Intravitreal Clindamycin Injection for Toxoplasmic Retinochoroiditis

PURPOSE: To present cases of toxoplasmic retinochoroiditis (TRC) treated successfully with intravitreal clindamycin injection. CASE SUMMARY: (Case 1) A 41-year-old man presented with blurred left eye vision for several months. The patient had a large chorioretinal scar with infiltrations at the boundaries, and fluorescein angiography (FA) showed active retinochoroiditis. Antitoxoplasmosis (antiTX) immunoglobulin G (IgG) was positive, and the patient was started on antiTX medication. Despite several weeks of treatment with maximum doses of antiTx, the TRC progressed and visual acuity worsened. Pars plana vitrectomy (PPV) with intravitreal clindamycin injection (1.0 mg/0.1 ml) was performed, and an additional injection was given 4 weeks later. Six weeks after the second injection, TRC wascompletely resolved with 20/20 vision. (Case 2) A 67-year-old man presented with decreased left eye vision for 1 year. Fundus examinations showed vitreous opacity and epiretinal membranes. The FA revealed retinochoroiditis and the antiTX IgG titer was elevated. The presumed diagnosis was TRC, and oral medications of trimethoprim-sulfamethoxazole, clindamycin, and prednisolone was administered. Inflammation began to improve however, as the patient was not tolerating systemic antiTx medications, an intravitreal injection of clindamycin (1.0 mg/0.1 ml) was administered with PPV. The patientdiscontinued oral medication after surgery, and the inflammation resolved 5 weeks later. CONCLUSIONS: Intravitreal clindamycin injections may be an additional treatment option for TRC in patients who are unable to tolerate systemic therapy or whose disease progresses despite systemic therapy.

Influence of Application Methods on Results of Contact Transscleral Nd:YAG Laser Cyclophotocoagulation

PURPOSE: To examine the influence of irradiation methods on the long-term results of contact transscleral Nd:YAG laser cyclophotocoagulation and to evaluate the factors that affect changes in intraocular pressure (IOP) and occurrence of ocular hypotony after cyclophotocoagulation. METHODS: In this retrospective study, 36 refractory glaucomatous eyes of 36 patients were observed for at least one year after a cyclophotocoagulation procedure. Contact transscleral Nd:YAG laser cyclophotocoagulation was performed with 7 to 10 Watts of power, a duration of 0.7 seconds, with one or two rows, and ranges of either greater or less than 180 degrees. The change in IOP, the success rate of the procedure, and the occurrence rate of hypotony were analyzed with regard to the methods of cyclophotocoagulation. RESULTS: In this series of patients with refractory glaucoma, the final IOP and success rate were not significantly influenced by the laser application method or by the total energy used. The eyes with ocular hypotony showed significantly decreased IOP one year after cyclophotocoagulation when compared with eyes without ocular hypotony. The IOP percent reduction in the patients with ocular hypotony tended to decrease more rapidly than did that of the patients without hypotony, beginning three months after the operation. CONCLUSIONS: The application methods of cyclophotocoagulation appear to have no significant influence on success rate, IOP or ocular hypotony rate. The percent reduction in IOP was higher in the hypotony group, including during the early postoperative periods.

Serous Retinal Detachment Following Combined Photodynamic Therapy and Intravitreal Bevacizumab Injection

We report a case of serous retinal detachment following combined photodynamic therapy (PDT) and intravitreal bevacizumab injection in subfoveal choroidal neovascularization (CNV).

