Acute macular edema and peripapillary soft exudate after pancreas transplantation with accelerated progression of diabetic retinopathy.

BACKGROUND: The effect of pancreas transplantation on diabetic retinopathy remains inconclusive. Herein, we report six patients with type 1 diabetes mellitus (DM) who underwent pancreas transplantation and developed acute macular edema and peripapillary soft exudate with rapid progression to proliferative diabetic retinopathy. METHODS: In this retrospective observational study, diabetic patients who underwent pancreas transplantation in a single medical center and developed symptomatic acute macular edema and peripapillary soft exudate within 3 months after the operation were enrolled. The complete ophthalmic course and medical records of the patients were retrospectively reviewed. Diabetic retinopathy and progression following treatment after pancreas transplantation were measured. RESULTS: Six Chinese women with type 1 DM were enrolled in this study. Mean hemoglobin (Hb) A1c was 13.4% prior to transplantation and decreased rapidly to 6.5% within 2 months postsurgery. The patients had no or mild pretransplant diabetic retinopathy and developed acute symptomatic macular edema and peripapillary soft exudate in both eyes after pancreas transplantation. All macular edema resolved either with or without treatment. Five cases progressed to proliferative diabetic retinopathy and received panretinal photocoagulation. Diabetic retinopathy remained stable in all eyes after treatment, and the visual prognosis was good, except in one eye that had macular branch retinal artery occlusion with foveal involvement. CONCLUSION: Acute macular edema after pancreas transplantation has a favorable treatment outcome despite rapid progression to proliferative diabetic retinopathy. High pretransplant HbA1c and abrupt blood sugar normalization may be related to the disease course.

Verification of a formula developed to predict the postoperative intraocular pressure after cataract surgery in primary angle-closure glaucoma.

BACKGROUND: The aim of this study was to verify the accuracy of a formula predicting postoperative intraocular pressure (IOP) after phacoemulsification and intraocular lens implantation (PHCE-IOL) in primary angle-closure glaucoma (PACG). In a retrospective chart review of patients with PACG who underwent PHCE-IOL between 2011 and 2014, we collected preoperative IOP, axial length, anterior chamber depth (ACD), number of pre-PHCE glaucoma medications, and IOP and glaucoma medications at 1 month and 3 months post-PHCE. METHODS: Post-PHCE IOP values at 1 month and 3 months were compared with those predicted using the formula: postoperative IOP = 6.354 + 0.186 pre-PHCE IOP × pre-PHCE ACD. Agreements between measured and predicted IOP values were analyzed using correlation coefficients and Bland-Altman plots. RESULTS: Of the 62 eyes included, the average pre-PHCE IOP was 19.47 ± 5.84 mm Hg. Post-PHCE IOP values were 14.94 ± 4.03 mm Hg at 1 month and 14.21 ± 3.51 mm Hg at 3 months. Patients using more preoperative medications tended to show greater postoperative declines in medication usage. Predicted IOP significantly correlated with post-PHCE IOP measured at 1 month (R = 0.314, p = 0.013) and 3 months (R = 0.325, p = 0.01). Bland-Altman plots of difference against average of measured and estimated IOP revealed two cases falling outside±1.96 standard deviation at 1 month, and five cases at 3 months, indicating good consistency between measurement and prediction. CONCLUSION: This formula was useful for predicting IOP at 1 month and 3 months after PHCE-IOL in PACG. It aids clinicians in preoperative assessment of whether PHCE-IOL alone is likely to achieve acceptable postoperative IOP control.

Retinal detachment with a break at pars plicata associated with congenital malformation of the lens-zonule-ciliary body complex.

Retinal detachment with a break at the pars plicata associated with congenital malformation of lens-zonule-ciliary body complex is rare; most reports are of young Japanese male patients with atopic dermatitis. The present case report is the first to describe the condition in a Chinese patient with no atopic dermatitis or trauma history. A 22-year-old male presented with blurred vision in the left eye for 4 months. Fundus examination revealed shallow lower temporal retinal detachment. Further examination with scleral indentation under maximal pupil dilatation identified a break at the far periphery beyond the ora serrata and pars plana. Gonioscopy revealed a pars plicata break at the nonpigmented ciliary epithelium associated with congenital ciliary process hypoplasia and subtle lens defect at the same meridian. The retina was successfully reattached after segmental scleral buckling, cryopexy, and laser photocoagulation.

Non-traumatic ocular and periocular hemorrhages in a hypertensive patient under continuous ambulatory peritoneal dialysis and warfarin therapy.

