Multiple Endocrine Neoplasia Type 2B: Early Diagnosis Based on Conjunctival Neuroma

PURPOSE: To report a case of multiple endocrine neoplasia type 2B (MEN 2B) diagnosed early based on conjunctival neuroma. CASE SUMMARY: A 15-year-old female presented with red eye and conjunctival mass in both eyes. A 5 x 5 mm-sized yellowish conjunctival mass adjacent to the limbus was observed in her right eye and a 3 x 3 mm-sized mass in her left eye. Excisional biopsy was performed and the patient was diagnosed with conjunctival neuroma. Other abnormalities were not found on the ophthalmic examination, but she had characteristic appearances such as thickened upper eyelid, mild telecanthus and nodular edematous upper lip. She was transferred to the Endocrinology Department for systemic evaluation in consideration of multiple endocrine neoplasia. Abdominal pelvic computed tomography and a 24-hr urine collection analysis showed asymptomatic pheochromocytoma. Thyroid ultrasonography and fine-needle biopsy revealed medullary thyroid carcinoma. Finally, MEN type 2B was confirmed by using a RET mutation gene test. CONCLUSIONS: Thyroid carcinoma can occur in MEN 2B in combination with pheochromocytoma and mucosal neuroma. Thickened corneal nerve fiber and perilimbal conjunctival mass have been regarded as ophthalmologic characteristics of MEN 2B and may be accompanied by telecanthus, thickened upper eyelid and marfanoid habitus. A biopsy of the mass is required for pathological diagnosis. Medullary thyroid carcinoma is the most significant clinical component of MEN 2B syndrome and thyroidectomy is indicated. MEN 2B may be a rare syndrome, but its consequences are serious and the ophthalmologist may play a lifesaving role in its diagnosis.

Calculated CT Volumes of Lacrimal Glands in Normal Korean Orbits

PURPOSE: We used computed tomography (CT) scans to describe normal Korean lacrimal gland volume and lacrimal gland size and then examined their correlations with patient age. METHODS: CT scans were obtained in 213 orbits of 111 patients who underwent CT from January to August of 2013. Aquarius iNtuition (TeraRecon, Foster City, CA, USA) software was used to outline the lacrimal gland in consecutive axial slices and to calculate the volume. RESULTS: The mean volume of the lacrimal gland was 0.589 cm3 in right orbits (SD = 0.090), 0.583 cm3 in left orbits (SD = 0.289), 0.596 cm3 in males (SD = 0.083), and 0.575 cm3 in females (SD = 0.094). There was no significant difference in mean lacrimal gland volume according to laterality (p = 0.614) or sex (p = 0.102) (2-sample t-tests). We investigated mean lacrimal gland volume in 3 age groups. Mean lacrimal gland volume was 0.630 cm3 (SD = 0.080) for the 20 to 40 year old group, 0.553 cm3 (SD = 0.734) for the 41 to 60 year old group, and 0.544 cm3 (SD = 0.885) for the older than 60 years old group. There was an inverse relationship between gland volume and age (Pearson r = -0.384, p = 0.00). CONCLUSIONS: The mean volume of the lacrimal gland decreased with age and there was no significant difference between right and left orbits or between male and female patients.

Analysis of the Results Endonasal Dacryocystorhinostomy Related to Nasal Cavity State

