Long-term Clinical Outcomes of Macular Hole Surgery Using Internal Limiting Membrane Flap or Insertion

Purpose@#To evaluate the long-term outcomes of inverted internal limiting membrane (ILM) flap and ILM insertion in idiopathic macular hole (MH) and to compare the outcomes between the two techniques. @*Methods@#We retrospectively reviewed the medical records of 17 eyes that underwent an inverted ILM flap procedure (flap group, n = 9) or ILM insertion procedure (insertion group, n = 8) for idiopathic MH. Within each group, best-corrected visual acuity (BCVA) before surgery was compared with that at the final follow-up. The BCVA at the final follow-up was compared between the two groups. In addition, the incidence of restoration of the external limiting membrane (ELM) and ellipsoid zone was evaluated. @*Results@#The mean follow-up period was 25.1 ± 13.7 months after surgery. All MHs were closed after the surgery. In all 17 eyes, the logarithm of minimal angle of resolution BCVA had improved significantly from a mean value of 0.88 ± 0.23 before surgery to 0.42 ± 0.23 at the final follow-up (p < 0.001). The BCVA was significantly improved in both the flap group (from 0.92 ± 0.25 to 0.37 ± 0.29, p = 0.007) and the insertion group (from 0.83 ± 0.19 to 0.48 ± 0.15, p = 0.018). There was no significant difference in BCVA at the final follow-up between the two groups (p = 0.075). The incidence of restoration of the ELM and ellipsoid zone was significantly higher in the flap group (seven eyes, 77.8%) than in the insertion group (one eye, 12.5%). @*Conclusions@#Both inverted ILM flap and ILM insertion are effective in MH treatment. The restoration of retinal outer layers was better in the flap group. Further studies with a larger study population are needed to evaluate the long-term visual outcomes of the two methods.

Long-term Clinical Outcomes of Macular Hole Surgery Using Internal Limiting Membrane Flap or Insertion

Purpose@#To evaluate the long-term outcomes of inverted internal limiting membrane (ILM) flap and ILM insertion in idiopathic macular hole (MH) and to compare the outcomes between the two techniques. @*Methods@#We retrospectively reviewed the medical records of 17 eyes that underwent an inverted ILM flap procedure (flap group, n = 9) or ILM insertion procedure (insertion group, n = 8) for idiopathic MH. Within each group, best-corrected visual acuity (BCVA) before surgery was compared with that at the final follow-up. The BCVA at the final follow-up was compared between the two groups. In addition, the incidence of restoration of the external limiting membrane (ELM) and ellipsoid zone was evaluated. @*Results@#The mean follow-up period was 25.1 ± 13.7 months after surgery. All MHs were closed after the surgery. In all 17 eyes, the logarithm of minimal angle of resolution BCVA had improved significantly from a mean value of 0.88 ± 0.23 before surgery to 0.42 ± 0.23 at the final follow-up (p < 0.001). The BCVA was significantly improved in both the flap group (from 0.92 ± 0.25 to 0.37 ± 0.29, p = 0.007) and the insertion group (from 0.83 ± 0.19 to 0.48 ± 0.15, p = 0.018). There was no significant difference in BCVA at the final follow-up between the two groups (p = 0.075). The incidence of restoration of the ELM and ellipsoid zone was significantly higher in the flap group (seven eyes, 77.8%) than in the insertion group (one eye, 12.5%). @*Conclusions@#Both inverted ILM flap and ILM insertion are effective in MH treatment. The restoration of retinal outer layers was better in the flap group. Further studies with a larger study population are needed to evaluate the long-term visual outcomes of the two methods.

Clinical Outcomes of Idiopathic Epiretinal Membrane Removal in Patients 80 Years or Older

