An Overview of the Korean Intermittent Exotropia Multicenter Study by the Korean Association for Pediatric Ophthalmology and Strabismus

The Korean Intermittent Exotropia Multicenter Study (KIEMS), which was initiated by the Korean Association of Pediatric Ophthalmology and Strabismus, is a collaborative multicenter study on intermittent exotropia in Korea. The KIEMS was designed to provide comprehensive information, including subjective and objective findings of intermittent exotropia in a large study population. A total of 65 strabismus specialists in 53 institutions contributed to this study, which, to date, is one of the largest clinical studies on intermittent exotropia. In this article, we provide a detailed methodology of the KIEMS to help future investigations that may use the KIEMS data.

Correlation between Changes in Thyroid Stimulating Immunoglobulin Levels and Chorioretinal Vessels in Thyroid Eye Disease

Purpose@#To investigate the changes in retinal and choroidal vessels according to changes in thyroid stimulating immunoglobulin (TSI) in patients with thyroid eye disease (TED). @*Methods@#A total of 41 patients (82 eyes) with TED were enrolled. The subjects were divided into two groups: an experimental group with clinically significant TSI sample-to-reference ratio (%) abnormalities (> 140) and a control group. Within the experimental group, the median value of 451 was used to further classify patients into groups A and B. Using optical coherence tomography/angiography, the sizes of the superficial fovea avascular zone (sFAZ) and deep fovea avascular zone, the diameter of the macular center 1 mm fovea, 3 mm parafovea superficial capillary plexus density (sCPD), deep capillary plexus density, choroidal thickness, and choroidal vascularity index were measured. @*Results@#In the experimental group, the change in the TSI value and the change in the 3 mm parafovea sCPD showed a significant positive correlation (p = 0.040) with a correlation coefficient of 0.307. Among group B patients of the experimental group, the changes in the TSI value and sFAZ showed a strong negative correlation (-0.417), but it was not statistically significant (p = 0.053). @*Conclusions@#In TED patients with clinically significant TSI levels (> 140), blood vessel density in the superficial layer of the 3 mm parafovea significantly increased with TSI. Especially in the high TSI (≥ 451) group, superficial retinal vessel density.

Correlation between Thyroid-stimulating Antibody Level Change and Extraocular Muscle Thickness Change in Thyroid Eye Disease

Purpose@#To investigate the changes in extraocular muscle thicknesses by variations in the thyroid stimulating antibody (TSAb) level in patients with thyroid eye disease (TED). @*Methods@#A total of 67 TED patients were enrolled. They were divided into two groups: an experimental group with clinically significant elevated TSAb levels (≥140 IU/L) and a control group (TSAb <140 IU/L). All of the lateral, medial, superior, and inferior rectus muscle thicknesses were measured with the aid of anterior segment optical coherence tomography (OCT). The average thicknesses for both eyes were recorded for each patient based on the values measured at the ends of the muscles (which become vertically thinner from the points of tendon attachment). We measured changes in TSAb levels and extraocular muscle thicknesses after two follow-up periods and sought correlations among these parameters. @*Results@#At the initial visits, the inferior rectus muscle thickness was positively correlated with the TSAb level in the experimental group (p = 0.045, r = 0.478). None of the medial, superior, or lateral rectus muscle thicknesses were so correlated. On follow-up, the variation in TSAb level correlated negatively with changes in lateral rectus muscle thickness (p = 0.038, r = -0.357). The superior rectus muscle thickness tended to be negatively correlated with the TSAb level, but statistical significance was not attained (p = 0.146, r = -0.669). The thicknesses of the inferior and superior rectus muscles did not change over time. @*Conclusions@#In TED patients, TSAb variations seem to reflect the extent of periorbital tissue edema, thus correlating negatively with especially lateral rectus muscle thickness changes.

An Overview of the Korean Intermittent Exotropia Multicenter Study by the Korean Association for Pediatric Ophthalmology and Strabismus

The Korean Intermittent Exotropia Multicenter Study (KIEMS), which was initiated by the Korean Association of Pediatric Ophthalmology and Strabismus, is a collaborative multicenter study on intermittent exotropia in Korea. The KIEMS was designed to provide comprehensive information, including subjective and objective findings of intermittent exotropia in a large study population. A total of 65 strabismus specialists in 53 institutions contributed to this study, which, to date, is one of the largest clinical studies on intermittent exotropia. In this article, we provide a detailed methodology of the KIEMS to help future investigations that may use the KIEMS data.