The Antimydriatic Effect of Brimonidine 0.15% on the Dark-adapted Pupil in Dark Brown Irides

PURPOSE: To analyze the effect of the daily use of brimonidine tartrate 0.15% on the dark-adapted pupil diameter in dark brown irides. METHODS: Twenty-five healthy volunteers administered brimonidine tartrate 0.15% to their right eyes once daily for 3 weeks. Infrared digital photographs of the pupil were taken before administration and 1 hour and 4 hours after administration after dark adaptation (at <0.1 lux ambient illumination for 5 minutes). The diameters of both pupils were measured on the first day, on administration days 7 and 21, and on washout day 7. RESULTS: Four hours after the first administration, pupils showed a decrease of 0.95+/-0.74 mm, 1.03+/-0.94 mm, 0.61+/-0.85 mm on the first day, administration day 7, and administration day 21, respectively (p<0.01), compared with baseline data. The anti-mydriatic effect of brimonidine was sustained for 3 weeks, but the proportions of the eyes showing a reduction in pupil diameter by 0.5 mm or more were 84%, 76%, 68%, and 52% at 4 hours on the first day, administration days 7 and 21, and washout day 7, respectively. CONCLUSIONS: The anti-mydriatic effect of the daily use of brimonidine 0.15% on dark brown irides in a scotopic condition is maintained during the instillation period but has a tendency to fade over time. This point should be considered when using this compound as a miotic agent.

Retinal Artery Occlusion in a Healthy Pregnant Patient

PURPOSE: We report a case of branch retinal artery occlusion (BRAO) in a healthy pregnant woman. METHODS: A 29-year-old pregnant woman presented with decreased vision in her left eye. She had a pale retina with macular edema consistent with BRAO. An extensive workup was performed to determine an etiologic factor. All test results were within normal limits except for her factor VIII activity. Her visual acuity improved from finger counting to 20/30 over 2 months without any treatment. RESULTS: This case suggests that BRAO can occur in healthy patients without any systemic or ocular disorders. CONCLUSIONS: BRAO can occur in healthy patients without any systemic or ocular disorders, despite an extensile evaluation.

Retinal Artery Occlusion in a Healthy Pregnant Patient

PURPOSE: We report a case of branch retinal artery occlusion (BRAO) in a healthy pregnant woman. METHODS: A 29-year-old pregnant woman presented with decreased vision in her left eye. She had a pale retina with macular edema consistent with BRAO. An extensive workup was performed to determine an etiologic factor. All test results were within normal limits except for her factor VIII activity. Her visual acuity improved from finger counting to 20/30 over 2 months without any treatment. RESULTS: This case suggests that BRAO can occur in healthy patients without any systemic or ocular disorders. CONCLUSIONS: BRAO can occur in healthy patients without any systemic or ocular disorders, despite an extensile evaluation.

Effect of Vitrectomy on IOL Calculation for Cataract Surgery : Study of Vitrectomized Eyes

PURPOSE: To evaluate the effect of vitrectomy in IOL power calculation for cataract surgery in the eyes that previously performed vitrectomy. METHODS: This study comprised 41 eyes of 37consecutive patients who underwent cataract surgery after previous vitrectomy. IOL power calculation with the measurement of axial length and corneal power was conducted before vitrectomy and before cataract surgery. Target refractions at each surgery, assuming that the same power of IOL was implanted, were compared to actual manifest refraction after cataract surgery. RESULTS: There was no statistically significant change in both axial length and corneal power after vitrectomy (p>0.05). Before vitrectomy, target refraction was -0.22+/-0.61D compared to -0.37+/-0.52D before cataract surgery. The actual refraction after cataract surgery was -0.47+/-0.94D, and there were no significant differences among the three refractions (p>0.05). CONCLUSIONS: In the eyes that underwent vitrectomy, vitrectomy itself does not have an influence on calculating IOL power for cataract surgery.

