The Analysis of Ocular Deviations between Dominant and Non-dominant Eye Using Video-oculography in Intermittent Exotropia

PURPOSE: To measure and analyze ocular deviations between dominant and non-dominant eyes using video-oculography (VOG) in intermittent exotropia. METHODS: Fourteen subjects who were diagnosed with intermittent exotropia from July 2017 to July 2018 with age of 5 or more, visual acuity of 20/30 or better and corrected visual acuity of 20/25 or more and difference in vision of both eyes of 1 line or less on Snellen optotype were included. The subjects were asked to fixate on a black-on-white optotype at 1 m, which subtended a visual angle of 50 minutes of arc. The video files and data about ocular deviations were obtained using VOG with alternate cover test. We analyzed angles of ocular deviations in dominant and non-dominant eyes. RESULTS: Among the 14 subjects in this study, the mean age were 7.6 ± 1.7 (range 5–9 years). Seven of 14 subjects had the right eye dominance. Six of the 14 subjects were men. There was no significant difference of ocular deviations between the dominant and non-dominant eyes in VOG (p = 0.167). Additionally, there was no significant difference of the values of VOG when one eye was exodeviated or re-fixated (p = 0.244), when both eyes were deviated, and when both eyes were re-fixated (p = 0.195, 0.637). CONCLUSIONS: In this study, there was no significant difference of ocular deviations between the dominant and non-dominant eyes, between when an eye was exodeviated or fixated using VOG. Therefore, it may not be a problem even if alternate prism cover test is performed in any eye in intermittent exotropia of more than 50 prism diopter without amblyopia or refraction abnormality that could affect the uncorrected visual acuity.

A Case of Surgical Diagnosis and Treatment of Idiopathic Orbital Myositis with Sudden Vision Loss

PURPOSE: We report a case of idiopathic orbital myositis with sudden onset of unilateral visual loss and hypertrophy of the lateral rectus muscle at the apex of the orbit that was diagnosed using orbital biopsy and treated with intravenous corticosteroids. CASE SUMMARY: We examined a 20-year-old woman who complained of decreased visual acuity and binocular diplopia for 2 weeks. She showed 40-prism diopter left esotropia at the primary position. Her visual acuity with eyeglasses was 0.7 and 0.2 in the right and left eyes, respectively. Brain magnetic resonance imaging (MRI) revealed a round mass on the left lateral rectus muscle at the apex of the orbit with optic nerve compression. We planned orbital biopsy to exclude orbital lymphoma and other biopsy-requiring diseases. After 3 weeks, the visual acuity of her left eye decreased to 0.02. Repeated MRI revealed enlargement of all extraocular muscles on the left orbit. With biopsy showing several lymphocytes infiltrating muscle fibers, we made a diagnosis of idiopathic orbital myositis. Intravenous injection of corticosteroids was administered during hospitalization. After 2 weeks of corticosteroid therapy, the visual acuity of her left eye was improved to 0.63, the esotropia disappeared, and the enlargement of the left lateral rectus muscle was improved on orbital MRI. CONCLUSIONS: For non-specific idiopathic orbital myositis located at the apex of the orbit and enlargement of the extraocular muscle in a short period with decreased visual acuity, administration of intravenous injection of corticosteroids before orbital biopsy could help restore vision.

Efficacy of Primary Intravitreal Ranibizumab Injection for Treatment of Type 1 Retinopathy of Prematurity

PURPOSE: To evaluate the effectiveness and safety of primary intravitreal ranibizumab injection as a treatment for retinopathy of prematurity. METHODS: Retrospective analysis of the medical records of patients diagnosed with retinopathy of prematurity and treated with intravitreal ranibizumab injection from January 1, 2013 to January 1, 2016 was performed. We complied with the standards for ‘prethresold, type 1’ established by the Early Treatment of Retinopathy of Prematurity study for intravitreal ranibizumab injection. The follow-up period after injection was at least 9 months. Patients who received additional treatment such as laser photocoagulation or intravitreal injection without reactivation of retinopathy of prematurity were excluded. RESULTS: A total of 21 patients (39 eyes) were included in this study. Nine (16 eyes) were male and 12 (23 eyes) were female. The average duration between treatment decision and intravitreal ranibizumab injection was 2.1 ± 1.5 days. Complete regression of the plus sign occurred 18.2 ± 9.1days after injection. One eye with reactivation was treated with panretinal laser photocoagulation while four other eyes with reactivation were treated with intravitreal bevacizumab injection. There were 87.1% (34/39) eyes that underwent primary intravitreal ranibizumab injection with stable results without any reactivation. There were no systemic complications related to intravitreal ranibizumab injection. CONCLUSIONS: Primary intravitreal ranibizumab injection as a treatment for retinopathy of prematurity showed good efficacy and safety. However, thorough evaluation is needed after primary intravitreal ranibizumab injection due to the potential for reactivation. Long-term monitoring is needed after intravitreal ranibizumab injection.

