A Case with Corneal Decompensation in Pseudoexfoliation Syndrome

Purpose@#To report a case with corneal decompensation in a patient of pseudoexfoliation syndrome.Case summary: A 70-year-old woman was referred to our clinic to evaluate decreased visual acuity in the right eye. She had no history of previous ocular surgery or laser treatment. The best corrected visual acuity was 0.5 in both eyes. The patient had diffuse corneal edema in the epithelium and stroma in the right eye. The left eye showed diffuse endothelial pigment deposits. Deposition of pseudoexfoliation material on the iris and anterior lens capsule was observed in both eyes. The intraocular pressure was 15 mmHg in both eyes without treatment. Specular microscopy was limited in the right eye due to the corneal edema and the left eye showed endothelial cell loss, increased pleomorphism, and atypical guttata. Anterior segment optical coherence tomography revealed irregular thickening of the corneal stroma and protrusion of Descemet’s membrane in the right eye. @*Conclusions@#In patients with pseudoexfoliation syndrome, corneal decompensation can occur without intraocular pressure elevation and glaucomatous damage.

A Case with Corneal Decompensation in Pseudoexfoliation Syndrome

Purpose@#To report a case with corneal decompensation in a patient of pseudoexfoliation syndrome.Case summary: A 70-year-old woman was referred to our clinic to evaluate decreased visual acuity in the right eye. She had no history of previous ocular surgery or laser treatment. The best corrected visual acuity was 0.5 in both eyes. The patient had diffuse corneal edema in the epithelium and stroma in the right eye. The left eye showed diffuse endothelial pigment deposits. Deposition of pseudoexfoliation material on the iris and anterior lens capsule was observed in both eyes. The intraocular pressure was 15 mmHg in both eyes without treatment. Specular microscopy was limited in the right eye due to the corneal edema and the left eye showed endothelial cell loss, increased pleomorphism, and atypical guttata. Anterior segment optical coherence tomography revealed irregular thickening of the corneal stroma and protrusion of Descemet’s membrane in the right eye. @*Conclusions@#In patients with pseudoexfoliation syndrome, corneal decompensation can occur without intraocular pressure elevation and glaucomatous damage.

A Case of Congenital Glaucoma in Associated with Nail-patella Syndrome

PURPOSE: To report a case of congenital glaucoma associated with nail-patella syndrome. CASE SUMMARY: A 20-day-old female was referred to our clinic for bilateral intraocular pressure (IOP) elevation and treatment of corneal opacities. Her IOP was 25 mmHg and 30 mmHg in the right and left eyes, respectively. After a diagnosis of congenital glaucoma, bilateral trabeculotomy was performed under general anesthesia. On the first postoperative day, the IOP was 12 mmHg in the right eye and 10 mmHg in the left eye, and remained stable thereafter. The infant was the second of fraternal twins (birth weight of 2.42 kg) and had no family history of any particular disease. During the regular checkup, she was referred to an orthopedic clinic for disorders of the elbow and knee. She presented with a dystrophic thumbnail, patella hypoplasia, elbow hypoplasia, and bilateral triangular protrusions of the lateral iliac crest (iliac horn). Based on the above findings, typical nail-patella syndrome was diagnosed and a mutation in the LMX1B gene was detected. CONCLUSIONS: If glaucoma patients have nail deformities or musculoskeletal abnormalities, nail-patella syndrome should be suspected and a multidisciplinary approach should be conducted.

Risk Factors of Secondary Glaucoma after Congenital Cataract Surgery in Korean Patients

PURPOSE: To assess the risk of development of secondary glaucoma after congenital cataract surgery using a long-term follow-up study. METHODS: In total, 148 eyes of 91 patients who underwent congenital cataract surgery at our hospital or other hospitals were included in a retrospective chart review. A diagnosis of secondary glaucoma was made if the intraocular pressure (IOP) exceeded 21 mmHg and the corneal diameter, axial length, or the cup-to-disc ratio increased, or surgery was performed to control the IOP. To analyze the clinical features and risk factors of secondary glaucoma, we evaluated the mean age at cataract surgery, binocularity, presence of a nuclear cataract, methods of cataract surgery, presence of an intraocular lens (IOL), duration of diagnosis of secondary glaucoma after cataract surgery, duration of follow-up, recent best-corrected visual acuity, and refractive errors. RESULTS: Thirty-five eyes (23.6%) were diagnosed with secondary glaucoma as a complication of congenital cataract surgery. Of these, 11 eyes (31.4%) were treated with glaucoma surgery a mean of 3.4 times. The mean duration from congenital cataract surgery to diagnosis of glaucoma was 112.2 ± 113.1 months. Patients with aphakia had a higher risk of developing secondary glaucoma compared with patients undergoing primary IOL implantation (p = 0.001). Younger age (<3 months at surgery), a nuclear cataract, and aphakia were risk factors for the development of secondary glaucoma (p = 0.03, p = 0.006, and p < 0.001, respectively), and the risk of developing secondary glaucoma increased with secondary IOL implantation (p = 0.052). CONCLUSIONS: Secondary glaucoma after congenital cataract surgery was more common in patients with secondary IOL implantation, aphakia, a younger age (<3 months), and a nuclear cataract. Patients who underwent congenital cataract surgery had an increased risk for developing secondary glaucoma. Long-term monitoring of the IOP and optic nerve is therefore required for these patients.