We herein present the first reported case of severe proptosis caused by ocular and periocular hemorrhages in a continuous ambulatory peritoneal dilaysis patient without previous history of trauma. The bleeding tendency caused by uremia and the use of warfarin during uncontrolled high blood pressure were most likely responsible for her ocular and periocular hemorrhages. Appropriate control of blood pressure and adequate self-care education are important for the prevention and treatment of any bleeding complications in uremic patients receiving both maintenance anticoagulation therapy and peritoneal dialysis.

Persistent exudative retinal detachment after photodynamic therapy and intravitreal bevacizumab injection for multiple retinal capillary hemangiomas in a patient with von Hippel-Lindau disease.

Photodynamic therapy (PDT) has been used in treating peripheral retinal capillary hemangioma (RCH) with satisfactory results. We report a rare case of von Hippel-Lindau (VHL) disease with three large peripheral RCHs, treated with PDT and intravitreal bevacizumab injection (IVB), who developed persistent bullous exudative retinal detachment (RD) despite significant tumor regression. The patient is a sporadic case of VHL disease, with a de novo nonsense mutation in codon 161 with C → T transition at nucleotide position 694 of the VHL gene. Multiple RCHs were noted in both eyes. Four small RCHs were found in the left eye and were treated with laser photocoagulation. Three large RCHs in the peripheral retina of the right eye were complicated with cystoid macular edema and subretinal fluid accumulation. The RCHs were treated with PDT combined with IVB, and bullous exudative RD developed on the second day after treatment. Three months after PDT, the tumors had regressed significantly, but exudative RD persisted, despite multiple IVB and intravitreal triamcinolone acetonide injection (IVTA). External drainage with sclera buckling, IVB, and IVTA were performed, and the retina attached after surgical intervention. The application of PDT in the treatment of RCHs and its possible complications are discussed.

Comparison of the effect of reduced-fluence photodynamic therapy with intravitreal bevacizumab and standard-fluence alone for polypoidal choroidal vasculopathy.

BACKGROUND: Photodynamic therapy (PDT) has previously been reported to be effective in treating polypoidal choroidal vasculopathy (PCV), with satisfactory polyp regression. However, the optimum treatment protocol remains controversial. This study compared the effect of reduced-fluence PDT combined with intravitreal bevacizumab (rPDT/IVB) and standard-fluence PDT (sPDT) alone for treating symptomatic PCV in Chinese patients. METHODS: A retrospective review was carried out of the medical records of patients with PCV who were treated with rPDT/IVB (14 eyes of 13 patients) or sPDT (12 eyes of 12 patients) with at least 6 months of follow-up. RESULTS: The mean best-corrected visual acuity of the rPDT/IVB group improved significantly at the 6-month follow-up (p = 0.041). Only one eye (7.1%) in the rPDT/IVB group showed a decrease in visual acuity, compared with four eyes (33.3%) in the sPDT group. A total of 40.0% of eyes in the sPDT group showed increased lipid exudate at follow-up 1 month after treatment, whereas no increase in lipid exudate was observed in the rPDT/IVB group (p = 0.015). The mean maximum area of post-treatment hemorrhage in the rPDT/IVB group was smaller than that in the sPDT group (2.57 ± 2.74 mm(2) vs. 12.69 ± 10.28 mm(2), p = 0.042). CONCLUSION: Combination therapy with rPDT/IVB for patients with PCV showed encouraging results in vision improvement, a lower decrease in visual acuity, significantly less post-treatment lipid exudate and a smaller area of post-treatment hemorrhage at the 6-month follow-up than patients treated with sPDT.

The effect of photo-oxidative stress and inflammatory cytokine on complement factor H expression in retinal pigment epithelial cells.

PURPOSE: Genetic variation in complement factor H (CFH) has been implicated as a major risk factor for age-related macular degeneration (AMD). The reduction in CFH amount or its complement-modulating activity may lead to inadequate control of complement-driven inflammation at the outer retina. We explored the effect of photo-oxidative stress and inflammatory cytokine on the expression of CFH in retinal pigment epithelial (RPE) cells. METHODS: Cultured human RPE cells were exposed to blue light in the presence of interferon-γ (IFN-γ). CFH expression in cell lysate was examined by Western blot and the secretory CFH in culture medium was analyzed by ELISA. RPE cells were treated with vitamin C and exogenous superoxide dismutase mimetic (Tempol) before photo-oxidative treatments. The intracellular reactive oxygen species were examined by flow cytometry. RESULTS: IFN-γ increased CFH expression in RPE and the expression was suppressed significantly under concomitant blue light illumination. The secretory CFH level also decreased significantly under blue light illumination, which was related to the decreased intracellular mRNA and protein expressions of CFH. The suppression was mediated through an oxidative mechanism, and was particularly related to superoxide anion generation. The suppression of CFH expression in RPE under blue light illumination was abrogated by vitamin C and Tempol. CONCLUSIONS: Photo-oxidative stress reduces the ability of IFN-γ to increase CFH expression in RPE. Apart from reducing the oxidative damage, vitamin C reduces the suppression of CFH under photo-oxidative stress. These results suggest a new perspective of the interaction between oxidative stress and inflammation, and provide a potential novel treatment strategy for age-related macular degeneration.

