A Report of Two Case of Ocular Toxicity Resulting from Direct or Indirect Bee Venom

PURPOSE: To report a patient stung by a bee, who was diagnosed with sterile endopthalmitis and another patient diagnosed with optic neuritis, with decreasing visual acuity, after refined bee venom injection around the orbital tissue. CASE SUMMARY: A 82-year-old female visited our hospital for decreased visual acuity in the right eye and ocular pain due to a bee sting. The bee sting penetrated the sclera into the vitreous. In the anterior segment, severe cornea edema and anterior chamber cells were seen. Using ultrasonography, inflammation was seen around the intravitreal area. After 3 months, intravitreal inflammation regressed but the patient's visual acuity was light perception negative, and corneal opacity, neovascularization, and phthisis bulbi were detected. A 55-year-old male visited our hospital for ocular pain in the right eye and decreasing visual acuity after refined bee venom injection around the orbital tissue. The best-corrected visual acuity in the right eye was 15/100, there was moderate injection on the conjunctiva. A relative afferent pupillary defect, abnormal color vision test results, and a defect in the visual field test were observed. There was no pain during external ocular movement, and other general blood tests, and a brain MRI were normal. Based on these symptoms, methylprednisolone megatherapy was started for treatment of optic neuritis. After treatment, visual acuity of the right eye was 9/10 and all other clinical optic neuritis symptoms regressed. CONCLUSIONS: Based on these two cases, ocular toxicity from bee venom could result from both direct and indirect courses. Treatment using refined bee venom might be harmful, and caution is recommended in its use.

A Case of Posterior Ischemic Optic Neuropathy Accompanied by Carotid Artery Plaque

PURPOSE: To report a case of posterior ischemic optic neuropathy accompanied by carotid artery plaque in a patient with retrobulbar optic neuritis. CASE SUMMARY: A 48-year-old man visited our clinic complaining of headache, decreasing visual acuity and defect of inferior visual field in his left eye for 3 days. The best corrected visual acuity was 1.0 in the right eye and 0.1 in the left eye. The anterior segment state, intraocular pressure, fundus examination and optical coherence tomography were normal in both eyes. Relative afferent pupillary defect, color vision deficiency and total scotoma were observed in his left eye. The results of the laboratory test and brain magnetic resonance imaging were normal. He was discharged from the hospital after 3 days of systemic steroid treatment on the basis of retrobulbar optic neuritis. A week later, fluorescent angiography and carotid ultrasonography were performed because of his history memory loss and left upper limb weakness before admission. A focal filling defect of the peripapillary area was found on fluorescent angiography. A plaque with a thickness of 1.9 mm and a length of 1.4 cm was found on carotid ultrasonography. After 6 months, the best corrected visual acuity was 0.4 in the left eye and the visual field showed a partially improved defect. CONCLUSIONS: Fluorescent angiography is recommended for potential posterior ischemic optic neuropathy in patients with retrobulbar optic neuritis, even though it is rare. Carotid ultrasonography is useful in finding atherosclerosis to prevent stroke or cardiovascular disease if ischemic cause is suspected on fluorescent angiography.

A Result of Pneumatic Retinopexy for Pseudophakic Retinal Detachment

PURPOSE: To evaluate the clinical effectiveness of pneumatic retinopexy as a treatment method for pseudophakic retinal detachment. METHODS: A retrospective chart review was conducted of medical records of 38 patients who underwent pneumatic retinopexy using SF6 gas from January 2003 to December 2011 and who were observed during a follow-up period longer than 6 months. Primary and final success rates and final visual acuity were analyzed. Primary success was defined as retinal attachment at the last visit without additional surgery. Final success was defined as retinal reattachment at the last visit regardless of additional surgery. RESULTS: The mean patient age was 58.47 ± 17.00 years. All retinal tears were located in the upper retina (from 8 to 4 o'clock). Preoperative mean visual acuity was 1.17 ± 1.00 log MAR, and postoperative mean visual acuity was 0.42 ± 0.48 log MAR. The primary success rate was 61%, and patients with re-detached retina underwent repeat pneumatic retinopexy or other surgery such as scleral buckling or pars plana vitrectomy. At the final visit, all of the patients demonstrated successful results. CONCLUSIONS: Pneumatic retinopexy does not result in strabismus or refractive error, and the final success rate was 66% in our study. Therefore, pneumatic retinopexy can be considered as an effective management technique for some pseudophakic retinal detachment patients.

