Clinical Manifestations of Syphilitic Uveitis in the Korean Population

PURPOSE: In recent, years, an increase of syphilis infections has become an issue in Korea as well as globally. Herein, we report a recent clinical manifestation of syphilitic uveitis in a Korean population. METHODS: Over a 5-year period (2007-2012), we collected and analyzed the medical records of 16 patients with syphilitic uveitis in three tertiary eye clinics in Pusan. Sixteen patients were confirmed to have syphilis based on serological tests. Retrospective chart review was performed to determine the best corrected visual acuity, anterior and posterior segments, and treatment regimen, as well as ancillary test results including fluorescein angiogram (FAG). RESULTS: Of the 16 patients, 12 were males and four were females. The mean age of the patients was 51.16 years. Non-granulomatous anterior uveitis was observed in nine eyes (47.4%). Vitritis was the most frequently observed posterior segment finding (16 eyes, 84.2%). Retinal vasculitis and chorioretinitis were found in 11 (57.9%) and five eyes (26.3%), respectively. All patients had negative results in the serum HIV antibody test. Of the 16 patients, 15 were treated with penicillin or ceftriaxone due to neurosyphilis. Mean visual acuity improved from 1.33 +/- 1.1 to 0.58 +/- 0.68 after treatment. CONCLUSIONS: Clinical manifestation of syphilitic uveitis in Korean patients is different from occurrences in Western countries. Ophthalmological findings of syphilitic uveitis are diverse; thus, serological testing for syphilis is recommended for all uveitis patients. Further research regarding long-term treatment, relapse of syphilitic uveitis, and complications is necessary.

A Case of Adult-Onset Vitelliform Dystrophy Treated with Intravitreal Injection of Bevacizumab

PURPOSE: To report a patient diagnosed with adult-onset vitelliform dystrophy (AOVD) who received an intravitreal injection of bevacizumab in both eyes. CASE SUMMARY: A 47-year-old female presented with blurred vision and metamorphopsia in both eyes. On color fundus photograph, small, round, yellowish dots on the foveola and subreitnal fluid were observed. Optical coherence tomography (OCT) showed thick hyperreflective structures in the retinal pigment epithelium (RPE) layer with serous retinal detachment and subretinal fluid. Despite an intravitreal injection of bevacizumab on both eyes, anatomical improvement was not observed on fundus photography and OCT.

A Case of Intravitreal Bevacizumab Injection for the Treatment of Choroidal Neovascularization in Morning Glory Syndrome

PURPOSE: We report a case of intravitreal bevacizumab injection for the treatment of choroidal neovascularization in morning glory syndrome. CASE SUMMARY: A 51-year-old male visited our hospital for a 1.5-year visual disturbance in his right eye. The patient's best-corrected visual acuity was 0.1 in the right eye. After fundus examination, we found characteristic findings of morning glory syndrome with submacular hemorrhage and serous retinal detachment in the right eye. Optical coherence tomography, fluorescein angiography and indocyanine green angiography were performed for evaluation. Retinoschisis, subretinal fluid, and choroidal neovascularization were detected, and thus bevacizumab was injected in the right eye. After intravitreal bevacizumab injection, retinoschisis was improved, and subretinal fluid was decreased. However, retinal pigment epithelial detachment was newly detected, and serous retinal detachment persisted. After 2 months, a second bevacizumab injection was performed. After these intravitreal bevacizumab injections at 1 and 2 months, visual acuity was 0.4 and 0.6, respectively. Visual acuity improved to 1.0 after 3 months. Visual acuity was maintained for at least 6 months with no relapse of choroidal neovascularization. CONCLUSIONS: The choroidal neovascularization in morning glory syndrome was effectively treated with intravitreal bevacizumab injections.