Determinants of long-term intraocular pressure after phacoemulsification in primary angle-closure glaucoma.

AIMS: To determine the preoperative factors associated with long-term intraocular pressure (IOP) after cataract surgery in primary angle-closure glaucoma (PACG). METHODS: The data of 56 PACG patients who had undergone phacoemulsification consecutively were analyzed after detailed chart review. The associations between postoperative IOP and various preoperative factors were determined by multivariate linear regression analyses. RESULTS: The mean postoperative follow-up was of 33.0±13.6 months. The postoperative IOP decreased (P<0.05 at each visit) from the preoperative level over the years, with a mean percent reduction of 20%. Glaucoma medication number also reduced significantly, except at month 30 (P=0.088), 36 (P=0.585), and 48 (P=0.104). Preoperative factors of higher IOP (P<0.001) and deeper anterior chamber depth (ACD) (P=0.006) were associated with higher postoperative IOP over the years. The multiplication product IOP×ACD accounted for 49% of the IOP variations 1 year after surgery, and eyes with this index less than or equal to 35 were more likely to achieve postoperative IOP readings of less than or equal to 12 mm Hg (odds ratio, 9.2, P=0.001) than those with an index more than 35. CONCLUSIONS: Long-term IOP after phacoemulsification in PACG is positively associated with preoperative IOP and preoperative ACD.

Increase of 8-hydroxy-2'-deoxyguanosine in aqueous humor of patients with exudative age-related macular degeneration.

PURPOSE: Oxidative stress has been implicated as a major contributor to age-related macular degeneration (AMD). 8-Hydroxy-2'-deoxyguanosine (8-OHdG) is one of the most abundant oxidative products of DNA damage and represents a noninvasive and sensitive biomarker of oxidative stress. The authors investigated the 8-OHdG levels in aqueous humor of patients with exudative AMD. METHODS: Twenty-four eyes of 24 patients with active exudative AMD and 31 eyes of 31 age-matched subjects who underwent cataract surgery were enrolled. Aqueous humor samples were collected from all subjects, and the 8-OHdG levels were determined by a commercially available enzyme-linked immunosorbent assay kit. The choroidal neovascularization (CNV) subtype was classified by fluorescein angiography. The macular lesion, including CNV membrane, exudation, and retinal hemorrhage, was measured. The correlation between 8-OHdG level and the clinical features was analyzed. RESULTS: The 8-OHdG level in the aqueous humor of AMD patients was significantly higher than it was in controls (0.581 ± 0.258 ng/mL vs. 0.251 ± 0.116 ng/mL; P < 0.001), after adjusting for age and lens status. There was no difference in the 8-OHdG levels between AMD patients with classic/predominantly classic and occult/minimally classic CNV (0.591 ± 0.262 vs. 0.566 ± 0.266 ng/mL; P = 0.639). The 8-OHdG level in aqueous humor was significantly correlated with the lesion size (ρ = 0.492; P = 0.017). CONCLUSIONS: The 8-OHdG level in aqueous humor was higher in patients with exudative AMD, and the level was correlated with the area of macular lesion. This suggests that oxidative stress plays an important role in the disease course of AMD.

Intraocular pressure elevation after intravitreal triamcinolone acetonide injection in a Chinese population.