PURPOSE: To evaluate clinical outcomes of idiopathic epiretinal membrane removal in patients ≥ 80 years of age.METHODS: A retrospective review of medical records was performed with 56 patients who underwent vitrectomy and removal of idiopathic epiretinal membrane. In the ≥ 80 years of age group (n = 28), the best-corrected visual acuity (BCVA) and central macular thickness (CMT) before surgery were compared with those at the final follow-up. The amount of change in the BCVA after surgery was also compared between the ≥ 80 years of age group and the < 80 years of age group (n = 28).RESULTS: In the ≥ 80 years of age group, the mean follow-up period was 19.1 ± 17.0 months. Before surgery, 11 eyes were pseudophakic and 17 eyes were phakic. Combined cataract surgery was performed with epiretinal membrane removal in all 17 phakic eyes. The mean logarithm of the minimal angle of resolution BCVA was 0.75 ± 0.30 before surgery, which improved to 0.50 ± 0.30 at the final follow-up (p < 0.001). The CMT was 458.0 ± 79.7 µm before surgery, which decreased to 367.2 ± 83.4 µm at the final follow-up (p < 0.001). There was no significant difference in the amount of change in the BCVA after the surgery between the ≥ 80 years of age group and the < 80 years of age group (p = 0.547).CONCLUSIONS: In patients with idiopathic epiretinal membrane who were ≥ 80 years of age, the visual acuity was improved or maintained, and was accompanied with anatomical improvement after epiretinal membrane removal with or without cataract surgery. These results suggest the usefulness of epiretinal membrane removal in older patients.

Clinical Presentations of Focal Choroidal Excavation and Results of Long-term Follow-up

PURPOSE: To evaluate the clinical presentations of focal choroidal excavation and to report long-term outcomes of cases without retinal disorders at the initial presentation. METHODS: A retrospective review of medical records was performed for patients diagnosed with focal choroidal excavation. Concomitant retinal disorders at the initial presentation were identified. In cases without retinal disorders, the development of retinal disorders during follow-up was also evaluated. RESULTS: Forty-five eyes in 45 patients were examined in this study. Focal choroidal excavation was accompanied with retinal disorders in 16 eyes (35.6%). In the remaining 29 eyes, only focal choroidal excavation was noted without any accompanying retinal disorders. The accompanying retinal disorders included choroidal neovascularization (n = 8), central serous chorioretinopathy (n = 4), epiretinal membrane (n = 1), macular hole (n = 1), branch retinal vein occlusion (n = 1), and uveitis (n = 1). Of the 29 eyes without retinal disorders, 22 were followed up for a mean period of 33.5 ± 18.2 months. Consequently, choroidal neovascularization was found to have developed in one eye at 59 months, and subretinal fluid had developed in two eyes at 17 and 28 months, respectively. CONCLUSIONS: Focal choroidal excavation was accompanied by retinal disorders in 35.6% of the included patients. In patients without retinal disorders, the development of a retinal disorder was noted in some eyes, suggesting the need for long-term regular follow-up in patients diagnosed with focal choroidal excavation.

Endophthalmitis Caused by Stenotrophomonas maltophilia after Cataract Surgery: Clinical Features, Antibiotic Sensitivities, and Outcomes

PURPOSE: To describe the clinical manifestations, treatment results, and antibiotic susceptibility in 6 cases of Stenotrophomonas maltophilia endophthalmitis. METHODS: We retrospectively reviewed 6 eyes of 6 patients who were diagnosed with Stenotrophomonas maltophilia endophthalmitis. Specifically, we considered each patient's age, sex, past history, visual acuity, hypopyon, treatment, and prognosis. RESULTS: For our study, we considered patients treated during the period of January 2008 to December 2015. Stenotrophomonas maltophilia (6 eyes) was the second most common gram-negative bacteria cause of total bacterial endophthalmitis while Pseudomonas aeruginosa (14 eyes) was the most common gram-negative bacteria cause during the same period. Visual disturbance was the dominant symptom being found in all 6 patients. Other symptoms include ocular pain and hypopyon. The initial visual acuity was light perception (1 patient), hand motion (3 patients), finger count (1 patient), and 0.02 (1 patient). Excluding the 1 patient with light perception, the mean initial visual acuity was logMAR 1.72 (Snellen equivalent; 20/1,049). Overall, 5 patients underwent vitrectomy and intravitreal antibiotics injection, while, the remaining other patient was treated with intravitreal antibiotics injection, followed by vitrectomy. All 6 patients showed sensitivity to Ceftazidime and Levofloxacin and 2 patients showed sensitivity to Trimethoprim/Sulfamethoxazole. CONCLUSIONS: Stenotrophomonas maltophilia endophthalmitis was the second most common gram negative organism to cause endophthalmitis after cataract surgery. All 6 of the tested isolates were found to be sensitive to ceftazidime and levofloxacin. Urgent treatment outcomes were similar to previous reports.

