The Clinical Characteristics and Surgical Results in the Intermittent Exotropia more than 15 Years of Age

We analyzed preoperative clinical characteristics, incidence of amblyopia, surgical results according to the type, resolution of preoperative symptoms and postoperative complications in 62 patients with intermittent exotropia, who were more than 15 years of age. The most frequent preoperative annoying symptom was eye strain from fatigue(40%), and the next one was cosmesis(23%). But, diplopia(14%) was relatively infrequent presenting complaint. Among 62 patients, 45 (72%) patients had equal vision, and 11 patients (18%) had amblyopia with two line difference between two eyes. The overall surgical success rate were seventy-seven percent. The 3 patients with postoperative esodeviation more than 5 prism diopters(PD) showed persistent uncrossed diplopia. The 4 patients with undercorrection more than 15 PD did not improve symptomatically. All patients with` postoperative exodeviation less than 15 PD had improvement or resolution of the symptoms. Our results suggest that overcorrection often resulted in unexpected diplopia in adults with intermittent exotropia. Therefore, it may be desirable to make undercorrection within 15 PD or orthotropic state in the patients more than 15 years of age.

Ultrastructure of surgically excised subfoveal neovascular membranes

We studied the ultrastructural features of four consecutive subfoveal neovascularmembranes (SFNM) associated with age-related macular degeneration. Cellular components of the membranes included retinal pigment epithelial (RPE) cells, endothelium-lined vascular channels, macrophages, myofibroblasts, fibrocytes, glial cells, erythrocytes, and lymphocytes. Extracellular interstitial constituents included collagen fibrils, basal laminar deposits, fibrin and young elastic fibrils. These findings show that SFNMs consist of various cells originating from surrounding tissues and vessels. Among these RPE cells and macrophages are the main cellular components and in conjunction with various extracellular matrix, especially collagen, may play an important role in the formation and maintenance of the membranes.

Double-pass excimer laser photorefractive keratectomy: treatment in 62 eyes with high myopia

To evaluate the efficacy and safety of Excimer Laser Photorefractive Keratectomy (PRK) on the correction of high myopia, we performed planned double-pass PRK procedure at the same session on 62 eyes of 55 patients with myopia ranging from -6.30D to -15.25D (mean, -9.94D). In the first pass, a myopic correction of -6.00D with a 4.5 millimeter ablation zone was performed, and immediately after, a second correction of remaining myopia with a 5.0 millimeter ablation zone was performed. Attempted correction ranged from -6.30D to -9.50D (mean, -8.70D). The eyes were divided into two groups which were -10.50D or less (group A), and higher than -10.50D (group B). All the eyes received topical corticosteroid therapy postoperatively. One year after double-pass PRK, uncorrected visual acuity in group A and B improved to 20/40 or better in 84.0%, and 73.3% of the eyes and to 20/30 or better in 75.0% and 33.3% of the eyes respectively. The mean refractive errors at 12 months after PRK were -0.3 +/- 1.6D in group A, and -1.5 +/- 2.1D in group B. The percent of achieved correction within +/- 1.0D were 70.8% in group A, and 46.7% in group B 12 months after surgery. The epithelium healed by three days and there were no corneal erosions. Corneal haze (Grade 2 or more) was seen in 9.0% in group A and 36.4% in group B at 12 months after PRK. A planned double-pass PRK is a promising approach to correct high myopia (up to -10.50D), but long-term follow up will be required.

The Inhibitory Effects of 5-fluorouracil on Experimental Proliferative Vitreoretinopathy

Proliferative vitreoretinopathy (PVR) is the main cause of failure in retinal reattachment surgery, Vitrectomy combined with pharmacologic therapy to inhibit proliferating and contracting epiretinal membranes appears to be a promismg approach in the management of PVR. We investigated the inhibitory effect of intravitreal 5-fluorouracil (5-FU) on experimental PVE induced by intravitreal injection of homologous dermal fibroblast in pigmented rabbits. At 6 weeks after intravitreal injection, Goup I (fibroblast only), Group II (early treatment with 1mg of 5-FU), and Group Ill (delayed treatment with 1mg of 5-FU) developed the retinal detachment in 85.7%, 33.3%, and 58.3% respectively. The rate of retinal detachment was lower in treatment groups than in non-treatment group, but there was a statistically significant difference only between non-treatment group (Group I) and early-treatment group (Group II) (p<0.05). In the group that only 5-FU was injected (Group IV), the retinas were preserved in normal clinically and pathologically. These results show that 5-FU may exert a significant anti proliferative effect on intraocular proliferative disorders including PVR especially if the drug is administered more earlier.