PURPOSE: This study evaluated the relationship of nasal cavity state and surgical results after endonasal dacryocystorhinostomy (DCR). METHODS: We retrospectively analyzed 306 eyes of 204 patients between January 2007 and December 2011. The correlation between the existence of preoperative nasal cavity abnormality, postoperative nasal cavity complications after proper management of nasal cavity abnormality, and postoperative nasal cavity complications according to nasal packing material were investigated. We analyzed the success rates and the correlation between each set of factors. RESULTS: The success rate of primary operations performed six months after tube removal was 87.3% (267/306). The success rate after secondary revision, granuloma removal and punctoplasty was 90.5% (277/306). Postoperative nasal cavity complications were inspected in 40 eyes. Of the 306 eyes, patients treated with Nasopore showed significantly more postoperative nasal cavity complications (47.8%, 32/67) than in patients treated with Merocel (3.3%, 8/239). The rate of postoperative nasal cavity complications was 8.7% in patients with normal nasal cavity, 16.7% in patients who received treatment, and 20% in patients without treatment, with significant statistical increase if the nasal cavity was abnormal (p = 0.019). The incidence of complications influenced the primary success rate (p = 0.008); however, preoperative nasal cavity abnormalities were not correlated with primary success (p = 0.479). CONCLUSIONS: In the case of endonasal DCR, preoperative nasal cavity abnormality and type of nasal packing material used did not affect the success rate but significantly affected postoperative nasal cavity complications. In conclusion, endonasal DCR with preoperative treatment of nasal cavity abnormality and Merocel packing is expected to reduce postoperative nasal cavity complications and increase patient satisfaction.

Analysis of the Results Endonasal Dacryocystorhinostomy Related to Nasal Cavity State

PURPOSE: This study evaluated the relationship of nasal cavity state and surgical results after endonasal dacryocystorhinostomy (DCR). METHODS: We retrospectively analyzed 306 eyes of 204 patients between January 2007 and December 2011. The correlation between the existence of preoperative nasal cavity abnormality, postoperative nasal cavity complications after proper management of nasal cavity abnormality, and postoperative nasal cavity complications according to nasal packing material were investigated. We analyzed the success rates and the correlation between each set of factors. RESULTS: The success rate of primary operations performed six months after tube removal was 87.3% (267/306). The success rate after secondary revision, granuloma removal and punctoplasty was 90.5% (277/306). Postoperative nasal cavity complications were inspected in 40 eyes. Of the 306 eyes, patients treated with Nasopore showed significantly more postoperative nasal cavity complications (47.8%, 32/67) than in patients treated with Merocel (3.3%, 8/239). The rate of postoperative nasal cavity complications was 8.7% in patients with normal nasal cavity, 16.7% in patients who received treatment, and 20% in patients without treatment, with significant statistical increase if the nasal cavity was abnormal (p = 0.019). The incidence of complications influenced the primary success rate (p = 0.008); however, preoperative nasal cavity abnormalities were not correlated with primary success (p = 0.479). CONCLUSIONS: In the case of endonasal DCR, preoperative nasal cavity abnormality and type of nasal packing material used did not affect the success rate but significantly affected postoperative nasal cavity complications. In conclusion, endonasal DCR with preoperative treatment of nasal cavity abnormality and Merocel packing is expected to reduce postoperative nasal cavity complications and increase patient satisfaction.

A Case of Orbital Abscess with Central Retinal Artery Occlusion

PURPOSE: To report a case of rapidly progressed orbital abscess after central retinal artery occlusion. CASE SUMMARY: A 60-year-old man with right periorbital pain and edema starting 3 days earlier visited the hospital. His first visual acuity was 1.0 for the right eye with peripheral edema and tenderness; severe hemorrhagic chemosis, proptosis (approximately 3 mm) and extraocular motility limitation were also observed. According to the CT findings, a 2.5 x 1 cm-sized encapsulated cystic mass was found in the right orbital cavity, along the medial orbital wall; with a diagnosis of orbital abscess, he was hospitalized with systemic antibiotic treatment and abscess drainage. On the second day of hospitalization, the best corrected visual acuity was reduced to light perception, and relative afferent pupillary defect, pale retina and cherry red spot were found. Therefore, emergent incisional drainage, optic massage, and antibiotics were given to the patient. Immediately after the surgery, the peripheral edema and proptosis improved; nevertheless, central retinal artery occlusion did not resolve and vision did not improve. Two months later, best corrected visual acuity for the right eye was counting fingers and central retinal artery occlusion showed no further improvement. CONCLUSIONS: No case report on rapidly progressing orbital abscess has been proposed in Korea to date. In the case of rapidly progressed orbital abscess, incisional drainage and antibiotics should be administered promptly.

