Pseudallescheria boydii Necrotizing Scleritis Treated with Several Antifungal Agents

Purpose@#We report a case of post-pterygium excisional Pseudallescheria boydii (P. boydii) necrotizing scleritis successfully treated with multi-antifungal agents.Case summary: A 73-year-old female with a history of pterygium excision 6 years prior was referred to our institute because of worsening scleritis in the left eye during high-dose, 2-week steroid treatment. On the initial visit, an oval ulcer was observed in the temporal sclera adjacent to the limbus. All steroids were stopped and 1% voriconazole, 5% natamycin, 2.5% vancomycin, and 5% ceftazidime eyedrops were applied every hour and oral voriconazole 200 mg prescribed once a day, but the scleral necrosis continued to worsen. On day 10, the filamentous fungus P. boydii was isolated; 0.5% caspofungin eyedrops were added and the topical voriconazole concentration increased to 2%. Six weeks later, despite epithelization over the scleral necrosis, choroidal detachment developed. The antifungal treatment was continued and a dispersive, ophthalmic viscosurgical device inserted in the anterior chamber. At 14 weeks of treatment, the scleral necrosis was completely epithelialized and the choroidal detachment had disappeared. @*Conclusions@#When encountering a case of P. boydii-caused necrotizing scleritis developing after pterygium excision surgery, long-term intensive treatment with several antifungal agents must be considered.

Purtscher-like Retinopathy after Aortic Valve Replacement Surgery

Purpose@#We report a case of Purtscher-like retinopathy after aortic valve replacement surgery.Case summary: A 52-year-old male with bacteremia suspicious of infectious endocarditis was referred to our department for ophthalmic examination. Inflammatory reaction was evident in both anterior chambers. Fundus examination revealed infiltrative lesions with a Roth spot, and the patient was diagnosed with chorioretinitis. After 3 days, aortic valve replacement surgery was performed in the cardiac surgery department using cardioplegic solutions. Ophthalmologic exams were repeated after the valve surgery. The Roth spot had disappeared and infiltrated, leaving a clear margin. An anterior chamber cell was not noted. However, there were newly developed peripapillary superficial cotton-wool spots and delayed hemorrhagic lesions. Based on the medical history and specific pathognomonic fundus findings, the patient was diagnosed with Purtscher-like retinopathy. Four months later, all characteristic funduscopic features of Purtscher-like retinopathy had disappeared, leaving a remaining retinal nerve fiber defect and central visual field defect without any ophthalmologic treatment. @*Conclusions@#Although rare, doctors should be aware of the possibility of Purtscher-like retinopathy after valve replacement surgery. Further studies are needed to understand the unknown pathophysiology of Purtscher-like retinopathy.

Purtscher-like Retinopathy after Aortic Valve Replacement Surgery

Purpose@#We report a case of Purtscher-like retinopathy after aortic valve replacement surgery.Case summary: A 52-year-old male with bacteremia suspicious of infectious endocarditis was referred to our department for ophthalmic examination. Inflammatory reaction was evident in both anterior chambers. Fundus examination revealed infiltrative lesions with a Roth spot, and the patient was diagnosed with chorioretinitis. After 3 days, aortic valve replacement surgery was performed in the cardiac surgery department using cardioplegic solutions. Ophthalmologic exams were repeated after the valve surgery. The Roth spot had disappeared and infiltrated, leaving a clear margin. An anterior chamber cell was not noted. However, there were newly developed peripapillary superficial cotton-wool spots and delayed hemorrhagic lesions. Based on the medical history and specific pathognomonic fundus findings, the patient was diagnosed with Purtscher-like retinopathy. Four months later, all characteristic funduscopic features of Purtscher-like retinopathy had disappeared, leaving a remaining retinal nerve fiber defect and central visual field defect without any ophthalmologic treatment. @*Conclusions@#Although rare, doctors should be aware of the possibility of Purtscher-like retinopathy after valve replacement surgery. Further studies are needed to understand the unknown pathophysiology of Purtscher-like retinopathy.