A Case of Meningioma Masquerading as Ischemic Optic Neuropathy

PURPOSE: We report a case of meningioma diagnosed as ischemic optic neuropathy. CASE SUMMARY: A 45-year-old women presented with decreased visual acuity in her left eye without eye movement pain. Her best corrected visual acuity (BCVA) in that eye was 0.3. She showed a relative afferent pupillary defect, abnormal color vision test, and inferior visual field defect in her left eye. The optic disc showed slight blurring superiorly and pallor temporally. Fluorescein angiography showed choroidal filling defect, and ischemic optic neuropathy was suspected. The carotid artery sonography showed normal results. The BCVA of the left eye was 0.5 after 7 months. The visual field test and color vision test were improved after 7 months. The optic disc was pale. The magnetic resonance imaging was performed because of persistent headache, and that showed a suprasellar mass that was removed by surgical resection and diagnosed as meningioma on biopsy. CONCLUSIONS: The possibility of compressive optic neuropathy should be considered in presumed ischemic optic neuropathy if the patient complains of persistent headache.

Cases of Oculomotor Nerve Palsy in Herpes Zoster Ophthalmicus

PURPOSE: To report two case of oculomotor palsy accompanied by herpes zoster ophthalmicus (HZO). CASE SUMMARY: Two patients with HZO who were suffering from skin lesions, facial pain, and medicated with an antiviral agent from the dermatologic department, were diagnosed with oculomotor palsy. They presented with ptosis, dilated pupils, and ophthalmoplegia after 10 days, and 4 days after began developing skin lesions. They were diagnosed with HZO-induced oculomotor palsy and the ophthalmoplegia improved in all cases. CONCLUSIONS: Oculomotor nerve palsy rarely occurrs in HZO patients and is usually followed by skin lesions. We recommend examinations for functions of extraocular motility, ptosis, and pupil to diagnose and treat the HZO-induced oculomotor nerve palsy even if consulted with the dermatologic department or only showing mild conjunctivitis, episcleritis, or keratitis.

Short-Term Clinical Outcomes of Laser Trabeculoplasty Using a 577-nm Wavelength Laser

PURPOSE: To evaluate the pressure-lowering effects of single-spot laser trabeculoplasty and patterned laser trabeculoplasty using a 577-nm wavelength laser. METHODS: A total 35 eyes of 35 patients with primary open-angle glaucoma were enrolled in this study. Eighteen eyes of 18 patients were treated with 360degrees single-spot laser trabeculoplasty and 17 eyes of 17 patients were treated with 360degrees patterned laser trabeculoplasty. All patients were evaluated after laser trabeculoplasty at 1 week, 1 month, 3 months, and 6 months using slit lamp examination and Goldmann applanation tonometry. RESULTS: At 6 months postoperatively, the single-spot laser trabeculoplasty group had a mean IOP of 15.89 +/- 3.89 mm Hg with a mean IOP reduction of 37.1%, while the patterned laser trabeculoplasty group had a mean IOP of 17.57 +/- 2.64 mm Hg with a mean IOP reduction of 27.1%. CONCLUSIONS: Laser trabeculoplasty with a 577-nm optically pumped semiconductor laser was safe and demonstrated an IOP lowering effect. There were no significant differences in the IOP lowering effects between the single-spot laser trabeculoplasty and the patterned laser trabeculoplasty.