Correlation between Changes in Thyroid Stimulating Immunoglobulin Levels and Chorioretinal Vessels in Thyroid Eye Disease

Purpose@#To investigate the changes in retinal and choroidal vessels according to changes in thyroid stimulating immunoglobulin (TSI) in patients with thyroid eye disease (TED). @*Methods@#A total of 41 patients (82 eyes) with TED were enrolled. The subjects were divided into two groups: an experimental group with clinically significant TSI sample-to-reference ratio (%) abnormalities (> 140) and a control group. Within the experimental group, the median value of 451 was used to further classify patients into groups A and B. Using optical coherence tomography/angiography, the sizes of the superficial fovea avascular zone (sFAZ) and deep fovea avascular zone, the diameter of the macular center 1 mm fovea, 3 mm parafovea superficial capillary plexus density (sCPD), deep capillary plexus density, choroidal thickness, and choroidal vascularity index were measured. @*Results@#In the experimental group, the change in the TSI value and the change in the 3 mm parafovea sCPD showed a significant positive correlation (p = 0.040) with a correlation coefficient of 0.307. Among group B patients of the experimental group, the changes in the TSI value and sFAZ showed a strong negative correlation (-0.417), but it was not statistically significant (p = 0.053). @*Conclusions@#In TED patients with clinically significant TSI levels (> 140), blood vessel density in the superficial layer of the 3 mm parafovea significantly increased with TSI. Especially in the high TSI (≥ 451) group, superficial retinal vessel density.

Effects of Thyroid-stimulating Hormone Receptor Autoantibody on Retinal and Choroidal Vessels in Thyroid Eye Disease

Purpose@#We describe the use of optical coherence tomography angiography (OCTA) to investigate the relationship between thyroid-stimulating hormone receptor autoantibody (TSHR Ab) levels and retinal vessel and choroid changes in patients with thyroid eye disease (TED). @*Methods@#We enrolled 23 TED patients with abnormal TSHR Ab levels (>1.5 IU/L; all right eyes). Sex, visual acuity, intraocular pressure and TSHR Ab level were recorded at baseline and after 1 month. We used OCTA to determine the size of the superficial and deep foveal avascular zones (sFAZ and dFAZ, respectively), as well as the 1-mm foveal and 3-mm parafoveal superficial capillary plexus density (sCPD) and choroidal thickness (CT), at baseline and after 1 month later. @*Results@#The mean age of the 23 patients was 43.30 ± 16.16 years and 18 were female (78%). The mean baseline TSHR Ab level was 11.47 ± 11.22 IU/L. The TSHR Ab level showed non-significant correlations with sFAZ and dFAZ size, and with the 1-mm foveal sCPD; the correlation coefficients were 0.173, 0.073, and 0.266, respectively (p = 0.465, p = 0.759, and p = 0.224, respectively). The 3-mm parafoveal sCPD and CT showed non-significant correlations with the TSHR Ab level; the correlation coefficients were -0.185 and -0.16 (p = 0.421, p = 0.487). @*Conclusions@#In TED patients, changes in TSHR Ab level over 1 month do not affect retinal blood flow or CT, but show a non-significant positive association with the 1-mm foveal sCPD.

Differences in Retinal and Choroidal Vessels between Dominant and Non-dominant Eyes in Intermittent Exotropia

