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.

Fourteen Anti-vascular Endothelial Growth Factor Injections for Age-related Macular Degeneration: Ending Period and Clinical Outcome

PURPOSE: To evaluate the clinical course of patients who had completed 14 ranibizumab or aflibercept monocular treatments. METHODS: Retrospective medical record analysis was performed to 24 patients who were diagnosed with monocular neovascular age-related macular degeneration and had completed 14 ranibizumab or aflibercept monocular injections, allowed by the Korean National Health Care system. Time to completion was measured along with the percentage and timing of medication switch. Best-corrected visual acuity (BCVA) was measured at the time of diagnosis, after 3-loading injections, and the time of completion. Additionally, we searched for any other factors that had influenced the time to completion. RESULTS: The average time to completion of 14 injections was 32.3 ± 6.2 months (21–48 months). The switching was performed in 17 eyes (70.8%), and it was done after 9.4 ± 2.1 injections (4–14 injections) with prior medication. After 14 injections, the BCVA improved in 6 eyes (25.0%), unchanged in 8 eyes (33.3%), and worsened in 10 eyes (41.7%). Complete resolution of intraretinal fluid and subretinal fluid after 3 loading injections were observed in 20 eyes, and it was significantly related to time to the first recurrence and time to the completion of 14 injections (p = 0.007, r = 0.583). CONCLUSIONS: The average time to completion of 14 injections was 32.3 months, and switching of medication was performed in 70.8%. Longer time to the first recurrence was related to longer completion time. This study will provide useful facts when informing the patients their future treatment plans under the Korean Health Care system.

Natural Short-term Course of Recurrent Macular Edema Following Intravitreal Bevacizumab Therapy in Branch Retinal Vein Occlusion

PURPOSE: To evaluate the 3-month natural course of recurrent macular edema secondary to branch retinal vein occlusion (BRVO) treated with intravitreal bevacizumab. METHODS: This retrospective, observational study included 36 eyes with macular edema secondary to BRVO. All patients were initially treated with intravitreal bevacizumab for macular edema. Recurrence of macular edema was either not treated (untreated group) or treated with a single intravitreal bevacizumab injection (treated group). Central foveal thickness (CFT) and best-corrected visual acuity (BCVA) were compared at the time of recurrence and 3 months later. RESULTS: At the time of recurrence, the mean CFT and logarithm of the minimum angle of resolution BCVA were 484.9 ± 124.1 µm and 0.58 ± 0.26 in the untreated group (n = 19) and 456.3 ± 126.8 µm and 0.51 ± 0.21 in the treated group (n = 17), respectively. Three months later, the mean CFT and BCVA had changed to 493.7 ± 123.9 µm and 0.62 ± 0.29 in the untreated group and 294.7 ± 104.4 µm and 0.40 ± 0.24 in the treated group, respectively. The differences in CFT and BCVA between the two time points were not significant in the untreated group (p = 0.106 and p = 0.687, respectively), whereas statistically significant differences were noted in the treated group (p = 0.002 and p < 0.001, respectively). CONCLUSIONS: Unlike the first episode of macular edema following BRVO, recurrent macular edema following intravitreal bevacizumab therapy did not spontaneously resolve, suggesting the potential benefit of prompt treatment.

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.

Comparison of Short-Term Clinical Outcomes between Intravitreal Ranibizumab and Aflibercept in Retinal Angiomatous Proliferation

PURPOSE: To evaluate the 6-month outcomes of intravitreal ranibizumab and aflibercept treatment for patients with retinal angiomatous proliferation (RAP). METHODS: A retrospective review of medical records of 28 patients (31 eyes) diagnosed with RAP was performed. All patients were initially treated with 3 consecutive intravitreal ranibizumab or aflibercept injections after diagnosis. Additional treatment was performed when exudation recurred. The best-corrected visual acuity (BCVA) and central foveal thickness were measured before the first injection and 3 and 6 months after the first injection. The values measured before the treatment were compared with those after treatment. RESULTS: Sixteen eyes were treated with ranibizumab and 15 eyes with aflibercept. The logarithm of minimal angle of resolution (log MAR) values of BCVA before the first injection and 3 and 6 months after the first injection were 0.78 +/- 0.50, 0.47 +/- 0.30 and 0.59 +/- 0.41 in the ranibizumab group and 0.96 +/- 0.52, 0.83 +/- 0.52 and 0.74 +/- 0.56 in the aflibercept group, respectively. Central foveal thickness was 315.75 +/- 115.44, 188.38 +/- 57.33 and 218.50 +/- 96.49 microm in the ranibizumab group and 249.00 +/- 74.88, 143.73 +/- 32.73 and 196.73 +/- 94.08 microm in the aflibercept group, respectively. BCVA was significantly improved and central foveal thickness was significantly reduced at 6 months (p < 0.05) compared to measurements before the first injection in both groups. However, BCVA improvement and central foveal thickness were not significantly different between the 2 groups. CONCLUSIONS: Both intravitreal ranibizumab and aflibercept treatments were beneficial for both normalizing macular thickness and improving visual acuity in patients with RAP. The efficacy of the 2 drugs was not noticeably different.