A Case of Dexamethasone Intravitreal Implant Fragmentation During the Injection Procedure in Central Retinal Vein Occlusion

PURPOSE: We report a case of dexamethasone intravitreal implant (Ozurdex(R); Allergan, Inc.) fragmentation during the injection procedure in macular edema due to central retinal vein occlusion. CASE SUMMARY: A 57-year-old man visited our hospital for visual disturbance in his right eye. The patient's best-corrected visual acuity was 0.02 in the right eye and 1.2 in the left eye. After fundus examination, the patient was diagnosed with central retinal vein occlusion with macular edema, thus bevacizumab was injected in the right eye. However, the macular edema did not improve, and a dexamethasone intravitreal implant was injected in the right eye. Immediately after the dexamethasone intravitreal implant injection, on fundus exam, the drug was observed to be fragmented into 3 pieces without any additional treatment. After 2 months, the patient's best-corrected visual acuity was 0.4 in the right eye and 1.2 in the left eye. Macular edema decreased according to optical coherence tomography. CONCLUSIONS: A case of dexamethasone intravitreal implant fragmentation during an injection procedure has not been previously reported in Korea. Although the drug fragmented, the treatment was effective without complications.

Predictive Factors for Visual Outcome after Treatment for Myopic Choroidal Neovascularization

PURPOSE: To determine predictive factors associated with visual outcome after treatment for myopic choroidal neovascularization (mCNV). METHODS: Medical records of the patients who underwent photodynamic therapy (PDT), intravitreal anti-vascular endothelial growth factor (Anti-VEGF) injection, or combination therapy of PDT and Anti-VEGF for myopic CNV, and followed up for more than a year, were reviewed retrospectively. Multiple linear regression analyses were performed to evaluate the predictive factors significantly associated with the visual outcome at 1 year after the treatment. RESULTS: Mean best-corrected visual acuity (BCVA) of 45 eyes of 45 patients showed statistically significant improvement 1 year after the treatment with a mean of 3.5 line improvement (p < 0.01, Wilcoxon signed rank test). Age, 1-month BCVA after treatment and treatment type appeared to be associated with the 1-year visual outcome after treatment for mCNV (p = 0.033, p < 0.001, and p = 0.044, respectively, multivariate linear regression analysis). CONCLUSIONS: Younger age (less than 40 years), better 1-month BCVA after treatment, intravitreal Anti-VEGF monotherapy were associated with improved visual outcome after treatment for mCNV. In particular, 1-month BCVA after treatment is a useful indicator to predict therapeutic response after treatment for mCNV.

Vogt-Koyanagi-Harada Disease in a Pregnant Patient Successfully Treated with Intravitreal Triamcinolone Injection

PURPOSE: To report a case of Vogt-Koyanagi-Harada (VKH) disease in a pregnant patient treated with intravitreal triamcinolone injection. CASE SUMMARY: A 21-year-old female in the 19th week of gestation presented with bilateral blurring of vision associated with mild headache and tinnitus. Her initial best corrected visual acuity was 0.15 in the right eye and 0.3 in the left eye. Multiple serous retinal detachment and anterior chamber inflammation were observed, and VKH disease was diagnosed. Because of her pregnancy, the patient did not want high-dose systemic prednisolone therapy which may cause an abortion or low birth weight infant when used in a pregnant patient. Therefore, an intravitreal triamcinolone (4 mg/0.1 ml) injection was given in the right eye and topical steroid eye drops were used in the left eye. After 1 day, serous retinal detachment was significantly decreased and anterior chamber inflammation disappeared in the right eye. After 1 week, no serous retinal detachment was observed. In the left eye, serous retinal detachment was decreased after using steroid eye drops. After 10 days, serous retinal detachment disappeared but anterior chamber inflammation was still observed. After 1 month, best corrected visual acuity was 1.0 in both eyes and serous retinal detachment had not recurred. On follow-up, VKH disease had not recurred and a healthy normal weight infant was delivered. CONCLUSIONS: Intravitreal triamcinolone injection is an effective and safe treatment for VKH disease in pregnant women.