Analysis of Referred 113 Patients with Endophthalmitis after Cataract Surgery and Associated Prognostic Factors

PURPOSE: To evaluate factors affecting final visual acuity by analyzing patients referred with infectious endophthalmitis after cataract surgery. METHODS: A retrospective investigation of clinical notes of 113 patients referred with endophthalmitis following cataract surgery was conducted from January 2008 to December 2013. To evaluate factors affecting final visual acuity, initial visual acuity, onset of endophthalmitis after the cataract surgery, types of treatment, presence of hypopyon and culture results were investigated. RESULTS: Of the 113 patients, visual acuities at presentation were hand motions or less in 75 patients (66.3%) and final visual acuities after treatments were 0.5 or better in 73 patients (64.6%). Cases with initial visual acuity of hand motions or better achieved favorable outcomes whereas cases with gram-negative infection or endophthalmitis occurring within 2 days postoperatively showed poor prognosis. Statistically, vitrectomy versus intraocular antibiotic injection as primary means of treatment showed no differences in final visual acuity in patients with initial visual acuity of hand motion or better. CONCLUSIONS: Visual acuities at presentation, type of cultured organism and onset of endophthalmitis after cataract surgery are significantly related to visual prognosis. Advantages of initial vitrectomy versus intraocular antibiotic injections were unclear and further investigations are necessary to clarify these issues.

The Efficacy of Intravitreal Aflibercept in Submacular Hemorrhage Secondary to Wet Age-related Macular Degeneration

PURPOSE: To evaluate the efficacy of intravitreal aflibercept monotherapy in submacular hemorrhage (SMH) secondary to wet age-related macular degeneration (AMD). METHODS: This study included 25 eyes in 25 patients with SMH involving the fovea secondary to wet-AMD. All patients were treated with three consecutive monthly intravitreal aflibercept (2.0 mg/0.05 mL) injections, followed by as-needed reinjection. They were followed for at least 6 months. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and area of SMH were measured at diagnosis, as well as at 3 and 6 months after treatment initiation. RESULTS: The BCVA significantly improved from 0.79 ± 0.41 logarithm of the minimum angle of resolution (logMAR) at baseline to 0.54 ± 0.41 logMAR at 6 months (p < 0.001). BCVA ≥3 lines and stable vision were observed in 96% of the eyes. The CFT significantly decreased from 560.8 ± 215.3 µm at baseline to 299.8 ± 160.2 µm at 6 months (p < 0.001). The area of SMH significantly decreased from 10.5 ± 7.1 mm² at baseline to 1.8 ± 6.5 mm² at 6 months (p < 0.001). The BCVA, CFT, and area of SMH at baseline, as well as duration of symptoms, all correlated with BCVA at the 6-month follow-up. CONCLUSIONS: Intravitreal injection of aflibercept is an effective treatment option for patients with SMH secondary to wet-AMD; however, there may be limited efficacy in eyes with large SMH area and cases in which treatment is delayed.

Clinical Characteristics of Retinal Detachment Associated with Atopic Dermatitis

PURPOSE: To evaluate the clinical characteristics and surgical outcomes of retinal detachment associated with atopic dermatitis. METHODS: A retrospective investigation of clinical notes of 37 patients with retinal detachment associated with atopic dermatitis was conducted from January 2009 to December 2015. Initial visual acuity, medical history, type of retinal detachment, number of tears, types of treatment, success rate of treatment, and presence of cataract were investigated. To evaluate the relationship with cataract, the patients were classified into three groups according to lens status: group A (eyes with clear lens), group B (eyes with cataract), and group C (pseudophakic eyes). RESULTS: Of the 37 patients, 29 were male and 8 were female; 10 patients had bilateral retinal detachment (27.0%). The retinal breaks were often located temporally (89.4%), with only 5 cases (10.6%) involving nasal-side retinal breaks. No significant differences were noted in the ratio of males to females, age distribution, visual acuity before and after treatments, axial length, and location of retina breaks among the three groups. After primary surgery, retinal detachment recurred in 12 patients (14 eyes), 5 of whom were initially diagnosed with bilateral retinal detachment. In addition, 12 of 14 eyes underwent a second operation, in which detachment recurred in 3 eyes. CONCLUSIONS: Incidence of bilateral retinal detachment was high in patients with atopic dermatitis, and the retinal breaks were often found on the temporal side. Retinal re-detachment was statistically high in patients with cataract or pseudophakic eyes compared to patients with clear lens (p = 0.024).