Bilateral Simple Ectopia Lentis Associated with FBN1 Gene Mutation

PURPOSE: To report a case of bilateral simple ectopia lentis associated with FBN1 gene mutation. CASE SUMMARY: A 47-year-old women presented with a one-month history of ocular pain and decreased visual acuity of the right eye. She had a family history of crystalline lens dislocation but showed no systemic abnormality or trauma history. Intraocular pressure was 45 mmHg in the right eye, which showed a myopic shift (−6.5 D). The crystalline lens of the right eye was subluxated to the anterior chamber, and the angle was closed. Phacoemulsification with scleral fixation of the posterior chamber intraocular lens of the right eye was performed. After that, best corrected visual acuity of the right eye was 1.0, and intraocular pressure was 15 mmHg. After 2 years, she presented with intermittent ocular pain and decreased visual acuity of the left eye. The crystalline lens of the left eye was subluxated to the anterior chamber. Phacoemulsification with scleral fixation of the posterior chamber intraocular lens of the left eye was performed. After that, intermittent ocular pain and visual acuity of the left eye were improved. Genetic testing confirmed an FBN1 gene mutation in the patient. CONCLUSIONS: A bilateral ectopia lentis patient without history of definite trauma should undergo complete systemic and ophthalmic examination to rule out accompanying disease, and a detailed family history should be collected. If hereditary ectopia lentis is suspected, genetic testing of probands and their family should be performed and will be helpful for genetic counseling and ophthalmic surveillance.

A Case of Hyphema after Selective Laser Trabeculoplasty

PURPOSE: To report a case of hyphema after selective laser trabeculoplasty (SLT) in a patient with pseudoexfoliative glaucoma. CASE SUMMARY: A 77-year-old female was referred for elevation of intraocular pressure (IOP). Previously, she had been diagnosed with pseudoexfoliative glaucoma in the right eye and was using topical IOP-lowering agents. The best corrected visual acuity was 20/100 in the right eye and 20/40 in the left eye. IOP, measured with Goldmann applanation tonometer, was 32 mm Hg in the right eye and 20 mm Hg in the left eye. Gonioscopy revealed open-angle glaucoma with +2 trabecular meshwork pigmentation but without peripheral anterior synechiae or neovascularization. SLT was performed in the right eye. Two days later, the patient had sudden onset of blurred vision and pain in the right eye. Visual acuity was limited to light perception, and IOP was 34 mm Hg in the right eye. Slit-lamp examination revealed 1.1 mm hyphema with 4+ red blood cell count in the anterior chamber. Three weeks after the SLT, hyphema in the right eye disappeared, but IOP was measured to be 42 mm Hg. The patient underwent trabeculectomy in the right eye. CONCLUSIONS: SLT is an effective means of lowering IOP with low risk of complications. However, hyphema can rarely occur after SLT and can affect the outcome of the treatment.

A Case of Steroid Glaucoma in a Child Treated with Systemic Steroid as Graft-Versus-Host Disease

PURPOSE: To report a case of steroid-induced glaucoma in a child who was treated with systemic steroids for a long period due to graft-versus-host disease. CASE SUMMARY: A 10-year-old male was referred to our ophthalmologic clinic for examination of papilledema due to persistent headache and nausea. He was diagnosed as aplastic anemia 8 years prior and took approximately 4,000 mg of oral prednisolone for 8 years from April 2007 to April 2015 for treatment of lung graft-versus-host disease after hematopoietic stem cell transplantation. His best corrected visual acuity was 0.8 (decimal) in the right eye, 0.5 in the left eye and intraocular pressure (IOP) measured using a Goldmann applanation tonometer was 42 mm Hg in the right eye and 43 mm Hg in the left eye. His cup-to-disc ratio was 0.8 in the right eye and 0.7 in the left eye. Additionally, superior and inferior neuroretinal rim thinning was present in both eyes. Despite using IOP-lowering agents, IOP was not controlled. However, after trabeculectomy with mitomycin C in both eyes, IOP became normalized. CONCLUSIONS: In cases of pediatric patients treated with systemic steroids for a long period of time, regular observation is necessary to prevent IOP elevation and steroid-induced glaucoma.