A Case of Traumatically Ruptured Medial and Inferior Rectus Muscles with an Avulsed Optic Nerve

PURPOSE: To report the good surgical results of multiple ruptured rectus muscles with avulsion of the optic nerve. CASE SUMMARY: A 39-year-old male patient underwent surgical exploration after rupture of the inferior and medial rectus muscles and avulsion of the optic nerve. The disinserted muscles were attached at the primary insertion site, and a served optic nerve was not found. Six months after the injury, the patient had orthotropia in the primary position without ischemia of the anterior segment. CONCLUSIONS: In rare instances, blunt trauma can result in optic nerve avulsion with ruptured inferior and medial rectus muscles. Surgical treatment can result in a favorable outcome.

A Case of Acute Incomitant Esotropia Associated with Wernike's Encephalopathy

PURPOSE: We report a case of an acute incomitant esotropia with Wernike's encephalopathy. CASE SUMMARY: A 64-year-old male visited our hospital because of diplopia lasting a week. He was a chronic alcoholic drinking two bottles of makgeolli daily and eating little for a month. He showed -2 underaction of bilateral lateral rectus muscles and 45 prism diopters of esotropia at the primary position at the first visit. He had ataxia and mild cognitive impairment. There were high signal intensities in the periaqueductal area and mammillary bodies in the brain fluid attenuated inversion recovery magnetic resonance image. He was diagnosed with Wernike's encephalopathy clinically and was immediately treated with intravenous thiamine. He showed -0.5 underaction of bilateral lateral muscles and 8 prism diopters of esotropia at the primary position 3 days after thiamine treatment. CONCLUSIONS: Wernicke's encephalopathy is a medical emergency. If diagnosis and treatment are delayed, patients may have neurological sequelae that can lead to death. Esotropia and diplopia can be the presenting manifestations in Wernike's syndrome without other symptoms. In taking patient histories, physicians should ask about alcohol consumption and low food intake because of the possibility of acute incomitant esotropia associated with Wernicke's encephalopathy.

Comparison between 20 and 25 Prism Diopters in Bilateral Rectus Muscle Recession for Intermittent Exotropia

PURPOSE: To compare the outcomes of bilateral lateral rectus recession between 20 and 25 prism diopters (PD) for intermittent exotropia. METHODS: A retrospective study was performed with a total of 584 patients who underwent surgery for intermittent exotropia and were followed up for more than 12 months. The patients were classified into either the 20 PD group (5 mm bilateral rectus muscle recession [BLR]) or the 25 PD group (6 mm BLR). Successful postoperative motor alignment was defined as within 10 PD of exotropia and 4 PD of esotropia. RESULTS: Cumulative probabilities of surgical success rates for 24 months were 77.9% in the 20 PD group and 54.8% in the 25 PD group, respectively (p < 0.001). Postoperative deviations in recurrence patients were 13.41 +/- 3.64 PD and 14.66 +/- 3.87 PD (p = 0.062) at postoperative 12 months. CONCLUSIONS: All patients with relatively small angle of exodeviation such as 20 PD had a higher success rate and small postoperative exodaviation at 12 months. Therefore, surgery could be considered when the eye is exodeviated with a relatively small angle. However, in the group with the exotropic drift, approximately 2/3 of the preoperative angle of deviation is measured with similar outcomes between preoperative and postoperative angles of deviation.

Clinical Study of Efficacy of Super Elastic Wire for Ingrown Nails of Great Toe / 대한피부과학회지

BACKGROUND: Ingrown toenail is one of the most common nail complaints. It occurs mostly on the great toes, where is an excessive lateral nail growth into the nail fold, leading to painful irritation, inflammation, and growth of the granulation tissue. Many treatments have been described, but these classic treatment modalities may lead to severe damage of the nail fold or frequent relapses. OBJECTIVE: We attempted to evaluate the therapeutic efficacy of super elastic wire (SE-wire, Machiwire(R)), a non-invasive treatment for ingrown toenails. METHODS: Fifteen patients with ingrown toenail were treated with super elastic wire. Objective assessment was evaluated by use of the width index (width of the nail tip/width of the nail root) and height index (height of the nail tip/width of the nail root). Subjective assessment was evaluated by use of a visual analogue scale declared by patients. In addition, wound complications and recurrence were described. RESULTS: The width index and height index were improved (width index: 75.0%-->90.0%, height index: 76.5%-->27.7%). Pain was relieved in 100% of the cases. For subjective assessment, all of the patients were satisfied (more than "satisfactory": 100%). There were two relapsed cases during 5 to 12 month period (mean time: 9 months). CONCLUSION: We recommend super elastic wire method as an alternative treatment for ingrown toenail, because it is simple, easy to perform, noninvasive, effective, and well-tolerated.

