Discordance in Retinal and Choroidal Vascular Densities in Patients with Type 2 Diabetes Mellitus on Optical Coherence Tomography Angiography.

PURPOSE: In the present study, the retinal and choroidal vascular densities (VDs) in type 2 diabetes mellitus (DM) patients were analyzed using optical coherence tomography angiography (OCTA). METHODS: The study included 282 eyes of 152 patients with type 2 DM (114 without retinopathy, 79 nonproliferative diabetic retinopathy (NPDR), 48 severe NPDR, and 41 proliferative diabetic retinopathy (PDR) eyes). The superficial and deep retinal vessel, choriocapillaris, and choroidal VDs were measured using a binarization method on OCTA images. VDs were compared based on retinopathy severity. Correlations among densities were analyzed. RESULTS: Retinal and choriocapillaris VDs were lower in PDR than in NPDR (all P < 0.05). Correlation analysis showed significant positive correlations among densities of superficial and deep retinal vessels and choriocapillaris (all P < 0.001). Choroidal VD showed a negative correlation with superficial and deep retinal vessels and choriocapillaris (all P < 0.001). Retinal and choriocapillaris VDs showed a negative correlation with diabetic retinopathy (DR) grade (all P < 0.001); however, the choroidal VD showed a weak positive correlation (P=0.030). CONCLUSION: Choroidal VD increased as retinal and choriocapillaris VDs decreased, indicating that the outer layer of the choroid is less affected by DR severity and VD of larger choroidal vessels may even be increased as a compensatory mechanism for decreased retinal and choriocapillaris VDs in type 2 DM patients.

Classification of pachychoroid on optical coherence tomography using deep learning.

PURPOSE: Pachychoroid is characterized by dilated Haller vessels and choriocapillaris attenuation that are seen on optical coherence tomography (OCT) B-scans. This study investigated the feasibility of using deep learning (DL) models to classify pachychoroid and non-pachychoroid eyes from OCT B-scan images. METHODS: In total, 1898 OCT B-scan images were collected from eyes with macular diseases. Images were labeled as pachychoroid or non-pachychoroid based on strict quantitative and qualitative criteria for multimodal imaging analysis by two retina specialists. DL models were trained (80%) and validated (20%) using pretrained convolutional neural networks (CNNs). Model performance was assessed using an independent test set of 50 non-pachychoroid and 50 pachychoroid images. RESULTS: The final accuracy of AlexNet and VGG-16 was 57.52% for both models. ResNet50, Inception-v3, Inception-ResNet-v2, and Xception showed a final accuracy of 96.31%, 95.25%, 93.40%, and 92.61%, respectively, for the validation set. These models demonstrated accuracy on an independent test set of 78.00%, 86.00%, 90.00%, and 92.00%, and an F1 score of 0.718, 0.841, 0.894, and 0.920, respectively. CONCLUSION: DL models classified pachychoroid and non-pachychoroid images with good performance. Accurate classification can be achieved using CNN models with deep rather than shallow neural networks.

Choroidal changes in eyes treated with high-dose systemic corticosteroids for optic neuritis.

AIM: To analyze the effect of systemic high-dose corticosteroid on the choroid in patients with unilateral optic neuritis. METHODS: A retrospective comparative cohort study. Seventy-six eyes of 38 patients with unilateral optic neuritis that received systemic high-dose corticosteroid treatment were enrolled. Choroidal thickness (CT) and choroidal vascularity index (CVI) were measured in both affected and the fellow eyes at baseline, 1wk, 1 and 3mo. Changes in CT and CVI were analyzed in both eyes and compared between eyes. RESULTS: The mean CT and CVI were 349 µm and 0.70 in the affected eyes and 340 µm and 0.69 in the fellow eyes at baseline (P=0.503 and 0.440, respectively). Decrement of CT and CVI at month 3 were significant in affected eyes (P=0.017 and P<0.001). Decreased CVI began 2wk after treatment whereas CT decreased from 1mo. The CVI also decreased significantly in fellow eyes at 3mo compared to the baseline (P=0.001). CONCLUSION: A significant decrement in CT and CVI can appear after 3mo in optic neuritis patients treated with high-dose systemic corticosteroid treatment. The decrease in CVI appeared earlier than the decrease in CT, suggesting choroidal vasoconstriction caused by systemic steroid as a possible mechanism.