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.

Intravitreal Anti-Vascular Endothelial Growth Factor for Retinal Pigment Epithelial Tear in Retinal Angiomatous Proliferation

PURPOSE: To evaluate the treatment outcomes of intravitreal anti-vascular endothelial growth factor (VEGF) therapy for retinal pigment epithelial (RPE) tear in retinal angiomatous proliferation (RAP). METHODS: In the present study we retrospectively analyzed the medical records of 14 patients (14 eyes) diagnosed with RPE tear secondary to RAP treated with intravitreal anti-VEGF. Best-corrected visual acuity (BCVA) when the RPE tear developed was compared with BCVA at 6 months and at the final follow-up. RESULTS: The mean age of the study patients was 75.1 +/- 7.0 years and the mean follow-up period was 23.7 +/- 13.7 months. During the follow-up period, patients were treated with a mean of 2.8 +/- 1.3 intravitreal anti-VEGF injections. The mean logarithm of minimal angle of resolution BCVA when the RPE tear developed, at 6 months and at the final follow-up was 1.25 +/- 0.44, 1.44 +/- 0.56, and 1.65 +/- 0.39, respectively. The BCVA at 6 months was not different from the baseline value (p = 0.258), whereas the BCVA at the final follow-up was significantly worse than the baseline value (p = 0.002). CONCLUSIONS: The prognosis of RPE tear in RAP is poor despite anti-VEGF therapy. This result suggests further investigations regarding the prevention of RPE tear or more effective treatment method for this condition are necessary.

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.

Intravitreal Anti-vascular Endothelial Growth Factor for Typical Exudative Age-related Macular Degeneration in Eyes with Good Baseline Visual Acuity

PURPOSE: To investigate 12-month treatment outcomes of anti-vascular endothelial growth factor therapy in eyes with typical exudative age-related macular degeneration with good baseline visual acuity. METHODS: This retrospective observational case series included 18 eyes (18 patients) with typical exudative age-related macular degeneration with a baseline best-corrected visual acuity of 20 / 25 or better. Patients were treated with anti-vascular endothelial growth factor monotherapy during the 12-month follow-up period. Baseline visual acuity and central foveal thickness were compared to the values at 12 months. RESULTS: Patients received an average of 4.4 +/- 1.3 intravitreal anti-vascular endothelial growth factor injections. The mean logarithm of minimum angle of resolution visual acuity was 0.08 +/- 0.04, 0.08 +/- 0.07, 0.12 +/- 0.09, and 0.16 +/- 0.11 at baseline, three months, six months, and 12 months, respectively. Visual acuity at 12 months was significantly worse than the baseline value at diagnosis (p = 0.017), and the mean central foveal thickness at the defined time points was 270.2 +/- 55.6, 204.4 +/- 25.4, 230.1 +/- 56.3, and 216.8 +/- 48.7 microm, respectively. The central foveal thickness at 12 months was significantly less than the baseline value at diagnosis (p = 0.042). CONCLUSIONS: Deterioration in visual acuity was noted in eyes with typical exudative age-related macular degeneration with good baseline visual acuity, suggesting the need for close patient monitoring and prompt treatment even in patients with good baseline visual acuity.

Characteristics and Surgical Outcome of Macular Holes Developing after Rhegmatogenous Retinal Detachment Repair

PURPOSE: To report the characteristics and surgical outcome of macular holes (MHs) that develop after rhegmatogenous retinal detachment (RRD) repair. METHODS: A retrospective chart review was performed in patients who developed a new full-thickness macular hole after RRD repair between May 2010 and July 2013. For eyes that underwent pars plana vitrectomy with internal limiting membrane peeling and gas tamponade for MH repair, main outcomes included macular attachment status and postoperative visual acuity. RESULTS: Fourteen full-thickness MHs were detected in a series of 2,815 eyes (0.49% prevalence) that had undergone prior RRD surgery. Ten MHs developed after primary vitrectomy and four after scleral bucking surgery. The fovea was detached in eight of the 14 eyes at the time of RRD. Fourteen of 14 eyes were managed by pars plana vitrectomy, internal limiting membrane peeling, and intravitreal gas tamponade, and 12 of 14 eyes achieved MH closure. Mean preoperative Snellen best-corrected visual acuity (BCVA) was 20/63 (+/-0.25). Nine of 14 eyes had an improvement in visual acuity of at least two Snellen lines, and five eyes remained unchanged. CONCLUSIONS: In this small retrospective study, the secondary MHs were found predominantly in foveal detachments after RRD repair, most commonly occurring after primary vitrectomy. In conclusion, the surgical outcome and postoperative visual acuity improvement were satisfactory, although the final BCVA depended on the macular status during the RRD.

