Effects of Smoking on Tear Film and Ocular Surface

This study was performed to evaluate the changes of tear film and ocular surface caused by smoking. Symptom scoring, tear film break-up time (BUT), basal tear secretion test, corneal sensitivity test, keratoepitheliopathy scoring, and conjunctival impression cytology were performed in 29 smokers (58 eyes) and 26 non-smokers (52 eyes). Tear film BUT, basal tear secretion, corneal sensitivity, and squamous metaplasia were 7.71 +/- 2.66 sec, 6.29 +/- 2.85 mm, 53.69 +/- 5.69 mm, and 2.45 +/- 1.26 in smokers and 9.62 +/- 3.14 sec, 10.04 +/- 3.87 mm, 56.46 +/- 4.79 mm, and 1.12 +/- 0.83 in non-smokers, respectively (p< 0.05). Symptom score, keratoepitheliopathy score, and goblet cell density were not significantly different between the two groups. Tear film BUT was shorter, basal tear secretion and corneal sensitivity were lower, and squamous metaplasia was higher in heavy smokers than in light smokers. In conclusion, smoking deteriorates the tear film and ocular surface with decreased quantity and quality of tear film, decreased corneal sensitivity, and squamous metaplasia, and this deterioration is related to the amount of smoking.

Long-term Study of Radial Optic Neurotomy in Central Retinal Vein Occlusion

PURPOSE: To determine the clinical effect of radial optic neurotomy (RON) in central retinal vein occlusion (CRVO). METHODS: The retinal findings, visual acuity and complications were analyzed in patients who had undergone RON for the treatment of CRVO and were followed up 10 months or more after surgery. RESULTS: Of all 16 patients (16 eyes), the mean age was 55 years and the follow-up period was 14 months. Preoperative anterior segment and retinal neovascularization was observed in each three eyes. All eyes showed improvement in the retinal findings within two weeks after RON. The postoperative complications included vitreous hemorrhage in 1 eye, chorioretinal collateral circulation in 1 eye, neovascular glaucoma in 1 eye, vitreous hemorrhage and neovascular glaucoma in 1 eye. The visual acuity was counting fingers or less in 8 eyes preoperatively and in 2 eyes finally, and was less than 0.1 in 13 eyes preoperatively and in 10 eyes finally. The mean visual improvement in the 3.8 lines was in 11 eyes and a loss of 2.5 lines in 2 eyes. The maximum velocity of the blood flow of CRV improved with 1.95 +/- 0.93 cm/sec on the average in the 7 eyes examined by color doppler. CONCLUSIONS: RON appears to be safe and effective for improving the retinal findings, visual acuity and blood flow of CRV in CRVO. However, the visual recovery is limited.

Animal Study of Photodynamic Therapy with Verteporfin in Corneal Neovascularization

PURPOSE: To determine the efficacy of photodynamic therapy (PDT) with verteporfin (Visudyne(R), Norvatis Ophthalmics AG, Hettingen, Switzerland), a benzoporphyrin derivative, in the treatment of corneal neo-vascularization (CN) in a rabbit eye model. METHODS: CN was induced by placing instrastromal sutures in the cornea. Two weeks after suturing, verteporfin was administrated intravenously and 1 hour later, the right eye (treated group) was exposed to a laser with a 689 nm wavelength, and the left eye was used as the control. The changes in CN were analyzed using biomicroscopy and optical microscopy in twelve rabbits. RESULTS: The mean percentages of the neovascular area in the control and treated groups were 96.4 +/- 1.9% and 90.3 +/- 3.5% (P=0.009) at three days after the PDT, 88.6 +/- 4.6% and 71.6 +/- 6.2% (P<0.001) at one week, and 76.8 +/- 4.4% and 43.6 +/- 15.1% (P<0.001) at two weeks, respectively. Optical microscopy showed significant differences between the control and treated group in terms of the area and number of CN (P<0.05). CONCLUSIONS: PDT with verteporfin is a safe and effective procedure for regressing CN. However, a further study will be necessary.