The Assessment of Stereoacuity in Patients with Strabismus

PURPOSE: To analyze stereoacuity in patients with strabismus using various stereotests. METHODS: Stereoacuity was assessed in children who were diagnosed with intermittent exotropia or refractive accommodative esotropia using the Titmus stereotest, TNO stereotest, and the Lang II stereotest. Patients with amblyopia or previous ocular surgery were excluded. RESULTS: Ninety-four patients with intermittent exotropia and 36 patients with refractive accommodative esotropia were included; the mean age was 7.2 years. The mean stereoacuity in intermittent exotropia was 143.1+/-207.9 seconds of arc with the Titmus stereotest, 130.2+/-103.7 seconds of arc with the TNO stereotest, and 200.0+/-0.0 seconds of arc with the Lang II stereotest. The mean stereoacuity in refractive accommodative esotropia was 430.3+/-288.6 seconds of arc, 232.5+/-90.0 seconds of arc, and 230.0+/-97.9 seconds of arc, respectively. The absence of stereoacuity was more frequent in patients with refractive accommodative esotropia than in patients with intermittent exotropia, and both groups of patients showed the largest proportion of absent stereopsis with the TNO stereotest. No factor was significant for stereopsis in patients with intermittent exotropia and patients with refractive accommodative esotropia. CONCLUSIONS: Stereoacuity showed various seconds of arc according to the type of stereotest in the same patient. Patients with refractive accommodative esotropia showed lower stereoacuity in all stereotests than patients with intermittent exotropia. TNO stereotests are sensitive enough to detect the absence of stereopsis in patients with strabismus.

The Amblyopia and Strabismus Accompanied with Anisometropia

PURPOSE: To study the characteristics of the accompanying amblyopia and strabismus in patients with anisometropia. METHODS: We retrospectively reviewed the medical records of 193 patients, who had either spherical or cylindrical anisometropia of more than 1.00D. Patients were divided into four groups: spherical hyperopic anisometropia, spherical myopic anisometropia, cylindrical hyperopic anisometropia, and cylindrical myopic anisometropia. We investigated the accompanying amblyopia and strabismus. Amblyopia was treated with lens correction and patch therapy and we analyzed the results for 78 patients who fulfilled six-month follow-up examinations. RESULTS: There was no significant difference in the frequency of amblyopia between spherical and cylindrical anisometropia. Spherical myopic anisometropia of more than 3.00D showed a significant increase in the incidence of amblyopia (p=0.001). Spherical hyperopic anisometropia of more than 1.00D, cylindrical hyperopic anisometropia of more than 2.00D, and cylindrical myopic anisometropia of more than 2.00D showed an increased tendency for amblyopia. Between spherical and cylindrical anisometropia, there were no significant differences in the results and duration of amblyopia treatment, and type and frequency of strabismus. CONCLUSIONS: In spherical anisometropia, hyperopic anisometropia has a higher risk for developing amblyopia. We could find the threshold for the development of amblyopia.

A Case of Kabuki Syndrome with Ocular Manifestation

PURPOSE: Kabuki syndrome is a rare syndrome of multiple congenital anomalies and mental retardation, which is characterized by a peculiar face resembles Kabuki actor, postnatal growth retardation, and skeletal abnormalities. The ocular feature such as strabismus, amblyopia, ptosis, blue sclera and long palpebral fissure with eversion of the lateral portion of lower eyelid can be seen in this syndrome. We experienced a Kabuki syndrome patient with ocular feature. CASE SUMMARY: A 6 years old girl visited ophthalmology department for frequent blinking, abnormal movement of eyelid. She showed growth retardation, high palate arch, bifid uvula and low hairline. Best corrected visual acuity was 0.5 in the right eye and 0.4 in the left eye. She also presented with mixed astigmatism (right: +sph 1.00;-cyl 3.00 Ax 180, left: +sph 1.00;-cyl 3.50 Ax 180). In addition, Marcus-Gunn jaw winking in her left eye and a long palpebral fissure were noted. She had intermittent exotropia and a tilted optic disc in the left eye.

Factor Influencing Anatomical Failure of Simple Rhegmatogenous Retinal Detachment