Intravitreal Anti-vascular Endothelial Growth Factor for Newly Diagnosed Symptomatic Polypoidal Choroidal Vasculopathy with Extrafoveal Polyps

PURPOSE: To evaluate the 12-month outcome of anti-vascular endothelial growth factor (VEGF) treatment for extrafoveal polypoidal choroidal vasculopathy (PCV). METHODS: This retrospective observational study included 32 eyes of 32 patients newly diagnosed with extrafoveal PCV (polyps located more than 500 microm from the center of the fovea). Patients were treated with intravitreal ranibizumab, bevacizumab, or both. The best-corrected visual acuity (BCVA) and central foveal thickness (CFT) at diagnosis and at 12 months were compared. Eyes were divided into two groups according to the presence of submacular hemorrhage. The BCVA in each group was compared at baseline and at 12 months. RESULTS: During the 12-month study period, patients received an average of 4.0 +/- 1.1 anti-VEGF injections. The BCVA at baseline, three-month post-diagnosis, and 12-month post-diagnosis was 0.59 +/- 0.40, 0.34 +/- 0.38, and 0.38 +/- 0.38, respectively. The BCVA at 12 months was significantly better than the baseline value (p = 0.002). The CFT at baseline, three-month, and 12-month post-diagnosis was 477.1 +/- 194.2 microm, 214.5 +/- 108.8 microm, and 229.8 +/- 106.1 microm, respectively. The CFT at 12 months was significantly lower than the baseline value (p < 0.001). A significant improvement in BCVA was noted in eyes with and without submacular hemorrhage (n = 13, p = 0.032 and n = 19, p = 0.007, respectively). CONCLUSIONS: Anti-VEGF therapy was beneficial in extrafoveal PCV, regardless of the presence of submacular hemorrhage.

Outcomes of Relaxing Retinectomy in Patients with Proliferative Vitreoretinopathy

PURPOSE: To report the outcomes of relaxing retinectomy for retinal detachment in patients with proliferative vitreoretinopathy (PVR). METHODS: Sixty-four cases of relaxing retinectomy for PVR with a minimum follow-up of 6 months were retrospectively reviewed. The outcomes included achievement of complete retinal reattachment, PVR recurrence, the mean number of additional operations, visual acuity and incidence of postoperative complications. We analyzed the influence of intraoperative factors including lens status, retinectomy extent, additional scleral buckling, and tamponade agent on primary retinal reattachment. RESULTS: Complete retinal reattachment was achieved in 47 eyes (74.3%) without an additional surgery. PVR recurred in 19 eyes (29.7%) and an additional operation was performed in 17 eyes (26.6%). Fifty-seven (89.1%) eyes showed complete retinal reattachment and 40 eyes (62.5%) had visual acuity of 0.02 or more at the final follow-up visit. Hypotony was the major complication and developed in 10 eyes (15.6%). Eyes undergoing smaller ( or = 180degrees) retinectomy or gas tamponade (p = 0.043 and 0.013, respectively). CONCLUSIONS: Relaxing retinectomy is a useful technique for retinal detachment with PVR, but risk of recurrent proliferation or hypotony should be considered.