Changes of Tear Film and Ocular Surface in Diabetes Mellitus

This study was performed to investigate the changes of tear film and ocular surface in diabetic patients, as well as the ocular and systemic factors related to these changes. We assessed the scoring of keratoepitheliopathy, corneal sensitivity test, tear film break-up time (BUT), Schirmer test, and conjunctival impression cytology in 94 eyes of 47 patients with noninsulin-dependent diabetes mellitus and in 60 eyes of 30 normal subjects. The degree of keratoepitheliopathy was severe, and the corneal sensitivity, BUT, and tear secretion were significantly reduced in the diabetic patients. Conjunctival impression cytology showed a higher grade of conjunctival squamous metaplasia and lower goblet cell density in the diabetic patients. All parameters were related to the status of metabolic control, diabetic neuropathy, and stage of diabetic retinopathy. We think that diabetic patients with poor metabolic control, neuropathy, and advanced stage of retinopathy should be examined for tear film and ocular surface changes.

Internal Limiting Membrane Peeling Using Indocyanine Green in Vitrectomy for Idiopathic Macular Hole

PURPOSE: To evaluate the effectiveness of internal limiting membrane (ILM) peeling using indocyanine green (ICG) on the surgical results of the vitrectomy for idiopathic macular holes. METHODS: We analyzed the anatomical and functional results of the macular hole surgeries without internal limiting membrane (ILM) peeling (group I; 32 eyes) and with ILM peeling using ICG (group II; 22 eyes). RESULTS: In group I and group II, mean age was 62 years and 64 years, and follow-up period was 17 months and 8 months, respectively. Anatomical success (P=0.528); 28 eyes (87.5%) vs. 20 eyes (90.9%), mean best visual acuity (P=0.004); 0.41 vs. 0.26, final visual acuity (P=0.006); 0.32 vs. 0.16, improvemant of best visual acuity (P=0.051); 2.88 lines vs. 1.59 lines, improvement of final visual acuity (P=0.048); 1.97 lines vs. 0.82 lines, and functional success rate (P=0.063); 24 eyes (75.0%) vs. 12 eyes (54.5%) were shown. Visual acuities better than 0.4 were found in 12 eyes (37.5%) of group I and in 5 eyes (22.7%) of group II (P=0.001). CONCLUSIONS: ILM peeling using ICG might produce a negative effect on the functional results, thereby requiring care with handling ICG.

Mechanical Treatment of Phthiriasis Palpebrarum

Phthiriasis palpebrarum is a rare disease in which crab lice infest the eyelashes. It can cause pruritic lid margins or unusual blepharoconjunctivitis and is difficult to diagnose and treat. We diagnosed and managed a case of phthiriasis palpebrarum in both upper eyelids, accompanied by nits, on the scalp of a 6 year-old female child. We removed the eyelashes, including lice and nits, by pulling with fine forceps without sedation. On the second month after treatment, all lice and nits were eradicated without recurrence and the eyelashes grew back. In conclusion, phthiriasis palpebrarum can be diagnosed by close examination of the eyelashes and eyelid margins with slit lamp and can be managed mechanically.

Frosted Branch Angiitis

PURPOSE: Frosted branch angiitis is a rare retinal disease with the characteristic sheathing in the retinal vessels. We report a typical case of this disease. METHODS: A thirty-year-old woman complained of sudden decrease of visual acuity developed in both eyes three days ago. Visual acuity was 0.4 with several inflammatory cells in the anterior chambers of both eyes. There were diffuse vascular sheathing like frosted branch in both retinas. Fluorescein angiogram showed staining and leakage of dye along the vascular sheathing. RESULTS: Visual acuity recovered to 1.0 and retinal findings returned normal 2 weeks after treatment with the low dose of systemic steroid. There was no recurrence during follow-up period. CONCLUSIONS: Typical frosted branch angiitis occurs suddenly in both eyes of the young, and it responds well to treatment with the low dose of systemic steroid.