PURPOSE: This study analyzes the factors influencing anatomical failure of the primary operation for simple rhegmatogenous retinal detachment. METHODS: The patients in this study were diagnosed with simple rhegmatogenous retinal detachment and operated on by a single physician. The success group comprised 251 eyes and the failure group comprised 29 eyes. The factors analyzed between the two groups were the type of primary procedure, the type of retinal defect; the numbers of retinal defects; the extent of retinal detachment; the duration of retinal detachment; the existence of peripheral degeneration; carrying out of subretinal fluid drainage; the type of tamponade material used and the position of retinal defects. RESULTS: The anatomical success rate of the primary operation for simple rhegmatogenous retinal detachment was 89.64%. Patient sex, the type of tamponade material used and the position of the retinal defect showed significant differences between the success and failure groups. There was a higher percentage of male patients in the failure group than in success group (p=0.034). Silicone oil used as the tamponade material resulted in a greater chance of failure than success (p=0.017). Analysis of the position of the retinal defect showed that, defects distributed in the inferior retina or through multiple area led to a greater likelihood of anatomical failure (p=0.036). CONCLUSIONS: Due ti the greater possibility of anatomical failure of the primary operation when retinal defects are distributed in the inferior retina or through multiple area, clinicians should consider intensive treatment for such cases.

Analysis of Corneal Topographic Optical Zone and Decentration after Myopic Refractive Surgery

PURPOSE: To identify factors influencing the ablation center and to evaluate the size of the ablation zone after PRK and LASIK using Technolas 217 C. METHODS: This study examined the results of refractive surgery using Technolas 217 C Excimer laser with eye tracking system in 69 eyes, of which 31 underwent PRK and 38 LASIK. The ablation zone and degree of decentration were determined through corneal topography. We divided the eyes into two groups according to the degree of decentration: less than 0.5 mm as the first group, and from 0.5 to 1.0 mm as the second. The ablation zone diameter in topography was compared with the programmed preoperative optical zone. RESULTS: The only factor influencing the ablation center in the PRK group was preoperative spherical equivalent(p=0.016), and no factor influenced the ablation zone in the LASIK group. In both groups, the long axis of the ablation zone was longer than that of the programmed optical zone(p=0.003), while the short axis was shorter (p=0.001). CONCLUSIONS: After refractive surgery using Technolas 217 C Excimer laser with eye tracking system, there was no clinically significant decentration. With greater preoperative spherical equivalent, more decentered ablation was noted in the PRK group. The topographical long axis of the ablation zone was longer than that of the programmed ablation zone, while the short axis of the ablation zone was shorter. During refractive surgery, we should be aware of the possibility that the short axis of the postoperative ablation zone may be shorter than that of the programmed preoperative optical zone.

Effect of Correction Lens for Anisometropia on Aniseikonia and Binocular Function

PURPOSE: To study the effect of the corrective lens for anisometropia on aniseikonia and binocular function. METHODS: The study subjects were 30 patients without strabismus and amblyopia, who had anisometropia of more than 1.00D between the spherical equivalent of each correction lens. The amount of aniseikonia was measured by Awaya's New Aniseikonia Test. The degree of stereopsis and fusion were determined with Titmus Stereo Test and fusion card of major amblyoscope, respectively. RESULTS: The amount of aniseikonia increased significantly with increasing level of anisometropia (p=0.000). There was a statistically significant correlation between the amount of anisometropia and fusion (p=0.046). With increased aniseikonia, the stereopsis declined consequently, but the decline was not statistically significant. Aniseikonia was induced when there was more than 2.00D of anisometropia. With anisometropia increased by 1.00D, the odds ratio of induced aniseikonia was 7.197 (p=0.047). CONCLUSIONS: Anisometropia is an important factor for aniseikonia and can disturb binocular function.

Effect of Mitomycin C with Different Application Methods on Rabbit Cornea after Excimer Laser Surgery

PURPOSE: We evaluated the effect of Mitomycin C (MMC) applied by different methods, on corneal healing after excimer laser phototherapeutic keratectomy (PTK) in rabbits. METHODS: PTK was performed on 34 eyes of 17 New Zealand white rabbits. The control group underwent PTK alone, while the experimental groups underwent PTK with intraoperative application of either annular or discoid filter paper soaked with 0.02% MMC for 2 minutes. At postoperative 4, 12, and 24 weeks, the degree of corneal haziness was determined using a slit lamp biomicroscope, and the proliferation of keratocytes was observed histologically. RESULTS: At 4 weeks, the degree of corneal haziness was significantly lower in both MMC-treated groups than in the PTK-alone group (P<0.001). The two MMC-treated groups also showed decreased corneal haziness at 12 and 24 weeks, although the change was not statistically significant. In addition, the MMC-treated groups showed less proliferation of keratocytes at 4 and 12 weeks. At 24 weeks, the group that received annular application of MMC showed a significant decrease of keratocytes compared with the control group(p=0.026), while the group with discoid application showed no significant difference. CONCLUSIONS: In this study, we found that the annular application of MMC after PTK not only shows similar effect on wound healing but also reduces the side effects of MMC by minimizing the application surface.