Altered Levels of Sphingosine and Sphinganine in Psoriatic Epidermis

BACKGROUND: Ceramides are the main lipid component of the stratum corneum and are a structurally heterogeneous and complex group of sphingolipids of which sphingoid bases are the basic structural constituents. Altered levels of sphingoid bases have been reported in skin conditions that involve dryness and barrier disruption, including atopic dermatitis. OBJECTIVE: The purpose of this study was to investigate the altered levels of sphingoid bases in psoriatic epidermis and their relationship with the clinical severity of the psoriasis. METHODS: Samples from the lesional and non-lesional epidermis were obtained from eight psoriasis patients. Levels of sphingosine and sphinganine were analyzed by high-performance liquid chromatography. The expression of ceramide synthase and ceramidase proteins, which are related to sphingosine and sphinganine metabolism, were measured using Western blot analysis. RESULTS: Levels of sphingosine and sphinganine in the lesional epidermis were significantly higher than those in the non-lesional epidermis. Although there was no altered ceramide synthase and ceramidase, there was a highly significant positive correlation between the % change of ceramidase, the degradative enzyme of ceramide into sphingosine, and the Psoriasis Area Severity Index (PASI) score. CONCLUSION: The levels of sphingosine and sphinganine were significantly increased in psoriatic epidermis and the % change of ceramidase was positively correlated with the clinical severity of psoriasis.

Altered Levels of Sphingosine and Sphinganine in Psoriatic Epidermis

BACKGROUND: Ceramides are the main lipid component of the stratum corneum and are a structurally heterogeneous and complex group of sphingolipids of which sphingoid bases are the basic structural constituents. Altered levels of sphingoid bases have been reported in skin conditions that involve dryness and barrier disruption, including atopic dermatitis. OBJECTIVE: The purpose of this study was to investigate the altered levels of sphingoid bases in psoriatic epidermis and their relationship with the clinical severity of the psoriasis. METHODS: Samples from the lesional and non-lesional epidermis were obtained from eight psoriasis patients. Levels of sphingosine and sphinganine were analyzed by high-performance liquid chromatography. The expression of ceramide synthase and ceramidase proteins, which are related to sphingosine and sphinganine metabolism, were measured using Western blot analysis. RESULTS: Levels of sphingosine and sphinganine in the lesional epidermis were significantly higher than those in the non-lesional epidermis. Although there was no altered ceramide synthase and ceramidase, there was a highly significant positive correlation between the % change of ceramidase, the degradative enzyme of ceramide into sphingosine, and the Psoriasis Area Severity Index (PASI) score. CONCLUSION: The levels of sphingosine and sphinganine were significantly increased in psoriatic epidermis and the % change of ceramidase was positively correlated with the clinical severity of psoriasis.

Surgical Treatment of Face Turn, and Up and Down Shoot in Duane Retraction Syndrome

PURPOSE: To present the results of patients undergoing surgical treatment and determine clinical guidelines for the face turn, and up and down shoot in Duane retraction syndrome (DRS). METHODS: Thirty-four patients with DRS were treated with single horizontal rectus muscle recession, lateral rectus (LR) recession with Y-splitting, or LR recession with Y-splitting combined with medial rectus (MR) recession. The different treatment approaches were based on the angle of deviation in the primary position, versions, and ductions. In all patients, ocular alignment, face turn and up and down shoot were assessed preoperatively and postoperatively. RESULTS: The average standard deviation reduced from 18.5 +/- 6.5 prism diopters (PD) to 4.6 +/- 5.8 PD in horizontal rectus muscle recession and 14.4 +/- 5.5 PD to 1.6 +/- 2.8 PD in LR recession with Y-splitting. LR recession with Y-splitting combined with MR recession was effective in reducing globe retraction. Postoperative 4-mm LR recession with Y-splitting did not change ocular alignment; 7-mm LR recession with Y-splitting showed an average correction of 12.8 PD. Postoperatively, all patients presented a reduction in face turn; however, there was no statistically significant difference between the 2 procedures (Mann-Whitney U test, p = 0.620). CONCLUSIONS: Decisions regarding surgical approaches in DRS should be based on the amount of deviation in primary eye position, the expression of up and down shoot, and the degree of face turn. Surgeons planning Y-splitting of LR with MR recession must consider modifying the MR recession amount due to the smaller LR recession effect of Y-splitting compared with conventional LR recession.