Vitrectomy in Severe Giant Retinal Tear

PURPOSE: To determine the results of pars plana vitrectomy (PPV) for the treatment of severe giant retinal tear. METHODS: We analyzed the clinical records of patients who had 150degrees or greater of giant retinal tear and underwent PPV. RESULTS: Of all 10 patients (10 eyes), 7 were male patients and mean age was 29.8 years. Giant retinal tear was idiopathic in 6 eyes and traumatic in 1 eye, and occurred after vitrectomy in 3 eyes. Primary operations were scleral buckle in 1 eye, PPV with intraocular gas injection in 2 eyes and with silicone oil (SO) injection in 7 eyes. In 3 eyes without SO injection, secondary operations were PPV with intraocular gas injection in 1 eye and with SO injection in 2 eyes. In 1 eye with PPV and intraocular gas injection, tertiary operation was PPV with SO injection. Removal of SO was done in all 10 eyes and SO was re-injected due to proliferative vitreoretinopathy in 2 eyes. Visual acuity was counting fingers or worse in 8 eyes before the primary operation and, on the final visit, 0.1 or better in 6 eyes and 0.3 or better in 3 eyes. CONCLUSIONS: These results suggest that PPV with SO injection might be better for the treatment of severe giant retinal tear than with intraocular gas injection.

Orbital Trapdoor Fracture in Children

This study was performed to evaluate the clinical symptom, fracture finding, and surgical outcome in children with orbital trapdoor fracture. Forty-four patients with pure orbital trapdoor fracture, under 18 yr of age, were included. Time interval between injury and surgery, length of time for improvement, resolution of ocular motility restriction, and other factors were analyzed in 36 patients who underwent surgery. The median improvement time was 3.5 days for patients (n=8) receiving surgery within 5 days, 18.0 for those (n=19) receiving surgery between 6 and 14 days, and 50.0 for those (n=9) receiving surgery after 15 days (p=0.03). One month after operation, the mean change in supraduction limitation was 3.50+/-0.53 for patients receiving surgery within 5 days, 2.11+/-1.24 for those receiving surgery between 6 and 14 days, and 1.67+/-0.82 for those receiving surgery after 15 days (p=0.04). Three months after operation, the mean change in supraduction limitation was 3.88+/-0.35, 2.94+/-1.55, and 2.50+/-1.38, respectively (p=0.14). In conclusion, trapdoor fracture of the orbit in children must be diagnosed by careful CT evaluation and clinical evidence of entrapment. For patients with severe limitation of ocular motility, early surgery within 5 days of injury leads to more rapid and better postoperative improvement.

Phacofragmentation for the treatment of a completely posterior dislocation of the total crystalline lens

In order to evaluate the effectiveness and safety of intravitreal phacofragmentation, we analyzed cases of pars plana vitrectomy (PPV) with intravitreal phacofragmentation and scleral fixation of an intraocular lens (IOL) performed in patients with a crystalline lens completely dislocated into the vitreous cavity without any damage to the lens capsule. Of the 23 eyes examined, the dislocated lens was related with a hypermature cataract in 4 eyes and Marfan syndrome in 2 eyes, developed after argon and Nd:YAG laser iridotomy in 2 eyes, and was due to ocular trauma in 15 eyes. The dislocated lens was present for more than a year in 6 eyes and less than 4 weeks in 13 eyes. PPV, intravitreal phacofragmentation and scleral fixation of IOL were performed in all 23 eyes. Additionally, trabeculectomy was performed in 4 eyes, iridoplasty in 1 eye and cryopexy with intravitreal injection of sulfur hexafluoride in 2 eyes. Perfluorocarbon liquid was used in 9 eyes. The mean follow-up period was 11.7 months. On final examination, the visual acuity was better than 20/40 in 17 eyes (73.9%) and counting fingers in 1 eye due to traumatic optic neuropathy. There was no postoperative retinal detachment. These results demonstrated that PPV with intravitreal phacofragmentation and other combined procedures is a safe and effective surgical method for treating a completely dislocated crystalline lens.