Combined Phacoemulsification, Synechiolysis without Gonioprism Lens and Intracameral Tissue Plasminogen Activator Injection for Angle-Closure Glaucoma

PURPOSE: In this study we evaluated the safety and efficacy of combined phacoemulsification and synechiolysis without aid of gonioprism lens and intraoperative intracameral tissue plasminogen activator (tPA) injection for angle-closure glaucoma. METHODS: The method used in this study was synechiolysis with Kuglen hook without aid of gonioprism lens and intraoperative intracameral tPA injection following cataract surgery. RESULTS: A total of 20 patients with a mean age of 71.4 +/- 5.4 years were treated. Mean follow-up time was 31.3 +/- 24.3 months. Mean preoperative and last visit intraocular pressures (IOPs) were 21.70 +/- 9.50 mm Hg and 12.40 +/- 2.30 mm Hg, respectively (p < 0.0001). The mean number of glaucoma medications decreased from 2.40 to 0.30 (p < 0.0001). IOP was maintained below 16 mm Hg in all cases. No significant intraoperative and postoperative complications, hyphema, or fibrin reaction occurred. CONCLUSIONS: Combined phacoemulsification and peripheral anterior synechiolysis with Kuglen hook without aid of gonioprism lens and intraoperative intracameral tPA injection is an effective and safe surgical procedure.

Clinical Features and Risk Factors of Glaucomatous Change in Posner-Schlossman Syndrome

PURPOSE: To analyze the clinical features and determine the factors that affect glaucomatous change of patients with Posner-Schlossman syndrome (PSS). METHODS: A retrospective analysis of 51 eyes of 51 patients diagnosed with PSS was performed. We analyzed the factors including age of first attack, highest intraocular pressure (IOP), duration of the disease, number of the attacks and interval between attacks among the patients who developed glaucoma and those who did not and compared the 2 groups. RESULTS: The age of first attack was 34.73 +/- 10.77 years, and highest IOP was 47.75 +/- 9.43 mm Hg. Duration of the disease was 62.06 +/- 69.84 months, number of the attacks was 6.20 +/- 7.73 times, and interval between attacks was 12.65 +/- 8.95 months. Of 51 eyes of 51 patients, 12 eyes (23.5%) of 12 patients showed significant glaucomatous change. In the glaucoma group, highest IOP was 52.81 +/- 7.87 mm Hg, number of attacks was 11.91 +/- 10.63 times, and interval between attacks was 8.07 +/- 3.97 months. In the non-glaucomatous group highest IOP was 46.19 +/- 9.14 mm Hg, number of attacks was 4.59 +/- 5.94 times, and interval between attacks was 14.59 +/- 9.79 months, respectively. Highest IOP was significantly greater, number of attacks was higher, and interval was shorter with statistical significance in the glaucoma group (p = 0.025, p = 0.001, p = 0.028). CONCLUSIONS: A significant number of patients with PSS tend to show glaucomatous change over time. Patients with high IOP during attacks and those having frequent attacks with short intervals should be closely monitored and evaluation for glaucomatous damage is recommended.

Axial Length Correlation to Lamina Cribrosa Thickness, Prelaminar Tissue Thickness, and Anterior Laminar Displacement

PURPOSE: In this study we determined the correlation of axial length to lamina cribrosa thickness (LCT), prelaminar tissue thickness (PT), and anterior laminar displacement (ALD) in young healthy eyes. METHODS: The optic discs of 60 eyes from 30 young healthy subjects with myopia were scanned using enhanced-depth imaging spectral-domain optical coherence tomography (Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany). The LCT, PT, and ALD were measured at the superior midperipheral, middle, and inferior midperipheral of the optic nerve head, respectively. A linear mixed-effects model was used to determine the relationship between the axial length and the LCT, axial length and PT as well as axial length and ALD. RESULTS: The mean, superior midperipheral, and middle LCT were not significantly correlated with axial length. Conversely, the inferior midperipheral LCT was negatively correlated with axial length (p = 0.019, beta = -7.34). There was no significant association between axial length and PT. Mean ALD was negatively correlated with axial length (p = 0.022, beta = -17.17). CONCLUSIONS: In the present study, the inferior midperipheral LCT and mean ALD were negatively correlated with axial length, but PT showed no significant association with axial length.