Clinical Outcomes of Double Staining and Additional ILM Peeling during ERM Surgery

PURPOSE: To assess the clinical outcomes in idiopathic epiretinal membrane (ERM) patients after vitrectomy and ERM removal with or without additional indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling. METHODS: The medical records of 43 patients with an idiopathic ERM that underwent vitrectomy and ERM removal between July 2007 and April 2010 were reviewed. The patients were divided into two groups: triamcinolone-assisted simple ERM peeling only (group A, n = 23) and triamcinolone-assisted ERM peeling followed by ICG staining and peeling of the remaining internal ILM (group B, n = 20). RESULTS: No difference was found between the two groups in terms of visual acuity, macular thickness, P1 amplitude or implicit time on multifocal-electroretinogram (mfERG) at six and 12 months postoperatively. In group B, ICG staining after ERM peeling demonstrated that the ILM had been removed together with the ERM in 12 eyes (60%), and all 12 eyes showed punctate retinal hemorrhages during ERM peeling. There was no recurrence of an ERM in either group. CONCLUSIONS: Additional procedures involving ICG staining and ILM peeling during ERM surgery do not appear to have an additive effect on the clinical outcomes in terms of visual acuity, retinal function based on mfERG, or recurrence rate.

Long-Term Effects of Intravitreal Bevacizumab Injection for Macular Edema Secondary to Branch Retinal Vein Occlusion

PURPOSE: To report the long term effects of intravitreal bevacizumab injection (IVAI) for the treatment of macular edema due to branch retinal vein occlusion (BRVO). METHODS: In this retrospective study, 47 consecutive patients (47 eyes) whose visual acuity under 20/40 and macular thickness over 250 microm from BRVO received IVAI (1.25 mg). All patients were observed over 12 months. The patients were classified into three groups: one, resolved macular edema after first injection, second, persistant, third, recurrant. At 12 months after injection, best corrected visual acuity (BCVA) and central macular thickness (CMT) were compared with one another. RESULTS: Comparing with baseline BCVA (0.96 +/- 0.32, 1.13 +/- 0.42, 0.85 +/- 0.24 log MAR unit), the mean at 12 months was significantly increased (0.50 +/- 0.30, 0.76 +/- 0.51, 0.55 +/- 0.35) in each group. The mean CMT at baseline was 510.84 (+/- 171.07), 538.5 (+/- 216.87), 522.6 (+/- 101.82) microm decreased to 211.58 (+/- 42.74), 232 (+/- 132.68), 270.6 (+/- 85.27). CONCLUSIONS: IVAI was a result of significant decrease of CMT with improvement of BCVA in patients with BRVO after a follow-up of 12 months.

The Clinical Features of Macular Pucker Formation after Pars Plana Vitrectomy for Primary Rhegmatogenous Retinal Detachment Repair

PURPOSE: To investigate the incidence and predisposing factors of macular pucker formation after pars plana vitrectomy in patients who developed primary rhegmatogenous retinal detachment. METHODS: We retrospectively reviewed a consecutive series of 284 eyes in 284 patients who underwent primary retinal detachment repair by pars plana vitrectomy alone between January 1, 2009 and December 31, 2010. Patients with a history of retinal surgery or another visually significant ocular problem were excluded. RESULTS: Postoperatively, of the 264 eyes that completed at least six months of follow-up, 16 (6.1%) eyes developed obvious macular pucker at clinical examination. Of these 16 eyes, ten (70.0%) underwent repeat vitrectomy with membrane peeling for macular pucker removal during the follow-up period. The mean time from primary vitrectomy for the retinal reattachment to the secondary vitrectomy with membrane peeling for macular pucker was 7.9 months. The mean improvement in vision after membrane peeling surgery was 0.37 (logarithm of the minimum angle of resolution). Using an independent t-test, chi-square test, and Mann-Whitney U-test, we found that the number or size of retinal break and vitreous hemorrhage could be significant risk factors of macular pucker. CONCLUSIONS: In our study, 6.1% of eyes which underwent pars plana vitrectomy alone for primary retinal detachment developed a postoperative macular epiretinal membrane. Multiple or large retinal breaks and postoperative vitreous hemorrhage were related to macular pucker formation. Overall, the 70.0% of eyes which underwent secondary vitrectomy with membrane peeling for removal of macular pucker showed a favorable visual outcome.