The Effect of One Myopic Eye on Visual Field Testing

PURPOSE: To investigate the effect of lens-corrected myopia on Humphrey Matrix and Humphrey Field Analyser (HFA). METHODS: A total of 59 lens-corrected myopic eyes of 59 normal volunteers underwent Humphrey Field Analyser and Humphrey Matrix (FDP) testing. Spherical equivalent divided into 3 groups: -3 < or = D < 0, -6 < or = D < -3, D < -6. HFA and FDP sensitivity for mean deviation (MD) and pattern standard deviation (PSD), as well as axial length and astigmatism, were compared between these 3 groups. RESULTS: The MD of the fields as determined by the HFA decreased significantly as the refractive errors increased, despite correction. However, there were no significant differences in MD or PSD of FDP, or in the PSD of HFA. There were no significant differences in axial length or astigmatism as calculated by MD and PSD for HFA and FDP. CONCLUSIONS: The spherical equivalent showed that lens correction alters the MD for HFA but not for FDP.

A Case of Conjunctival Mass with Infectious Mononucleosis by EBV

PURPOSE: To report a case of conjunctival mass with infectious mononucleosis by Epstein-Barr virus (EBV) confirmed with Epstein-Barr encoding region (EBER) in situ hybridization. CASE SUMMARY: A 8 year-old male without underlying disease was referred with counjunctival mass on the right eye starting 3 days ago. In ophthalmologic evaluation, there was injected, nontender, and "salmon patch" appearance conjunctival lesion on right superior bulbar conjunctiva. The patient was admitted to pediatrics with sore throat and fever. The tonsil were enlarged and white blood cell count was 14960/uL. EBV polymerase chain reaction (PCR) test and Viral capsid antigen Immunoglobulin M (VAC IgM) test were positive, the diagnose of infectious mononucleosis by EBV was made. After 5 days steroid eyedrop therapy, biopsy was performed because the lesion was not improved. There were lymphocyte infiltration, chronic inflammation and positive in EBER in situ hybridization. CONCLUSIONS: Elevated and pinkish lesion on conjunctiva, EBV lesion should be considered as differential diagnosis.

A Case of Severe Vaso-Occlusive Retinopathy as the First Manifestation Associated with Systemic Lupus Erythematosus

PURPOSE: To report a case of severe vaso-occlusive retinopathy with significant decrease of bilateral visual acuity as the first manifestation associated with systemic lupus erythematosus (SLE). CASE SUMMARY: A 23-year-old man was referred to our clinic with bilateral visual impairment of hand motion (HH). Fundus examination revealed severe retinal hemorrhage, cotton-wool patch, occlusive retinal vasculitis with vascular engorgement, and diffuse retinal edema in both eyes. Because of a malar rash on both cheeks, generalized edema was observed on initial examination with hypertension, azotemia, anemia, and thrombocytopenia, The patient was diagnosed with SLE, strongly positive to antinuclear antibody (ANA), and received an intravitreal injection of Bevacizumab (Avastin, Genentech Inc., San Francisco, CA, USA) in the left eye in addition to hemodialysis, transfusion, systemic corticosteroid and immunosuppressant treatment due to lupus nephritis. Eighteen months later, the retinal edema, cotton-wool patch and hemorrhage resolved, leaving epiretinal membrane without traction in his left eye and diffuse degeneration of the right eye. Final visual acuity was HM in the right eye and 20/100 in the left eye. CONCLUSIONS: Vaso-occlusive retinopathy in SLE can result in permanent visual impairment. In a patient with a high possibility of SLE retinopathy, a periodic fundus examination and intensive management of systemic disease should be considered.

Retinal Nerve Fiber Layer Thickness and Optic Disc Parameters in Dominant Compared with Non-Dominant Eyes

PURPOSE: To investigate the comparison of retinal nerve fiber layer (RNFL) thickness and optic disc parameters measured by optical coherence tomography (Cirrus HD-OCT(R)) in dominant and non-dominant eyes. METHODS: Seventy-one subjects without underlying ocular disease were recruited for the present study. Ocular dominance was determined using the hole-in-the-card test. Comprehensive standardized eye examinations were performed. Scans of the optic disc and RNFL were performed using OCT. RESULTS: The mean intraocular pressure (IOP) of the dominant eye was higher than its counterpart (p = 0.025). No significant differences were observed in uncorrected visual acuity, refractive error and axial length between dominant and non-dominant eyes (p = 0.235, 0.180, 0.850). No RNFL and optic disc features were identified in the dominant from non-dominant eyes. CONCLUSIONS: Although dominant eyes tended to have higher IOP than non-dominant eyes, no consistent ocular structural differences between dominant and non-dominant eyes with the use of OCT were found.