Morphometric Analysis of the Corneal Endothelial Cells in Normal Korean

To investigate the morphometric characteristics of the corneal endothelial cells in normal Korean, specular microscope has been used in 84 eyes of 42 normal Korean volunteers, 42 eyes in male, 42 eyes in female ranging in age from 5 to 71 years of age. We have analyzed cell density, cell area, coefficient of variation of cell area (CV), perimeter, shape factor, hexagonality, and side lengths, and compared the changes in each parameters according to age, right and left eye, and sex. The mean cell density was 3025 cells/mm2, and mean hexagonality was 67.01%. The values in these two parameters decreased with age (p

The Clinical Report on Seven Cases of Epikeratoplasty

After the first description of epikeratoplasty for the correction of aphakia, it has been widely used in high myopia and keratoconus for improvement of visual acuity. Seven epikeratoplasties were performed on five high myopia and two keratoconus patients showing intolerance to eye-glasses and contact lens, with the mean follow-up period of 9.7 months. In high myopia, mean spherical equivalent decreased from -15.90D to -2.05D postoperatively. In keratoconus, mean keratometric value decreased more than 4.94D postoperatively and the progression of disease stopped. All patients showed an imporvement in thei uncorrected visual acuity and best corrected visual acuity. In all cases, reepithelialization completed in 4-23 days (mean 14 days).

Morphometric Analysis of Corneal Endothelium in the Intercapsular Cataract Extraction with Posterior Chamber Lens Implantation

To compare corneal endothelial damage in intercapsular cataract extraction with post erior chamber lens implantation (Intercapsular P-ECCE+PCL) to that in conventional extracapsular cataract extraction with posterior chamber lens implantation (P-ECCE+PCL), and to detect the most appropriate index for comparision of the endothelial damage, the author has measured morphologic characteristics of corneal endothelium in 20 cases of intercapsu1ar P-ECCE+PCL (Group 1), and 21 cases of P-ECCE+PCL (Group 2) preoperatively and one week after surgery. Morphometric data (density, area, coefficient of variation, perimeter, shape factor, hexagonality, lengths) were obtained by contact type specular microscope, computer assisted digitizer and image analysis program. The mean endothelial cell loss one week after surgery was 10.82% in group 1, and 20.22% in group 2 respectively. The mean hexagonality loss one week after surgery was 28.05% in group 1, and 38.84% in group 2 (p<0.05). The mean coefficient of variation (CV) loss at postoperative one week was 30.68% in group 1, and 38.84% in group 2. As a whole, group 1 showed less reduction of endothelial damage compared to group 2 but no statiscally significant changes were noted except hexagonality. Therefore, the corneal endothelium was less damaged after intercapsular P-ECCE+PCL than after P-ECCE+PCL, and the adequate index for comparision of endothelial damage are CV and hexagonality as well as cell density, among which hexagonalty is the most important parameter.

Clinical efficacy of topical homologous fibronectin in persistent corneal epithelial disorders

The clinical efficacy was investigated of topical homologous fibronectin on persistent corneal epithelial defects of various etiologies. Fibronectin was purified from blood bank homologous plasma by gelatin-Sepharose 4B affinity chromatography. Twenty eight eyes of twenty five patients with persistent corneal epithelial defects and sterile corneal ulcers that failed to improve with standard therapy were treated by the instillation of homologous fibronectin eyedrops 5 times a day (500 microgram/ml). Complete reepithelialization was achieved in all patients except two eyes due to uncontrolled glaucoma and the taking of steroids. The healing time tended to be different depending on the duration of persistent corneal epithelial defects and the severity of underlying diseases. The mean +/- standard deviation duration of epithelial defect was 68.18 +/- 77.80 days. Average healing time was 42.07 +/- 17.47 days. Ocular symptoms were relieved significantly and no side effects were observed. Over an average follow-up period of about 8 months, two cases of recurrences were noted. These results show that homologous fibronectin was also effective in patients with persistent corneal epithelial defects and corneal ulcers.

The Effect of a Collagen Shield on Concentrations of Tobramycin in Corneas

Collagen shields made of porcine scleral collagen were immersed in a solution containing tobramycin sulfate(40 mg/ml) for five minutes, then applied to rabbit corneas. One, four and eight hours after application, the corneas were assayed for antibiotics by agar diffusion bioassay. We divided study groups as 4 groups, that is, collagen shield, subconjunctival, therapeutic soft contact lens and topical group, and compared the corneal concentradon of tobramycin in each group. Shields immersed in 40 mg/ml tobramycin produced significantly higher concentrations of tobramycin in the cornea at one and four hours than those of the other groups. Tobramycin concentrations in cornea eight hours after application became lower than those of one and four hours after application but, higher than minimal inhibitory concentration of Pseudomonas aeruginosa. Collagen shield containing antibiotics can serve as a vehicle for drug delivery and may prove superior to current methods for the initial treatment of bacterial keratitis, and preoperative and postoperative antibiotic prophylaxis.