Risk Factors for Retinal Breaks in Patients with Symptom of Floaters

PURPOSE: To identify the risk factors of retinal breaks in patients with symptoms of floaters and to determine the associations between those risk factors and retinal breaks. METHODS: A retrospective chart review of patients who visited with the symptom of vitreous floaters between July 2012 and October 2012 was performed. Patient information, such as age, sex, symptoms (e.g., multiple floaters and flashing), duration of symptoms, refractive error, and complete eye examination were recorded. The patients were divided into 2 groups: the control group had symptoms of floaters with no retinal breaks and the retinal breaks group had symptoms of floaters with retinal breaks. The chi-square test and univariate logistic regression were used for statistical analysis. RESULTS: A total of 1744 eyes were examined in this study, including 1706 eyes in the control group and 38 eyes in the retinal breaks group. Univariate analysis revealed that patients with high myopia and multiple floaters showed increased risk of retinal breaks by 3.4 and 4.4 times, respectively, when compared to patients with a single floater alone. Lattice degeneration and vitreous or retinal hemorrhage increased the risk of retinal breaks by 10.8 and 37.5 times when compared to eyes that did not have lattice degeneration or vitreous or retinal hemorrhage. During the follow-up period after laser photocoagulation, a new retinal tear was found in 2 patients (2/38, 5.3%). CONCLUSIONS: Vitreous or retinal hemorrhage, lattice degeneration, multiple floaters, and high myopia are risk factors of retinal breaks in patients with the symptom of floaters. Therefore, it is important for ophthalmologists to be aware of these risk factors and the patients at risk should be encouraged to attend follow-up examinations.

A Case of Susac Syndrome

The purpose of this article is to report on the first known Korean case of Susac syndrome. An 18-year-old female came to our clinic reporting blurred vision of the left eye for 2 days. She also complained of decreased hearing with tinnitus of the right ear and mild headache. She was previously healthy and had no remarkable medical history. Best-corrected visual acuity was 20 / 50 in the left eye and 20 / 20 in the right eye. An axiomatic triad of ocular, cochlear, and neurologic involvement was observed in the patient. Fluorescein angiography showed branched retinal arterial occlusions in the left eye. A sudden right sensorineural hearing loss was observed on audimetry. Magnetic resonance images showed a hyperintense lesion in the white matter around the corpus callosum. The patient was treated with high doses of systemic corticosteroids, and no neuropsychological sequelae were observed. This is the first case report of Susac syndrome in Korea. In cases of retinal arterial occlusion with hearing loss or neuropsychological symptoms, Susac syndrome should be suspected.

Short-term Effectiveness of Intravitreal Bevacizumab vs. Ranibizumab Injections for Patients with Polypoidal Choroidal Vasculopathy

PURPOSE: To compare the effectiveness of intravitreal injections of bevacizumab and ranibizumab in patients with treatment-naive polypoidal choroidal vasculopathy (PCV). METHODS: Records from 106 consecutive patients who received intraviteral bevacizumab (n = 58, 1.25 mg) or ranibizumab (n = 52, 0.5 mg) for treatment of PCV were retrospectively reviewed. After three initial monthly loading injections, injection was performed as needed. The main outcome measures included best-corrected visual acuity (BCVA), foveal central thickness (FCT) as assessed by spectral domain optical coherence tomography, and the changes in polypoidal lesions based on an indocyanine green angiography. RESULTS: The average number of injections was 3.31 +/- 1.25 in the bevacizumab group and 3.44 +/- 0.92 in the ranibizumab group. Mean logarithm of the minimum angle of resolution of BCVA from baseline to 6 months after injection improved by 0.17 in the bevacizumab group (p = 0.03) and by 0.19 in the ranibizumab group (p = 0.01). Average FCT decreased from 322 +/- 62.48 microm to 274 +/- 40.77 microm in the bevacizumab group (p = 0.02) and from 338 +/- 50.79 microm to 286 +/- 36.93 microm in the ranibizumab group (p = 0.02). Polyp regression rate was 20.7% (12 of 58 eyes) in the bevacizumab group and 21.2% (11 of 52 eyes) in the ranibizumab group. There was no statistically significant difference between groups in BCVA improvement achieved, FCT improvement achieved, and polyp regression rate between groups. CONCLUSIONS: Intravitreal injections of bevacizumab and ranibizumab have similar effects in stabilizing of visual acuity, macular edema, and regression of polypoidal complex in PCV eyes over the short term.

Comparison of Spectral-Domain and Time-Domain Optical Coherence Tomography in Solar Retinopathy

The purpose of this article is to compare spectral-domain (SD) and time-domain (TD) optical coherence tomography (OCT) findings in patients with solar retinopathy. Complete ocular examinations and OCT were performed in two patients presenting with acute solar retinopathy soon after observation of an eclipse. Both patients were evaluated with SD-OCT and TD-OCT at the same time. SD-OCT demonstrated characteristic defects at the level of the inner and outer segment junction of the photoreceptors in all the affected eyes and decreased reflectiveness of the retinal pigment epithelium layer. TD-OCT images showed unremarkable findings in two eyes with deteriorated visual acuity. SD-OCT improves diagnosis and assessment of the degree and nature of foveal damage in patients with solar retinopathy and may be an important tool for use in identifying foveal damage not detected by TD-OCT. SD-OCT may be preferable to TD-OCT for confirmation or assessment of the degree of foveal damage in patients with solar retinopathy.