Effect of Acetazolamide on Choroidal Morphology in Central Serous Chorioretinopathy.

PURPOSE: We sought to elucidate the influence of acetazolamide on choroidal structure changes during the treatment of central serous chorioretinopathy (CSC). METHODS: This was a retrospective study of 45 eyes from 45 patients with acute CSC who were divided into an acetazolamide group (group 1, n = 20) and an observation group (group 2, n = 25). The main outcome measures were the changes in best-corrected visual acuity, subretinal fluid (SRF) height, subfoveal choroidal thickness (SFCT), and choroidal vascularity index (CVI) at one week, one month, two months, and three months, respectively. RESULTS: Although statistical significance was not reached, best-corrected visual acuity improved in both groups at month 3 (from 0.06 ± 0.07 to 0.01 ± 0.03 in group 1 and 0.17 ± 0.24 to 0.09 ± 0.18 in group 2; p = 0.083 and 0.183, respectively). Separately, SRF height and CVI showed a significant decrease at three months in both groups (all p < 0.05), while a significant SRF height decrease was also noted in group 1 at one month (p = 0.038). In group 1, a significant decrease in the SFCT and CVI started at one week and one month (p = 0.021 and 0.008), respectively. However, in group 2, a significant decrease in the SFCT and CVI started at one month and two months (p = 0.005 and 0.015), respectively. CONCLUSIONS: Acetazolamide has no effect on final functional or anatomical status at three months in eyes with CSC but does shorten the time for SRF absorption and accompanying choroidal structural changes.

Analysis of Choroidal Vascularity in Children with Unilateral Hyperopic Amblyopia.

This institutional case control study was carried out to compare choroidal vascularity (CV) in amblyopic eyes, fellow eyes, and control eyes in children with unilateral hyperopic amblyopia. Sixty-four eyes of 32 childeren with unilateral anisometropic hyperopic amblyopia and 38 eyes of 19 healthy children (controls), aged 3 to 16 years. Subfoveal choroidal thickness (CT) and CV were measured using spectral domain optical coherence tomography. The mean subfoveal CT of amblyopic eyes (338.9 ± 60.0 µm) was greater than that of fellow eyes (315.3 ± 63.3 µm, P = 0.043) and control eyes (313.0 ± 42.1 µm, P = 0.025). The mean CV of amblyopic eyes (0.715 ± 0.020) was greater than that of control eyes (0.700 ± 0.020, P < 0.001). While a positive correlation between CT and CV was found in normal eyes (r = 0.470, P = 0.004), a strong negative correlation existed in amblyopic eyes (r = -0.684, P < 0.001). In conclusion, although mean CV was higher in amblyopic eyes, the negative correlation between CT and CV may suggests insufficient blood supply to the outer retina and choroid in the affected eyes of patients with unilateral anisometropic hyperopic amblyopia.

Relationship between Age and Retinal Nerve Fiber Layer Thickness in Normal Children.

PURPOSE: To evaluate the effect of age and ocular factors on peripapillary retinal nerve fiber layer (RNFL) thickness in children. METHOD: A total of 198 normal subjects aged <19 years received a comprehensive ophthalmologic examination, including measurement of visual acuity, axial length, and cycloplegic refraction. Fast optical coherence tomography RNFL scans were obtained and average RNFL thickness was adjusted for ocular magnification. One eye of each subject was randomly selected as the study eye. The correlations between age and other ocular variables were examined. RESULTS: Mean subject age was 8.61 ± 3.12 years. Average RNFL thickness and ocular magnification-corrected average RNFL thickness were 107.71 ± 11.83 and 103.03 ± 12.53 µm, respectively. There was no significant correlation between observed RNFL thickness and spherical equivalent of the refractive error (SE), axial length, or age (all P >0.05). Corrected RNFL thickness was positively correlated with age and axial length and negatively correlated with SE (P <0.01). Age was negatively correlated with the percent difference between observed and corrected RNFL thickness (P <0.001). Multivariate linear regression analysis showed that both axial length and age were correlated with corrected RNFL thickness in subjects <15 years old (P <0.05). CONCLUSION: The RNFL thickness is likely to be overestimated in children <15 years old. Additionally, an RNFL thickness increase was observed in children <15 years old. Thus, ocular magnification and RNFL thickness increase should be considered when assessing RNFL thickness in patients <15 years old.