Topical fibronectin treatment in persistent corneal epithelial defects and corneal ulcers

Topical fibronectin, autologous and homologous, was used to treat nine patients (eleven eyes) with persistent corneal epithelial defects and corneal ulcers that failed to improve with standard therapy. The fibronectin was purified from autologous and homologous plasma by gelatin-Sepharose 4B affinity chromatography and administered topically, 500 micrograms/ml five times a day, for three weeks. Complete or nearly complete reepithelialization was achieved in all patients regardless of the source of fibronectin, autologous or homologous. But healing times varied. The average healing time was 41.7 +/- 14.7 days (35.7 +/- 12.4 days for autologous, 50.8 +/-14.4 days for homologous). Ocular symptoms were relieved significantly, and no side effects were observed. Over an average follow-up period of 5.2 months, no recurrences were noted. The results showed that homologous, as well as autologous, fibronectin was effective in patients with persistent corneal epithelial defects and corneal ulcers.

The Influence of Fluorescein Concentration on the Tear Film Break-Up Time(BUT)

The Tear Film Break-Up Time(BUT) in the diagnosis of the dry eye syndrome was widely used, but its results were variable according to the methods of measuring BUTs. Especially, the method of Fluorescein administration and concentration had a great influence on BUT. The purpose of this study was to standardize the method used in measurement of BUT, particularly fluorescein solution concentration. We measured BUT in seven groups of different fluorescein solution concentration and total subjects were 464 persons. The results were as follows; 1. The mean BUT was 14.24 +/- 2.04 seconds in 0.12% Fluorescein solution, 11.73 +/- 2.11 seconds in 0.25% solution, 11.34 +/- 3.00 seconds in 0.5% solution, 10.3 +/- 3.50 seconds in 1% solution, 9.59 +/- 2.74 seconds in 2% solution, 7.56 +/- 1.84 seconds in 5% solution and 5.55 +/- 1.20 seconds in 8% solution. 2. The more Fluorescein concentration was, the shorter BUT became and there were statistically significant decrease in 0.25%, 0.5% and 2% Fluorescein solution.

Topical Autologous Fibronectin in the Treatment of Persistent Corneal Epithelial defects

Fibronectin, a glycoprotein, is present in plasma and extracellular matrix and is responsible for cellular adhesion. Fibronectin was purified from autologous plasma of two persistent corneal epithelial defect patients by affinity chromatogaphy and administered topically 500 micro ml, 2 dropsper time, five times a day for 3 weeks. Reepithelization began three to seven days after initiation of treatment with autologous purified fibronectin eyedrops, and epithelial defects healed nearly completely and subjective symptoms were relieved. No side effects were observed. Over a follow-up period of 4 to 23 wks, no recurrences were noted.

A Study of the Change in Angle Deviation under General Anesthesia in Horizontal Strabismus Patients