Choroidal Effusion after Consecutive General Anesthesia

PURPOSE: To report a case of extensive choroidal effusion following the Valsalva maneuver under consecutive general anesthesia. CASE SUMMARY: A 41-year-old man who underwent panretinal photocoagulation with proliferative diabetic retinopathy had pars plana vitrectomy and endolaser photocoagulation under general anesthesia due to vitreous hemorrhage. Urology cooperated as the patient had hematuria; the day after the operation, he was transferred to the urology department. Two days after vitrectomy, the patient had an urgent transurethral bladder tumor resection under general anesthesia with suspicion of bladder tumor. At 6 days postoperatively, extensive choroidal effusion was observed from 8 to 10 o'clock on fundus examination and ultrasonography. On day 23 after urological surgery, the choroidal effusion had disappeared without treatment. CONCLUSIONS: Consecutive general anesthesia requires caution, as it is not only burdensome to the body as a whole but may also cause choroidal effusion in the eye.

Pilot Study: An Ocular Biomarker for Diagnosis of Attention Deficit Hyperactivity Disorder

OBJECTIVE: Biomarkers of attention deficit hyperactivity disorder (ADHD) are crucial for early diagnosis and intervention, in which the identification of biomarkers in other areas of the body that represent the immature brain of children with ADHD is necessary. The present study aimed to find biomarkers of ADHD in the retina and assessed the relationship between macular thickness of the retina and cortical thickness of the brain in children with ADHD. METHODS: Twelve children with ADHD and 13 control children were recruited for the study. To find ocular markers of ADHD, we investigated the correlation between clinical symptoms of ADHD assessed with the Korean ADHD Rating Scale (K-ARS), cortical thickness of the brain, and macular thickness measured with the mean thickness from the Early Treatment Diabetic Retinopathy Study (ETDRS). RESULTS: Children with ADHD showed increased macular thicknesses quantified as an ETDRS ring in both eyes, compared to control subjects. Moreover, the right inner ETDRS ring had a positive correlation with K-ARS scores. The ADHD group had an increased ratio of thickness of the right frontal lobe to that of the parietal cortex, compared with the control group. There were positive correlations between the means of the inner ETDRS ring (right) and the left paracentral/right isthmus cingulate thicknesses in the control group. However, there were negative correlations between the means of the inner ETDRS ring (right) and the left frontal pole/right pars triangularis thicknesses in the ADHD group. The results of both groups were at the uncorrected level. CONCLUSION: The different patterns of macular thickness might represent the immature cortical thickness of the brain in children with ADHD.

A Case of Atypical Vogt-Koyanagi-Harada Disease Preceded by Acute Angle Closure Glaucoma

PURPOSE: To report a case of atypical Vogt–Koyanagi–Harada disease that occurred after an acute angle closure glaucoma attack. CASE SUMMARY: A 48-year-old female presented with bilateral visual disturbance accompanied by headache and ocular pain. The patient had no specific past medical or family history except taking oral contraceptives for 10 years. Despite the normalization of intraocular pressure in a local clinic, a shallow-depth anterior chamber and forward displacement of the iris–lens diaphragm remained unresolved. The depth of the anterior chamber had increased in both eyes after laser therapy but without recovery of her visual acuity. B-scans showed ciliochoroidal effusion. Anterior chamber inflammation was observed in both eyes. Optical coherence tomography showed lobulated and serous retinal detachment involving the macula of both eyes. However, fluorescence angiography findings showed no multiple hyperfluorescence, which is unusual for typical cases of Vogt–Koyanagi–Harada disease. The patient was diagnosed with atypical Vogt–Koyanagi–Harada disease and was treated with eyedrops and intravenous steroid pulse therapy, after which she was converted to oral medications with immunosuppressants. After 1 month, no serous retinal detachment was detected. After 3 months, best corrected visual acuity (logMAR) was 0.0 in both eyes, and there has been no recurrence on follow-up. CONCLUSIONS: Atypical Vogt–Koyanagi–Harada disease at presentation can mimic acute attacks of angle closure glaucoma. Therefore, if there is no improvement after treatment for angle closure glaucoma including laser iridotomy, other diseases including Vogt–Koyanagi–Harada disease must be considered and the patient should be closely monitored.