A Case of Ocular Siderosis with Cataract and Delayed-Onset Secondary Glaucoma

PURPOSE: We report a rare case of ocular siderosis with delayed-onset secondary glaucoma occurring 10 years after cataract and iron foreign body removal. CASE SUMMARY: A 47-year-old male who suffered an ocular injury with an iron material to his left eye 3 years prior to his initial visit was treated in our clinic for a cataract with siderosis lentis. Ten years after he underwent cataract surgery he developed secondary open-angle glaucoma. Trabecular block taken during trabeculectomy showed no iron material, however, a fibrosclerotic change was observed. CONCLUSIONS: In patients with a history of traumatic siderosis lentis, a potential risk of siderosis remains for a long period.

A Case of Cataract Surgery after Radial Keratotomy

PURPOSE: To report a patient who underwent successful cataract surgery without wound dehiscence in the eye that had undergone previous radial keratotomy by performing a clear corneal incision between previous incisions. CASE SUMMARY: A 59-year-old female visited our medical center for decreased vision. The patient underwent radial keratotomy for correction of myopia in both eyes 11 years prior. On slit-lamp examination, cataract and eight radial keratotomy incisions were found. Phacoemulsification and posterior capsule intraocular lens implantation were performed for both eyes at a one-week interval. For the right eye, a clear corneal incision was made over the previous incision scar and wound dehiscence was successfully managed by prompt corneal suturing. For the left eye, a clear corneal incision was made between the previous incision scars, and wound dehiscence did not occur. CONCLUSIONS: As radial keratotomy patients age, cataract surgery should be considered. A successful surgery was possible without wound dehiscence in an eye that had undergone previous radial keratotomy in which a clear corneal incision was made between previous incision scars.

Discriminating Between Normal and Glaucomatous Eyes Using the Modified ISNT Rule

PURPOSE: To evaluate the diagnostic ability of the modified ISNT rule (disc rim thickness of the smaller of inferior and superior > the larger of nasal and temporal) for normal and glaucomatous eyes compared to the classic ISNT rule (disc rim thickness of inferior > superior > nasal > temporal). METHODS: Color stereo optic disc photographs of 113 normal subjects and 108 open angle glaucoma patients with early and moderate stage were morphometrically evaluated. The classic ISNT rule and the modified ISNT rule were assessed by masked evaluation of disc photographs at the 3, 6, 9 and 12 o'clock positions. RESULTS: Among normal subjects, 58 of 113 eyes (51.3%) were normal and in open angle glaucoma patients, 104 of 108 eyes (96.3%) were abnormal with the classic ISNT rule. Among normal subjects, 98 of 113 eyes (94.2%) were normal and in open angle glaucoma patients, 102 of 108 eyes (94.4%) were abnormal with the modified ISNT rule. The modified ISNT rule was more accurate than the classic ISNT rule in terms of Cohen's Kappa analysis used for discriminating between normal and glaucomatous eyes. CONCLUSIONS: The modified ISNT rule is useful for differentiating between normal and glaucomatous optic nerves and easily applied in clinical practice.

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.

Comparison of Intraocular Lens Power Calculation Methods for Cataract Surgery after Refractive Surgery: A Retrospective Surgery

PURPOSE: To investigate the predictability of and propose guidelines for intraocular lens (IOL) power calculation in post-cataract surgery patients with prior corneal refractive surgery and suggest the guideline. METHODS: Medical records of 18 eyes of 16 patients were retrospectively evaluated for IOL power calculation predictability using three combinations of METHODS: 1) clinical history method, modified Maloney method, and the Feiz-Mannis method; 2) single-K formula versus double-K formula; and 3) Three IOL formulas (SRK/T, Holladay 1, and Hoffer Q). RESULTS: The clinical history method using the single-K formula with the SRK/T and Holliday 1 formula showed the best predictability, with an absolute error of 0.60+/-0.63 D and 0.74+/-0.60 D, respectively. The Feiz-Mannis method showed a tendency of myopic prediction, whereas the modified Maloney method showed a tendency of hyperopic prediction, especially in the patients with myopia more than 7 D prior to the refractive surgery. The double-K formula, when compared to the single-K formula, prevented hyperopic prediction when used with the clinical history method or modified Maloney method. CONCLUSIONS: IOL power calculation using the clinical history method with SRK/T or Holliday 1 formula showed the best predictability in patients after corneal refractive surgery. IOL power calculation using the modified Maloney method, however, because of the hyperopic prediction tendency, should be used cautiously, especially for patients with myopia of 7 D or more prior to the refractive surgery.