The Success Rate and Factors Influencing the Results of Pneumatic Retinopexy

PURPOSE: To evaluate the success rate of pneumatic retinopexy and the preoperative factors influencing the results in the rhegmatogenous retinal detachment patients. METHODS: We analyzed retrospectively the preoperative and postoperative retinal findings and postoperative complication in 152 eyes of 150 patients with uncomplicated rhegmatogenous retinal detachment, who had undergone pneumatic retinopexy and were followed up for at least 3 months. We analyzed preoperative factors, including age, sex, location and numbers of retinal tears, duration of retinal detachment, lens status, and refractive error. RESULTS: The success rate of the initial surgery was 72.37%. The success rate was significantly higher in non-high myopic and phakic eyes, and when the retinal detachment was less than 3 quadrants with the retinal break located superiorly. Accordingly, the success rate was 85.87% (79 of 92 eyes). CONCLUSIONS: In the present study, the anatomical success rate of primary pneumatic retinopexy was more than 70%. If pneumatic retinopexy is performed to non-high myopic, phakic eyes, and retinal detachment is less than 3 quadrants with superior retinal break, the surgeon can expect good anatomical outcomes and consider pneumatic retinopexy as a first management in rhegmatogenous retinal detachment patients.

Spontaneous Reattachment of Descemet's Membrane Detachment at Postoperative Two Months, Which Occurred During Cataract Surgery

PURPOSE: To report a case of spontaneously reattached Descemet's membrane detachment, which first occurred during the cataract surgery, and still remained after injection of 100% air into the chamber. CASE SUMMARY: A 78-year-old woman came to the clinic with decreased visual acuity. She had a brunescent cataract and underwent extracapsular cataract extraction with a posterior chamber lens implantation. During the irrigation and aspiration procedure, the Descemet's membrane was torn and detached. An anterior chamber injection of 100% air was performed prior to the conclusion of surgery. Descemet's membrane detachment remained at the center of the cornea and was naturally reattached without any surgical procedure. At 2 months after the surgery, a well-reattached Descemet's membrane and a clear central cornea were observed. CONCLUSIONS: Descemet's membrane detachment is a rare but potentially serious complication of intraocular surgery. The authors report a case of naturally reattached Descemet's membrane detachment which remained after injection of 100% air into the chamber.

A Case of Bilateral Endogenous Endophthalmitis in a Streptococcus pneumoniae Meningitis Patient

PURPOSE: To report a case of bilateral endogenous endophthalmitis in a Streptococcus pneumoniae meningitis patient. CASE SUMMARY: A 45-year-old woman with bacterial meningitis was referred to the ophthalmologic clinic with acute visual impairment in both eyes. The patient's visual acuities were hand motion in both eyes. Ophthalmoscopy revealed inflammation in the anterior chamber and vitreous opacities in both eyes. Streptococcus pneumoniae was isolated in the cerebrospinal fluid sample, but not in vitreal, blood samples. Vision improved to 70/100 in the right eye and 2/100 in the left eye after 8 days of treatment. CONCLUSIONS: Endogenous endophthalmitis constitutes a rare complication of Streptococcus pneumoniae meningitis, and a prompt diagnosis and administration of empirical intravitreal antibiotics can lead to a more favorable visual prognosis.

