Closed-loop Scleral Fixation with 4-eyelet Intraocular Lens Implantation for Aphakia: Clinical Outcomes

Purpose@#We present a modified, closed-loop scleral fixation technique. We inserted a 4-eyelet intraocular lens (IOL) into the anterior chamber prior to fixation. We investigated the clinical results. @*Methods@#We retrospectively reviewed 39 eyes (39 patients) that underwent modified four-point scleral fixation of an inserted lens in our center from May 2019 to June 2022. The surgical procedure features conjunctival peritomy, 4-eyelet IOL insertion, eyeball penetration using a 9-0 polypropylene needle, eyelet placement using an ab externo technique to form a continuous loop, centering of the optic, and tying of a knot. We compared preoperative and 6-month postoperative changes in best-corrected visual acuity (BCVA), intraocular pressure, and refraction errors, and described postoperative complications. @*Results@#The mean patient age was 62 years. The indications for surgery included complicated cataracts (20.5%), aphakia (20.5%), staged surgery for complicated cataract (12.8%), non-traumatic IOL dislocation (30.8%), traumatic IOL dislocation (12.8%), and crystalline lens dislocation (5.1%). The postoperative BCVA (0.40 logarithm of the minimum angle of resolution [logMAR]) was significantly better than the preoperative BCVA (0.69 logMAR) (p = 0.018). The postoperative spherical equivalent and the target diopter measurement were in high agreement (p = 0.002, intraclass correlation coefficient = 0.616). All of ocular hypertension (7.7%), hypotony (5.1%), bullous keratopathy (5.1%), and macular edema (5.1%) were noted, but 78% of the conditions improved with short-term medication. There was no re-dislocation of a fixated IOL. @*Conclusions@#Our surgical technique simply and rapidly treats aphakia. Optic repositioning was easy, the IOL stability high, and the risk of complications during IOL fixation low.

A Case of Transient Posterior Capsular Opacity After Intravitreal Bevacizumab Injection

Purpose@#We are reporting a case of transient posterior capsular opacity after intravitreal Bevacizumab (Avastin®, Roche Pharma Schweis AG, Zurich, Switzerland) injection in a phakic patient.Case summary: A 34-year-old man visited our clinic with sudden blurred vision in his left eye one day after the intravitreal injection for central serous chorioretinopathy. His visual acuity was 1.0 before the injection and decreased to 0.1 at the presentation. On slit-lamp examination, a snow-flake appearance opacity was noted behind the posterior capsule. No newly appearing lesion was presented on fundus exam, so topical antibiotics and steroid eyedrops were continued. One week after the injection, the visual acuity improved to 1.0 and posterior capsular opacity remained but decreased. Five weeks after the injection, the posterior capsular opacity resolved. Fundus exam revealed improved but persistent subretinal fluid, so he overwent another intravitreal injection. The posterior capsular opacity did not recur for seven months. @*Conclusions@#Iatrogenic lens damage or the turbidity formed by medication can cause a posterior capsular opacity after intravitreal injection. If structural damage is uncertain, close monitoring is needed and ultimately, cataract surgery may be required for chronic crystalline lens opacity.

Impact of Cataract Surgery on Foveal Avascular Zone Detected by Optical Coherence Tomography Angiography

Purpose@#To investigate the influence of cataract surgery on detection of a foveal avascular zone (FAZ) and retinal capillary density (RCD) by optical coherence tomography angiography (OCTA). @*Methods@#In this study, 64 eyes of 64 patients with cataracts who underwent surgery were included and studied retrospectively. All patients underwent cataract surgery of the included eye and a FAZ was detected on OCTA preoperatively and postoperatively using one of two kinds of OCTA devices. The FAZ and RCD were compared before and after cataract surgery using paired t-test. @*Results@#Using the Cirrus Angioplex OCTA device, there was no significant pre- or post-operative difference in the FAZ area (p = 0.060), perimeter (p = 0.052) and circularity (p = 0.190). It also revealed no significant difference between the central (p = 0.310), inner (p = 0.310), and outer (p = 0.310) zones and full RCD (p = 0.228) before and after cataract surgery The Spectralis OCTA device also showed no significant difference in the FAZ area (p = 0.239) before and after cataract surgery. @*Conclusions@#Cataract surgery does not affect detection of the FAZ and RCD on OCTA. Although patients who have a FAZ-related retinal disorder such as diabetic retinopathy and undergo cataract surgery are followed up regularly, it seems that the results gained by OCTA are reliable and comparable to the preoperative result.