Purpose@#To distinguish the dominant eye in patients with intermittent exotropia by comparing the width of the foveal avascular zone (FAZ), the vascular density (VD), and the choroidal thickness (CT) in both eyes. @*Methods@#A total of 34 subjects with intermittent exotropia were enrolled. Optical coherence tomography angiography (OCTA) was performed after discrimination of the dominant eye using a prism cover test (PCT). FAZ widths in the superficial capillary plexus (referred to here as superficial FAZ or SFAZ) and in the deep capillary plexus (deep FAZ or DFAZ); VDs of the 1-mm fovea and 3-mm parafovea, specifically the superficial capillary plexus density (SCPD); and CT measured by OCTA were compared between both eyes using a one-sample t-test. These abovementioned parameters were compared between dominant and non-dominant eyes through Pearson’s correlation analysis. @*Results@#The widths of SFAZ and DFAZ, the 1-mm fovea and 3-mm parafovea SCPDs, and CT of dominant eye showed positive correlations with respect to the non-dominant eye. Although there was no statistically significant difference in SFAZ and DFAZ widths, the 3-mm parafovea SCPD, or CT between eyes, the 1-mm fovea SCPD in the non-dominant eye showed a statistically significant higher density than that of the dominant eye (p = 0.039). @*Conclusions@#Our results suggest that the higher 1-mm fovea SCPD in the non-dominant eye is due to the secondary development of capillaries around the FAZ of the non-dominant eye after the retina of both eyes had developed to some extent.

Effects of Thyroid-stimulating Hormone Receptor Autoantibody on Retinal and Choroidal Vessels in Thyroid Eye Disease

Purpose@#We describe the use of optical coherence tomography angiography (OCTA) to investigate the relationship between thyroid-stimulating hormone receptor autoantibody (TSHR Ab) levels and retinal vessel and choroid changes in patients with thyroid eye disease (TED). @*Methods@#We enrolled 23 TED patients with abnormal TSHR Ab levels (>1.5 IU/L; all right eyes). Sex, visual acuity, intraocular pressure and TSHR Ab level were recorded at baseline and after 1 month. We used OCTA to determine the size of the superficial and deep foveal avascular zones (sFAZ and dFAZ, respectively), as well as the 1-mm foveal and 3-mm parafoveal superficial capillary plexus density (sCPD) and choroidal thickness (CT), at baseline and after 1 month later. @*Results@#The mean age of the 23 patients was 43.30 ± 16.16 years and 18 were female (78%). The mean baseline TSHR Ab level was 11.47 ± 11.22 IU/L. The TSHR Ab level showed non-significant correlations with sFAZ and dFAZ size, and with the 1-mm foveal sCPD; the correlation coefficients were 0.173, 0.073, and 0.266, respectively (p = 0.465, p = 0.759, and p = 0.224, respectively). The 3-mm parafoveal sCPD and CT showed non-significant correlations with the TSHR Ab level; the correlation coefficients were -0.185 and -0.16 (p = 0.421, p = 0.487). @*Conclusions@#In TED patients, changes in TSHR Ab level over 1 month do not affect retinal blood flow or CT, but show a non-significant positive association with the 1-mm foveal sCPD.

Differences in Retinal and Choroidal Vessels between Dominant and Non-dominant Eyes in Intermittent Exotropia

Purpose@#To distinguish the dominant eye in patients with intermittent exotropia by comparing the width of the foveal avascular zone (FAZ), the vascular density (VD), and the choroidal thickness (CT) in both eyes. @*Methods@#A total of 34 subjects with intermittent exotropia were enrolled. Optical coherence tomography angiography (OCTA) was performed after discrimination of the dominant eye using a prism cover test (PCT). FAZ widths in the superficial capillary plexus (referred to here as superficial FAZ or SFAZ) and in the deep capillary plexus (deep FAZ or DFAZ); VDs of the 1-mm fovea and 3-mm parafovea, specifically the superficial capillary plexus density (SCPD); and CT measured by OCTA were compared between both eyes using a one-sample t-test. These abovementioned parameters were compared between dominant and non-dominant eyes through Pearson’s correlation analysis. @*Results@#The widths of SFAZ and DFAZ, the 1-mm fovea and 3-mm parafovea SCPDs, and CT of dominant eye showed positive correlations with respect to the non-dominant eye. Although there was no statistically significant difference in SFAZ and DFAZ widths, the 3-mm parafovea SCPD, or CT between eyes, the 1-mm fovea SCPD in the non-dominant eye showed a statistically significant higher density than that of the dominant eye (p = 0.039). @*Conclusions@#Our results suggest that the higher 1-mm fovea SCPD in the non-dominant eye is due to the secondary development of capillaries around the FAZ of the non-dominant eye after the retina of both eyes had developed to some extent.