Visual Acuity and Astigmatism after Simultaneous Surgery for Upper and Lower Eyelid Epiblepharon in Children

PURPOSE: To study the changes in vision and astigmatism in epiblepharon patients undergoing simultaneous surgery for both upper and lower eyelid epiblepharon. METHODS: The study subjects consisted of 40 eyes of 20 patients who underwent surgery for both upper and lower eyelid epiblepharon from March 2007 to December 2008. The patients were divided into groups depending on the degree of corneal erosion. Uncorrected and best corrected vision, refractive error and the degree of corneal erosion were measured before and three months after the surgery. RESULTS: The mean patient age was 7.40 years, and all but three patients showed postoperative grade 0 corneal erosion. Mean uncorrected logMAR visual acuity was 0.44 preoperatively and 0.25 three months after the operation. The mean best corrected logMAR visual acuity was 0.13 preoperatively and 0.04 three months after the operation (p = 0.02, 0.01). Mean astigmatism showed a significant decrease from 1.46 preoperatively to 1.19 three months after surgery (p = 0.03). CONCLUSIONS: After simultaneous surgery for upper and lower eyelid epiblepharon in children, uncorrected and best corrected visual acuity and corneal erosion were all improved. The astigmatism was largely with-the-rule, both before and after surgery.

A Clinical Feature of the Patients of Orbital Wall Fracture With Diplopia

PURPOSE: To analyze the clinical features of orbital wall fracture with diplopia between the surgical treatment group and the conservative treatment group. METHODS: The study comprised of 109 eyes of 109 patients with orbital wall fracture and diplopia. The patients were divided into two groups: the surgical treatment group (59 cases) and the conservative treatment group (50 cases). The groups were analyzed retrospectively according to age, gender, cause, CT, the period and severity of diplopia, and enophthalmos with time. RESULTS: In the conservative treatment group, 38 cases (64.4%) had medial wall fracture, and the average fracture size was 26alpha of the inferior wall and 33% of the medial wall. In addition, at the first visit, the patients showed diplopia within 45.5 degrees, and diplopia disappeared completely within 17 days on average (57 cases, 96.6%). In the group that underwent the reconstruction of orbital wall fracture, 27 cases (54.0%) had inferior wall fracture, and the average fracture size was 41% of the inferior wall and 35% of the medial wall. Additionally, in the first visit, the patients showed diplopia within 20.3 degrees. The muscle incarceration occurred in 12 cases (24%). In the surgical treatment group, diplopia disappeared completely within 30 days on average (45 cases, 90.0%). CONCLUSION: In the group of conservative treatment, they showed diplopia within 45.5 degrees at the first visit. Diplopia disappeared completely within 17 days on average (57 cases, 96.6%). In the group of surgical treatment, they showed diplopia within 20.3 degrees at the first visit. Diplopia disappeared completely within 30 days on average (45 cases, 90.0%).

Clinical Characteristics and Treatment of Congenital Nasolacrimal Duct Obstruction

PURPOSE: A comparison analysis of the clinical characteristics and treatment results of congenital NLD obstruction. METHODS: The present study involved 216 pediatric patients (258 eyes) diagnosed with and treated for congenital NLD obstruction. Treatment was applied step by step starting with conservative massaging, lacrimal probing, and silicone tube intubation. RESULTS: The treatment results of congenital NLD obstruction in pediatric patients under 12 months of age showed an 87.3% success rate after an average of 4.3 months of treatment in the group using lacrimal sac massage and antibiotic eye drops (conservative treatment). The group treated by correct massaging techniques showed a 93.6% success rate after an average of 3.8 months of treatment. The success rate of lacrimal probing, applied to patients not showing improvement after massage therapy was 77.8%. Pediatric patients not showing improvement after lacrimal probing underwent silicone tube intubation. All patients showed improvement except in 1 case that had an early silicone tube dislocation. DISCUSSION: A step-by-step approach is effective in treating congenital NLD obstruction patients, and correct lacrimal massage techniques improve the success rate during conservative therapy. The period of conservative treatment and number of probing times did not have a statistically significant correlation with the success rate of lacrimal silicone tube intubation. Silicone tube intubation showed a high success rate in patients sustaining the silicone tube for a minimum of 2.1 months.