Effect of small head tilt on ocular fundus image: Consideration of proper head positioning for ocular fundus scanning.

Head tilt and resultant ocular cyclotorsion can influence the results of ophthalmologic examinations. Thus, proper head positioning during fundus scanning has been emphasized. However, there is no perfect method to control the head tilt and little is known about the effect of small head tilts. In this study, we investigated the effect of minimal head tilt on the ocular cyclotorsion which we cannot easily detect.Forty-seven participants without ophthalmologic or vestibular abnormalities were recruited as normal subjects. Their faces were positioned at the desired head tilt using a customized adjustable head tilter and facial and fundus photographs of both the left and right eyes were taken in the upright neutral position; as well as at rightward and leftward head tilts of 2°, 4°, and 6°. The actual head tilt was determined using the facial photographs by measuring the slope of a line that intersected the corneal reflexes of both eyes. Rotational changes in the fundus images were recorded and the correlation of these changes with the degree of head tilt was determined.The degree of head tilt was significantly correlated with rotational changes in the fundus images from both the right and left eyes (P < 0.001; right eye: R = 0.897, left eye: R = 0.899). The mean relative compensations for head tilt, mediated by the ocular counterrolling reflex, were 0.376 ±â€Š0.255 in the right eye (range: -0.02 to 1.0), and 0.350 ±â€Š0.263 in the left eye (range: -0.03 to 1.0), and exhibited a significant negative correlation with head tilt (P < 0.05). The mean relative compensation of the right eye did not differ significantly from that of the left eye (P = 0.380), but the value did vary widely among individuals and within individuals.Even very small head tilt was partially and variably compensated for, and caused significant rotation in the fundus image. We concluded that proper head positioning does not guarantee the minimal ocular cyclotorsion change of the eyes and image-adjusting technique would be a better solution for minimizing errors from ocular cyclotorsion changes.

Fungal corneal ulcer and bacterial orbital cellulitis occur as complications of bacterial endophthalmitis after cataract surgery in an immunocompetent patient.

PURPOSE: To report a case of fungal corneal ulcer and bacterial orbital cellulitis as complications of bacterial endophthalmitis following cataract surgery. METHODS: A 51-year-old man underwent anterior chamber irrigation and aspiration in the left eye one day after cataract surgery because of bacterial endophthalmitis. Marked lid swelling with purulent discharge was developed after 5 days. Slit lamp examination showed generalized corneal ulcer and pus in the total anterior chamber. A computerized tomography scan showed left retrobulbar fat stranding with thickened optic disc. Streptococcus pneumonia was cultured from corneal scraping, vireous, and subconjunctival pus. RESULTS: The patient improved gradually with antibiotics treatments, but the corneal ulcer did not fully recover 2 months after cataract surgery. Candida albicans was detected in repetitive corneal culture. After antifungal and antibacterial therapy, the corneal epithelium had healed, but phthisis bulbi had developed. CONCLUSION: Fungal corneal ulcer and bacterial orbital cellulitis can occur as complications of endophthalmitis in an immunocompetent patient.

Astigmatic changes after horizontal rectus muscle surgery in intermittent exotropia.

PURPOSE: To evaluate the changes of refractive astigmatism after horizontal rectus muscle surgery in intermittent exotropic children. METHODS: Sixty-nine exotropic patients were retrospectively reviewed. Of those, 35 patients received unilateral lateral rectus recession (BLR group, 35 eyes) and 34 patients received unilateral lateral rectus recession and medial rectus resection (R&R group, 34 eyes). Non-cycloplegic refractions were measured until 6 months postoperatively. Spherical equivalent (SE), J0 and J45 using power vectors were calculated to determine and compare the changes of refractive astigmatism and axis in both groups. RESULTS: SE significantly decreased after surgery for the first week and did not changed thereafter in both groups (p = 0.000 and p = 0.018, respectively). In BLR group, J0 showed significant changes at the first week and 1 month after surgery (p = 0.005 and p = 0.016, respectively), but in R&R group, J0 changed significantly between 1 week and 3 months postoperatively (p = 0.023 and p = 0.016, respectively). J45 did not change significantly as time passed in both groups (all p > 0.05). There was no statistically significant difference in the magnitude of changes in SE, J0 and J45 between the two groups after the 6-month follow-up (p = 0.500, p = 0.244 and p = 0.202, respectively). CONCLUSIONS: Horizontal rectus muscle surgery in intermittent exotropic children tends to induce a statistically significant change in astigmatism in the with-the-rule direction and myopic shift in SE. This astigmatism change seems to occur within the first 3 months after surgery. Thus, astigmatism induced by surgery should be checked and corrected at least 3 months after horizontal strabismus surgery.

