Evaluation of Subconjunctival Remnant Particles after High-frequency Radio-wave Electrosurgery for Conjunctivochalasis

PURPOSE: To investigate the clinical manifestations and properties of remnant particles in the subconjunctival space after high-frequency radio-wave electrosurgery for conjunctivochalasis. METHODS: We performed a retrospective, observational case series with in vitro experimental imaging in nine eyes from eight patients who presented with small dark-gray lesions during follow-up after high-frequency radio-wave electrosurgery for conjunctivochalasis. General examination including slit-lamp examination and visual acuity testing was performed preoperatively and postoperatively. During follow-up, we evaluated remnant particles and any other complications including granuloma or conjunctival injection with slit-lamp photography and anterior optical coherence tomography. Coagulation tips were investigated with scanning electron microscope and energy dispersive X-ray spectroscopy to analyze the insulating electrode and assess changes to tips after repeated use. RESULTS: None of the patients included in this study experienced any change in visual acuity or major complications postoperatively. Small dark-gray lesions (0.3 to 0.5 mm in size) were observed in the inferior bulbar sub-conjunctival space in the location where high-frequency radio-wave electrosurgery had been performed. Cirrus high-definition optical coherence tomography images revealed focal hyper-reflection with a posterior shadow, suggesting foreign particles. Scanning electron microscopy and energy dispersive X-ray spectroscopy imaging analysis revealed peaks of carbon and fluorine complexes, consistent with the polytetrafluoroethylene coating on the electrode. CONCLUSIONS: There were no instances of inflammatory reaction, particle migration, or major complications due to particles. Physicians should be aware of the possibility of remnant polytetrafluoroethylene particles in subconjunctival tissue when using insulated coagulation tips subjected to repeat sterilization.

Clinical Effectiveness of a Brinzolamide 1%-Brimonidine 0.2% Fixed Combination for Normal Tension Glaucoma in South Koreans

PURPOSE: This study evaluated the efficacy and safety of a brinzolamide 1%-brimonidine 0.2% fixed combination (BBFC) for normal tension glaucoma (NTG) in a South Korean population. METHODS: This study included 45 patients who were newly diagnosed with NTG and treated with BBFC as the first therapy from January 2016 through December 2016. The unilateral eye of NTG eyes of all patients were enrolled. If both eyes were eligible, the eye with the more severe glaucomatous change was selected. If the glaucomatous change was similar in both eyes, the right eye was selected. The patients received the BBFC twice a day. Diurnal intraocular pressure (IOP) was measured every 2 and 1/2 hours between 09:00 am and 04:30 pm. The IOP change with respect to body position (positional IOP) was measured at baseline and at 6 months after eyedrop instillation. Throughout the study, all side effects were recorded and monitored by the investigators. RESULTS: Ten patients were excluded due to an allergic reaction or follow-up loss. A total of 35 patients were enrolled in this study. The mean IOP was 15.32 ± 4.00 mmHg at baseline and 13.38 ± 3.30 mmHg at 6 months after BBFC instillation (p < 0.001). The IOP fluctuation decreased from 3.33 ± 3.10 to 2.35 ± 1.40 mmHg after BBFC instillation; however, the difference was not statistically significant (p = 0.150). The mean change in positional IOP showed a statistically significant reduction from 16.94 ± 3.18 to 14.80 ± 3.27 mmHg (p = 0.025). There was no serious adverse drug reaction except in three cases of allergic reaction. CONCLUSIONS: BBFC is effective for the reduction of mean IOP and positional IOP in NTG patients.

Awareness of Students' Emotional and Behavioral Screening Test based on Parental and Teacher Ratings

OBJECTIVES: Since 2013, the Students' Emotional and Behavioral Screening Test (SEBT) has been conducted annually for 1st grade and 4th grade elementary school students, 1st year middle school students, and 1st year high school students. The SEBT has been considered to have effectiveness and strength for screening high risk students who have a strong possibility of harboring emotional or behavioral problems in school. Therefore, in this study, we conducted an investigation into the awareness of the SEBT based on the rating score of the parents and teachers to determine its future direction and management. METHODS: A total of 731 parents and 149 teachers participated in this study. Each participant completed a self-administered questionnaire on their awareness of the SEBT. RESULTS: 428 (58.5%) parents and 99 (66.4%) teachers rated their overall satisfaction at more than 4 points out of a total of 5 points. The test reliability was rated at more than 4 points out of a total of 5 points by 52.1% of the parents (n=381) and 47.7% of the teachers (n=71). CONCLUSION: Both parents and teachers consider the SEBT to be highly satisfactory and reliable.