Poorly Differentiated Neuroendocrine Carcinoma of the Eyelid

PURPOSE: To report a case of poorly differentiated neuroendocrine carcinoma of the eyelid. CASE SUMMARY: A 70-year-old male presented with a 5-month history of a right upper eyelid mass. The mass appeared as 1.2 × 1.2 cm on the right upper eyelid. A mass excision was performed under frozen section control. The tumor was completely excised with a safety margin clearance and an upper eyelid reconstruction was performed. Histopathological examination revealed a tumor composed of small atypical cells which showed a high nuclear/cytoplasm ratio, nuclear molding, and increased mitotic activity. Immunohistochemical examination revealed positive reactivity for Ki-67, synaptophysin, CD56, and negative reactivity for chromogranin, cytokeratin 20, and thyroid transcription factor-1. CONCLUSIONS: Primary neuroendocrine carcinoma of the eyelid is extremely rare, but the tumor has high malignancy and readily metastasizes. Poorly differentiated neuroendocrine carcinoma should be considered in the differential diagnosis of a rapidly growing eyelid mass.

A Case of Orbital Chondroma

PURPOSE: To report a case of orbital chondroma. CASE SUMMARY: A 15-year-old male presented with an 8-month history of left hypertropia. The best-corrected visual acuity was 20/20 in both eyes. The exophthalmometry showed no exophthalmos, with 13 mm in both eyes. There was a hard palpable mass at the superonasal orbit of the left eye. Orbital computed tomography showed a heterogenous soft tissue shadow at the superonasal orbit of the left eye, and orbital magnetic resonance imaging revealed a 25 × 16 × 20 mm well-defined mass with low signal intensity in the T1-weighted image, high signal intensity in the T2-weighted image, and heterogenous enhancement in the contrast enhanced T1-weighted image. The mass was surgically removed with anterior orbitotomy. A 27 × 17 mm well-capsulated lobular mass was found, and histopathological examination revealed hyaline cartilage and chondrocyte. The mass was diagnosed as a chondroma. CONCLUSIONS: A chondroma is a benign tumor, which usually occurs in long bones and the small bones of the hands and feet. It is very rare in the facial and pelvic bones. The sites of chondroma occurring in the head and neck include the ethmoid sinus and maxilla, but it is extremely rare in the orbit.

Horizontal Extraocular Muscle and Scleral Anatomy in Children: A Swept-Source Anterior Segment Optical Coherence Tomography Study

PURPOSE: To evaluate the efficacy of anterior segment swept-source optical coherence tomography (SS-OCT) for examining horizontal extraocular muscle thickness, distance from the corneal limbus to the insertion of the horizontal extraocular muscle (limbus to insertion distance), and scleral thickness in Korean pediatric strabismus patients. METHODS: This study included pediatric strabismus patients between 5 and 10 years of age. Children with any ocular disease other than strabismus or a history of ocular surgery were excluded. SS-OCT was used to measure horizontal extraocular muscle thickness, limbus to insertion distance, and scleral thickness. Eyes were classified into subgroups by sex, spherical equivalent of the refractive error (measured with cycloplegic refraction), and fixating/deviating eye. RESULTS: One patient initially included in this study was excluded due to poor cooperation. Of the remaining 35 eyes of 20 patients, 19 eyes (54.3%) were from male patients and 16 eyes (45.7%) were from female patients. The mean patient age was 7.86 ± 1.38 years. Lateral scleral thickness was greater in male eyes than in female eyes (p = 0.048). No other differences were noted between male and female children. Additionally, there were no statistically significant differences between fixating and deviating eyes or among spherical equivalent groups for any parameter examined. CONCLUSIONS: Anterior segment SS-OCT can successfully and comfortably measure horizontal extraocular muscle and scleral anatomy in children. These measurements may be helpful for treatment and follow-up of pediatric strabismus patients.