The Relationship between the Visual Prognoses of Branch Retinal Artery Obstruction and Foveal Thickness on OCT

PURPOSE: To determine the correlation between the prognosis of branch retinal artery obstruction (BRAO) and the foveal thickness or outer nuclear layer (ONL) thickness on optical coherence tomography (OCT). METHODS: Twenty-one eyes (21 patients) in patients with resolved, non-complicated BRAO and a normal control of 10 eyes (10 volunteers) were used in this study. The average macular thickness, foveal thickness and ONL thickness at central fovea were measured in both the patients and the control group using spectral domain OCT. The thickness between the patient group and the control group were compared and correlation between the best corrected visual acuity (BCVA) and each thickness was determined. RESULTS: The average age of the patients was 52 +/- 5.8 years. The average macular thickness, foveal thickness and ONL thickness at the central fovea of the patients were significantly (p < 0.001, p = 0.023, p = 0.021, respectively) thinner than that of the control group. Both the foveal thickness (r(s) = 0.56, p = 0.008) and ONL thickness (r(s) = 0.86, p < 0.001) were significantly correlated with BCVA. There was no significant correlation between the average macular thickness and BCVA. CONCLUSIONS: The foveal thickness and ONL thickness at the fovea was positively correlated with the BCVA in patients with resolved BRAO.

The Characteristics of Acute Concomitant Esotropia of Adulthood

PURPOSE: To identify the characteristics of adult patients who develop acute concomitant esotropia during adulthood. METHODS: Using a retrospective noncomparative method, this study evaluated the medical charts of 10 adults who were diagnosed with acute onset esotropia between January 2003 and May 2005. All patients presented the symptoms of estotropia when they were older than age 18. All patients in the study group had no previous ocular history, no cause of interruption of fusion, no history of systemic disease or head trauma, and no abnormal findings on neurologic examination. RESULTS: The average follow-up period was 10.8 months (range, 5 ~ 17 months). The mean age was 44.7 years (range, 18 ~ 62 years). The average refractive error was -1.43 diopter (range, -5.50 ~ +0.50 diopter). An operation was performed in one case. The prism diopter decreased according to follow-up in other patients. CONCLUSIONS: There are characteristics of acute onset esotropia of adulthood that differentiate it from existing esotropia. Almost all patients were myopic, showed nearly the same prism diopter between near and far vision, and deviation improved with follow-up.

The Relationship Between Ascorbic Acid Concentration of Anterior Chamber and Complication in Alkali-Injured Rabbit Eyes

PURPOSE: To study the relationship between the concentration of ascorbic acid in the anterior chamber and the complications of an experimental alkali burn in rabbit corneas. METHODS: Standardized corneal alkali wounds were induced in both eyes of 33 albino rabbits by applying a 5.5 mm-sized round filter paper, soaked in 1N NaOH for 20 seconds. Then, the control group (22 eyes) was given Tears Natural II(R) (Alcon), treated group A (22 eyes) was given ascorbic acid (10%) for 2 hours, and treated group B (22 eyes) was given ascorbic acid (10%) for 6 hours. The concentrations of ascorbic acid in the anterior chamber were measured using a microplate assay immediately post-injury, and at 5 days, 15 days, and 30 days post-injury. During the experiment, clinical observation was performed to detect complications such as corneal ulcer or perforation. RESULTS: The incidence of ulceration was significantly lower between control group and treated groups A and B (p<0.05). The incidence of perforation was significantly lower in treated group A compared to the control group B (p<0.05). In addition, a higher concentration of ascorbic acid in the anterior chamber and a lower severity of corneal injury was significant (sigma=-0.302, P<0.05). CONCLUSIONS: Higher concentrations of ascorbic acid in the anterior chamber were associated with fewer complications in experimental alkali burns in rabbit corneas.