Atypical Multiple Evanescent White Dot Syndrome with Pigmented Patches of Recovery Phase

Purpose@#In the present study, an atypical case of multiple evanescent white dot syndrome (MEWDS) was reported, which thewhite dots of acute phase and the pigmented patches of recovery phase appeared on different location.Case summary: A seventeen years old male with no previous medical history was presented with decreased visual acuity of hisleft eye. On the first visit, his maximum corrected vision was 1.0 in right eye and 0.5 in left eye. The white dots with blurry marginwere noted at the nasal retina on fundus exam. Fundus autofluorescence photography, fluorescein angiography and indocyaninegreen angiography all showed typical foundings of MEWDS. Gradually the vision improved up to 1.0 with maximumcorrection in six weeks, with normalized ellipsoid zone contour. However, multiple panretinal pigmented patches appeared diffusely,not only at nasal, where the previous white spots were noted, but also at temporal. The patient was followed up withoutany medication. Finally, the pigmented lesions were disappeared spontaneously. @*Conclusions@#During the recovery phase of MEWDS, multiple pigmentations may appear in different part of the retina, where thewhite dots were not presented. However, they were disappeared with recovery of clinical symptoms gradually without anytreatment.

Optical Coherence Tomography Measurement and Visual Outcome in Acute Central Retinal Artery Occlusion

PURPOSE: This study investigated visual acuity (VA) values and differences depending on optical coherence tomography (OCT) findings in patients with acute central retinal artery occlusion (CRAO). METHODS: A retrospective chart review was performed on patients with acute CRAO who underwent macular and disc OCT. We evaluated changes in macular thickness and retinal nerve fiber layer (RNFL) thickness after acute CRAO onset based on OCT. We also determined the association of thickness changes with VA improvement. RESULTS: This study involved both eyes in a total of 12 patients with acute CRAO. A significant increase was observed in foveal (1 mm) thickness (p = 0.002), parafoveal (3 mm) thickness (p = 0.002), and peripapillary RNFL thickness (p = 0.005) in affected eyes with CRAO, but not in central foveal thickness (p = 0.266). A significant small difference in both eyes (affected eye – fellow eye) was shown in foveal (1 mm) and mean parafoveal (3 mm) thickness in the improved VA group (p = 0.008 and p = 0.004, respectively), but not in central foveal or peripapillary RNFL thickness (both p = 0.283). CONCLUSIONS: Both macular and RNFL thickness increased in patients with acute CRAO. RNFL thickness decreased over time with progression of RNFL atrophy. Less macular damage caused by acute CRAO could be predicted by a small difference in macular thickness between eyes (affected eye – fellow eye). In such cases, patients had a greater chance of VA improvement.

Visual Recovery after Macular Hole Surgery and Related Prognostic Factors

PURPOSE: To describe the visual recovery and prognostic factors after macular hole surgery. METHODS: A retrospective chart review was conducted. Charts of patients with idiopathic macular holes who underwent surgery by a single surgeon at Severance Hospital between January 1, 2013 and July 31, 2015 were reviewed. The best-corrected visual acuity (BCVA) score was recorded preoperatively and at 1 day and 1, 3, 6, 9, and 12 months after surgery. The variables of age, sex, macular hole size, basal hole diameter, choroidal thickness, and axial length were also noted. RESULTS: Twenty-six eyes of 26 patients were evaluated. Twenty-five patients (96.2%) showed successful macular hole closure after the primary operation. The BCVA stabilized 6 months postoperatively. A large basal hole diameter (p = 0.006) and thin choroid (p = 0.005) were related to poor visual outcomes. Poor preoperative BCVA (p < 0.001) and a thick choroid (p = 0.020) were associated with greater improvement in BCVA after surgery. CONCLUSIONS: Visual acuity stabilized by 6 months after macular hole surgery. Choroidal thickness was a protective factor for final BCVA and visual improvement after the operation.