The Effects of Alcohol on Visual Evoked Potential and Multifocal Electroretinography

The aim of this study was to investigate the acute effects of ethanol administration on pattern-reversal visual evoked potential (VEP) and multifocal electroretinography (mfERG). Fifteen healthy subjects with no ocular or general disease were recruited. VEP (0.25° pattern sizes) and mfERG with 19 elements in two recording segments were performed before ethanol administration to obtain baseline for each participant. A few days later, the participants visited again for VEP and mfERG measurements after ethanol administration. Ethanol (0.75 g/kg) was administered orally over the course of 30 minutes. VEP and blood alcohol concentration were evaluated one hour after ethanol administration, and mfERG was conducted after pupil dilation. The Wilcoxon signed-rank test was used to compare parameter changes after randomized eye selection. The mean blood alcohol concentration was 0.034% ± 0.05% by volume. VEP revealed a P100 latency delay (109.4 ± 5.3; 113.1 ± 8.2; P = 0.008) after alcohol administration. The P1 implicit time of ring 1 on mfERG showed a trend of shortening after alcohol administration (37.9 ± 1.0; 37.2 ± 1.5; P = 0.048). However, the changes did not show statistical significance after Bonferroni correction. In conclusion, orally administrated ethanol (0.75 g/kg) appears to suppress the central nervous system, but it is not clear whether alcohol intake affects the retina.

Aggressively Progressed MRSA Sepsis Accompanied by Endophthalmitis and Endocarditis in Preterm Infant / 대한주산의학회잡지

Methicillin-resistant Staphylococcus aureus (MRSA) is a critical source of infections in neonatal intensive care units. Early diagnosis and treatment are important due to the significant morbidity of MRSA infection. MRSA sepsis can be disseminated despite antibiotics, therefore the extent of the infection should be evaluated. Common complications of MRSA sepsis include infective endocarditis, pneumonia, osteomyelitis, meningitis, septic shock.Urgent evaluation of other possible suppurative complications in neoate are necessary. Therefore echocardiogram, chest X-ray, ophthalmic examination, brain sonography and spinal tapping are needed. In this study, we present a case of MRSA sepsis in a preterm infant, accompanied by endophthalmitis and endocarditis in spite of the early diagnosis and treatment.

Comparison between Glaucomatous and Non-glaucomatous Eyes with Unilateral Retinal Vein Occlusion in the Fellow Eye

PURPOSE: To evaluate and compare the clinical and angiographic characteristics of retinal vein occlusion (RVO) in glaucomatous and non-glaucomatous eyes with unilateral RVO in the fellow eye. METHODS: Twenty-one glaucomatous eyes (GL group) and 25 age-matched non-glaucomatous eyes (non-GL group) with unilateral RVO in the fellow eye were included in this study. Fluorescein angiographic images were assessed in both groups by 3 retina specialists in order to determine the RVO occlusion site. The occlusion site was divided into 2 types: arteriovenous (AV)-crossing and non-AV-crossing (optic cup or optic nerve sited). The clinical characteristics and prevalence of AV-crossing and non-AV-crossing RVO were compared between the 2 groups. RESULTS: The mean baseline intraocular pressures of the RVO eye and the fellow eye did not differ between the 2 groups (RVO eye: 14.3 +/- 2.5 mmHg [non-GL group], 15.5 +/- 3.9 mmHg [GL group], p = 0.217; fellow eye: 14.4 +/- 2.5 mmHg [non-GL group], 15.7 +/- 3.7 mmHg [GL group], p = 0.148). The prevalence of systemic disease did not differ between the 2 groups (e.g., diabetes mellitus and hypertension, p = 0.802 and 0.873, respectively). AV-crossing RVO was significantly more frequent in the non-GL group (19 eyes; 76%) than in the GL group (4 eyes, 19%, p < 0.001). CONCLUSIONS: Non-AV-crossing RVO, i.e., optic cup- or optic nerve-sited RVO, is more frequently associated with glaucomatous changes in the fellow eye. Therefore, this type of RVO should be monitored more carefully for indications of glaucoma in the fellow eye.