Clinical Analysis of Pars Planitis with Prominent Snowbank

PURPOSE: To evaluate the clinical characteristics of the intermediate uveitis with prominent snowbank, METHODS: We retrospectively reviewed the records of the patients with intermediate uveitis characterized by the snowbank larger than half a quadrant. RESULTS: Of all 49 patients, 67 eyes, the mean age was 37.3 years. Male patients was 31, and eighteen patients (36.7%) were bilateral. Snowbank was at the inferior in 56 eyes (83.6%), and larger than two quadrant in 16 eyes (23.9%). Mean follow-up was 27 months. Final visual acuity improved in 40 eyes (59.7%), worsened in 4 eyes (6.0%), and more than 0.5 in 51 eyes (76.1%). Complications were cystoid macular edema (23 eyes, 34.3%), retinal detachment (22 eyes, 32.8%), and vitreous hemorrhage (11 eyes, 16.4%). Procedures were barrier laser photocoagulation (45 eyes, 67.2%), pars plana vitrectomy(12 eyes, 17.9%), scleral buckling(2 eyes, 3.0%), cataract surgery (9 eyes, 13.4%), trabeculectomy(6 eyes, 9.6%), and cryopexy (1 eye, 1.5%). Statistically, there was no significant relationship in the final visual acuity and gender, bilaterality, initial visual acuity of 0.5 or above, snowbank larger than two quadrants, and barrier laser photocoagulation. However, pars plana vitrectomy showed a significant relationship (p<0.001). CONCLUSIONS: Intermediate uveitis with prominent snowbank seems to show the similar clinical prognosis to generally-reported intermediate uveitis, and the prognosis of pars plana vitrectomy is good.

Removal of Silicone Oil Using Sutureless Corneal Incisions in Aphakia

PURPOSE: To evaluate the efficacy and safety of silicone oil (SO) removal through sutureless corneal incisions in aphakia. METHODS: We analyzed the records of the patients who underwent SO removal using clear corneal incisions in aphakia. RESULTS: Of 43 patients, there were 43 eyes, and 26 were male. The mean age was 41.5 years and followup period was 19.1 months. Indications for SO injection were ocular trauma in 15 eyes, macular hole retinal detachment in 3 eyes, proliferative diabetic retinopathy in 2 eyes, giant retinal tear in 2 eyes, pars planitis in 1 eye and other complex retinal detachment including proliferative vitreoretinopathy in 20 eyes. The viscosity of SO were 1,300 centistroke (cs) in 6 eyes and 5,700 cs in 37 eyes. Postoperative complications included emulsified silicone droplets in 2 eyes (4.7%), temporary increase of intraocular pressure in 5 eyes (11.6%) and recurrent retinal detachment in 2 eyes (4.7%). CONCLUSIONS: Sutureless corneal incisions in aphakia might be brief, effective and safe method to remove SO.

Peeling of Internal Limiting Membrane for Diabetic Macular Edema with Severe Hard Exudates

PURPOSE: To evaluate the results of peeling of internal limiting membrane (ILM) for the treatment of diabetic macular edema with severe hard exudates. METHOD: We analyzed the records of the patients who had macular edema with severe hard exudates, underwent pars plana vitrectomy combined with indocyanine green (ICG)-assisted ILM peeling, and then were followed more than 4 months postoperatively. RESULTS: In 6 patients, 10 eyes, mean age was 60.2 years and follow-up period was 7.3 months. In all eyes, a attached posterior hyaloid was shown, and hard exudates and macular edema began to decrease within 1 week after operation. Visual acuity was less than 0.1 in 6 eyes before operation, in 3 eyes by the best visual acuity during follow-up period and in 4 eyes on the final examination, and 0.15 or better in 2 eyes, 6 eyes and 5 eyes, respectively. According to the best visual acuity, there was improvement in 8 eyes and no change in 2 eyes, and according to the final visual acuity, improvement in 6 eyes, no change in 3 eyes and deterioration in 1 eye. CONCLUSIONS: ICG-assisted ILM peeling would be helpful for the treatment of diabetic macular edema with severe hard exudates.