PURPOSE: To study the prevalence and risk factors of intraocular pressure (IOP) elevation and refractory IOP elevation after a single 4 mg intravitreal triamcinolone acetonide (IVTA) injection in a Chinese population. DESIGN: Retrospective, observational case series. METHODS: Retrospective chart review of all the patients who received an IVTA injection at one medical center from January 2003 through June 2005. A postoperative IOP increase of more than 6 mm Hg was defined as an IOP elevation. Postoperative IOP elevation that could not be controlled by glaucoma medications was defined as refractory IOP elevation. RESULTS: Sixty-four (43.5%) of the 147 enrolled patients experienced IOP elevation. Males had a higher risk of IOP elevation, with an odds ratio (OR) of 3.17 (95% confidence interval [CI], 1.38 to 7.27; P = .006), after adjusting for age, glaucoma history, and diagnosis of retinal disease. Patients 55 years of age and younger had a larger magnitude of IOP elevation than those older than 55 years (11.2 +/- 10.1 mm Hg vs 7.3 +/- 7.7 mm Hg; P = .020). Ten patients (6.8%) had refractory IOP elevation, and those 55 years of age or younger had a higher risk of refractory IOP elevation compared with those older than 55 years, with an OR of 8.16 (95% CI, 1.67 to 39.81; P = .009), after adjusting for preoperative IOP and diagnosis of retinal disease. CONCLUSIONS: Elevated IOP after IVTA injection is common in this Chinese population. Male patients have a higher risk of IOP elevation. Younger patients should be monitored carefully after IVTA injection because they exhibit a greater magnitude of IOP elevation and have an increased chance of developing refractory IOP elevation.

Factors related to corneal endothelial damage after phacoemulsification in eyes with occludable angles.

PURPOSE: To evaluate the influence of preoperative variables and early postoperative intraocular pressure (IOP) on the loss of corneal endothelial cells after phacoemulsification in eyes with occludable angles. SETTING: Taipei Veterans General Hospital, Taipei, Taiwan. METHODS: Sixty patients with occludable angles having phacoemulsification were prospectively enrolled. Corneal endothelial cell evaluation was conducted preoperatively and 3 months postoperatively. RESULTS: Three months postoperatively, the mean corneal endothelial cell density decreased by 14.5% +/- 25.8% (SD) (P < .001). Greater corneal endothelial cell loss was associated with shorter axial length (AL) (P = .008), steeper anterior corneal curvature (P = .03), greater nuclear opalescence (P = .04), and higher IOP measured 4 to 8 hours after surgery (P = .04) and the following morning (P = .002). Multiple linear regression analysis identified AL and the IOP measured 4 to 8 hours after surgery as the best predictors of postoperative corneal endothelial cell loss after adjusting for nuclear opalescence and phacoemulsification time (R2 = 0.40, P = .001). CONCLUSIONS: The corneal endothelial cell loss after phacoemulsification in eyes with occludable angles was associated with preoperative AL measurement and postoperative IOP within 24 hours. To minimize corneal endothelial cell damage, it is critical to avoid an IOP spike during the early postoperative period and to exercise extreme caution intraoperatively in eyes with an AL less than 22.6 mm.

Factors predicting intraocular pressure control after phacoemulsification in angle-closure glaucoma.

OBJECTIVES: To investigate whether the presence of glaucomatous optic neuropathy affects the reduction of intraocular pressure (IOP) after phacoemulsification in postiridotomy eyes with primary narrow angles, and to evaluate the preoperative factors associated with postoperative IOP control in primary angle-closure glaucoma (PACG). METHODS: Patients with PACG undergoing phacoemulsification were prospectively enrolled and received a complete ophthalmic examination. Diurnal IOP was measured 1 day before and 3 months after surgery. For comparison, patients with primary angle closure or angle closure suspect (PAC/S) undergoing phacoemulsification were also enrolled. RESULTS: Postoperative reduction of IOP was significant in the PACG group (n = 29; P = .001) and in the PAC/S group (n = 28; P<.001), with no significant difference between the groups. The number of glaucoma medications used decreased in both groups (both, P<.001). Multiple regression analysis for the PACG group showed that there was a positive correlation between postoperative IOP and preoperative factors of mean IOP (P = .001) and the anterior chamber depth (P = .03). CONCLUSIONS: The reduction of IOP 3 months after phacoemulsification is significant and is similar in extent in postiridotomy eyes with and without glaucomatous optic neuropathy. A higher postoperative IOP in PACG is associated with a higher preoperative IOP and with a deeper preoperative anterior chamber depth.

Association of the Y402H polymorphism in complement factor H gene and neovascular age-related macular degeneration in Chinese patients.