Three Cases of Waardenburg Syndrome Type 2 in a Korean Family

Waardenburg syndrome (WS) is a rare, autosomal dominant disorder characterized by sensorineural hearing loss, pigmentary disturbances of the skin, hair, and iris, and other developmental defects such as lateral displacement of both medial canthi and lacrimal puncta called dystopia canthorum. While mutations of the PAX3 (paired box) gene have been identified in about 99% of WS type 1 cases, WS type 2 is a heterogeneous group, with about 15% of cases caused by mutations in microphthalmia associated transcription factor (MITF). We have experienced three cases of typical WS type 2 in a Korean family, for whom full ocular examination and genetic studies were performed. The genetic studies revealed no mutation in either PAX3 or MITF genes. The genetic basis, as yet unknown for most cases of WS type 2, might be found with further investigation.

Effect of Spherical Lens Induced Aniseikonia on Binocular Function

PURPOSE: To study the effect of spherical lens induced aniseikonia on stereopsis and fusion. METHODS: One hundred subjects, with normal binocular function without any ophthalmic disease or surgery history, were examined. The aniseikonia was induced with spherical lenses in 1 diopter (D) stepwise manner from -2 D to +2 D. The amount of aniseikonia was measured by Awaya's New Aniseikonia Test. Stereopsis and fusion were determined with Titmus Stereo Test and fusion card of major amblyoscope respectively. RESULTS: As the amount of aniseikonia was increased, the stereopsis and fusion were decreased. The change was statistically significant (ANOVA, p<0.001). Aniseikonia was more correlated to fusion than stereopsis. A significant decline in the stereopsis was detected when the size of aniseikonia changed from 1% to 2%. A significant decline in fusion was noticed when aniseikonia changed from 2% to 3% (Independent t-test, p<0.01). CONCLUSIONS: Our study suggests that binocular function can be disturbed by experimentally induced aniseikonia in normal subjects and that stereoacuities and fusional amplitude can be decreased as the degree of aniseikonia becomes larger.

A Case of Ocular Hydroxyapatite Infection Diagnosed by Technetium 99m-labeled Leukocyte Scintigraphy

PURPOSE: To describe a low-grade infection of hydroxyapatite orbital implant diagnosed by 99mTc-labeled leukocyte scintigraphy. METHODS: A 34-year-old man diagnosed as phthisis bulbi due to corneoscleral laceration on left eye had been treated with evisceration and hydroxyapatite orbital implant insertion. After drilling for ocular prosthesis, the patient did not have any symptom for 3 years and 5 months. He presented with socket pain, erythematous lid swelling, severe conjunctival discharge. There was no improvement of symptom despite conservative treatment for 3 weeks. MRI revealed no abnormalities so 99mTc-labeled leukocyte scintigraphy was performed. RESULTS: Scintigraphy showed a dense accumulation of labeled leukocyte at the implant site. After diagnosed as hydroxyapatite orbital implant infection, orbital implant was removed and silicon sphere implantation was done. After operation, the inflammation signs disappeared. CONCLUSIONS: 99mTc-labeled leukocyte scintigraphy is a useful technique in diagnosing low-grade infection of hydroxyapatite orbital implant undetected using conventional imaging method such as MRI.