Excision with corneoscleral lamellar keratoplasty and amniotic membrane transplantation of a corneal displaced recurrent conjunctival melanoma.

An 81-year-old woman with a raised pigmented nodule over her left cornea for 7 months duration was examined. Dark conjunctival pigmentation was observed in the upper bulbar fornix conjunctiva. She had previously undergone primary surgical excision of a malignant conjunctival melanoma four years earlier. The tumor separated easily from the corneal surface, but remained slightly attached to the corneoscleral surface. A corneoscleral lamellar dissection of 3 mm in width and 2 mm in depth as well as a corneoscleral lamellar keratoplasty for the reconstruction of the corneoscleral defect were performed. The wide upper bulbar and fornix conjunctiva were excised, and an amniotic membrane transplantation was performed. Biopsy revealed an invasive melanoma with a depth of 1 mm. Left, right, and inferior tumor margins of the corneoscleral lesion and the pigmentary lesion in the conjunctiva were free of the tumor. After surgery, 0.04% mitomycin was administered topically 4 times daily for 4 weeks. There was no recurrence 2 years after surgery, and systemic evaluation revealed no metastasis.

"Iris-assisted," open-sky, continuous curvilinear capsulorhexis technique for combined cataract extraction and corneal transplantation.

The authors describe "iris-assisted," open-sky, continuous curvilinear capsulorhexis (CCC) in a triple procedure combining corneal transplantation, cataract extraction, and intraocular lens implantation. They do not use miotics or mydriatics. Patients receive oral acetazolamide (250 mg), intravenous mannitol (5 mL/kg), and Honan balloon at 30 mm Hg for 20 to 30 minutes before surgery. After trephination and excision of recipient cornea, the pupil assumes a mid-dilated position. After injection of 2.3% hyaluronic acid into the anterior chamber, a central linear incision is made in the anterior capsule using a cystotome needle and a CCC is made (approximately 5.5 mm) along the pupillary margin with CCC forceps. The mid-dilated iris can "assist" by resisting posterior pressure to reduce the risk of capsular extension. The nucleus passes through the capsulorhexis following hydrodissection. The keratoplasty is completed followed by cortex removal and in-the-bag intraocular lens implantation, which are facilitated by the CCC in a closed system.

Comparison of fibrin glue and sutures for conjunctival wound closure in strabismus surgery.

PURPOSE: To evaluate and compare the efficacy and tolerance of fibrin glue and sutures for closing conjunctival wounds in strabismus surgery. METHODS: In a prospective trial, we performed strabismus surgery using limbal incisions. Conjunctival wounds were closed with fibrin glue in 20 eyes of 20 patients (fibrin group) and 8-0 polyglactin suture in 20 eyes of 20 patients (suture group). Postoperative pain, tearing, and inflammation were compared at 1 day, 1 week, 3 weeks, and 6 weeks after surgery. Conjunctival incision healing was also investigated. RESULTS: One day and one week post-operatively, pain and tearing scores were lower in the fibrin group (p = 0.000, respectively). Mean surgery time was significantly shorter in the fibrin (48 ± 5 minutes) than the suture group (63 ± 7 minutes) (p = 0.000). Inflammation was significantly more severe in the suture group until 3 weeks postoperative (p = 0.000, respectively), but conjunctival healing did not differ between the groups. Hyperemia appeared more prominent in the fibrin group 3 and 6 weeks after surgery (p = 0.087 and 0.000, respectively). Two eyes in the fibrin group showed conjunctival gaps of more than 2 mm, which closed spontaneously by three weeks after surgery. No allergic reactions or infections developed. CONCLUSIONS: Fibrin glue proved to be as effective as sutures in closing conjunctival wounds. It provides more comfortable early postoperative courses and might be considered as an alternative to sutures in strabismus surgery.