Clinical Analysis of Factors Affecting Successful Occlusion Treatment and Visual Recovery Time in Amblyopia

PURPOSE: To evaluate the factors affecting successful occlusion treatment and visual recovery time in patients with amblyopia when best corrected visual acuity (BCVA) improved up to 1.0 after occlusion. METHODS: Forty-eight patients aged 2 to 13 years old with amblyopia due to refractive errors or strabismus were selected. The duration of treatment needed to achieve a BCVA of 1.0 was compared according to the cause of amblyopia (anisometropia, strabismus, combined), initial BCVA of the amblyopic eye, and the age at treatment, as well as other factors. RESULTS: The mean age of amblyopic treatment was 5.4 years old and the mean duration of treatment was 22.9 months. The duration of treatment was longer in children whose initial BCVA was lower than 0.2, those with spherical equivalent of the amblyopic eye higher than +3.0D and those older than 6 years old. However, there were no significant differences according to the cause of amblyopia. CONCLUSIONS: The duration of treatment needed to achieve a BCVA of 1.0 was prolonged when the initial BCVA in the amblyopic eye was lower than 0.2, the age at treatment was more than 6 years old, or the spherical equivalent of the amblyopic eye was higher than +3.0D at treatment. These factors can be used to predict the duration of occlusion treatment.

A Case of Endobronchial Aspergilloma Associated with Foreign Body in Immunocompetent Patient without Underlying Lung Disease / 결핵및호흡기질환

Aspergillus causes a variety of clinical syndromes in the lung including tracheobronchial aspergillosis, invasive aspergillosis, chronic necrotizing pulmonary aspergillosis, allergic bronchopulmonary aspergillosis, and aspergilloma. Aspergilloma usually results from ingrowths of colonized Aspergillus in damaged bronchial tree, pulmonary cyst or cavities of patients with underlying lung diseases. There are a few reports on endobronchial aspergilloma without underlying pulmonary lesion. We have experienced a case of endobronchial aspergilloma associated with foreign body developed in an immunocompetent patient without underlying lung diseases. A 59-year-old man is being hospitalized with recurring hemoptysis for 5 months. X-ray and computed tomography scans of chest showed a nodular opacity in superior segment of left lower lobe. Fiberoptic bronchoscopy revealed an irregular, mass-like, brownish material which totally obstructed the sub-segmental bronchus and a foreign body in superior segmental bronchus of the lower left lobe. Histopathologic examinations of biopsy specimen revealed fungal hyphae, characteristic of Aspergillus species.

A Case of Fusarium Keratitis Treated with Moxifloxacin 0.5% Ophthalmic Solution

PURPOSE: To report a case of fusarium keratitis treated with only moxifloxacin 0.5% ophthalmic solution (Vigamox(R), Alcon Laboratories, Inc., Ft Worth, TX, USA). CASE SUMMARY: A 37-year-old healthy male patient experienced a right eye injury due to grain 7 days prior to presentation at our hospital with visual disturbance and ocular pain. A 2.7 x 4.3 mm sized corneal epithelial defect with irregular featherlike midstromal infiltration was observed, and slit lamp examination revealed a dry, rough texture. Thus a smear and culture were performed. Moxifloxacin 0.5% ophthalmic solution (Vigamox(R)) and lubricant were applied for treatment. Three days after using the eye solution, all clinical features improved. Seven days later, Fusarium species was identified in culture. CONCLUSIONS: As standard treatment for Fusarium, the authors of the present study used an antifungal agent. Although hyphae were detected in culture, the use of only moxifloxacin 0.5% ophthalmic solution (Vigamox(R)) result in a satisfactory result and improvement in clinical features.

Synergistic Induction of iNOS by IFN-gamma and Glycoprotein Isolated from Dioscorea batatas

Dioscorea species continue to be used in traditional Chinese medicine, and represent a major source of steroid precursors for conventional medicine. In the previous study, We isolated glycoprotein (GDB) from Dioscorea batatas, characterized, and demonstrated immunostimulating activity in C57BL/6 mice. The aim of this study was to investigate the mechanism whereby GDB activates macrophages. Macrophages activation by GDB was investigated by analyzing the effects of GDB on nitric oxide (NO) production, iNOS expression, mitogen activated protein kinase (MAPK) phosphorylation, and transcription factor activation. In the presence of IFN-gamma, GDB strongly stimulated macrophages to express iNOS and produce NO. Furthermore, the activation of p38 was synergistically induced by GDB plus IFN-gamma , but SB203580 (a p38 inhibitor) inhibited GDB plus IFN-gamma-induced p38 activation. This study indicates that GDB is an important activator of macrophages. Furthermore, due to the critical role that macrophage activation plays in innate immune response, the activation effects of GDB on macrophages suggest that GDB may be a useful immunopotentiating agent.