The Outcome of Graded Inferior Oblique Recession in the Congenital Unilateral Superior Oblique Palsy

PURPOSE: To examine changes in vertical deviation and improvement in head tilt after graded inferior oblique (IO) recession surgery in patients with congenital unilateral superior oblique palsy (SOP). Frequency of inferior oblique overaction (IOOA) or bilateral SOP in the contralateral eye after surgery was also investigated. METHODS: We retrospectively reviewed medical records of 65 patients who had undergone graded IO recession surgery in unilateral congenital SOP with at least 1 year of postoperative follow-up. Postoperative vertical deviation was classified as excellent (under 3 prism diopters, PD), good (4-7 PD) or poor (over 8 PD). The occurrence of IOOA was considered if more than 2 IOOAs were observed in the contralateral eye after surgery. RESULTS: Forty-five of the 65 patients (69%) obtained excellent results and 67.3% had improvement in head tilt after surgery. IOOA in the contralateral eye was not observed in any patients before surgery. Postoperative IOOA in the contralateral eye occurred in 9 patients (13.8%) and a diagnosis of masked bilateral SOP was made in 1 patient (1.5%). CONCLUSIONS: The graded IO recession procedures are considered to be an effective surgical method for the treatment of unilateral congenital SOP. However, IOOA or masked bilateral SOP occurring in the contralateral eye was observed in 15.3% of the patients undergoing surgery.

Contralateral Inferior Oblique Overaction after Inferior Oblique Recession in Unilateral Moderate Primary Inferior Oblique Overaction

PURPOSE: To investigate the incidence rate of inferior oblique muscle overaction (IOOA) in the contralateral eye and the effect of inferior oblique (IO) muscle recession of the contralateral eye in the patients who received IO muscle recession for unilateral moderate (+2 or +3) primary IOOA. METHODS: Medical records of 88 patients with unilateral primary IOOA who underwent unilateral IO muscle recession were retrospectively reviewed and observed during a follow-up period of more than 1 year. Graded recession of the IO muscle was performed according to the degree of IOOA. If postoperative IOOA was below +1, the surgery was considered successful. If IOOA in the contralateral eye was more than +2 after surgery, the IOOA was considered to have occurred. RESULTS: In cases where IOOA was +2 and +3 before the surgery, the success rate was 98.2% and 100%, respectively, showing an overall success rate of 98.8%. The incidence of contralateral IOOA after recession of the unilateral IO muscle was 24.1% in the +2 group and 16.6% in the +3 group with an overall incidence rate of 21.6% and when the IO muscle recession of the contralateral eye was performed, the success rate was 100%. CONCLUSIONS: The incidence of contralateral IOOA was 21.6% after the unilateral IO muscle recession in moderate unilateral primary IOOA. A satisfactory outcome was obtained through an additional IO muscle recession in the contralateral eye.

Coexistence of Pilomatricoma and Epidermal Cyst (Hybrid Cyst) / 대한피부과학회지

Pilomatricoma is a benign tumor derived from the hair matrix. Pilomatricoma-like changes have been described in epidermal cysts in Gardner's syndrome. Apart from this association, a cyst can arise from various portions of a hair follicle, and combine to form a hybrid cyst. Follicular hybrid cyst is an interesting pathologic phenomenon, and needs to be explained for their pathogenesis. We present a case in which a pilomatricoma was situated in the immediate vicinity of an epidermal cyst. Histopathologic findings showed that one part of the cyst had a feature of an epidermal cyst, and the other part had a feature of a pilomatricoma.

Pyoderma-Pyostomatitis Vegetans without Inflammatory Bowel Disease / 대한피부과학회지

Pyodermatitis-pyostomatitis vegetans (PD-PSV) is a rare, benign pustular and vegetating mucocutaneous dermatosis with a tendency to affect the oral mucosa and the skin of the groin and axilla. The cutaneous lesions begin as crusted erythematous papulopustules, which coalesce to form large vegetating plaques, usually in the axillae, genital area and scalp. PD-PSV is known to be frequently associated with inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn's disease. We report a rare case of PD-PSV, which showed typical clinical and istopathological features, but was not accompanied by inflammatory bowel disease.

Cutaneous Metastasis from Small Cell Lung Cancer Expressing Thyroid Transcription Factor-1 / 대한피부과학회지

No abstract available.