Seroprevalences of Specific IgG Antibodies to Measles, Mumps, and Rubella in Korean Infants

In this study, the seroprevalences of measles, mumps, and rubella antibodies in infants were determined to assess the immunization strategy and control measures for these infectious diseases. Serum samples from infants < 1 year of age and their mothers were collected to measure the concentrations of specific IgG antibodies to measles, mumps, and rubella by enzyme-linked immunosorbent assay. For selected infant serum samples, measles-specific neutralizing antibody levels were determined by using the plaque reduction neutralization test. The sera from 295 of infants and 80 of their mothers were analyzed. No infants had past measles, mumps, or rubella infections. Almost all infants < 2 months of age were positive for measles and rubella IgG antibodies. However, seroprevalence of measles and rubella antibodies decreased with age, and measles IgG and rubella IgG were barely detectable after 4 months of age. The seroprevalence of mumps antibodies was lower than that of measles and rubella antibodies in infants ≤ 4 months old, and mumps IgG was barely detectable after 2 months of age. The seropositivity of measles-specific neutralizing antibody was 63.6% in infants aged 2 months and undetectable in infants ≥ 6 months old. Because the seropositivity rates of measles, mumps, and rubella antibodies were low after the first few months of age in Korean infants, active immunization with vaccines is strongly recommended for infants aged 6–11 months when measles is epidemic. Timely administration of the first dose of measles-mumps-rubella vaccine at 12 months of age should be encouraged in non-epidemic situations.

Chronic Hemorrhage from a Fistula between a Gastroduodenal Artery Aneurysm and the Duodenum / 대한내과학회지

Gastroduodenal artery (GDA) aneurysm is a very rare event, but it induces life-threatening clinical manifestations upon rupture or bleeding. The causes of GDA aneurysm are atherosclerosis, infection, trauma, surgery, iatrogenic lesions, mycotic or tuberculous disease, and autoimmune disease. We report the case of a 77-year-old female who presented with melena and vomiting. Upper gastrointestinal endoscopy revealed a 4 cm pulsatile extrinsic mass with a duodenal fistula at the duodenal bulb. Abdominal computed tomography showed a large aneurysm of the GDA. We successfully conducted transcatheter embolization of the aneurysm. After the procedure, the patient did not present with melena, and her hemoglobin level was stable. Follow-up endoscopy showed that the GDA aneurysm-duodenal fistula had decreased in size and was leaking a small amount of blood. An arteriography was performed and showed no evidence of contrast filling in the aneurysmal sac.

Reappraisal of the Immunogenicity and Safety of Three Hepatitis A Vaccines in Adolescents

Although the overall incidence of hepatitis A in Korea has been decreasing, adolescents remain highly vulnerable to its outbreaks. This study was conducted to compare the immunogenicity and safety of three hepatitis A vaccines in Korean adolescents. Healthy anti-hepatitis A virus seronegative subjects aged 13 to 19 yr were randomized in three equal groups to receive two doses of Avaxim(TM), Epaxal(R), or Havrix(R), 6 to 12 months apart. Seroconversion rates one month after the first dose were 98%, 95%, and 93% for Avaxim(TM), Epaxal(R), and Havrix(R), respectively. Seroconversion rates reached 100% for all vaccine groups one month after the second dose. Anti-HAV geometric mean concentrations (GMCs) were 7,207.7 mIU/mL (95% CI, 6023.1-8684.7), 1,750.5 mIU/mL (95% CI, 1362.9-2248.3), and 1,953.5 mIU/mL (95% CI, 1459.4-2614.7) after two doses of Avaxim(TM), Epaxal(R), and Havrix(R) respectively. Avaxim(TM) was significantly more immunogenic than Epaxal(R) and Havrix(R), whereas there were no significant differences in antibody responses between Epaxal(R) and Havrix(R). Local and systemic solicited adverse events (AEs) were mostly of mild-to-moderate intensity and resolved within 5 days. No serious AEs were reported. In conclusion, all three vaccines are highly immunogenic and well-tolerated in Korean adolescents. (Clinical Trial Registry NCT00483470)