A Case of Cystoid Macular Edema Associated with Paclitaxel Chemotherapy

We encountered a patient with cystoid macular edema (CME) secondary to paclitaxel use. A 57-year-old man presented with gradual decreased bilateral vision. His chemotherapeutic regimen consisted of bevacizumab, paclitaxel (175 mg/m2 for 5 months), and carboplatin. Optical coherence tomography imaging revealed bilateral CME greater than 500 microm. However, one year later, visual acuity was improved, best-corrected Snellen visual acuity was 40 / 80 in each eye, and CME was spontaneously improved. Our study confirmed that macular edema associated with paclitaxel use shows spontaneous resolution and improvement of visual acuity after a change of chemotherapeutic regimen.

Intravitreal Bevacizumab Treatment of Macular Edema in Central Retinal Vein Occlusion

PURPOSE: To report the effect of intravitreal injection of bevacizumab for the treatment of macular edema due to central retinal vein occlusion (CRVO). METHODS: In a retrospective study, 18 consecutive patients (18 eyes) with macular edema from CRVO received intravitreal bevacizumab (1.25 mg). Ophthalmic examination included best corrected visual acuity (BCVA) and central macular thickness (CMT) at baseline and follow-up visits. Fluorescein angiography was performed during follow-up visits if necessary. Primary outcomes included a change in BCVA and CMT. RESULTS: The mean duration from symptom detection to the first bevacizumab injection was 32.5 days. The patients received a mean of 2.17 injections of bevacizumab per eye. The mean baseline visual acuity (LogMAR) was 1.27 and increased to a mean of 0.75 at 5 weeks, and 0.81 at 24 weeks. The mean central macular thickness at baseline was 640.5 micrometer and decreased to a mean of 295.6 micrometer at 5 weeks and 284.7 micrometer at 24 weeks (p<0.05). In the ischemic CRVO group, no significant changes in visual acuity were found after 24 weeks. The increase in visual acuity did not correlate significantly with the decrease in CMT after 24 weeks (p=0.205). The result from the non-ischemic group was similar to the preceding result (p=0.151). CONCLUSIONS: Intravitreal bevacizumab resulted in a significant decrease in CMT in patients with CRVO after a 6-month follow-up. The visual acuity in patients with non-ischemic CRVO improved, but there was no significant improvement in the ischemic CRVO group.

Intravitreal Bevacizumab Injection for Macular Edema Secondary to Branch Retinal Vein Occlusion

PURPOSE: To examine the clinical effects of intravitreal bevacizumab injections for patients with macular edema secondary to branched retinal vein occlusion (BRVO). METHODS: Nineteen patients (19 eyes) diagnosed with BRVO within the three month study window, having visual acuities under 0.5 and significant macular edema within two-disc diameters of the fovea were included in the present study. The author evaluated the patients' responses to bevacizumab (1.25 mg/0.05 mL) treatment using visual acuity and central macular edema measurements. RESULTS: The mean visual acuity improved from 1.06 (+/-0.10 logMAR unit) at baseline to 0.68 (+/-0.09 logMAR unit), 0.279 (+/-0.049) at one month, 0.67 (+/-0.9 logMAR unit) at two months, 0.61 (+/-0.09 logMAR unit) at three months and 0.54 (+/-0.10 logMAR unit) at six months. The mean central macular thickness decreased from 552.9 micrometer (+/-41.0) at baseline to 290.0 micrometer (+/-36.7) at one month, 290.0 micrometer (+/-36.7) at three months and 281.3 micrometer (+/-30.1) at six months. No adverse side effects were observed following injections. CONCLUSIONS: The observed macular edema and visual acuity improvements, as well as lack of serious adverse side effects after intravitreal bevacizumab injection, demonstrated that intravitreal bevacizumab injection may be useful for treating patients with macular edema secondary to BRVO.

The Evaluation of Prognostic Factors after Vitrectomy for Idiopathic Macular Hole with OCT

PURPOSE: To evaluate the prognostic factors that predict visual outcome in eyes with successfully repaired idiopathic macular hole (MH) using optical coherence tomography (OCT). METHODS: We studied 48 eyes with stage 3 or 4 idiopathic MH that had undergone vitrectomy. All cases had anatomic closures and were followed-up for 6 months or more. We analyzed the preoperative macular hole in terms of minimum diameter, stage, hole form factor (HFF), and macular hole index (MHI), as well as the postoperative OCT images of the repaired macular hole and their relevance to visual recovery. RESULTS: We found significant differences in the preoperative minimum diameter of MH, HFF, the postoperative OCT images of the repaired macular hole, and postoperative visual acuvity. In contrast, we found no statistically significant differences in the preoperative base MH diameter, stage, HFF, MHI, and their relevance to visual recovery. CONCLUSIONS: Minimum diameter of MH, HFF, and the postoperative OCT images of the repaired MH are significant prognostic factors after vitrectomy for the treatment of idiopathic MH.