Comparison of Primary Vascular Dysregulation in Normal Tension Glaucoma and Primary Open Angle Glaucoma

PURPOSE: To evaluate the clinical symptoms or signs of primary vascular dysregulation (PVD) in patients with normal tension glaucoma (NTG) and primary open-angle glaucoma (POAG). METHODS: From June 2008 to June 2009, we administered questionnaires to patients with glaucoma. The questionnaire was composed of 11 items, and the questionnaire results were compared between patients with NTG and POAG. NTG patients were subdivided by age(criterion: 55 years) and perimetric mean deviation (criterion: -6dB). RESULTS: We detected a significant increase in hypotension (p=0.036) in NTG patients (n=133), compared to POAG patients (n=68). Migraines and emotional stress were more frequent in younger patients (55 years) with NTG (27.5%, 42.9%, p=0001). The frequency of drug sensitivity and systemic vasospasm is higher in older patients with NTG (28.6%, 17.4%) than younger patients with NTG (12.9%, 4.9%) but the rate of systemic vasospasm is much higher in younger patients, compared to the prevalence in the general Korean population. In patients with moderate and advanced NTG, hypotension is highly prevalent (p=0.018). CONCLUSIONS: Hypotension is a greater risk factor for NTG than for POAG. Indeed, vascular factors may be correlated with NTG, especially in younger patients with moderate, advanced visual field defects.

Comparision of Primary Vascular Dysregulation for Unilateral and Bilateral Eye Involvement in Normal Tension Glaucoma

PURPOSE: To compare the clinical symptoms and signs of primary vascular dysregulation (PVD) for unilateral and bilateral eye involvement in normal tension glaucoma (NTG). METHODS: The authors administered a questionnaire to assess PVD in patients with NTG. The answers to the 10-item questionnaire (cold hands, migraine, sleep latency, thirst, hypotension, orthostatic hypotension, emotional stress, drug sensitivity, vertigo, and systemic vasospasm) were compared between patients with unilateral involved NTG and bilateral involved NTG (N=61). The groups were classified again according to age (criteria: 55 years), sex, and mean deviation via standard automated perimetry (criteria: -6 dB). RESULTS: The answers to the questionnaire between patients with unilateral involved NTG and bilateral involved NTG were not different at the level of statistical significance. In groups classified according to age, sex, and mean deviation, none of the answers to the questionnaire were different at the level of statistical significance between the groups. CONCLUSIONS: Clinical symptoms and signs of PVD were not different between patients with unilateral or bilateral eye involvement in NTG. Systemic vascular factors may not be considered different between unilateral and bilateral eye involvement in NTG.

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.

Influence of Phacoemulsification on the Progression of Diabetic Retinopathy

PURPOSE: To evaluate influence of phacoemulsification on the progression of diabetic retinopathy METHODS: The medical charts of 82 eyes of 41 patients with nonproliferative diabetic retinopathy (DR) who had unilateral phacoemulsification were retrospectively reviewed. The course of diabetic retinopathy was followed up for more than 2 years. Each stage of DR progression was indicated by a unique score, and a comparison of the progression of DR between operated and non-operated eyes was performed using the devised scoring system. RESULTS: The progression of 82 eyes at a mean follow-up period of 28 months was evaluated. DR progressed more in operated eyes than in non-operated eyes (P=0.006). The progression of proliferative DR in operated eyes (19.5%, 8 eyes) was significantly greater (P=0.029) than in non-operated eyes (2.4%, 2 eyes). CONCLUSIONS: Phacoemulsification resulted in a progression of diabetic retinopathy. Careful approach to the cataract patients with diabetic retinopathy would be recommended.

Influence of Myopia on the Progression of Normal Tension Glaucoma

PURPOSE: To evaluate the influence of myopia on the progression of normal tension glaucoma. METHODS: A retrospective study of 72 patients with normal tension glaucoma who were treated from 1984. Subjects were divided into 4 groups which are myopic group (D-1). The change of MD (Mean deviation) and CPSD (corrected pattern standard deviation) of non-myopic group were compared to other myopic groups. In addition, we corrected each analysis in commensurate with age, basal IOP, post treated IOP, existence of hypertension and diabetes mellitus in order to preclude the possibility which these factors would influence to the progression. RESULTS: There was no statistically significant difference between non-myopic group and each myopic groups in MD and CPSD changes against refraction. Moreover, with the correction of other factors, there was no statistically significant difference (Mixed method, P>0.1). CONCLUSIONS: Myopia did not affect the progression of normal tension glaucoma once treated.