Clinical Characteristics of Retinal Arterial Macroaneurysms

PURPOSE: To determine the clinical features of retinal arterial macroaneurysm (RAM). METHODS: Clinical characteristics of RAM, and its managements and results were evaluated. RESULTS: Of a total of 17 patients (17 eyes), 11 patients were women and 12 were over seventh decade. Mean follow-up period was 9.2 months. Hypertension was associated in 6 patients. Single aneurysm was temporally located in 15 eyes, which was along the temporal vascular arcade. It was on the arteriovenous crossing site in 8 eyes and followed retinal branch vein occlusion in 4 eyes. Aneurysms were located nasally in 2 eyes. Type was hemorrhagic in 15 eyes and exudative in 2 eyes. Pars plana vitrectomy was performed in 5 eyes and intraocular gas was injected in 2 eyes. Photocoagulation was performed directly in 2 eyes and indirectly in 3 eyes. Five eyes received no special managements. Visual acuity was less than 0.1 in 11 eyes and 0.3 or better in 4 on the initial visit, and less than 0.1 in 1 eyes and 0.3 or better in 10 on the final visit. Twelve eyes showed visual improvement of 2 lines or more. CONCLUSIONS: RAM usually develops along the temporal vascular arcade and induces visual disturbance due to hemorrhage and exudate. However, visual prognosis is relatively good.

Intraocular Foreign Bodies: Clinical Characteristics and Visual Prognosis

PURPOSE: To determine the clinical characteristics and visual prognosis of intraocular foreign bodies (IOFBs). METHODS: We analyzed the patients with surgical removal of IOFB and follow-up of 4 months or longer. RESULTS: Of all 126 eyes of 126 patients, 118 patients (93.6%) were men and mean age was 42.7 years. The cause was lawn mower in 49 eyes (38.9%). Metal composition was in 114 eyes (90.5%), corneal inlet was present in 101 eyes (80.2%) and posterior location was in 97 eyes (73.0%) were there. Visual acuity was worse than 0.04 in 77 eyes (61.1%) before operation and in 36 eyes (28.6%) at the final visit. The final visual acuity was significantly related with initial visual acuity (criterion: 0.1, P=0.001), wound length (criterion: 3 mm, P< 0.001), location (anterior vs. posterior location, P< 0.001) and size (criterion: 3mm, P< 0.001) of IOFB, traumatic cataract (P=0.011), vitreous hemorrhage (P=0.001) and retinal tear (P< 0.001), respectively. CONCLUSION: Lawn mower is the main cause of IOFB and the countermeasure should be needed for it. Initial visual acuity, location and size of IOFB, wound length, vitreous hemorrhage and retinal tear may be the important factors on visual prognosis of IOFB.

Clinical Analysis of the Diabetic Vitrectomy According to Preoperative Dialysis

To determine the difference of the results induced by preoperative dialysis, we analyzed the medical records of the patients who had undergone pars plana vitrectomy (PPV) for the treatment of proliferative diabetic retinopathy (PDR). Of 65 patients (74 eyes) in total, there was the functional success (FS: final visual acuity> or =0.04) in 58 (78.4%), visual improvement of 2 lines or more (VI) in 55 (74.3%), central visual efficiency of 20% or more (VE) in 42 (56.8%), and anatomical success (AS) in 62 eyes (83.8%). The dialysis group with 16 patients(19 eyes) showed FS in 12 (63.2%), VI in 11 (57.9%), VE in 10 (52.6%), and AS in 14 eyes (73.7%). The non-dialysis group with 49 patients (55 eyes) showed FS in 46 (83.6%), VI in 44 (80.0%), VE in 32 (58.2%) and AS in 48 eyes (87.0%). There was more or less difference between the dialysis and non-dialysis group in AS, VI, VE and AS, but it was not significant on the statistics. Accordingly, there may not be significant effect of dialysis on the result of PPV for the treatment of PDR.

Pars Plana Vitrectomy for Macular Hole Retinal Detachment

PURPOSE: To evaluate the clinical characteristics and surgical results of retinal detachment due to macular hole. METHODS: We analyzed the record of the patient undergoing pars plana vitrectomy(PPV) for thetreatment of macular hole retinal detachment (MHRD). RESULTS: Of all 13 eyes, the follow-up period was 25.7 months on average and 10 eyes were highly myopic. Mean preoperative axial length was 26.58 mm (29.15 mm in high myopia group). In terms of visual acuity, 11 eyes showed less than 0.04 before the operation and on the final examination, 10 eyes 0.04 or more and 11 eyes improved 2 lines or more. Silicone oil was injected in a recurrent case. Finally there was the complete retinal attachment in all 13 eyes and sealed macular hole in 12 eyes. CONCLUSIONS: PPV seems to be an effective method for the treatment of MHRD.