Decreased Serum Epinephrine in Children With Positive Skin Prick Test

OBJECTIVES: To evaluate the association between catecholamine levels and skin prick test results among children. METHODS: Two hundred eight first grade children from one elementary school were invited to participate in this study. Skin prick test (SPT) for six allergens (2 house dust mites, cat, dog, mugwort, and pollen mixture) was performed, and patient demographic information was recorded. The parents were surveyed using questionnaires about rhinitis-related symptoms. Finally, venous blood sampling was done to measure catecholamine levels (epinephrine, norepinephrine, and dopamine) by high-performance liquid chromatography. RESULTS: Out of 208 children, 174 (106 boys and 68 girls) enrolled in this study. Ninety-six of the children (55%) had negative SPT (nonsensitization group), while 78 (45%) had a positive SPT to at least one of six allergens (sensitization group). The diagnosis of chronic rhinitis was more prevalent in the sensitization group (35.9%) than nonsensitization group (26.0%), however the finding was not significant (P=0.186). Epinephrine levels were decreased between the sensitization group compared to the nonsensitization group (P=0.004). There was no difference in norepinephrine and dopamine levels (P>0.05). CONCLUSION: Epinephrine levels are lower in children with positive SPT compared to controls, however, the level of the catecholamine was not associated with the presence or absence of rhinitis symptoms.

Comprehensive Comparison between Snoring and Non-Snoring Children / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Snoring is very common among children; however, there is a controversy regarding its effects on children. The purpose of this study is to identify risk factors and comorbidities associated with the condition collectively. SUBJECTS AND METHOD: 208 children were invited to participate in this study. Parents were surveyed for each child's snoring status, chronic rhinitis, behavior, and the parents' snoring and smoking status. Measurements were taken of each child's height, weight, waist and neck circumference, and blood pressure. X-rays and physical exams were used to record tonsil and adenoid size. All children also received an intelligence test and comprehensive blood test. Results were then compared between snoring and non-snoring children. RESULTS: Among 208 children, 175 participated in the study voluntarily. Out of the participants, 55 were snorers and 120 were non-snorers. Body mass index, neck and waist circumferences, and prevalence of chronic rhinitis were higher among the snorer. Mothers of snoring children snored more frequently. Inattention and impulsivity scores were also higher among snorers than non-snorers. There were no differences of cognition, tonsil or adenoid size, or blood test results between the two. CONCLUSION: There were some differences in physical, family-related, and behavior trait between snoring and non-snoring children.

Changes in the Retinal Nerve Fiber Layer after Intravitreal Injections of Bevacizumab in Glaucoma Patients

PURPOSE: To examine retinal nerve fiber layer (RNFL) changes after intravitreal injection of bevacizumab in patients with or without underlying glaucoma. METHODS: A total of 104 eyes of 104 patients with retinal disease undergoing intravitreal injection of bevacizumab were prospectively investigated. Bevacizumab injections (1.25/0.05 mg/mL) were performed using a standardized technique. In the patient who had pretreatment with intraocular pressure (IOP)-lowering medication, 1 drop of brimonidine was instilled 30 minutes before the injection. Before and after the intravitreal injections, the patients were monitored for IOP and evaluated with optical coherence tomography using Stratus at least 3 months after the injection. RESULTS: Thirty minutes after injection, 6.4% of patients had an IOP over 30 mm Hg in the non-pretreatment group while no patient had an IOP over 30 mm Hg in the pretreatment group. In eyes with only retinal diseases, the RNFL thickness did not change significantly after the injection regardless of pretreatment, whereas in eyes with underlying glaucomatous damage and no pretreatment, significant decrease in RNFL thickness was observed at the superior (p = 0.036) and temporal (p = 0.048) sectors of the optic nerve head without pretreatment. CONCLUSIONS: Intravitreal injection of bevacizumab did not typically cause significant changes in RNFL thickness; however, in eyes with underlying glaucoma without pretreatment, a significant decrease in RNFL thickness was observed in the superior and temporal sectors of the optic nerve head. Therefore, applying IOP-lowering pretreatment medication before intravitreal injection of bevacizumab is required for protection of RNFL in glaucoma patients.