Suppression of VEGF and STAT3 by Lipoic acid in Experimental Diabetic Rat Retina

PURPOSE: We evaluated whether lipoic acid as antioxidant could inhibit expression of VEGF and STAT3 in experimental diabetic rat retina. METHODS: Diabetes was induced chemically by injection of streptozotocin in 12 rats of 18 Sprague-Dawley rats. After induction of diabetes, lipoic acid was injected into the peritonium in 6 rats. So all rats were divided into 3 groups, normal group (n=6), diabetes mellitus (DM) group (n=6), lipoic acid treated group (n=6). The ocular tissue of the rats were collected on 8 weeks after diabetes induction. Difference of VEGF and STAT3 expression was investigated by immunohistochemistry, RT-PCR, western blot. The change of VEGF and STAT3 in lipoic acid treated group were evaluated in these experimental model. RESULTS: The VEGF and STAT3 expression was elevated in diabetic rat retina. The active form STAT3, phosphorylated STAT3 was also elevated. The VEGF and STAT3 expression in lipoic acid treated group was lower than DM group. CONCLUSIONS: The lipoic acid could inhibit the VEGF and STAT3 expression in diabetic rat retina.

Surgical Outcome of Epiretinal Membrane and Internal Limiting Membrane Removal for Macular Hole Retinal Detachment

PURPOSE: To evaluate the postoperative surgical outcome of vitreous surgery with removal of the internal limiting membrane assisted by indocyanine green (ICG) and the epiretinal membrane assisted by triamcinolone acetonide (TA.) METHODS: We examined the posterior vitreous state with ultrasound and OCT. The procedures performed included pars plana vitrectomy with internal limiting membrane removal assisted by ICG and epiretinal membrane peeling assisted by TA. We prospectively examined 9 eyes with retinal detachment resulting from a macular hole and with follow-up periods longer than 12 months. The main outcome was evaluated by the anatomical success rate, functional success rate, and postoperative complications. RESULTS: In the 7 of 9 eyes, the retina was reattached with closure of the macular hole and without closure of the macular hole in 1 of 9 eyes. Successful retinal reattachment was achieved in 8 eyes (88%) after the initial surgery and in one eye after an additional operation. Visual acuity was improved in 7 eyes, was unchanged in one eye, and decreased in one eye. The functional success rate was 78%. CONCLUSIONS: In retinal detachment resulting from a macular hole, removal of the internal limiting membrane by ICG, and the posterior hyaloid membrane and epiretinal membrane by TA typically results in anatomical and functional success.

Long-term Natural Course of Idiopathic Choroidal Neovascularization

PURPOSE: To evaluate the correlation between lesional variation and visual outcome and natural course of idiopathic choroidal neovascularization (CNV) in the patient who had been treated with conservative treatment only. METHODS: Best corrected visual acuity (BCVA), fluorescein and indocyanine angiographic examination (FAG and ICGA) and comparative analyses were performed for twenty eyes diagnosed with subfoveal and juxtafoveal idiopathic CNV and the long-term (mean, 24.7 months) natural course was followed. RESULTS: Juxtafoveal CNV occurred in 12 eyes (60%) and final BCVA in 17 eyes (85%) improved over 1 line or remained unchanged. Minimal or no leakage of final FAG was shown in 12 eyes (60%). In final ICGA, dark rim was found in 16 eyes (80%), hyperfluorescent area in 12 (60%) and focal choroidal venous dilatation in 3 (15%). Juxtafoveal CNV had more favorable visual outcome than subfoveal CNV and the increased dark rim and decreased hyperfluorescent area in ICGA were significantly correlated with favorable visual outcome. CONCLUSIONS: Idiopathic CNV had a favorable visual outcome during long-term follow-up period with conservative treatment only.