Cutaneous Extramedullary Hematopoiesis in Idiopathic Myelofibrosis / 대한피부과학회지

Extramedullary hematopoiesis is commonly seen in the liver, spleen and lymph nodes, but cutaneous extramedullary hematopoiesis (CEH) is very rare. CEH affects mainly children with intrauterine viral or hematologic disorders and rare manifestation of chronic myeloproliferative processes in adults. Idiopathic myelofibrosis (IM) is a chronic myeloproliferative disorder and some cases of IM have extramedullary hematopoiesis. IM is characterized by the proliferation of the endothelial cells and fibroblasts in the bone marrow, resulting in disruption of bone marrow, with subsequent migration and proliferation of the hematopoietic stem cells in other organs. We report a very rare case of cutaneous extramedullary hematopoiesis in a 74-year-old male with IM.

The Effect of Reoperation in Inferior Oblique Overaction

PURPOSE: To evaluate the efficacy of re-recession or extirpation of inferior oblique (IO) muscle in recurrent or undercorrected IO overaction (IOOA). METHODS: We reviewed the records of 26 patients (33 eyes) with the recurrent or undercorrected IOOA after the graded recession of IO muscle, who underwent re-recession or extirpation of IO muscle, and was followed up for at least 6 months. We performed extirpation of IO muscle overacting larger than +2 after 14 mm recession of IO muscle or larger than +3 after 10 mm recession of IO muscle. In case of +2 IOOA after 10 or 8 mm recession of IO muscle, we carried out 14 mm re-recession of IO muscle. IOOA under +1 was defined as a successful case after re-operation. RESULTS: Thirty one of 33 eyes (93.9%) were corrected successfully after re-operation; 24 eyes with extirpation of IO muscle (96.0%) and 7 eyes with 14 mm re-reccession of IO muscle (87.5%) were successful. CONCLUSIONS: One of the advantages of graded recession of IO muscle is that additional re recession or extirpation of IO muscle can be preformed if needed. Extirpation or 14 mm re-recession of IO muscle was effective re operation procedure to correct a recurred or undercorrected IOOA.

Clinical Course of Young Adults With Central Retinal Vein Occlusion

PURPOSE: To describe the clinical course of young patients with central retinal vein occlusion (CRVO). METHODS: We reviewed the records of patients 50 years or younger who presented with CRVO and who were followed up for at least 6 months. RESULTS: The average age of the patients was 37.7 years, and the mean follow-up time was 26.3 months. Participants included 27 patients with CRVO younger than 50 years among the total 393 patients with CRVO, and the sex distribution was nearly equal; 13 patients were male and 14 patients were female. Associated systemic diseases were hypertension (8 patients), diabetes (3 patients), stroke (3 patients), and myocardial infarction (1 patient). Of the 17 patients who had no systemic disease, 8 patients had hypercholesterolemia or another hematologic abnormalities. Of the 18 eyes with non-ischemic CRVO, 10 eyes (55.6%) showed improved final visual acuities (2 or more lines). Of the 9 eyes with ischemic CRVO, only 1 eye (11.1%) showed improved visual acuity. CONCLUSIONS: Hematological examination and treatment with systemic evaluation were recommended to younger patients with CRVO. The classification of retinal ischemia of young patients as well as that of older patients could be useful for the follow-up of patients and the assessment of its progression in the future.

The Effect of Intern and Resident's Perspective of Death on the Attitude to Patient Care / 신경정신의학

OBJECTIVES: This study aimed to investigate the effect of intern and resident's perspective of death on the attitude to Patients care. METHODS: Participants were recruited from interns and residents working in Chosun University Hospital. The questionnaires on perspective of death and attitudes to patient care include i) the perspectives of death and degree of fear of death ii) the attitude of telling truth to dying patients iii) the attitude to the disease frequently associates with the thought of "living with it is worse than dying", and iv) the avoidant or acceptable attitude when they are treating patients with low chance of recovery thus facing death. RESULTS: Eighty-eight interns and residents participated in this survey. The most frequent reply on the perspective of death was "death is a part, and a process of life" (48.9%). This group also choose more those types of diseases in which they think "living is worse than dying if oneself get it" (p=0.014). This group also showed more avoidant inclination in treating patients with low chance of recovery and facing death compared with other groups (p=0.068). Paradoxically those people who answered that they have no fear to death showed significantly more avoidant behavior against the care of dying patients (p=0.050). CONCLUSION: This study showed that interns' and resident's perspectives of death affect their pattern of patients care, particularly with avoidant patterns against patients. This study suggests the importance of the medical education on thanatology that including the ethical and moral aspects of death.