Pattern Laser Trabeculoplasty Intraocular Pressure Reduction Efficacy in Open-Angle Glaucoma Patients on Medical Therapy

PURPOSE: To assess the effectiveness and safety of Pattern Laser Trabeculoplasty (PLT) in patients with primary open-angle glaucoma (POAG) and normal tension glaucoma (NTG). METHODS: Twenty-six eyes in patients with POAG and 14 eyes in patients with NTG were targeted in this study. The intraocular pressure (IOP) for each patient needed to be reduced within proper ranges. The clinical outcome was assessed by IOP at 1 week, 1 month, 3 months, 6 months and 9 months after PLT. RESULTS: The mean (+/- standard deviation) IOP in the POAG group was 20.7 +/- 4.1 mm Hg before treatment. After PLT, the IOPs in POAG group were 16.4 +/- 3.1 mm Hg, 16.9 +/- 3.8 mm Hg, and 16.5 +/- 5.2 mm Hg at 1, 6 and 9 months, respectively, and the pressure remained stabled over 9 months of post-procedural follow-up. However, no statistical difference in IOP reduction was observed in the NTG group before and after treatment. CONCLUSIONS: PLT provides a possibility to decrease additional medical therapy in patients with POAG. In addition, PLT can be considered as an auxiliary therapy for POAG patients who tolerate maximal medical therapy prior to undergoing surgical treatment.

The Usefulness of External Bandage Suture for Management of Bleb after Trabeculectomy with Mitomycin C

PURPOSE: To evaluate the usefulness of external bandage suture for bleb-related management that follows trabeculectomy with mitomycin C. METHODS: External bandage sutures were performed on 10 patients having hypotony maculopathy, persistent low intraocular pressure (IOP) caused by either hyperfiltration or focal leakage, or a persisting large bleb caused by hyperfiltration and who received trabeculectomy using mitomycin C as an adjuvant treatment. The changes in IOP measured before and 4 weeks after the procedure along with complication incidences were evaluated. RESULTS: The mean IOP 4 weeks after the procedure compared with the mean IOP prior to the procedure increased from 5.8 +/- 2.0 mm Hg (3.0-9.0 mm Hg) to 14.1 +/- 8.5 mm Hg (4.0-32.0 mm Hg), with statistical significance (p = 0.008). After the procedure, improvement in visual acuity was observed but without statistical significance. One patient had persistent focal leakage from an avascular bleb and conjunctival advancement with removal of the avascular conjunctiva was performed. CONCLUSIONS: An external bandage suture can be a good alternative for correction of post-trabeculectomy hypotony and severe chemosis with minimal effect on blebs while correcting focal leakage and hyperfiltration.

The Analysis of the Clinical Findings and Effects of Biodegradable Collagen Matrix in Trabeculectomy

PURPOSE: To observe the effects of biodegradable collagen matrix (OculusGen(TM)) on filtering bleb formation and maintenance and to investigate its clinical effects and usefulness in trabeculectomy. METHODS: Ophthalmologic examinations were preformed 1 day, 2 weeks, 1 month, 2 months, 3 months, 6 months, and 12 months postoperatively in the case and control groups. The clinical findings of the filtering bleb were observed, and the clinical effects measured by mean intraocular pressure and complications were evaluated in both groups. RESULTS: The success rates were 76% in the case group and 88% in the control group, and there were no significant differences between the case and control groups. In the case group, postoperative conjunctival injection persisted for more than 1 month with increasing severity, while ultrasound biomicroscopy revealed increased echogenicity of the subconjuctival and tenon tissue with no definite space-occupying effect. CONCLUSIONS: Trabeculectomy utilizing collagen matrix showed similar clinical results compared to the current traditional trabeculectomy; slit-lamp and ultrasound biomicroscopy findings did not reveal any advantageous changes to filtering bleb function.

Bilateral Retrobulbar Hemorrhage and Visual Loss Following Traumatic Asphyxia

Retrobulbar hemorrhage and permanent visual loss are rare presentations following traumatic asphyxia. In this case, bilateral permanent visual disturbance developed in a woman after chest-crushing trauma without direct trauma to the orbits. A computed tomography scan confirmed bilateral retrobulbar hemorrhages. An ophthalmologic exam revealed bilateral subconjunctival hemorrhages and severe lid edema. Despite high-dose steroid therapy, visual recovery was limited, and optic nerve atrophy developed. Ischemia of the optic nerve associated with retrobulbar hemorrhage may be postulated as one of the causes of permanent visual impairment following traumatic asphyxia.