Changes in the Retinal Nerve Fiber Layer after Intravitreal Injections of Bevacizumab in Glaucoma Patients

PURPOSE: To examine retinal nerve fiber layer (RNFL) changes after intravitreal injection of bevacizumab in patients with or without underlying glaucoma. METHODS: A total of 104 eyes of 104 patients with retinal disease undergoing intravitreal injection of bevacizumab were prospectively investigated. Bevacizumab injections (1.25/0.05 mg/mL) were performed using a standardized technique. In the patient who had pretreatment with intraocular pressure (IOP)-lowering medication, 1 drop of brimonidine was instilled 30 minutes before the injection. Before and after the intravitreal injections, the patients were monitored for IOP and evaluated with optical coherence tomography using Stratus at least 3 months after the injection. RESULTS: Thirty minutes after injection, 6.4% of patients had an IOP over 30 mm Hg in the non-pretreatment group while no patient had an IOP over 30 mm Hg in the pretreatment group. In eyes with only retinal diseases, the RNFL thickness did not change significantly after the injection regardless of pretreatment, whereas in eyes with underlying glaucomatous damage and no pretreatment, significant decrease in RNFL thickness was observed at the superior (p = 0.036) and temporal (p = 0.048) sectors of the optic nerve head without pretreatment. CONCLUSIONS: Intravitreal injection of bevacizumab did not typically cause significant changes in RNFL thickness; however, in eyes with underlying glaucoma without pretreatment, a significant decrease in RNFL thickness was observed in the superior and temporal sectors of the optic nerve head. Therefore, applying IOP-lowering pretreatment medication before intravitreal injection of bevacizumab is required for protection of RNFL in glaucoma patients.

An Unusual Cause of Gastrointestinal Hemorrhage: Gastrocolic Fistula Caused by Colon Cancer Invasion / 영남의대학술지

Gastrocolic fistula is a fistulous communication between the stomach and the colon. It is a passage between the gastric epithelium and the colonic epithelium. This uncommon complication is caused by benign and malignant diseases of the stomach or the colon. Its clinical manifestations include weight loss, diarrhea and fecal vomiting; occasionally, anemia, poor oral intake, fatigue and dizziness; and very rarely, gastrointestinal bleeding. In this paper, an unusual case of gastrocolic fistula accompanied by hematochezia, which was revealed to have been caused by colon cancer invasion, is described.

Spontaneous Mediastinal Hemorrhage in a Patient with End Stage Renal Disease: An Unusual Case of Uremic Bleeding / 대한신장학회지

Hemorrhagic complications in patients with end stage renal disease (ESRD) are common. These abnormal bleeding tendencies are caused by several factors including anticoagulation during hemodialysis, anemia, and uremic platelet dysfunction. The most common clinical manifestation of uremic bleeding is hemorrhage of the gastrointestinal tract from gastric ulcer disease. Mediastinal bleeding, however, is rare in ESRD patients. Here, we report a case of spontaneous mediastinal bleeding in a patient with hemodialysis. A huge periesophageal hematoma was observed on the chest CT scan and the bleeding time representing platelet function was prolonged. This case underlies the diversity of uremic bleeding.

A Thrombotic Coronary Artery Aneurysm Associated with Atherosclerosis in a Patient with End Stage Renal Disease / 대한신장학회지

We present a case of thrombotic coronary aneurysm of the left anterior descending artery (LAD) presenting with recurrent severe orthopnea in an end stage renal disease patient. She was admitted to the hospital with progressive dyspnea, exertional chest pain, and profound orthopnea. The echocardiography revealed a well marginated mass lesion between the main pulmonary artery and the left atrium. Chest CT showed a space-occupying lesion surrounded by the main pulmonary artery, the left atrium and the appendage adjacent to the atherosclerotic calcified lesion. Coronary angiography confirmed a huge thrombotic aneurysm with total occlusion of the proximal LAD. The presentation and management of the coronary aneurysm was reviewed.