Correlation of Progression Rate between Optic Disc Cupping and Visual Field Damage in Treated Primary Open Angle Glaucoma

PURPOSE: To know the rate of optic disc cupping and visual field progression with correlation among them, and identify clinical factors associated with them. METHODS: Forty patients with POAG who treated over 10 years were evaluated, Cup progression rate was evaluated by using computer-aided planimetry and visual field declination was evaluated with Goldmann perimetry and manual grid template system. Optic disc cupping and visual field progression correlations were estimated using linear regression and all related clinical factors were evaluated using a multiple regression model. RESULTS: Optic disc cupping progression started from inferotemporal to superonasal, to superotemporal and to inferonasal portion (total 0.0067/year) and visual field loss progressed superonasal, inferonasal, superotemporal, inferotemporally (total -1.07%/year) in order with significant correlation. Incisional surgery before visit and higher yearly average higher intraocular pressure showed faster optic disc cup progression and higher initial intraocular pressure and lesser antiglaucoma medications at initial visits showed faster visual field progression. CONCLUSIONS: In treated patients with POAG, the rate of disc cupping and visual field decline showed slow progression rate with significant correlation and various clinical factors affected.

Normal Macular Thickness Measured Macular Mapping of OCT3

PURPOSE: The authors used the instrument, OCT3, to evaluate the reproducibility and map the macular thickness rapidly in normal subjects METHODS: Macular thickness was measured in 120 eyes of 62 normal subjects, aged 18 to 79 years, with the macular OCT3 map. There was no history of ocular disease in any of the subjects, and routine ophthalmoscopic examination results were normal. RESULTS: The coefficient value for macular thickness was lower than 2%, indicating that OCT3 provides reliable measurements. Macular thickness of normal subjects was 193.4 +/- 14.6 micro meter in the central ring, 273.0 +/- 14.8 micro meter in the inner ring and 238.2 +/- 15.6 micro meter in the outer ring. The nasal and superior quadrants of the inner ring and the nasal quadrant of the outer ring had higher thickness measurements than another. A decrease of retinal thickness was observed in the old group. However, gender did not have a significant effect on the values. CONCLUSIONS: Macular thickness analysis with OCT3 provided a detailed map of the macular thickness. This indicates that the method may provide a sensitive detection of pathologic thickening or thinning of the retina and suggests that the macular thickness decreases with age.

A Study on the Clinical Usefullness of Digitalized Random-dot Stereoacuity Test

Existing methods of stereoacuity testing need specific glasses or optical device for use. We have designed a new stereoacuity test for the digitalized, random-dot stereogram and researched its clinical usefulness. A digitalized, random-dot, stereoacuity test card was created with a computer program that used a preferred symbol and the designed system was tested along with the Randot preschool stereoacuity, Titmus-fly and Lang tests to compare their sensitivity and specificity. The mean success rate of the digitalized, random-dot test was 98.2%, while the rates of the Randot preschool stereoacuity, Titmus-fly and Lang tests were 89.3%, 74.2% and 86.1%, respectively. Sensitivity and specificity of the new test were 100% and 95.3%, respectively, which were not that different from those of the Randot preschool stereoacuity, Titmus-fly and Lang tests. We found that the digitalized, random-dot, stereoacuity test has a high success rate and can be appropriately used in medical examinations and follow-up tests for strabismus patients.

Binocular Retinal Detachment after Incomplete Diving

PURPOSE: To report a case of traumatic retinal detachment associated with ocular injury in incomplete diving. METHODS: A 15-year-old female complaining of floaters before the eyes was referred to our hospital. In both fundus, we found retinal holes in inferonasal quadrant. We investigated physical properties of retinal detachment associated with diving. RESULTS: When the human body falls down from 10 m height, the impact power is the same as the pressure exerted by 595 kg weight to the body for one second. And this power may cause retinal detachment. CONCLUSIONS: Today there are many sport activities and retinal injuries can occur by various mechanism. We report our clinical experience with retinal detachment associated with diving.