A Review of Nasal Retinopathy of Prematurity Cases

PURPOSE: The present study evaluated the developmental characteristics and causes of nasal retinopathy of prematurity (ROP). METHODS: A total of 111 eyes from 56 ROP-affected infants who had been treated with laser photocoagulation by retina specialists at the nasal site were examined. The gestational age at birth and diagnosis, location of the lesion, time, and number of laser photocoagulation therapies for nasal and temporal ROP were analyzed. RESULTS: Thirty-three cases (29.7%) were diagnosed with nasal ROP. The mean gestational age at birth was 28.43 weeks for nasal ROP, and 29.44 weeks for temporal ROP (p = 0.022). Additionally, the average gestational age of infants who received laser photocoagulation was 36.61 weeks for nasal ROP, and 39.71 weeks for temporal ROP (p = 0.001). The average number of ROP laser photocoagulation trials was 2936.03 for nasal ROP, and 1611.83 for temporal ROP (p = 0.0001). No case was observed with a wider avascular area in the nasal retina than in the temporal retina. Additionally, compared to the temporal ROP, the nasal ROP showed significant difference in progression rates, 33.3% in the nasal group and 8.97% in the temporal group (p = 0.001). CONCLUSIONS: Nasal ROP was due to the ROP lesions developing earlier in the nasal than the temporal retina, although not due to any atypically wider nasal avascular area. In these cases, nasal ROP showed more disease progression compared to temporal ROP.

Characterization and Immunopotentiating Effects of the Glycoprotein Isolated from Dioscorea Batatas

We demonstrate that glycoprotein isolated from Dioscorea batatas (GDB) has immunostimulatory effects including macrophage activation. Analysis of infiltration of inflammatory cells into peritoneal cavity showed GDB treatment significantly increased the recruitment of macrophages, lymphocytes, neutrophils, and monocytes into the peritoneal cavity. Treatment of spleen cells isolated from C57BL/6 mice with GDB significantly increased the proliferation of B cells and T cells induced by LPS and ConA, respectively. Treatment with GDB significantly increased the cytolytic capacity of NK cells and macrophages against YAC-1 and B16 cells, respectively. In order to further confirm and investigate the mechanism of GDB on macrophage activation, we analyzed the effects of GDB on the cytokine expression including iNOS, IL-1beta, and TNF-alpha in mouse macrophage cell line, RAW 264.7 cells. RT-PCR and ELISA showed that GDB increased the expression of IL-1beta, and TNF-alpha, whereas iNOS was not induced by GDB. Collectively, this series of experiments indicates that GDB stimulates immune system including macrophage activation.

A Ratio of Accommodative-Convergence to Accommodation in Patients With Refractive Accommodative Esotropia

PURPOSE: The goals of the present study were to measure a ratio of accommodative-convergence to accommodation (AC/A ratio) in child patients with refractive accommodative esotropia (RAET) and to compare it to the ratio in normal children. METHODS: Patient age, gender, and refractive errors were examined. The deviation angles were measured at near and distance using a prism cover test and were followed by the measurement of the interpupillary distance. The AC/A ratio was calculated using a heterophoria and a gradient method. RESULTS: The present study consisted of 59 patients, 38 patients with RAET and 21 normal children. The mean ages were 9.6 years in patients with RAET and 9.0 years in the normal children. The refractive errors in spherical equivalent were shown to be 4.6D in the right eye and 4.5D in the left eye in patients with RAET and -0.4D and -0.5D in the normal children. The mean values of the AC/A ratio using a gradient method were 1.8 in patients with RAET and 2.2 in the normal children(p=0.44). According to the heterophoria method, the AC/A ratio was 6.2 in patients with RAET and was 5.4 in the normal children(p=0.04). CONCLUSIONS: The AC/A ratio of child patients with RAET was higher than that of normal children when using a heterophoria method. However, there was no difference in the AC/A ratio between the normal children and RAET child patients when using gradient method.