Silicone Intubation and Dacryocystographic Finding in Incomplete Nasolacrimal Duct Obstruction

PURPOSE: To assess the relationship between the internal diameter of the nasolacrimal duct and the success rate of silicone tube intubation in incomplete nasolacrimal duct obstruction patients with epiphora. METHODS: Dacryocystography was performed 80 patients with symptoms of epiphora and the anteroposterior (AP) diameters and the lateral diameters of the nasolacrimal ducts were measured. These measurements were compared between the group of patients who demonstrated improvement after the operation, and the group without symptom improvement. RESULTS: The mean length of the nasolacrimal duct in the group with nasolacrimal stenosis was 11.7+/-0.1 mm, the mean lateral diameter was 1.0+/-0.2 mm, and the mean AP diameter was 1.1+/-0.1 mm. The AP diameter of the symptomatic nasolacrimal duct in the group with successful postoperative results was 1.1+/-0.1 mm, and 0.9+/-0.1 mm in the group with unsuccessful results. The group with successful postoperative results had an average of 18.1+/-7.0% stenosis in the side of the eye with nasolacrimal duct stenosis compared with the asymptomatic side, and the group with unsuccessful postoperative results had an average of 34%+/-3.6% stenosis. CONCLUSIONS: In cases with nasolacrimal duct stenosis, the success rate of silicone tube intubation was high when the AP diameter of the nasolacrimal duct was more than 1.1+/-0.1 mm and when the stenosis was less than 18.1+/-7.0% in the symptomatic side compared with the opposite side. These results are expected to help predict the success rates when preoperatively planning silicone tube intubation.

Clinical Features Associated With Outcomes of Canalicular Laceration Repair

PURPOSE: To evaluate clinical characteristics and outcome of repair of canalicular laceration with Crawford stent. METHODS: All 40 patients who underwent canalicular laceration repair from 2004 to 2007 in the hospital were retrospectively reviewed. Demographics, cause of canalicular injury, surgical management with Crawford stent, and its outcome were analyzed RESULTS: Most cases were male with step wound (34 cases 85%). Average age of fourty patients was 41.7 years old. Outcome had varied depending on the time of surgery, the location of laceration, the suture method, the wound condition, and the duration for stent. Maintaining silicone tube more than three months, and surgical approach within forty-eight hours resulted in statistically significant results. CONCLUSIONS: The outcome of canalicular laceration was better when surgical approach was done within forty-eight hours and silicone tube was maintained more than three months.

Success Rates According to the Shape of Rhinostomy After Endonasal Dacryocystorhinostomy

PURPOSE: To evaluate the success rates according to the shape of rhinostomy after endonasal dacryocystorhinostomy. METHODS: We analyzed 131 patients (188 cases) who had undergone endonasal dacryocystorhinostomy with a minimum follow-up of 6 months. After surgery, all cases were classified into flat, alcove, concave, or concealed concave types according to Jane's rhinostomy classification. Patency to irrigation and improved symptoms were considered indicative of a successful outcome. RESULTS: There were 81 flat type patients (125 cases), 31 alcove type patients (42 cases), 19 concave type patients (21 cases), and no cases were classified as concealed concave type. The success rates were 75.2%, 85.7%, 81.0% respectively, and the most common cause of failure was the formation of granulation within the ostium. The success rates did not significantly vary according to the shape of rhinostomy (p=0.144). CONCLUSIONS: The success rates after endonasal dacryocystorhinostomy of flat, alcove, and concave types in turn were 75.2%, 85.7%, and 81.0%.