Clinical Outcome of 457 Hepatic Resection Cases for the Treatment of Hepatocellular Carcinoma

BACKGROUND & PURPOSE: This purpose of this study was to determine the prognostic factors for hepatocellular carcinoma (HCC) in patients who received curative hepatectomies at our institution. PATIENT AND METHOD: A retrospective analysis was performed on 457 patients who had undergone hepatectomies between Mar 1987 and Feb 2008 for HCC at the Korea Cancer Center Hospital, Seoul, Korea. The number of males enrolled in the study was 366 and the number of females enrolled was 91. The mean age of the patients was 52.8 years old. Hepatitis B virus-related disease was the most frequent etiology (335/457 patients). Two hundred nine (209) patients had liver cirrhosis, and 93.9% of patients were classified in Child-Pugh Class A. RESULT: The complication rate was 30.6% (140/457) and the operative mortality was 1.5% (7/457). Reoperation was performed in 7 complicated patients. Five-and 10-year overall survival rates of the patients were 57.7% and 41.8% respectively. Poor prognostic factors of overall survival were Child B class, Edmonson-Steiner histologic grade 3 or 4, tumor vascular invasion, and postoperative complications. Five-and 10-year disease-free survival rates were 42.7% and 32.5%, respectively. Poor prognostic factors for disease free survival included the following an Edmonson-Steiner histologic grade of 3 or 4, tumor vascular invasion, and postoperative complications. CONCLUSION: Postoperative complication is independently a poor prognostic factor for overall and disease free survival in our study. We suggest that special care is needed while performing hepatic resections for the treatment of HCC in order to reduce postoperative complications.

Secondary Glaucoma and Sclerokeratitis After Cosmetic Eye Whitening by Regional Conjunctivectomy with Mitomycin C Application

PURPOSE: To report a case of secondary glaucoma and sclerokeratitis after cosmetic eye whitening by regional conjunctivectomy with Mitomycin C application. CASE SUMMARY: A 69 year-old man was referred to our clinic for a left ocular pain and ocular hypertension sustained for 3 months after cosmetic eye whitening by regional conjunctivectomy with Mitomycin C application for chronic conjunctival hyperemia. On first examination, the scleromalacia and large conjunctival epithelium defect in the nasal quadrant of the limbus area and diffuse sclerokeratitis were observed. Conjunctival and episcleral vessel deficit were seen except superior 30% portion in the left eye. The anterior chamber depth in the left eye was very shallow compared to the right eye and cell reaction in the left anterior chamber was detected. Intraocular pressure (IOP) in the left eye was 28 mmHg after Cosopt(R) and 15% mannitol 500 ml use. Glaucomatous cupping was detected. During follow-up, left IOP increased over 40 mmHg despite the maximal medical treatment and the progression of visual field defects was detected, so then left phacoemulsification, Ahmed valve implantation and amnion membrane transplantation were done. After surgery, the conjunctival epithelial defect and sclerokeratitis were improved much and IOP was regulated 20~30 mmHg without medication. Digital massage was done 2 times per day for decreasing IOP and wound remodeling after 1 month. At 3 month after surgery, the conjunctival epithelial defect recurred and scleromalacia was also progressed, so then we performed autoconjunctival flap and amnion membrane transplantation in left eye. The conjunctival epithelial defect were recovered completely, IOP was regulated 24~36 mmHg without medication, and 20~24 mmHg with Cosopt.(R) The compliance of patient is very poor, further management may be needed for IOP control. CONCLUSIONS: Cosmetic eye whitening by regional conjunctivectomy with Mitomycin C application can cause serious complications such as scleromalcia and secondary glaucoma. This case shows that particular care should be taken in order to minimize these complications.

Evaluation of Ocular Risk Factors Related to Asymmetric Visual Field Defects in Normal Tension Glaucoma

PURPOSE: To evaluate ocular risk factors related to asymmetric visual field defects in normal tension glaucoma (NTG). METHODS: We retrospectively evaluated 92 NTG patients (184 eyes) with asymmetric visual field defects; these patients were classified as having more affected eye (ME) group or less affected eye (LE) group. The differences between ME and LE based on the intra-individual comparison were assessed with several ocular risk factors such as best corrected visual acuity, refractive error, intraocular pressure (IOP), the number of glaucoma medications, disc hemorrhage, central corneal thickness, zone beta of peripapillary atrophy (PPA), and disc size. All subjects were divided into two groups according to the severity of bilateral mean deviation (MD, Delta6dB) and evaluated. RESULTS: The MD was -11.2+/-6.5 in the ME group, and -5.9+/-5.4 in the LE group (p=0.00). The optic disc size was 2.62+/-0.8 in the ME group, 2.48+/-0.5 in the LE group (p=0.00), and there were no statistically significant differences in the other factors. Regarding the difference in the MD, the optic disc size was statistically significant in the less different group, and the angle of PPA was statistically significant in the more different group (p=0.00 and p=0.01, respectively). CONCLUSIONS: The optic disc size is a risk factor related to visual field defects in the ME group and the less affected patients, and the PPA is a risk factor, thought to be associated with ischemia, related to visual field defects in the more affected patients with asymmetric normal tension glaucoma.