Use of Optical Coherence Tomography to Evaluate Visual Acuity and Visual Field Changes in Dengue Fever

Dengue fever is a viral disease that is transmitted by mosquitoes and affects humans. In rare cases, dengue fever can cause visual impairment, which usually occurs within 1 month after contracting dengue fever and ranges from mild blurring of vision to severe blindness. Visual impairment due to dengue fever can be detected through angiography, retinography, optical coherence tomography (OCT) imaging, electroretinography, event electroencephalography (visually evoked potentials), and visual field analysis. The purpose of this study is to report changes in the eye captured using fluorescein angiography, indocyanine green, and OCT in 3 cases of dengue fever visual impairment associated with consistent visual symptoms and similar retinochoroidopathic changes. The OCT results of the three patients with dengue fever showed thinning of the outer retinal layer and disruption of the inner segment/outer segment (IS/OS) junction. While thinning of the retina outer layer is an irreversible process, disruption of IS/OS junction is reported to be reversible. Follow-up examination of individuals with dengue fever and associated visual impairment should involve the use of OCT to evaluate visual acuity and visual field changes in patients with acute choroidal ischemia.

Use of Optical Coherence Tomography to Evaluate Visual Acuity and Visual Field Changes in Dengue Fever

Dengue fever is a viral disease that is transmitted by mosquitoes and affects humans. In rare cases, dengue fever can cause visual impairment, which usually occurs within 1 month after contracting dengue fever and ranges from mild blurring of vision to severe blindness. Visual impairment due to dengue fever can be detected through angiography, retinography, optical coherence tomography (OCT) imaging, electroretinography, event electroencephalography (visually evoked potentials), and visual field analysis. The purpose of this study is to report changes in the eye captured using fluorescein angiography, indocyanine green, and OCT in 3 cases of dengue fever visual impairment associated with consistent visual symptoms and similar retinochoroidopathic changes. The OCT results of the three patients with dengue fever showed thinning of the outer retinal layer and disruption of the inner segment/outer segment (IS/OS) junction. While thinning of the retina outer layer is an irreversible process, disruption of IS/OS junction is reported to be reversible. Follow-up examination of individuals with dengue fever and associated visual impairment should involve the use of OCT to evaluate visual acuity and visual field changes in patients with acute choroidal ischemia.

Comparison of 20, 23 and 25 Gauge Vitreoretinal Surgical Instruments

PURPOSE: To investigate the diameter, the infusion and aspiration rate of 20-, 23- and 25-gauge vitreous cutters, and compare the theoretical and practical intraocular pressure (IOP) change according to the height of the bottle. METHODS: A vitreous cutter was disassembled to measure the actual external and internal diameter. The infusion rate was measured at the height of 40, 60, 80, 100 and 120 cm and the suction rate was measured at a pressure of 100, 200, 300, 400 and 500 mm Hg for each gauge. IOP during the operation was calculated according to the bottle height and the actual IOP was measured using a mercury sphygmomanometer. RESULTS: The external diameter of the 20-, 23- and 25-gauge was 900, 596, and 500 mm, respectively, and the internal diameter was 670, 450, and 380 mm, respectively. The infusion rate increased in direct proportion to the bottle height. The aspiration rate increased as the pressure increased. However, the increment of the infusion and aspiration rate in the 20-gauge vitreous cutter was the highest and decreased in the 23- and 25-gauge, in that order. IOP was calculated as 29, 44, 59 and 74 mm Hg when the bottle height was at 40, 60, 80 and 100 cm, respectively, and was measured 34, 50, 62 and 74 mm Hg, respectively. CONCLUSIONS: The infusion and aspiration rates per outer diameter in the 23- and 25-gauge vitreous cutters and infusions using cannula were lower than in the 20-gauge vitreous cutter. The difference of the infusion and aspiration rates per diameter between the 23- and 25-gauge vitreous cutters and infusions was not significant.