A Case of a Visual Field Defect with Optical Coherence Tomography Changes after Sildenafil Citrate Overdose

PURPOSE: A case of a transient visual field defect and a change in spectral-domain optical coherence tomography (SD-OCT) after an overdose of sildenafil citrate is described. CASE SUMMARY: A 67-year-old male with no previous medical history presented with a bluish tinge and visual field defect in both eyes. He had consumed eight tablets of sildenafil citrate (800 mg) 3 days before the visit. His best-corrected visual acuity was 14/20 in the right eye and 20/20 in the left eye. No specific finding was noted on slit-lamp examination. Fundus examination and fundus photography revealed focal foveal hypopigmentation in both eyes. He underwent SD-OCT imaging with the Cirrus HD-OCT (Carl Zeiss Meditec, Oberkochen, Germany), and thickening of the ellipsoid zone and choroid was revealed by SD-OCT scans. He was advised not to take any more sildenafil citrate and was followed for 1 week after the first visit. Central scotomas of both eyes were revealed by a visual field test, and thickening of the ellipsoid zone and choroid remained. His eyes were re-evaluated 1 and 3 months after the first visit, and although the symptoms nearly disappeared, abnormalities in the visual field test and on SD-OCT remained, albeit with some degree of improvement. He revisited us 4 months after the first visit, at which time the visual field test and SD-OCT scans showed results within normal ranges. CONCLUSIONS: Sildenafil citrate overdose can result in a color anomaly (bluish tinge), visual field defects, and thickening of the ellipsoid zone and choroid on SD-OCT scans.

A Case of Unilateral Focal Pigmented Paravenous Retinochoroidal Atrophy

PURPOSE: We report a case of unilateral, focal, pigmented paravenous retinochoroidal atrophy (PPRCA). CASE SUMMARY: A 46-year-old female visited our clinic in complaint of a vague problem with her right eye identified during a general medical examination. The visual acuity (without correction) of both eyes was 1.0. Slit-lamp examination of both eyes revealed no specific signs. Fundus examination of the right eye revealed focal, bony-spicule-shaped retinochoroidal atrophy with pigmentation along the course of the superior retinal vein. A fundus autofluorescence examination revealed principally hypofluorescence with some hyperfluorescence at the margin of the atrophic retinochoroidal lesion. Optical coherence tomography revealed mixed clumping and atrophy of the retinal pigment epithelium (RPE) layer and thinning of the choriocapillaris layer. Fluorescence angiography revealed a window defect and blockage at the site of the lesion (the fluorescent material did not enter the lesion). The site of the window defect was in correlation with the atrophic RPE region. The site of the blockage at lesion also matched with the site of the regional pigment clumping. No definite leakage was observed. CONCLUSIONS: To the best of our knowledge, this is the first case of unilateral focal PPRCA reported from Korea.

Two Cases of Intraoperative Acute Opacification of Hydrophilic Intraocular Lens

PURPOSE: In the present study, two cases of intraoperative acute opacification of hydrophilic intraocular lens were reported. CASE SUMMARY: (Case 1) A sixty-seven year-old female presented with chronic visual impairment. Slit lamp examination revealed nuclear cataract of the left eye. Cataract surgery for her left eye was performed. A hydrophilic intraocular lens was checked before implantation and no defect was noted. Immediately after the implantation of the intraocular lens, acute whitish opacification of the intraocular lens occurred. However, the intraocular lens was not explanted, and the opacification cleared after one day. (Case 2) A 65 year-old male presented with chronic visual impairment of the left eye. Nuclear cataract of his left eye was noted, and he went through cataract surgery of the left eye. After the implantation of intraocular lens, acute whitish opacification of the intraocular lens was noted but it disappeared a day after. CONCLUSIONS: Intraoperative acute opacification of intraocular lens seems to occur due to radical temperature change. There is no need to remove or exchange the intraocular lens as opacification tends to clear within a day. No structural or mechanical change of intraocular lens was noted after opacification. Careful management of temperature for intraocular lens storage is necessary for prevention of intraoperative intraocular lens clouding.