Clinical Factors that Influence Intraocular Pressure Change after Cataract Surgery in Primary Open-Angle Glaucoma and Angle-Closure Glaucoma

PURPOSE: To evaluated the effect of cataract surgery on intraocular pressure (IOP) in primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG), and to find predictors for a favorable postoperative IOP after cataract surgery in patients with coexisting cataract and glaucoma. METHODS: Various clinical factors were evaluated in 68 patients (76 eyes) with well controlled primary glaucoma who had undergone cataract surgery. The differences in parameters between groups divided by postoperative IOP course were analyzed. RESULTS: For this study, successful IOP control was defined as an IOP between 6 mmHg and 21 mmHg without anti-glaucoma medication at last visit after cataract surgery. Eyes with the highest preoperative IOPs less than 28 mmHg in POAG and 42 mmHg in PACG had a significantly higher probability of success. In PACG, the probability of success was significantly higher, if fewer than three anti-glaucoma medications were given before surgery and if the areas of PAS before surgery were less than 4 hours. CONCLUSIONS: Primary small incision cataract surgery using phacoemulsification and foldable intraocular lens implantation could be considered the procedure of choice for a selective group of patients with coexisting glaucoma and visually significant cataract, with respect to IOP, the number of anti-glaucoma medications, and the area of peripheral anterior synechiae.

The Factors Associated with the Success of Ahmed Glaucoma Valve Implantation

PURPOSE: To evaluate the factors associated with the success of Ahmed glaucoma valve implantation in refractory glaucoma. METHODS: The medical records of 45 eyes of 45 patients that underwent Ahmed implant surgery for the treatment of refractory glaucoma were reviewed retrospectively. The success criterion was a stable postoperative intraocular pressure (IOP) between 6 and 21 mmHg with or without antiglaucoma medications during the study period. Failure was defined as an abnormal IOP outside of the above range on two consecutive visits, and cases that needed additional surgery to control IOP or to treat devastating surgical complications. We compared the differences in various clinical factors before surgery between the success and failure groups. RESULTS: The Kaplan-Meier cumulative success rate was 71.1% at 12 months. Among the various clinical factors age, gender, right or left eye, phakia or pseudophakia, systemic disease such as diabetes and hypertension, preoperative IOP, preoperative number of antiglaucoma medications, and the number of previous glaucoma or other ocular surgeries were not significantly different between the success and failure groups. Implantation at the superotemporal site and steroid non-responsders of the fellow eye showed a significantly greater success rate than the superonasal site and steroid responders, respectively, after Ahmed glaucoma valve implantation. CONCLUSIONS: The efficacy of lowering the IOP of an Ahmed glaucoma valve would be expected to be greater if the patient is a steroid non-responder. Given the same conditions in the superotemporal and superonasal areas, implanting the Ahmed glaucoma valve in the superotemporal quadrant showed an ito increased success rate.

MALT (mucosa associated lymphoid tissue) type Lymphoma of the Ocular Adnexa

PURPOSE: To report MALT (mucosa associated lymphoid tissue) type lymphoma in ocular adnexa. METHODS: This retrospective study included 11 patients (13 cases) of MALT type lymphoma between August 1995 and July 2000. We identified 11 lymphoma cases with MALT characteristics by conventional examination and immunohistochemical staining. Twelve cases were treated with partial excision and radiotherapy, one case with partial excision and chemotherapy. RESULTS: The patients consisted of 4 females and 7 males with an age range of 29~88 (average 48) years old. Mean follow up period was 24.8 (6~60) months following treatment. Eleven patients had ocular adnexal involvement at presentation; 7 eyes in conjunctiva, 5 eyes in orbit and one in eyelid. All cases represented extranodal marginal zone B-cell lymphoma by REAL classification. Control of lymphomas was achieved in all but 4 cases which developed recurrence after irradiation and chemotherapy, and were salvaged with further radiotherapy. Complications such as cataract, radiation retinopathy, ptosis and alopecia developed later in 4 eyes. CONCLUSIONS: Surgical excision and radiotherapy seemed to be effective for the treatment of primary ocular adnexal MALT lymphoma. Long-term follow up should be warranted.