Characteristic Findings of Optical Coherence Tomography in Retinal Angiomatous Proliferation

PURPOSE: To identify the unique pathologic findings of retinal angiomatous proliferation (RAP) in optical coherence tomography (OCT). METHODS: Retrospectively, 29 eyes of 25 patients with age-related macular degeneration and complicated RAP were analyzed. All 29 eyes had choroidal neovascularization (CNV) in the area of pigment epithelial detachment (PED) or adjacent to it, which was visible with fluorescein angiography or indocyanine green angiography. Cross-sectional images were obtained by OCT scanning through the CNV lesions. RESULTS: Six distinctive findings of OCT included drusen (100%), inner retinal cyst (80%), outer retinal cyst (68%), fibrovascular PED (84%), serous retinal detachment (40%), and PED (68%). CONCLUSIONS: Through analysis of OCT findings, we revealed six different types of lesions distinctive of RAP which may provide helpful diagnostic information for subsequent treatment and predicting the prognosis of RAP.

Twelve-Month Outcomes of Intravitreal Anti-Vascular Endothelial Growth Factor Therapy for Retinal Angiomatous Proliferation

PURPOSE: To evaluate the 12-month outcomes of anti-vascular endothelial growth factor (VEGF) treatment for patients with retinal angiomatous proliferation (RAP). METHODS: Retrospective review of medical records was performed for 33 patients (33 eyes) who were diagnosed with RAP. All patients were initially treated with three consecutive intravitreal anti-VEGF injections after diagnosis. Additional treatment was performed when the recurrence of exudation was noted. The best-corrected visual acuity (BCVA) was measured before the first injection and at 3, 6, and 12 months after the first injection. The value measured before the treatment was compared with those measured after treatment. RESULTS: The patients received an average of 4.2 +/- 1.7 intravitreal anti-VEGF injections during the 12-month follow-up period. The logarithm of minimal angle of resolution (log MAR) values of BCVA before the first injection and at 3, 6, and 12 months after the first injections were 0.76 +/- 0.49, 0.55 +/- 0.35, 0.67 +/- 0.41, and 0.70 +/- 0.50, respectively. BCVA was significantly improved at 3 and 6 months (p or =2 log MAR lines of improvement) BCVA. CONCLUSIONS: Anti-VEGF therapy was found to be beneficial in both normalizing macular thickness and in improving or maintaining visual acuity in the majority of patients with RAP.

Maculopathy Associated with Tacrolimus (FK 506)

A 63-year-old man with a history of liver transplantation presented to our clinic complaining of visual disturbance. He had been receiving tacrolimus (FK 506) for 30 months (6 mg/day for 2 years and 3 mg/day for 6 months); he reported that the visual disturbance began while taking tacrolimus. A full ophthalmologic examination and electrophysiologic and imaging studies were performed. The best corrected visual acuity was 0.1 in both eyes. There were no abnormal finding in the anterior segment, pupillary reflexes were normal and, there was no swelling in either optic disc. Although the foveal reflex was slightly decreased, fluorescein angiography revealed non-specific signs, with the exception of a window defect. A multifocal electro-retinogram revealed decreased amplitude of the central ring. A Swedish interactive threshold algorithm-standard 10-2 visual field test revealed a central scotoma. These findings suggest that tacrolimus may result in maculopathy. Therefore, careful ophthalmologic examination is necessary in the patients taking tacrolimus.

Clinical Course after Intravitreal Bevacizumab Injection in Ischemic Central Retinal Vein Obstruction

PURPOSE: To determine the clinical outcome of intravitreal bevacizumab injection in patients with ischemic central retinal vein obstruction (CRVO). METHODS: The present study was conducted retrospectively on 56 eyes of 56 patients who were diagnosed with CRVO and classified according to ischemic and non-ischemic type and underwent an intravitreal bevacizumab injection. The present study measured changes in visual acuity and central macular thickness, neovascularization in the anterior segment, development of neovascular glaucoma and other clinical complications. RESULTS: The average number of bevacizumab injections in both groups was 2.07 and 1.62 in the ischemic type. No patients developed neovascular glaucoma in the non-ischemic type group, 14 of 26 eyes in the ischemic type group developed neovascular glaucoma and the mean time to diagnosis was 28.75 weeks. log MAR visual acuity of the ischemic type group prior to injection was 1.56 +/- 0.65 on average which improved to 1.44 +/- 0.97 (p = 0.45). CONCLUSIONS: Intravitreal bevacizumab injection improves the condition of cystic macular edema clinically, but does not affect the development of neovascular glaucoma and improvement of visual acuity in ischemic type CRVO.