We measured the angle deviation by prism cover test before operating and by Hirschberg's method while under a surgical plane of anesthesia and studied the changes in 105 patients with uncomplicated comitant horizontal strabismus who underwent muscle surgery in the Department of Ophthalmology, Dongsan Medical Center, Keimyung University School of Medicine from June 1985 to February 1987. We excluded from the study those patients with previous muscle surgery, neurological disease, and those with mechanical restrictions of eye movement detected either by clinical examination or positive forced duction tests under general anesthesia, or both. The results were as follows: 1. Angle deviation at far was 28.7 +/- 13.8 delta in exotropia and 39.9 +/- 15.6 delta in esotropia, revealing a significantly larger angle deviation in esotropia than exotropla. 2. The change in angle deviation under general anesthesia showed a decrease in the amount of preoperative angle deviation of 15.5 +/- 12.0 delta in exotropia and 27.2 +/- 17.7 delta in esotropia, significantly more decreased in esotropia than in exotropia. The change according to sex and age was of no significance in exotropia and esotropia. 3. The relationship between the preoperative angle deviation at far(DF) and that under general anesthesia(DA) was linear and could be written as the approximate regression formula: DA=0.40DF+2.20(r=0.76). 4. The relationship between the preoperative angle deviation at far(DF) and the change in angle deviation under general anesthesia[D(A-F)] was linear and could be written as the approximate regression formula: D(A-F)=-0.60DF+2.20 (r= -0.87). The change in angle deviation under general anesthesia revealed a decrease in the amount of preoperative angle deviation both in exotropia and esotropia and, in general, the larger the preoperative angle deviation was, the greater was the change in angle deviation under general anesthesia. 5. In exotropia, the change in angle deviation under general anesthesia according to the difference between preoperative angle deviation at near and far was -14.4 +/- 11.9 delta in cases of larger angle deviation at near than far, -18.3 +/- 9.6 delta in cases of larger angle deviation at far than near, and -18.8 +/- 15.4 delta in cases of the same angle deviation at near and far, respectively, which was of no clinical significance. 6. In esotropia, the change in angle deviation under general anesthesia according to the difference between preoperative angle deviation at near and far was +26.7 +/- 14.3 delta in cases of larger angle deviation at near than far, +35.3 +/- 27.3 delta in cases of larger angle deviation at far than near, and +25.6 +/- 18.3 delta in cases of the same angle deviation at near and far, respectively, which again was of no clinical significance. Thus, our results suggest that the eye position under surgical anesthesia has a tendency to change toward the anatomical position of rest and the innervational imbalance may play a major role in the causation of horizontal strabismus. It seems to have no influence in changing the preoperative surgical plan on the basis of the change in angle deviation under general anesthesia in horizontal strabismus patients.

Average Value of Margin Limbal Distance in Koreans

The measurement of levator muscle function is the most important step in the evaluation of patients with blepharoptosis and also the most important factor in the choice of operation for blepharoptosis. There are two methods in measuring the levatormuscle function; one is Berke's method and the other is margin limbal distance(MLD). When the levator muscle resection procedure is indicated in blepharoptotic patients, preoperative MLD value is the clue to determine the amount of levator muscle to be resected by the MLD formula. MLD was measured in 419 normal Koreans who were examined in the Depart ment of Ophthalmology, Keimyung University School of Medicine from October 1987 to August 1988. The results were as follows: 1. The average value of MLD was 6.3 +/- 1.2mm. 2. The average value of MLD in males was 6.3 +/- 1.3mm and 6.2 +/- 1.2mm in females. 3. The average value of MLD in both eyes was 6.3 +/- 1.2mm. 4. The average value of MLD in different age groups was 5.7 +/- 1.0mm in the below 10 age gruop, 6.0 +/- 1.1mm in the 11-20 age group, 6.8 +/- 1.2mm in the 21-30 age group, 6.8 +/- 1.3mm in the 31-40 age group, 6.4 +/- 1.2mm in the 41-50 age group, 6.1 +/- 1.3mm in the 51-60 age group and 6.3 +/- 1.1mm in the above 60 age group, respectively. The average value of MLD was significantly different in the different age groups(p<0.01). Thus, the average value of MLD in normal Koreans was 6.3 +/- 1.2mm, which is significantly different from the 9mm of Putterman's. So we must consider 6.3 +/- 1.2mm as the normal value of MLD when determining the amount of levator muscle resection by the MLD formula.

A Case of Solitary Metastatic Iris Tumor from Bronchogenic Carcinoma: Responese to Chemotherapy

Metastatic tumors to the eye are probably the most common type of intraocular malignancies. The choroid is the most common site of involvement. Though the iris is a less common site of uveal involvement, metastases to the iris may occur and may produce a variety of clinical findings. The most common metastatic tumor to the eye is breast tumor and lung tumor is second, whereas the prompt most common metastatic tumor to the iris is lung tumor and breast tumor is second. The iris lesion may be the first presentation of the cancer and should make a search for the primary tumor. The diagnosis of metastatic tumor to the iris can be established by cytologic examination of aqueous. Local irradiation can spare the patient an enucleation and can preserve the eye for the generally few months of life that remain. Although the prognosis for vision is usually good, the prognosis for life is poor. The authors describe a 37 year old male patient having a metastasis from oat cell carcinoma of the lung to iris, which begins to respond to chemotherapy.