Surgical Results of Classic Harada-Ito Procedure with Intraoperative Adjustment for Excyclotorsion

PURPOSE: We evaluated the efficacy of classic Harada-Ito procedure with intraoperative adjustment for excyclotorsion. METHODS: This study represents a retrospective review of 22 patients surgically treated for the diagnosis of excyclotorsion with abnormal head posture between January 1995 and August 2001. Head tilt, facial asymmetry, diplopia and excyclotorsion were measured preoperatively and postoperatively. Intraoperative adjustment was made by observing the torsional position of the fundus with indirect ophthalmoscopy. Cyclotropia was measured with the Maddox double-rod test or fundus photography with the eyes in primary and down gaze. RESULTS: Causes of excyclotorsion were congenital (7 patients, 32%), trauma (11 patients, 50%)and idiopathic (4 patients, 18%). Of the 22 patients, 19 patients had a head tilt toward the nonparetic side and the others paretic side. Head tilt was uniformly eliminated in 19 of 22 patients (86%). Six of 22 patients had facial asymmertry. After surgical correction, facial asymmetry gradually disappeared in 2 congenital patients. Preoperatively fourteen of 22 patients had diplopia. Postoperatively, eighth of patients had no diplopia and the others had improved of the symptom except one case. The median measured value change of excyclotorsion before and after the surgery in the primary position was reduced from 7.2+/-5.2degrees to 1.7+/-2.8degrees (76%) and 5.3+/-2.2degrees to 0.4+/-1.1degrees in congenital patients, from 8.9+/- 6.6degrees to 1.5+/-2.6degrees in trauma and from 6.0+/-3.4degrees to 4.3+/-4.2degrees in idiopathic. In downgaze, the median measured value change from 10.9+/-5.3degrees to 2.9+/-3.3degrees (73%) and 7.0+/-3.9degrees to 1.1+/-3.0degrees in congenital patients, from 13.2+/-5.7degrees to 3.2+/-3.0degrees in trauma and from 11.5+/-1.0degrees to 5.0+/-4.1degrees in idiopathic. CONCLUSIONS: Intraoperative adjustable classic Harada-Ito procedure was an effective treatment in correcting head tilt, facial asymmetry and diplopia.

Clinical Results of LASIK using LaserScan LSX(R) for Myopia

PURPOSE: We evaluated the predictability and efficacy of LASIK using 1 mm spot scanning laser (LaserScan LSX(R)). METHODS: LASIK was performed on 135 eyes of 73 patients from December, 1999 to February, 2001. The range of refractive error was from .11.5 D to .2.0 D (mean+/-SD : .5.88 D+/-1.79 D) and age was from 20 to 42 years (mean age: 27.8 years). They were divided into two groups according to their manifest refractive error(spherical equivalent): Group I ( of = -6.0 D, 62 eyes). And according to their astigmatism: Group A ( or = 1.0 D, 48 eyes). RESULTS: Mean uncorrected visual acuity of 1 year after LASIK improved from 0.06 before operation to 1.0 in Group I and from 0.04 to 0.9 in Group II. Uncorrected visual acuity of 0.8 or better was achieved in 90% of eyes in Group I and 74% in Group II. Mean preoperative spherical equivalent was -4.6 D in Group I and -7.4 D in Group II. Mean spherical equivalent of 1 year after LASIK was -0.1 D in Group I and -0.37 D in Group II. The postoperative refractions within +/-0.5 D of emmetropia were 97% in Group I and 85% in Group II. Mean preoperative astigmatism was 0.56 D in Group A and 1.68 D in Group B. Mean postoperative astigmatism was 0.15 D in Group A and 0.17 D in Group B. Postoperative refraction showed slight regression of 0.16 D in Group I and 0.45 D in Group II throughout the follow-up period. CONCLUSIONS: We conclude that LASIK using spot scanning laser (LaserScan LSX(R)) appears to be a safe and relatively accurate procedure to correct moderate to high myopia and astigmatism.

Topographical Analysis of Ablation Decentration Between Eye Tracker-assisted and Unassisted LASIK

PURPOSE: This study was aimed to evaluate the efficacy of an eye-tracking system, in terms of the amount of decentration. Comparison was made between two LASIK groups operated with and without the use of eye-tracking system. METHODS: An eye-tracking system was used in 41 eyes(Group 1) and patient fixation alone without an eye-tracking system in 41 eyes(Group 2). Corneal topography(Humphrey ATLAS(TM) Corneal Topography System; Zeiss Humphrey Systems, Dublin, California, U.S.A.) was performed before surgery and 3 months postoperatively. The amount of ablation decentration was measured on the difference map obtained from the axial map. RESULTS: The mean +/-SD of decentration was 0.38 +/-0.23 mm in group 1, and 0.49 +/-0.24 mm in group 2(p=0.047). The amount of decentration was graded as follows: grade I(1.0 mm). Grade I, there was a significantly less decentration in group 1(p=0.037). For grade II, however, there was no significant difference between the two groups(p=0.766). CONCLUSIONS: Using eye-tracking system alone may not be effective in decreasing moderate decentration. Good fixation of the patients seemed to be as effective as an eye tracking system in achieving good ablation centration.