The Revision Operation Rate for Adjacent Segmental Degeneration by Survival Analysis in Mono-segment Lumbar Fusion / 대한정형외과학회잡지

PURPOSE: To analyze survival rates of patients after mono-segmental lumbar or lumbosacral fusion and to evaluate factors affecting the revision operation due to adjacent segmental degeneration. MATERIALS AND METHODS: This study enrolled 1,206 patients who had mono-segmental lumbar or lumbosacral fusion between March 1997 and December 2006 at the Seoul Spine Institute. The survival rates for the revision operation due to adjacent segmental degeneration were analyzed retrospectively. The age at index operation, sex, etiologic diagnosis, fusion method, fusion level, substance of bone graft, operator, body mass index (BMI), and smoking were considered as risk factors for the revision operation. RESULTS: There were 27 patients with a revision operation for adjacent segmental degeneration (2.24%). The average follow-up period was 39.0 months (6 months to 12 years 6 months) and the average age at operation was 47.0 years (13 to 85 years). The survival rate at 5 years was 97.3%, and at 10 years it was 89.4%. Patients less than 50 years old had a significantly lower revision operation rate than those aged 50 or more (p=0.002). When fusion between the 4th lumbar and the 5th lumbar spinal vertebrae was done, the revision operation rate was significantly higher than for other levels (p=0.003). Obese patients with BMI> or =25 had a significantly higher revision rate than did patients with BMI0.05). In multivariate analysis, age alone was a significant risk factor (p=0.048, Hazard ratio=2.50). CONCLUSION: The most important factor for survival without revision surgery for adjacent segmental degeneration following instrumented mono-segment lumbar or lumbosacral fusion is the age at index operation. Patients 50 year-old or older should be informed of the possibility of adjacent segmental disease after instrumented mono-segment lumbar or lumbosacral fusion.

A Comparison of Clinical Stability of Distal Instrument Fused Down to S1 with and without Sub-S1 Alar Screw in the Long Fusion using Segmental Pedicle Screw for Lumbar Degenerative Deformity

STUDY DESIGN: This is a retrospective study. OBJECTIVES: We wanted to assess the stability of distal instrumentation using the bilateral S1 and sacral alar screws for the treatment of degenerative lumbar deformity. SUMMARY OF LITERATURE REVIEW: Various instrumentation methods have been introduced for increasing the strength of lumbosacral fusion. However, there are not many clinical studies that have evaluated the effectiveness of a sub-S1 alar screw for treating degenerative lumbar deformity surgery. MATERIALS AND METHODS: A total of 39 patients with degenerative lumbar deformity were treated by long fusion and we retrospectively analyzed these patients after a minimum follow-up of 1 year. All the patients underwent an operation with distal instrumentation using either bilateral S1 screws alone (the S1 group) or additional bilateral sub-S1 sacral alar screws (the SA group). There were 19 patients in the S1 group and 20 patients in the SA group. The stability of the distal instrumentation was assessed by breakage or backout of a rod and/or screws based on simple radiography. RESULTS: Instability of the distal instrumentation was detected in 6 cases (32%) in the S1 group and in 1 case (5%) in the SA group. The SA group had a more stability of the distal instrumentation than that of the S1 group with a significant difference (P0.05). CONCLUSIONS: Bilateral sacral alar screws coupled with bilateral S1 screws can provide good distal fixation for stability of the distal instrumentation when performing long fusion for treating degenerative lumbar deformity.

A Case of Bilateral Morning Glory Syndrome

PURPOSE: To report a bilateral case of morning glory syndrome. CASE SUMMARY: On May 30, 2002, a six-year-old patient visited our clinic with impaired visual acuity of her left eye and was diagnosed as having a cataract on her left eye superimposed on a bilateral morning glory anomaly. According to cycloplegic refraction, the patient's corrected visions was 0.8 in the right eye and 0.1 in the left. On June 20, 2002, the patient received ultrasonographic phacoemulsification, intraocular lens implantation, synechiolysis and partial vitectomy in her left eye. Approximately 5.2 years after the surgery, according to manifest refraction, the patient's corrected visions were 0.8 in the right eye and 0.1 in the left, no prominent postoperative changes were observed on slit lamp microscopy and fundus examinations. The thickness of the central macula of her right eye had decreased according to optical coherence tomography; the physiologic scotoma size of the patient's right eye had increased with narrowed peripheral visual field of her left eye. CONCLUSIONS: Although monocular morning glory anomaly has previously been reported to occur, in the present study case, the anomaly occurred bilaterally. In morning glory patients, strabismus examination and additional evaluation of a patient's general state should be performed along with a regular fundus examination.