The Effect of In Vivo Grown Corneal Epithelium Transplantation on Persistent Epithelial Defects with Limbal Stem Cell Deficiency

We report our experience with corneal epithelium, grown in vivo, transplantation in three patients with persistent epithelial defect (PED). The three patients had ocular surface disease unresponsive to standard treatments and were therefore chosen for transplantation. They underwent transplantation of epithelial sheets, grown in vivo, to the most affected eye. In vivo cultivation was carried out in the cornea of a living related donor. After epithelialization was completed, the epithelium grown on an amniotic membrane was harvested gently; it was then transplanted into the patient's eye after debridement of fibrovascular tissue. The cultivated epithelium was completely epithelialized by 2 weeks; it was well-differentiated with well-formed hemidesmosome. On immunohistochemical staining, p63, connexin 43, and Integrin beta4 were expressed in the cells on the epithelial sheet. The PED was covered completely and maintained for 4 weeks in all cases. However, corneal erosion recurred after 5 weeks in two cases. This novel technique demonstrates the corneal epithelial cells can be expanded in vivo successfully on denuded amniotic membrane of a healthy cornea and harvested safely. A corneal epithelial sheet, grown in vivo, can be transplanted to treat eye with a severe ocular surface disease, such as total limbal deficiency.

A Case of Ocular Surface Reconstruction Using Nasal and Oral Mucosa Autograft

PURPOSE: To report a case of ocular surface reconstruction using nasal and oral mucosa auto grafts on a man whose ocular surface was deformed by a chemical burn. CASE SUMMARY: A 48-year-old man was injured when his right eye was exposed to alkali solution. He underwent fifteen operations, including amniotic membrane auto grafts and fornix reconstructions. However, his right eye still suffered from symble pharon, drying, corneal neovascularization, and erosion. We performed ocular surface reconstruction with free autologous nasal and oral mucosal transplantation and amniotic membrane graft. By one month after surgery, his eye showed no evidence of symble pharon or fibrovascularization recurrence on the cornea or conjunctiva. By six months after surgery, his ocular surface had stabilized. CONCLUSIONS: Ocular surface reconstruction with free autologous nasal and oral mucosal transplantation is a useful method on eyes that are injured by chemical burns.

Analysis of the Optic Nerve Head and RNFL Thickness Using Optical Coherence Tomography in Diabetes

PURPOSE: Retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) in diabetic patients with normal tension were analyzed using optical coherence tomography (OCT), which revealed that diabetes induce morphologic changes in optic disc and RNFL thickness. METHODS: A total of 192 patients with type 2 diabetes were analyzed with fundus examination and classified as having normal retina, mild - moderate, severe nonproliferative retinopathy (NPDR), or proliferative retinopathy (PDR). These patients were evaluated with OCT and compared with normal control group. RESULTS: The mean average thickness and nasal average thickness of RNFL in mild-moderate, and severe NPDR groups decreased compared with those of the other groups. There was an increase in the temporal average thickness of RNFL in the PDR group. As the duration of diabetes increased, the mean average and nasal average of RNFL thickness also decreased. The severity of diabetic retinopathy didn't show statistically significant differences in a topographic analysis of the optic nerve head. CONCLUSIONS: The mean average thickness and nasal average of RNFL decreased in NPDR groups. Diabetic changes should be considered when diabetes patients are diagnosed with glaucoma or glaucoma progression.