High-sensitivity C-reactive Protein Can Predict Major Adverse Cardiovascular Events in Korean Patients with Type 2 Diabetes

Inflammation is thought to play a role in the pathogenesis of major adverse cardiovascular events (MACE). It has been suggested that the measurement of markers of inflammation may aid in predicting the risk of such events. Here, the relationship between high-sensitivity C-reactive protein (hs-CRP) levels and MACE in Korean patients with type 2 diabetes is assessed. A retrospective cohort study was conducted as a follow-up among 1,558 patients with type 2 diabetes and without cardiovascular diseases over a mean period of 55.5 months. A Cox proportional-hazards model was used to determine whether increased hs-CRP levels are useful as a predictor for future MACE. The hazard ratio of MACE was 1.77 (95% CI; 1.16-2.71) in subjects who had the highest hs-CRP levels (> 0.21 mg/dL) compared to subjects who had the lowest hs-CRP levels (< 0.08 mg/dL), after adjusting for age, regular physical activity, current smoking, and duration of diabetes. The present results indicate that high hs-CRP levels can act as a predictor for the MACE occurrence in Korean patients with type 2 diabetes.

Postoperative Astigmatic Outcomes Based on the Haptic Axis of Intraocular Lenses Inserted in Cataract Surgery

PURPOSE: This study was conducted to compare post-operative astigmatic outcomes of two groups, with-the-rule (WTR) and against-the-rule (ATR) astigmatism patients, according to the haptic axis of intraocular lenses (IOLs) inserted in cataract surgery. METHODS: Seventy-two eyes with WTR astigmatism and 79 eyes with ATR astigmatism had cataract surgery through a clear corneal temporal incision. These two groups of eyes were then each divided into 2 groups based on whether the haptic axis of the inserted IOL was at 180degrees or 90degrees. For ATR patients, the outcomes were analyzed according to the three types of IOLs. RESULTS: There was no difference in corneal astigmatism, but WTR patients with a 180degrees haptic axis of the inserted IOL and ATR patients with a 90degrees hepatic axis of the inserted IOL had a significant decrease in postoperative refractive astigmatism (p < 0.05). The changes in ATR astigmatism according to the IOL type were more effective in single-piece acrylic IOLs than in the three-piece polymethylmethacrylate haptic IOL group. CONCLUSIONS: Insertion of the IOL at the 180degrees haptic axis in WTR patients and at 90degrees in ATR patients during cataract surgery may have an effect in reducing pre-existing astigmatism. This observed effect was not consistent among the different types of IOLs.

Tuberculous Peritonitis in a Patient with Rheumatoid Arthritis Treated with Infliximab

One of the severe adverse reactions to anti-tumor necrosis factor (TNF)-alpha therapy is the reactivation of tuberculosis. We present a case of tuberculous peritonitis in a 57-year-old woman with rheumatoid arthritis (RA) that appeared during treatment with infliximab. Confirming a diagnosis of tuberculous peritonitis is difficult and can be delayed because of the nonspecific symptoms, the rarity of the disease and the low detection rate of mycobacteria in ascites fluid. This case illustrates that prompt anti-tuberculous therapy is needed for suspected cases of tuberculous peritonitis in RA patients treated with infliximab.