A Statistical Observation of Non-Penetrating Ocular Injuries

PURPOSE: To investigate the clinical and social characteristics of non-penetrating ocular injuries and use the results for treatment and prevention. METHODS: A retrospective survey was performed on 468 eyes of 421 patients, who visited our clinic due to non-penetrating ocular injuries from January 2010 to December 2010. The incidence of ocular injuries, sex, age, monthly and seasonal distribution, side, cause, influence of alcohol, and change in visual acuity were reviewed statistically. RESULTS: The incidence of non-penetrating ocular injuries was 4.9%. The incidence was more common in males (82.9%), in the 3rd decade of life (23.5%) and in summer (30.8%). Minor injuries (36.1%) were the most common caused by scratches, finger pricks, nails, or small foreign bodies. The second common cause was violence (16.4%), followed by traffic accidents (14.7%). The injuries related to alcohol represented 12.6% of all cases. When considering initial diagnoses, periorbital contusion and corneal abrasion were the most common. The initial visual acuity was less than 20/200 in 9.4% of the eyes and the final acuity after a 6-months of treatment was less than 20/200 in 3.0% of the eyes. CONCLUSIONS: This survey gathered the clinical and social characteristics as well as new insights into non-penetrating ocular injuries which can be used for treatment and prevention.

Ischemic Retinopathy Due to Suspicious Gentamicin Retinal Toxicity after Primary Repair of Scleral Laceration

PURPOSE: To report a case of ischemic retinopathy due to suspicious gentamicin retinal toxicity after primary repair of a scleral laceration. CASE SUMMARY: A 45-year-old man presented to our department with decreasing vision in his right eye after ocular trauma. Best corrected visual acuity (BCVA) was 0.02 in the right eye and slit lamp examination revealed scleral laceration. Both intravenous and topical antibiotics (10% cefazolin and 2% gentamicin) were immediately administered. On intraoperative examination, a scleral laceration located 5 mm to 11 mm from nasal limbus, prolapsed vitreous body and partial division of medial rectus muscle were observed. After irrigation with gentamincin 0.2% around the wound, primary repair was performed. On postoperative day 3, fundus examination revealed a retinal break, barrier laser was performed. On postoperative day 4, diffuse retinal edema with intraretinal hemorrhage was observed as well as, superonasal ghost vessels. Subsequently, fluorescein angiography showed diffuse leakage of retinal vessels and a nonperfusion area at the periphery, especially on the nasal side. As vitreous opacity became worse, the patient underwent pars plana vitrectomy with endolaser. One month later, vitreous cavity was clearer and best visual acuity was 0.2. CONCLUSIONS: Large doses of intraocular gentamicin ccan cause retinal toxicity. Increased gentamicin application through a scleral laceration may lead to toxic antibiotic levels. When a scleral laceration wound irrigation is performed, precautions are necessary to prevent retinal ischemia associated with gentamicin toxicity.

Macular Hole after Single Intravitreal Injection of Ranibizumab in a Patient with Age-Related Macular Degeneration

PURPOSE: To report a case of a full-thickness macular hole after a single intravitreal injection of ranibizumab in a patient with choroidal neovascularization associated with age-related macular degeneration. CASE SUMMARY: A 63-year-old woman presented to our department with gradually decreasing vision in her right eye. Best corrected visual acuity (BCVA) was measured as 0.7 in the right eye and 1.0 in the left eye. Examination of the macula showed a choroidal neovascularization associated with subretinal hemorrhage in the right eye. Optical coherence tomography (OCT) confirmed incomplete posterior vitreous detachment, subretinal hemorrhage and serous elevation. The patient subsequently received an intravitreal ranibizumab injection. After 1 month, the best corrected visual acuity in the right eye was decreased to 0.4, and fundus examination revealed posterior vitreous detachment and a macular hole. The patient underwent pars plana vitrectomy with internal limiting membrane peeling and fluid-air exchange, SF6 gas injection, phacoemulsification and posterior chamber intraocular lens implantation. Three months later, the macular hole had closed completely and best visual acuity was 1.0. CONCLUSIONS: Although the occurrence of a full-thickness macular hole after intravitreal ranibizumab injection is uncommon, physicians should be well acquainted with this complication.

A Case of Corneal Perforation and IOL Prolapsed in Serratia Marcescens Endophthalmitis after Cataract Surgery

PURPOSE: To report a case of Serratia marcescens endophthalmitis following phacoemulsification and posterior chamber intraocular lens implantation. CASE SUMMARY: A 64-year-old male with a history of diabetes, hypertension, cardiovascular disease was referred with right ocular pain and reduced vision 1 day after cataract surgery. On admission, hypopyon on anterior chamber by slit lamp examination and anterior vitreous was hazy according to ultrasonography. We immediately performed intravitreal antibiotics injection and microbiological analysis of anterior chamber and vitreous samples was performed. On day 3, persistent cornea stormal infiltration and cornea perforation were visible and the organism was identified as S. marcescens. Despite appropriate antibiotic treatment the eye continued to deteriorate. CONCLUSIONS: S. marcescens endophthalmitis was diagnosed and treated immediately, but rapid progression and outcome were unsatisfactory.