Incidence and Risk Factors of Cystoid Macular Edema after Vitrectomy with Silicone Oil Tamponade for Retinal Detachment

PURPOSE: To investigate the incidence and risk factors of cystoid macular edema (CME) after silicone oil (SO) injection for retinal detachment. METHODS: Fifty-eight patients with retinal detachment treated by vitrectomy with SO tamponade during 2011 to 2015 were retrospectively assigned to CME and non-CME groups. Patients underwent complete ophthalmological examination, including color fundus photography and preoperative and postoperative optical coherence tomography. Risk factors for CME during SO tamponade were determined by regression analyses. RESULTS: Of the 58 eyes, 21 (36.2%) exhibited CME. The presence of posterior staphyloma in the CME group was significantly more frequent than in the non-CME group (p = 0.026). There were no significant differences in other demographic or clinical characteristics between the CME and non-CME groups. Significant correlations were observed between CME after vitrectomy with SO tamponade and the presence of posterior staphyloma (odds ratio, 4.03; p = 0.031). Of the 21 eyes with CME, 13 underwent SO removal, among which 11 experienced resolution of CME with or without further intervention. CONCLUSIONS: The presence of posterior staphyloma is significantly associated with CME after vitrectomy with SO tamponade. Patients with retinal detachment exhibiting posterior staphyloma should be evaluated for potential CME during SO tamponade.

A Case of Double Fovea Artifact Detected with Spectral-domain Optical Coherence Tomography

PURPOSE: In the present study, a case of double fovea artifact on spectral-domain optical coherence tomography (SD-OCT) was reported. CASE SUMMARY: A nine-year-old male presented with blurred vision of both eyes. His best corrected visual acuity (BCVA) was 20/20 in both eyes, and complete ophthalmologic evaluation including fundus examination and fundus photography revealed no abnormality in both eyes. He underwent SD-OCT imaging with the Cirrus HD-OCT. The Macular Cube 512 × 128 protocol of his right eye revealed an unusual pseudo-duplication of the fovea in the vertical meridian. The same protocol in his left eye also rendered a pseudo-duplication of two foveas in the vertical and horizontal meridians on the retinal thickness map. Re-examination with the same OCT system and protocol was performed two weeks later after the patient received counseling on fixation during the examination, and it revealed normal contour of the fovea in both eyes. CONCLUSIONS: Double fovea artifact seen in SD-OCT is a rare artifact that can possibly lead to misdiagnosis and inappropriate clinical treatment. Since the artifact was resolved with better fixation of the patient, repeating the scan with better patient compliance is necessary when such an artifact is encountered.

A Case of Supratarsal Injection of Triamcinolone in Management of Chronic Thygeson's Superficial Punctate Keratitis

PURPOSE: To report a case of supratarsal injection of triamcinolone for the management of chronic, steroid-dependent Thygeson's superficial punctate keratitis. CASE SUMMARY: A 37-years-old woman complained of redness, photophobia, and tearing in both eyes, which lasted for 6 years. The slit lamp examination revealed multiple intraepithelial and subepithelial, punctated corneal lesions which were elevated and scattered diffusely upon staining with fluorescein dye in both eyes. The patient was diagnosed with Thygeson's superficial punctate keratitis and treated with 0.1% fluorometholone, 0.05% cyclosporin, and 0.15% ganciclovir in both eyes. After 10 months of follow-up, recurrences were reported twice in the right eye, and 7 times in the left eye. The patient was treated with a supratarsal injection of triamcilonone in both eyes and after injection, the patient was treated only with artificial tears. Four months later, the patient did not complain of any symptoms and her cornea was clear. CONCLUSIONS: A supratarsal injection of triamcinolone may be an effective method to prevent recurrence of chronic, steroid-dependent Thygeson's superficial punctate keratitis.