Comparison of Changes in Manifest Refraction and Orbscan Power Maps after Photorefractive Keratectomy and Laser in Situ Keratomileusis

PURPOSE: To determine whether the refractive change obtained using the Orbscan-derived power maps is in concordance with the manifest refractive change produced after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK). METHODS: Forty eyes of 21 PRK patients and 40 of 21 LASIK patients were included in the study. Orbscan topographical analysis and manifest refraction were performed preoperatively and 1 month postoperatively. This study evaluated the concordance between the change in manifest refraction (corrected to the corneal plane) and the change measured by Orbscan power maps before and after PRK and LASIK. We also compared the concordance of the change in manifest refraction (corrected to the corneal plane) with the change calculated using the Gaussian optics formula, radius of anterior and posterior corneal surface , and corneal thickness measured by ultrasound pachymetry. RESULTS: The 3.0-mm zone axial power anterior map gave the best correlation between manifest refractive change, and Orbscan-measured corneal power change in PRK (r =0.733, P<0.001). The 4.0-mm zone of calculated refractive change using Gaussian optic formula map gave the best correlation with manifest refractive change in LASIK (r =0.531 , P<0.001). The change of anterior corneal surface maps in PRK and the change of total power maps in LASIK represented the best correlation with the change in manifest refraction, but they did not reliably represent the changes in manifest refraction due to high standard deviation value. CONCLUSIONS: The 3.0-mm zone axial power anterior map gave the best correlation between manifest refractive change, and Orbscan-measured corneal power change in PRK. The 4.0-mm zone of calculated refractive change using Gaussian optic formula map gave the best correlation with manifest refractive change in LASIK. Nevertheless, these maps did not reliably represent the changes in manifest refraction because of the high standard deviation value.

Treatment of Subperiosteal Abscess of the Orbit in Children

PURPOSE: The subperiosteal abscess in the orbit, caused mostly by sinusitis, has the major clinical finidings such as lid swelling, proptosis, limitation of the eye movement, and so on. The combined systemic administration of antibiotics and surgical drainage are the cornerstone of the treatment for the subperiosteal abscess. However, recent studies have shown that the systemic antibiotic therapy without any surgical intervention can effectively treat the disease. Therefore, this paper presents the case studies based on the treatment results of subperiosteal abscess. METHODS: The medical files of six patients are reviewed in detail, focused on the clinical findings and treatment results. The subjects had the subperiosteal abscess in the orbit and treated from June 1, 1996 to July 31, 2001. RESULTS: Five out of six patients were under the age of fifteen; 2 in the nasal side, 2 in the inferior side, and 1 in the superior side of the orbit. All of the five patients were treated effectively by the intravenous antibiotic therapy only. CONCLUSIONS: The subperiosteal abscess of the orbit in pediatric patients was treated by the intravenous antibiotic therapy only, including the one in the superior side. It is suggested that the intravenous antibiotic therapy can be enough to treat the subperiosteal abscess. However, we also recommend close monitoring of the patients to see whether the surgical intervention might be needed or not.

A Case of Juvenile Xanthogranuloma Invading Iris

PURPOSE: To report one case of juvenile xanthogranuloma invading iris, which resulted in secondary glaucoma due to hyphema. METHODS: A 6-month-old girl with no history of previous trauma visited the hospital complaining of severe injection in her left eye for 3 days. The initial IOP of the affected eye was 35 mmHg, showing gross hyphema. The eye did not show any improvement despite 3 days of conservative treatment. Therefore, the diffuse membranous tissue on iris was removed by the anterior chamber irrigation. The histologic and immunologic study was done on the removed tissue. RESULTS: On the third day after operation, the IOP of the affected eye was 13mmHg. The doses of steroid eye drops and oral steroid were reduced. On the seventh day after operation, the IOP of left eye was 17 mmHg without any specific findings. The pathologic findings showed proliferative histiocytes containing acidophillic cytoplasma with abundant vacuoles. Moreover, the tissue reacted with CD 68 in immunohistochemical stain. The tissue did not show any change in S-100 protein, CD 1a, and Cytokeratin. CONCLUSIONS: The authors report the first case of juvenile xanthogranuloma which represented as secondary glaucoma due to spontaneous hyphema without any trauma history.