Changes of ocular version with aging in normal Korean population.

The purpose of this study is to estimate normative values of maximum versions in healthy Koreans and investigate age-associated changes in eye movement, using lateral and vertical version light-reflex (LVR) test. Two hundred forty normal healthy subjects whose corrected visual acuity was better than 20/50 in both eyes, from 4 to 79 yr old (30 subjects in each decade) were studied. Maximum sustained values of dextroversion, levoversion, supraversion, and infraversion in each eye were measured using LVR test. Changes of versions according to age were analyzed. Mean normal value of dextroversion, levoversion, supraversion, and infraversion in normal Koreans was 7.7 mm, 41.6 degrees, 33.9 degrees, and 7.7 mm respectively. Contrary to values of Caucasians, levoversion (adductive movement) was more excessive and infraversion (depression) was smaller in Koreans. All versions were decreased with aging (P<0.001 for all). Levoversion had the largest decrease with aging compared with other versions (P<0.001, respectively) and infraversion had the least decrease with age than levoversion (P<0.001), supraversion (P<0.001). All maximal sustained versions were decreased with aging but the ranges of ocular movements in Koreans were different with Caucasians as version least affected and most affected by age was infraversion and levoversion in Koreans. The study standardized normal maximal versions and aging changes of versions in Koreans.

Kestenbaum procedure with posterior fixation suture for anomalous head posture in infantile nystagmus.

BACKGROUND: The purpose of this study was to report the effect of combining the Kestenbaum procedure with posterior fixation suture for infantile horizontal nystagmus with anomalous head posture (AHP) in children. METHODS: Nine consecutive patients who underwent combined Kestenbaum procedure plus posterior fixation suture to the recessed muscles at the same time were retrospectively studied. All patients were orthotropic before surgery and were followed for at least 6 months. Pre- and postoperative AHP and binocular corrected visual acuity (BCVA), and ocular alignment were assessed. RESULTS: Mean age at surgery was 4.8 +/- 1.5 years. The average follow-up was 29.7 months. The average head turn preoperatively was 27.4 degrees and postoperatively 7.2 degrees . The average net change in AHP was 24.8 degrees (P = 0.008). Seven of 9 patients (78%) achieved a residual head turn of 10 degrees or less. The average Log Mar BCVA was 0.33 preoperatively and 0.31 postoperatively (P = 0.68). Only 1 patient needed additional surgery for residual horizontal AHP. No patient developed strabismus. CONCLUSION: Combined Kestenbaum procedure with posterior fixation suture was an effective and stable procedure in reducing AHP of the range of 20 degrees to 35 degrees in children with infantile nystagmus.

Comparison of orbital magnetic resonance imaging in duane syndrome and abducens palsy.

PURPOSE: To help resolve the clinical ambiguity between Duane syndrome with severe abduction deficit and abducens palsy, we performed orbital magnetic resonance imaging (MRI) to qualify abnormalities of the lateral rectus (LR) muscle in these entities. DESIGN: Prospective observational case series. METHODS: Orbital MRI was performed in 13 subjects with Duane syndrome (19 eyes), 10 subjects with chronic abducens palsy (10 eyes), and 10 orthotropic control subjects (18 eyes). High-resolution, surface coil, T(1)-weighted MRI was used to obtain contiguous, 2-mm thick quasi-coronal images of the orbits in central gaze. Digital image analysis was used to quantify cross-sectional area of the ipsilesional and contralesional LR to provide comparison with control measurements. RESULTS: Mean maximum LR cross-sectional area in Duane syndrome was statistically similar to control (P = .454) and contralesional LR cross-sectional area (P = .227). However, in chronic abducens palsy, mean maximum ipsilesional LR cross-sectional area was markedly smaller than contralesional (P = .003) and control cross-sectional areas (P < .0001), as well as smaller than the LR in Duane syndrome (P= .0017). CONCLUSIONS: The LR muscle in abducens palsy exhibits profound atrophy. The sparing of the LR in Duane syndrome from denervation atrophy despite absence of normal abducens innervation suggests existence of alternative LR innervation. High-resolution MRI can noninvasively demonstrate LR muscle size and distinguish Duane syndrome from chronic abducens palsy in uncertain cases.