Visualization of Subconjunctival Lymphatics and Its Significance

PURPOSE: To observe and characterize subconjunctival lymphatics in patients with subconjunctival hemorrhages. METHODS: Patients who visited our clinic with subconjunctival hemorrhage resulting from ocular trauma, or subconjunctival injection of gentamicin and betamethasone during a cataract operation, were included in this study. Subconjunctival hemorrhages and subconjunctival lymphatics were observed using slit lamp biomicroscopy. RESULTS: Apparent dilated lymphatics were found in one patient with subconjunctival hemorrhage after rubbing of the eye; thin lymphatics were found in 10 patients with traumatic subconjunctival hemorrhages; and apparent dilated lymphatics were found in 10 patients after subconjunctival injection. Slit lamp biomicroscopy using a green filter allowed easy visualization of subconjunctival lymphatics. CONCLUSIONS: Subconjunctival lymphatics, which are not visible in normal ocular conditions, are evident on subconjunctival hemorrhages, especially after subconjunctival drug injection.

Research on the Quality of Life of Low Vision Patients

PURPOSE: To Carry out a low vision quality of life questionnaire and to evaluate subjective quality of life of low-vision patients. METHODS: The subject were 250 patients whose visual acuity was between hand motion and 0.3 among the patients at our clinic. The normal control group included 60 patients. After a review of the literature, we selected a useful questionnaire to assess quality of life in low vision patients and translated the questionnaire into Korean. The questionnaire used had 25 items concerning low vision and each question was multiple-choice, and the sum of the total points was used to assess of the quality of life. RESULTS: The range of scores was from 0 to 125 points (the higher the score, the higher the quality of life). Fifty-one patients among 250 patients in the low vision group replied to our questionnaire. Fifty patients among 60 patients in the control group replied. The average low vision quality of life (LVQOL) score for patients with low vision (67.3+/-26.7) was significantly lower than the average score of those with normal vision (114+/-9.72). There was no statistically significant difference between the average score of patients questioned by mail versus telephone CONCLUSIONS: The score of low vision patients was significantly lower than that of the control group, so this questionnaire can be applied to low vision patients specifically to evaluate quality of life. Optimally, the the questionnaire shoud be administered before and after the low vision consultation. The comparision of prerehabilitation score with postrehabilitation score might be helpful to evaluate the quality of life in a post rehabilitation state.

Research on the Quality of Life of Low Vision Patients

PURPOSE: To Carry out a low vision quality of life questionnaire and to evaluate subjective quality of life of low-vision patients. METHODS: The subject were 250 patients whose visual acuity was between hand motion and 0.3 among the patients at our clinic. The normal control group included 60 patients. After a review of the literature, we selected a useful questionnaire to assess quality of life in low vision patients and translated the questionnaire into Korean. The questionnaire used had 25 items concerning low vision and each question was multiple-choice, and the sum of the total points was used to assess of the quality of life. RESULTS: The range of scores was from 0 to 125 points (the higher the score, the higher the quality of life). Fifty-one patients among 250 patients in the low vision group replied to our questionnaire. Fifty patients among 60 patients in the control group replied. The average low vision quality of life (LVQOL) score for patients with low vision (67.3+/-26.7) was significantly lower than the average score of those with normal vision (114+/-9.72). There was no statistically significant difference between the average score of patients questioned by mail versus telephone CONCLUSIONS: The score of low vision patients was significantly lower than that of the control group, so this questionnaire can be applied to low vision patients specifically to evaluate quality of life. Optimally, the the questionnaire shoud be administered before and after the low vision consultation. The comparision of prerehabilitation score with postrehabilitation score might be helpful to evaluate the quality of life in a post rehabilitation state.

Terrien's Marginal Degeneration with Peripheral 360 degrees Lipidopathy

PURPOSE: We report an atypical case of Terrien's marginal degeneration with epithelial defect and peripheral 360 degrees lipidopathy. METHODS: A 59-year-old female patient visited our clinic complaining of severe foreign body sensation in her right eye. She had visited our clinic with foreign body sensation 11 years before. She has been followed-up for 11 years with a diagnosis of Terrien's marginal degeneration. Upon ocular exmaniation, visual acuity of both eyes was 20/20. Both eyes had 360 degrees circumferential peripheral thinning with deposition of lipids. The lesion progressed very little over past 11 years. For the patient's most recent examination, the foreign body sensation is believed to be caused by calcified lipid deposition protruding from the corneal stroma with an epithelial defect. RESULTS: What makes this case unique is the 360 degrees circumferential peripheral thinning with deposition of lipid and calcification of lipid deposition which protruded from corneal stroma with an epithelial defect.