Bilateral Central Retinal Vein Occlusion in Patient with Disseminated Intravascular Coagulation

PURPOSE: To report a case of bilateral central retinal vein occlusion (CRVO) as one of the initial signs of disseminated intravascular coagulation (DIC). CASE SUMMARY: A 33-year-old woman with a history of pregnancy-induced thrombotic thrombocytopenic purpura presented to our hospital with bilateral visual loss. On her initial visit, visual acuity was counting fingers at 30 cm in both eyes. Based on the findings of a funduscopic examination, the patient was diagnosed with bilateral CRVO. Laboratory tests confirmed the diagnosis of DIC combined with thrombotic thrombocytopenic purpura (TTP). Plasma exchange and transfusion of cryoprecipitate with fresh frozen plasma was performed. The ocular fundus findings did not improve. Despite medical treatment, the patient's systemic condition deteriorated and she died of metabolic acidosis two weeks later. CONCLUSIONS: Bilateral central retinal vein occlusion occurred as a sign of aggravation of preexisting TTP and progression to DIC in the presented case. In patients with severe bilateral retinal venous changes, there should be a very high level of suspicion for presence or progression of systemic disease, with the possibility of effective early systemic evaluation and therapy.

Treatment of Hypotony Maculopathy Caused by Silicone Oil Removal With Gas Tamponade

PURPOSE: To report a case of hypotony maculopathy after silicon oil removal treated by intravitreal gas injection. CASE SUMMARY: A 35-year-old women presented with decreased visual acuity of the right eye for two weeks. Retinal detachment with peripheral retinal tears was observed in the patient's right eye. Pars plana vitrectomy including lensectomy, endolaser photo-coagulation and silicone oil injection was performed. Silicone oil removal was performed to improve patient's visual acuity two months after the operation. After the silicone oil removal, visual acuity was decreased to hand motion, and intraocular pressure was decreased below 3 mmHg while observing chorioretinal folding in fundus for two months. Intraviteal C3F8 gas injections were performed three times in the two months after silicone oil removal. After three gas injections, gradual reduction of chorioretinal folding was observed. Visual acuity was improved to 0.2 and IOP was maintained at 8 to 10 mmHg for 18 months after the last gas injection. CONCLUSIONS: Intravitreal gas injection offers a safe and effective method for treating hypotony retinopathy after silicon oil removal.

Retinal Vasculopathy as First Manifestation of Chronic Myelogenous Leukemia

PURPOSE: To present a case of bilateral retinal vasculopathy as the first manifestation of chronic myelogenous leukemia. CASE SUMMARY: A 59-year-old man with no medical history such as diabetes, hypertension and no ocular history complained of decreased visual acuity for 1 month. Fundus examinations showed diffuse multiple dot and blot hemorrhages over the panretina of both eyes and vessels showed tortuous vascular changes. The fluorescein angiogram was evaluated, and showed diffuse microaneurysms at the peripheral retina and posterior pole. Hematologic and biochemical examinations as well as a carotid sonogram were performed based on the possibility of systemic disease. The patient showed hematologic abnormality and therefore was transferred to internal medicine for diagnosis of chronic myelogenous leukemia. CONCLUSIONS: The authors examined a chronic leukemia patient, who showed bilateral retinal vasculopathy as the first manifestation of chronic myelogenous leukemia. This case shows the importance of considering the possibility of systemic disease.

Bilateral Adrenal Gland Lymphoma Masquerading as Vogt-Koyanagi-Harada Syndrome

PURPOSE: To report a case of bilateral adrenal gland lymphoma mimicking symptoms of Vogt-Koyanagi-Harada syndrome. CASE SUMMARY: A 57-year-old woman complained of decreased visual acuity and metamorphopsia in both eyes. She had no prior medical history, but had experienced headaches in the past week. Fundus examination revealed multiple serous retinal detachment. Fluorescein angiography of the fundus revealed multiple pinpoint leaks in early stages and subretinal dye pooling in the retinal detachment area in late stages. The most likely diagnosis was therefore Vogt-Koyanagi-Harada syndrome. Two days later, mild fever developed and a systemic evaluation was performed. Computed tomography of chest and abdomen showed bilateral adrenal gland T-cell lymphoma. Through prompt combination chemotherapy, the patient's systemic condition recovered, and her fundus recovered with improved visual acuity. CONCLUSIONS: We experienced a rare case of bilateral adrenal lymphoma which masqueraded as Vogt-Koyanagi-Harada syndrome. When there are systemic symptoms such as mild fever and headaches, systemic evaluation should be done so as not to miss more serious systemic pathology.