The Result of Canaliculodacryocystorhinostomy with Double Probing in Common Canalicular Obstruction

PURPOSE: To evaluate the results of endoscopic canaliculodacryocystorhinostomy with double probing to resolve common canalicular obstruction. METHODS: A total of 47 patients (56 eyes) with common canalicular obstruction underwent endoscopic canaliculodacryocystorhinostomy. The double probing method was applied to 28 eyes; the remaining 28 eyes were in the control group. The success rate, degree of symptom improvement, and complication rate of the two groups were compared and analyzed. RESULTS: The postoperative success rate was 96% in the group that underwent surgery with the double probing method and 86% in the control group (P=0.160). The rate of symptom improvement without tearing was 86% in the double probing method group and 61% in the control group (P=0.038). Postoperative complication rates such as granuloma formation were 7% and 29% in the study and control groups, respectively (P=0.036). CONCLUSIONS: Endoscopic canaliculodacryocystorhinostomy with double probing to resolve common canalicular obstruction is proven to be effective in enhancing patient satisfaction and lowering complication rates, with no additional costs and risks.

A Simple New Method for Identifying the Proximal Cut End in Lower Canalicular Laceration

PURPOSE: We report a simple and effective method of identifying the medial cut end of lower canalicular laceration cases. METHODS: Twenty-seven eyes with lower canalicular lacerations as a result of trauma were involved in the study. Surgery was performed within 48 hours after injury for canalicular reconstruction. Upper canalicular probing was utilized to identify the medial cut end of deep canalicular lacerations when difficulties were encountered. Total time from the initiation of the probing procedure to the identification of the medial cut end of the lower canaliculus was measured. RESULTS: A total of 27 eyes with lower canalicular lacerations were reconstructed. In 20 eyes, the medial lacerated end was located by upper canalicular probing. The mean time from initiation of the probing procedure to identification of the medial cut end of the lacerated canaliculus was 2 minutes. CONCLUSIONS: We conclude that upper canalicular probing in patients with lower canalicular lacerations significantly reduces the time from the initiation of the operation to the identification of the medial cut end of the lower canaliculus.

Results of Conjunctiva-Muller Muscle Resection in Mild Eyelid Ptosis

PURPOSE: To assess surgical outcomes after adjusting the amount of resection of the conjunctiva and the Muller muscle according to 10% phenylephrine test results. METHODS: The charts of 32 patients (32 eyes) with mild upper eyelid ptosis were reviewed retrospectively. They all had conjunctiva-Muller muscle resections. A preoperative 10% phenylephrine test was performed to determine the resection amount of the Muller muscle and conjunctiva. An 8 mm resection was performed when phenylephrine raised the ptotic lid to the same level as that of the contralateral lid. A 7 mm resection was performed when the ptotic lid was raised to a level higher than that of the contralateral lid. A 9 mm resection was performed when the ptotic lid was raised to a level not quite to the level of the contralateral lid. RESULTS: Of the 32 patients, 28 were female and 4 were male. The mean age of the patients was 30.8+/-10.2 years. Patients were followed up for an average of 40.2+/-36.8 days, postoperatively. Postoperative upper lid positions were exactly symmetrical in 26 of the 32 patients. Five patients showed undercorrection, and 1 patient showed overcorrection. CONCLUSIONS: Excellent results were obtained by resecting the conjunctiva and Muller muscle according to the phenylephrine reaction of a ptotic eyelid.