A Case of Enterococcus Faecalis Endophthalmitis after Phacoemulsification

PURPOSE: To report a case of Enterococcus faecalis endophthalmitis which occurred two days after phacoemulsification and posterior chamber intraocular lens implantation. A vitrectomy performed during the early stage of infection showed retinal and vitreous presentation. We report the clinical manifestation, operative findings, and treatment of this pathogen. METHODS: A healthy, 71-year-old female, presented with a sudden loss of vision and eyeball pain two days after phacoemulsification and intraocular lens implantation. As inflammation of the anterior chamber and vitreous cavity progressed rapidly, we performed intravitreal antibiotics injection (Amikacin, 0.4 mg/0.1 ml, Vancomycin, 1 mg/0.1 ml). Since this was ineffective, pars plana vitrectomy, silicone oil tamponade, and intravitreal antibiotics injection (Vancomycin, 1 mg/0.1 ml) were performed. During the procedure, we noted that the vitreous humor was cloudy and apparently filled with pus. We also noted an edematous retina with hemorrhages and necrotic changes. Enterococcus faecalis was identified on vitreous and aqueous fluid culture. RESULTS: Twelve weeks after vitrectomy, her corrected visual acuity was hand motion and there was no evidence of recurrence.

A Report of Localized Corneal Amyloidosis Secondary to the Trichiasis

PURPOSE: To report our experience in the diagnosis and treatment of a localized corneal amyloidosis secondary to trichiasis. METHODS: Case 1. A 55-year-old woman visited our clinic due to discomfort of her right eye. Thirty years previously, she received a lower lid blepharoplasty due to lower lid entropion. Biomicroscopy revealed some trichiasis and a 3 mm, grayish-white nodule at the center of the cornea. Case 2. A 30-year-old woman visited our clinic due to chronic irritation of both eyes. Ten and 3 years previously, she received a lower lid blepharoplasty. Biomicroscopy revealed some trichiasis of the right lower lid and a grayish-white, patch-like lesion at the inferior cornea of both eyes. Lamellar keratectomy and amniotic membrane transplantation with careful electrolysis were performed. RESULTS: Hematoxylin and eosin stain revealed a pink, amorphous, hyaline material under the epithelium, and Congo-red stain showed birefringence of the whitish lesion. Electron microscopy revealed multidirectional, fibrillar arrangement. Secondary, localized amyloidosis of the cornea was diagnosed without any systemic involvement. No clues to the origin of the amyloid were found by immunohistochemical staining. By the sixth month after operation, the patients showed favorable vision and no evidence of recurrence. CONCLUSIONS: In the identification of a corneal mass, a secondary, localized amyloidosis should be considered, which can be managed successfully.

Clinical Effect of Auto-focusing Low Vision Devices

PURPOSE: To evaluate the clinical results of the auto-focusing low vision device (EYE FINE) in low vision patients. METHODS: We assessed the clinical effect after prescription of the device in 21 patients who visited the low vision clinic from July 2004 to January 2005. We examined visual acuity and contrast sensitivity before and after prescription. RESULTS: Mean distant visual acuity increased from 1.00+/-0.30 LogMAR to 0.69+/-0.34 LogMAR and the differences were statistically significant (P<0.01). Mean near visual acuity increased from 0.89+/-0.25 LogMAR to 0.71+/-0.30 LogMAR (P<0.01). And mean contrast sensitivities at spatial frequencies of 1.5, 3, 6, 12 and 18 cycles per degree (cpd) increased from 7.9+/-4.5, 10.8+/-7.4, 10.5+/-9.6, 3.9+/-3.8 and 2.0+/-2.7 to 10.5+/-8.0, 15.1+/-10.6, 16.3+/-13.6, 6.5+/-7.3 and 2.5+/-3.0, respectively. CONCLUSIONS: EYE FINE offers the advantage of auto-focusing according to working distance.