Clinical Analysis According to Treatment Methods in Simple Retinal Detachment

PURPOSE: To determine the difference among the results of three kinds of methods for the treatment of simple retinal detachment. METHODS: We analyzed the patients undergoing primary pars plana vitrectomy(Group I: January to June, 1997), scleral buckling(Group II: January to June, 1996) and pneumatic retinopexy(Group I: January to June, 1995) to treat simple retinal detachments with retinal breaks located in peripheral retina, smaller than one clock hour, breaks in the superior eight clock hours, multiple breaks extending less than two clock hours and no severe retinal traction. RESULTS: The final visual acuity was 5/200 or more(functional success) in 19 eyes(100%) of Group I, 19 eyes(100%) of Group cII and 20 eyes(90.9%) of Group I. Primary retinal reattachment(anatomical success) was in 17 eyes(89.5%) of Group I, 19 eyes(100%) of Group II and 18 eyes(81.8%) of Group I with no statistically significant difference among the three groups. The final retinal reattachment rate was 100% in all groups. CONCLUSIONS: This result suggests the scleral buckling might be a little bit better for the treatment of simple retinal detachment, though each of three surgical methods showed no statistical difference of functional and anatomical results.

Transient Cortical Blindness Related to General Anesthesia

PURPOSE: We report a case of cortical blindness due to transient cerebral ischemia associated with general anesthesia. METHODS: A 45 year-old woman complained of bilateral visual loss after emergent incision and drainage for the treatment of extensive pyogenic abscess around the left mandibular space causing severe respiratory distress, and transient cerebral ischemia due to difficult tracheal intubation. At first ophthalmologic examination, 8 days after the operation, visual acuity was hand movement. Functions of external ocular muscles, blinking reflex, accommodation, pupillary light reflex, color vision test, intraocular pressure, and the findings of anterior segment, optic nerve and fundus were normal. Humphrey visual field examination showed nonspecific visual field defect, and pattern visual evoked potential examiantion showed flattening of waveforms. Both brain magnetic resonance imaging and electroencephalography were normal. However, brain single positron emission computerized tomography demonstrated general decrease of blood perfusion in the cerebrum including the occipital lobes. RESULTS: Without any specific treatment, her vision improved gradually, and 6 weeks after operation, it was 0.4 in the right and 0.7 in the left eye. After 3 months, it was 0.9, and no other abnormal ocular findings were noted on both eyes. CONCLUSIONS: Cortical blindness can occur by transient cerebral ischemia associated with general anesthesia, and its visual prognosis may be good.

Clinical Evaluation of Pneumatic Retinopexy

Result and complications were evaluated in 28 eyes of 28 patients who had undergone pneumatic retinopexy for rhegmatogenous retinal detachment from December 1994 to May 1995 and were followed for at least 4 months. Twenty four eyes were phakic, one eye aphakic and three eyes pseudophakic. 0.3mlof perfluoropropane(4 eyes)or 0.45ml of sulfur hexafluoride(24 eyes)was injected. Mean follow-up time was 33.3 months. Perioperative complications included subconjunctival gas in 2 eyes, subretinal gas in 1 eye and delayed absorption of subretinal fluid in 5 eyes. Retinal reattachment was obtained in 22 eyes(79%) and final reattachment rate was 100% with an additional procedure of scleral buckle(4 eyes)or pars plana vitrectomy(2 eyes). Final visual acuity improved in 25 eyes(89%), and decreased in 2 eyes. Postoperatively following complications were noted;mild proliferative vitreoretinopathy(3 eyes), epiretinal membrane(1 eye), central retinal artery occlusion(1 eye), nucleosclerosis(4 eyes)and cataract operation(2 eyes). This result suggests that pneumatic retinopexy could be a good method for the treatment of rhegmatogenous retinal detachment.