Bilateral Microcornea with Cornea Plana in a Family

Microcornea is a condition characterized by a small cornea in an otherwise normal eye and can be defined when corneal diameter is less than 11.00mm. Microcornea may occur as an isolated abnormality or accompany other anterior segment anomalies like aniridia and anterior chamber cleavage abnormalities. Microcornea is part of nanophthalmos, a condition in which a reduction in global dimensions is the only structural abnormality, as well as microphthalmos, a term generally, used to signify a small, abnormal globe. Microcornea is a rare anomaly and its etiology is probably a primary aberration of the growth of the ectoderm of the optic cup. Both autosomal dominant and autosomal recessive patterns of inheritance occur, but it may appear sporadically. Cornea plana is usually seen in association with microcornea wherein the corneal curvature is less than normal. It is often associated with diffuse opacities of the cornea stroma. Cornea plana might be caused by a deep developmental arrest in the fourth month, at which time the cornea begins to increase its curvature relative to the sclera. The authors experienced a case of bilateral microcornea with cornea plana in a family which seemed to transmit as the dominant trait.

Bilateral Microcornea with Cornea Plana in a Family

Microcornea is a condition characterized by a small cornea in an otherwise normal eye and can be defined when corneal diameter is less than 11.00mm. Microcornea may occur as an isolated abnormality or accompany other anterior segment anomalies like aniridia and anterior chamber cleavage abnormalities. Microcornea is part of nanophthalmos, a condition in which a reduction in global dimensions is the only structural abnormality, as well as microphthalmos, a term generally, used to signify a small, abnormal globe. Microcornea is a rare anomaly and its etiology is probably a primary aberration of the growth of the ectoderm of the optic cup. Both autosomal dominant and autosomal recessive patterns of inheritance occur, but it may appear sporadically. Cornea plana is usually seen in association with microcornea wherein the corneal curvature is less than normal. It is often associated with diffuse opacities of the cornea stroma. Cornea plana might be caused by a deep developmental arrest in the fourth month, at which time the cornea begins to increase its curvature relative to the sclera. The authors experienced a case of bilateral microcornea with cornea plana in a family which seemed to transmit as the dominant trait.

A Case of Rieger's Anomaly

Rieger's anomaly refers to a dysgenesis that features bilateral hypoplasia of the iris stroma, posterior embryotoxon and the associated angle anomalies, pupillary distortion, polycoria, and a high likelihood of glaucoma. In addition to glaucoma, other defects, usually dental, may be present in Rieger's anomaly. When glaucoma occurs, it usually develops during the first to third decades but infrequently occurs in infancy. Frequently mesodermal dysgenesis accompanies ectopia of the pupil and polycoria. In these anomalies no new synechias are formed such as occur in essential iris atrophy. Cataracts are occasionally part of the picture. The anomaly is extremely variable in its expression with the full-blown disease in one member of a family and only minimun signs in another. The authors experienced a case of Rieger's anomaly which occurred in both eyes of 18 year old male who had above characteristic ocular findings and associated juvenile onset glaucoma.

A Clinical Study on A and V Patterns

A and V patterns are manifest by a horizontal change of alignment of the eyes that occurs on midline upgaze and downgaze as the eyes are moved from the primary position. A and V patterns may be associated with orthophoria, esodeviation, or exodeviation in the primary position. Compensatory head postures are frequently found in patients having A and V patterns. A great deal has been written about the etiology, however, no single etiologic factor can explain all A and V patterns. A and V patterns are revealed by prism and alternate cover midline measurements, comparing 30 degrees upgaze, primary position, and 30 degrees downgaze. A difference of 15 delta between up and down measurements in V patterns and 10 delta in A patterns is necessary for a valid diagnosis. Some surgical methods were described to correct the A and V patterns, only two methods receive widespread acceptance: vertical transposition of the insertions of the horizontal rectus muscles and weakening of the oblique muscles. The authors studied clinically 8 cases of V patterns and 1 case of A pattern in 118 strabismic patients. The results were as follows; 1) The prevalence of A and V patterns was about 8%(9/118). 2) In V patterns, weakening procedures on the inferior oblique muscles with surgery on the horizontal rectus muscles corrected 7 delta to 12 delta between primary position and upgaze. And combining vertical transposition of horizontal rectus muscles corrected an additional 17 delta to 28 delta of V patterns between up and downgaze. 3) In A pattern, resecting inferior rectus muscle with surgery on the horizontal rectus muscles corrected 6 delta of A pattern.

A Case of Takayasu's Arteritis

A 27-year-old woman had a cataract in the left eye and absent radial pulses in both upper extremities. Fundus examination of the right eye disclosed arteriovenous anastomosis about the disc and segmentation of venous blood column. Aortogram revealed complete obstruction of brachiocephalic, left common carotid and left subclavian arteries, which were the branches of aortic arch. Takayasu's arteritis is an uncommon disorder which causes obliteration of branches of aortic arch and pulmonary artery. Its characteristics are absence of pulsation in the upper extremities and arteriovenous anastomosis around the disc. It affects mainly young females and its etiology is uncertain.