Modified Surgical Technique for Transscleral Fixation of a Single-Piece Acrylic Intraocular Lens in the Absence of Capsular Support

PURPOSE: To introduce a new surgical method of transscleral intraocular lens (IOL) fixation using a foldable, single-piece acrylic IOL with 4 loop haptics and to report the surgical results. METHODS: After a single-piece acrylic IOL with 4 loop haptics was injected into the anterior chamber and positioned on top of the iris diaphragm, a 10-0 Prolene STC-6 straight needle and a 27-gauge needle were used to string the prolene thread through the haptic openings from front to back fixating the IOL to the sclera, resulting in a transscleral "1 loop 4 points" fixation. Twenty-eight eyes of 28 patients who had received transscleral fixation via this new technique were retrospectively reviewed. The best corrected vision acuity (BCVA) was measured after a postoperative period of at least 6 months. Intraoperative and postoperative complications were investigated. RESULTS: In 27 out of 28 eyes (96.4%), the postoperative BCVA was better than 0.5 (Snellen chart). The only complication found was 1 case of choroidal detachment (3.6%). CONCLUSIONS: The new transscleral "1 loop 4 points" fixation technique of a foldable, single-piece acrylic IOL in the absence of capsular support is an easy procedure and reduces surgical time and hastens visual rehabilitation due to excellent IOL positioning stability. Additionally, the technique described in the present study may be a safe procedure with minimal complications.

Modified Surgical Technique for Transscleral Fixation of a Single-Piece Acrylic Intraocular Lens in the Absence of Capsular Support

PURPOSE: To introduce a new surgical method of transscleral intraocular lens (IOL) fixation using a foldable, single-piece acrylic IOL with 4 loop haptics and to report the surgical results. METHODS: After a single-piece acrylic IOL with 4 loop haptics was injected into the anterior chamber and positioned on top of the iris diaphragm, a 10-0 Prolene STC-6 straight needle and a 27-gauge needle were used to string the prolene thread through the haptic openings from front to back fixating the IOL to the sclera, resulting in a transscleral "1 loop 4 points" fixation. Twenty-eight eyes of 28 patients who had received transscleral fixation via this new technique were retrospectively reviewed. The best corrected vision acuity (BCVA) was measured after a postoperative period of at least 6 months. Intraoperative and postoperative complications were investigated. RESULTS: In 27 out of 28 eyes (96.4%), the postoperative BCVA was better than 0.5 (Snellen chart). The only complication found was 1 case of choroidal detachment (3.6%). CONCLUSIONS: The new transscleral "1 loop 4 points" fixation technique of a foldable, single-piece acrylic IOL in the absence of capsular support is an easy procedure and reduces surgical time and hastens visual rehabilitation due to excellent IOL positioning stability. Additionally, the technique described in the present study may be a safe procedure with minimal complications.

Choice of One-Piece Intraocular Lens Power and Changes of Anterior Chamber in Sulcus Implantation due to Posterior Capsular Rupture during Cataract Surgery

PURPOSE: To evaluate the appropriate correction of predicted intraocular lens (IOL) power when sulcus implantation due to posterior capsular rupture was performed and to compare the anterior chamber angle of sulcus-implanted eyes with in-the-bag implanted eyes using anterior segment optical coherence tomography (Visante OCT). METHODS: Fifty-two eyes of 52 patients who had IOL implantation in the sulcus due to posterior capsular rupture during cataract surgery were retrospectively reviewed. A 0.5 lower diopter IOL than predicted IOL power using SRK-T formula was chosen. The difference between the predicted refractive error and the spherical equivalence at the 3-month time-point after sulcus implantation were evaluated. Among 52 patients, 16 patients whose fellow eye had an in-the-bag IOL implantation underwent Visante OCT and the anterior angle of affected eyes and normal fellow eyes were compared. RESULTS: The difference between the predicted refractive error using SRK-T formula and the spherical equivalence after sulcus implantation was a myopic shift of 0.597 +/- 0.879 diopter. The mean iridocorneal angles, angle opening distance (AOD), trabecular iris surface area (TISA) at 500 um and 750 um for both nasal and temporal sides in sulcus implantation were all significantly lower than in-the-bag implantation. CONCLUSIONS: A choice of a 0.5 lower diopter power IOL than the power for in-the-bag implantation may be considered because of greater myopic shift than predicted refractive error when sulcus implantation due to posterior rupture is performed. Anterior chamber angle in sulcus IOL implantation was shallower than in-the-bag IOL implantation.