Postoperative Deposition of Calcium on the Surface of a Hydrophilic Acrylic IOL in Diabetic Patients

PURPOSE: Through a study of 3 diabetic patients who experienced decreased visual acuity due to deposit on the surface of hydrophilic acrylic IOLs which were inserted after cataract extraction, the authors attempted to examine pathological and histochemical characteristics of such undesirable deposit on the IOL surface and also evaluate whether a correlation exists between that and diabetes mellitus. METHODS: A 42 year old male patient with bilateral proliferative diabetic retinopathy who has had diabetes for 10 years, a 43 year old male with identical clinical history, and a 46 year old male with bilateral proliferative diabetic retinopathy and clinically significant macular edema who has had diabetes for 13 years were selected for the study. Cataract was extracted by phacoemulsification and after hydrophilic acrylic IOL was inserted into the bag, deposit appeared on IOL surface which caused decreased visual acuity. IOL exchange was conducted thereafter, and by studying the pathological and histochemical characteristics of deposit found on the surface of the retrieved IOL, and by examining the deposit's fine details with electron microscope, the authors attempted to identify the causative material and also evaluate whether diabetes plays a significant role in giving rise to such undesirable deposit. RESULTS: All three IOL that have been retrieved from the patients were covered with multiple deposits which took on a structure with fine circular granules, and all these deposits tested positive when 1% alizarin red staining and von Kossa staining (designed to identify calcium in a given material) were conducted. Electron microscopic study of the deposit also showed needlelike calcium crystals.

Observation on Anxiety and Depression of Glaucoma Patients

PURPOSE: To determine whether correlation exists between anxiety/depression and the advent/ progression of the disease in glaucoma patients. We compared the degree of anxiety and depression among 3 groups which consist of glaucoma patients, cataract patients, and healthy individuals. METHODS: Between July 1, 1999 and December 31, 1999, a written survey was conducted on three groups of people-glaucoma patients, cataract patients, and healthy individuals, who visited Dankook University Hospital's Ophthalmology Outpatient Depatment. Each group consists of 25 people. The Spielberg's State-Trait Anxiety Inventory (STAI) was employed to quantify the degree of anxiety. STAI consists of 40 questions; 20 questions were designed to measure State Anxiety (STAI-S) and 20 questions to measure Trait Anxiety (STAI-T). In each question, the participants were asked to give scores of 1 to 4. In order to measure the degree of depression, Beck Depression Inventory (BDI) was employed which consists of 21 questions with a 0 to 3 scoring scale for each question. RESULTS: In glaucoma patient group, the average STAI-S score was 44.76+/-13.64, STAI-T score 43.92+/-11.66, and BDI score 15.72+/-10.16. The obtained score was significantly higher compared to cataract patient group (34.64+/-9.17, 34.84+/-10.76, 8.44+/-6.80) and normal group (35.56+/-7.30, 34.52+/-7.70, 8.76+/-4.92) and such findings implied that the degree of anxiety and depression was significantly higher in glaucoma patient group. The severity of intraocular pressure, visual field, visual acuity, and cup to disc ratio did not seem to be correlated with anxiety and depression. DISCUSSIONS: In glaucoma patients, a psychological self training in daily life, in addition to surgical or medical treatment, which can help reduce anxiety and depression can be a useful complement to the conventional treatment modalities.

A Case of Central Serous Chorioretinopathy Following Systemic Corticosteroid Therapy

Central serous chorioretinopathy(CSC) is characterized by a serous elevation of neurosensory retina in the posterior pole of the fundus. Its etiology and pathophysiological basis are still unknown. But it is known to be related to corticosteroid therapy. We experienced a development of CSC in a patient who had taken high dose systemic corticosteroid to treat sudden hearing loss. So we report this case with a review of the literatures.

A Case of Congenital Toxoplasmosis in the Neonate

Congenital toxoplasmosis is caused by vertical transmission of Toxoplasma gondii from the mother during pregnancy. The road clinical spectrum of congenital toxoplasmosis ranges from stillbirth or death shortly after birth to survival with either cerebral damage or mild or subclinical disease, consisting usually of ocular involvement. Recently we experienced a neonate with congenital toxoplasmosis. The diagnosis of congenital toxoplasmosis was confirmed on the basis of clinical findings such as chorioretinitis, CT findings of multiple cerebral calcifications calcifications, hydrocephalus, and positive serologic test for toxoplasma IgM anti body. Therefore, we report our case with a review of related literature.