A Case of Fungal Keratitis after Intracorneal Ring Segment Implantation for Keratoconus

PURPOSE: To report a case of fungal keratitis 3 days after intracorneal ring segment (ICRS) implantation for keratoconus. CASE SUMMARY: A 65-year-old woman was referred to our clinic with refractory infectious keratitis in her left eye 3 days after ICRS insertion for keratoconus. Slit lamp examinations revealed infiltrates around the incision site with cellular reaction in the anterior chamber after the ICRS had been removed. Corneal scrapings were obtained for staining and cultures, and intensive topical antibiotics were administered. Initial microscopy and cultures were negative. Despite the use of intensive topical antibiotics, there was no improvement. Hyphae were isolated from additional corneal scrapings. The patient's symptoms and corneal findings improved following administration of topical amphotericin B and oral itraconazole. CONCLUSIONS: Infectious keratitis after ICRS implantation is an uncommon but sight-threatening complication. Fungal keratitis should also be considered if infectious keratitis after ICRS is unresponsive to antibiotics.

Neovascular Glaucoma with Ocular Ischemia in Superior Vena Cava Syndrome

PURPOSE: To report a case of neovascular glaucoma (NVG) with ocular ischemia in superior vena cava syndrome (SVCS). CASE SUMMARY: A 57-year old male who had been treated for small cell lung cancer (SCLC) visited our hospital because of SVCS-like symptoms and decreased visual acuity in the right eye. On the initial examination, best corrected visual acuity was 0.5, intraocular pressure (IOP) was 38 mm Hg and relative afferent papillary defect was positive in the right eye. Slit lamp examination showed mild dilatation and tortuosity of the episcleral vessels and ruobeosis iridis. Gonioscopic examination showed neovascularization of the opened angle. Fluorescein angiography showed delayed choroidal filling and nevascularization of the disc. The patient was diagnosed with NVG with ocular ischemia in SVCS and was treated with chemotherapy and steroid therapy. In addition, intravitreal bevacizumab and IOP lowering eyedrops were administered to the right eye. During follow-up, neovascularizations disappeared and IOP was well controlled. CONCLUSIONS: NVG with ocular ischemia in SVCS should be considered as a possible cause of high IOP in SCLC patients.

Traumatic Eyeball Protrusion with Optic Chiasmal Injury

PURPOSE: To report a case of eyeball protrusion with optic chiasmal injury due to eyeball trauma. CASE SUMMARY: A 59-year-old male presented to the emergency room for right eyeball pain, eyeball protrusion and decreased visual acuity after collision with a metal pipe. On initial examination, the right eyeball was protruded, the patient could not perceive light, his pupil was dilated and did not respond to the light. The patient had a laceration of the lower canaliculi and the medial, superior and inferior rectus muscles were separated from the eyeball. Abnormal left pupil response was observed, and visual acuity of the left eye was 0.7. He underwent primary repair of the right medial, inferior and superior rectus muscles and reconstruction of the lower canaliculi. Because the visual field of the left eye at post-operative day 1 demonstrated temporal hemianopsia, an optic chiasmal injury was revealed on brain magnetic resonance imaging (MRI). The patient underwent left optic chiasmal decompression because the visual field was aggravated despite the immediate high dose of corticosteroid therapy. At post-operative 2 months, the patient's left visual acuity was 0.3 and the visual field was stable. CONCLUSIONS: Optic chiasmal injury should be considered and promptly diagnosed through visual field test and MRI when ipsilateral optic nerve injury with abnormal contralateral pupil response is caused by eyeball protrusion. Optic chiasmal decompression should be considered when traumatic optic nerve and chiasmal injuries do not respond to high-dose corticosteroid therapy.