars plana vitrectomy underwent Ahmed valve implantation. All the eyes were in critical condition, and intraocular pressure could not be controlled with anti-glaucoma medications. Success was characterized by an intraocular pressure less than 22 mmHg and greater than 6 mmHg, regardless of anti-glaucoma medication usage. RESULTS: The total success rate was 83.4% at 6 months and 76.4% at the final visit. The reduction in intraocular pressure and the number of medications used postoperatively were both statistically and clinically significant (p< 0.005). Postoperative complications included: transiently increased intraocular pressure, transient hyphema, early postoperative hypotony, choroidal detachment, malposition of the valve tip, and phthisis bulbus. CONCLUSIONS: Ahmed valve implantation is a safe and effective method for refractory glaucoma following vitrectomy.

Induction of Angiogenic Cytokines in Cultured RPE by Oxidative Stress

PURPOSE: This study was undertaken to investigate whether expression of angiogenic cytokines including IL-8 and MCP-1 is induced in the cultured RPE by oxidative stress. METHODS: ARPE-19 cells were exposed to H2O2 and paraquat for 24, 48, and 72 hours and then assayed for the detection of IL-8 and monocyte chemotactic protein (MCP)-1 expression by reverse transcriptase polymerase chain reaction (RT-PCR) method. To determine whether the antioxidant overcame the oxidative stress, we observed expression of IL-8 and MCP-1 gene after ARPE cells were treated by paraquat and antioxidants including N-acetylcysteine (NAC) and pyrrolidine dithiocarbamate (PDTC) at the same time for 72hr. RESULTS: Expressions of the angiogenic cytokines, IL-8 and MCP-1 were increased by incubating with paraquat for 72hr. Antioxidants including NAC and PDTC decreased the expression of IL-8 and MCP-1 gene by counteracting the paraquat effect. CONCLUSIONS: Oxidative stress stimulates angiogenic cytokines including IL-8 and MCP-1 in the cultured RPE. These results may be significant for understanding the cause of age-related macular degeneration and its treatment.

A Case of Air-bag Associated Severe Ocular Injury

Air-bags have received widespread support as an effective means of enhancing automotive safety, and they are becoming more common as standard automobile equipment on many cars. Although air-bag induced ocular injuries are rare, they present a serious concern because of the possibility of permanent damage or visual impairment. To date, most reports have investigated ocular injury from high velocity motor vehicle accidents and reports of ocular injury from low speed motor vehicle accidents have been rare. We describe a patient who sustained severe ocular injury, including periorbital fracture, hyphema, vitreous hemorrhage, and choroidal rupture of the macular area, due to an inflated air-bag in a low speed motor vehicle accident.

The Effect of Vitrectomy on the Complication of Branch Retinal Vein Occlusion

PURPOSE: This study was designed to evaluate the effect of vitrectomy on the recovery of impaired visual acuity from complication of branch retinal vein occlusion (BRVO). METHODS: The medical records were obtained from all patients who underwent vitreoretinal surgery for complication of BRVO and were followed up at least for 6 months postoperatively. RESULTS: The Surgical indications included vitreous hemorrhage (29 patients), epiretinal membrane (7), and retinal detachment (4). Mean follow-up was 13 months. Preoperatively, best corrected visual acuity was greater than or equal to 0.1 in 14 eyes (35.0%). Six months postoperatively, best corrected visual acuity was greater than or equal to 0.1 in 36 eyes (90.0%). Clinical features associated with better visual outcome included better preoperative visual acuity (P<0.01) and absence of preoperative macular edema (P<0.02). CONCLUSIONS: Vitrectomy is a good procedure for the recovery on the visual impairment due to BRVO complication.

Translocation of the scleral suture knot on scleral-fixated posterior chamber intraocular lens

PURPOSE: To evaluate exposure rate of suture material at the transscleral suture fixation of posterior chamber intraocular lens (TSFPCIOL) with the method in which the scleral suture knots are trans positioned from both nasal and temporal sclera to superonasal. METHODS: With retrospective chart review 16 eyes of 15 patients who underwent TSFPCIOL with the transpositioned suture site, the authors checked their visual recovery rate and complicated disorders after the surgeries. RESULTS: Average corrected visual acuities at final visits improved to 0.67+/-0.32 from 0.14+/-0.17 at initial. Six eyes (37.5%) had complicated disorders at early postoperative period and 5 eyes (31.25%) had at their final visits. No exposure of suture material over the conjunctiva did occur. CONCLUSIONS: These results suggest that translocated suture to superotemporal sclera may be an efficient method for reducing exposure rate of suture material after TSFPCIOL.

Comparison of Sugical Outcome between Early and Delayed Repair of Orbital Wall Fracture

PURPOSE: We analyzed the preoperative and postoperative clinical findings of orbital wall fracture patients between the group operated within 2 weeks (early group) and the group operated 3 weeks or later (delayed group). METHODS: Eighty three patients who had been operated from January 1997 to December 2001 were included, 68 patients were early group and 15 patients were delayed group. We analyzed retrospectively the degree of diplopia, limitation of extraocular motility and enophthalmos for more than 6 months following surgery. RESULTS: Orbital wall fracture predominantly occurred in male than in female (p>0.05), and mostly between 21 and 40 years old. The main cause was from violence and traffic accidents. The major coexisting diseases were head trauma and fractures of low extremities, especially in the group of delayed operation. The common locations of fracture were either inferior wall or combined inferior and medial walls. The early group showed less severe preoperative clinical states and better outcomes of postoperative improvement than the delayed group. However, there was no statistically significant difference between two groups in the degree of postoperative limitation of extraocular motility and enophthalmos. CONCLUSIONS: The early group tended to be less severe preoperatively and showed better postoperative outcome than the delayed group. However, the repair of orbital wall fracture was be indicated to improve clinical states even after 3 weeks following injury.