PURPOSE: Age-related macular degeneration (AMD), with its complex traits and multiple risk factors, is the leading cause of blindness in the elderly. A strong association between a coding variant, Y402H, in the complement factor H gene (CFH) and AMD has been recently identified in white patients. This study was conducted to investigate the association between the Y402H polymorphism in CFH and neovascular AMD in Chinese patients. METHODS: One hundred sixty-three Chinese patients with neovascular AMD and 232 age-matched healthy controls were enrolled in the study. Genomic DNA from white blood cells was extracted. The Y402H polymorphism in CFH, with the substitution of T to C at nucleotide position 1277 in exon 9, was determined by polymerase chain reaction-restriction fragment length polymorphism analysis. The association between the genetic polymorphism and the disease was examined by chi(2) test and logistic regression. RESULTS: The frequency of the risk allele, 1277C, was 11.3% in AMD patients compared with 2.8% in controls (P < 0.00001). Genotype frequency differed significantly between the two groups (1277TT 81.0%, 1277TC 15.3%, and 1277CC 3.7% in the AMD group; 1277TT 94.4%, 1277TC 5.6%, and 1277CC 0% in the control group; P < 0.0001). The 1277C allele significantly increased the risk for neovascular AMD and had an odds ratio of 4.4 (95% confidence interval [95% CI], 2.3-8.5; P < 0.00001). CONCLUSIONS: The allele frequency of Y402H polymorphism in CFH has an ethnic variation, with much lower 1277C frequency in Chinese than in white patients. Despite this, the polymorphism is significantly associated with neovascular AMD in the Chinese population.

Patterns of visual field defects in chronic angle-closure glaucoma with different disease severity.

PURPOSE: To evaluate the patterns of visual field defects in patients with chronic angle-closure glaucoma (CACG) with varying extent of optic nerve damage. DESIGN: Prospective, consecutive, observational case series. PARTICIPANTS: One hundred forty-six Asian patients with well-controlled CACG. METHODS: Visual field tests were performed using program 24-2 of the Humphrey Field Analyzer (Humphrey Instruments, San Leandro, CA) with the Swedish interactive thresholding algorithm standard. One hundred ten eligible visual fields were scored with the system adopted by the Advanced Glaucoma Intervention Study and were categorized into 4 groups accordingly: mild, moderate, severe, and end-stage. Each hemifield was divided into the nasal, paracentral, and arcuate areas, and field loss that involved respective areas was defined as nasal step, paracentral scotoma, and arcuate scotoma. MAIN OUTCOME MEASURES: The distribution of field defect patterns in each group was evaluated. The mean deviation (MD) was compared among the 3 areas within one hemifield and between each pair of corresponding areas across the median raphe. RESULTS: The nasal area was the most commonly damaged area in the mild group, being noted in 52% of eyes in the superior hemifield and 58% of eyes in the inferior hemifield. In the moderate group, field loss involving both the nasal and arcuate areas dominated the superior hemifield, whereas field loss involving all three areas dominated the inferior hemifield. The MD of the nasal area was the worst among the three areas in each hemifield of the mild and moderate groups, as well as in the inferior hemifield of the severe group (all P < 0.001). There were no significant differences in the MD of each area between the superior hemifield and their inferior counterparts. However, the superior hemifield as a whole showed a better MD than the inferior hemifield (P=0.034) in the mild group. CONCLUSIONS: Visual field loss that involved the nasal area was the most common pattern in the early stage of CACG. The MD of the nasal area was worse than those of the arcuate and the paracentral areas within the same hemifield in the mild, moderate, and severe groups of CACG patients.

Pseudomonas corneal ulcer related to overnight orthokeratology.

PURPOSE: To report two cases of Pseudomonas aeruginosa corneal ulcers as a complication of overnight orthokeratology lens wear. METHODS: Case report. RESULTS: Two 11-year-old girls with acute central corneal ulcers were referred to our hospital. In both cases, the ulcers were about 2 mm in diameter, located centrally, contained dense cellular infiltration, and discharged purulent material. Intensive topical ceftazidime was applied to treat the ulcers. Cultures of the scraped corneal tissues and the contact lens storage solutions in both cases grew P. aeruginosa, which was sensitive to the antibiotic. The presenting best-corrected visual acuity was hand motion at 20 cm in one patient and 6/20 in the other. Both patients had received several months of overnight orthokeratology treatment with rigid gas permeable contact lenses to correct myopia (-4.25 D and -4.75 D in the two affected eyes). The final best-corrected visual acuity was 6/60 in one patient and 6/7.5 in the other. CONCLUSIONS: Overnight orthokeratology contact lens wear carries a potential risk of corneal ulcer and may cause significant visual impairment in children.

Ipsilateral globe penetration and transient contralateral amaurosis following retrobulbar anesthesia.

PURPOSE: To report a rare complication of retrobulbar anesthesia with ipsilateral globe penetration and transient contralateral amaurosis. DESIGN: Interventional case report. METHODS: A 63-year-old woman complained of vision loss in the right eye immediately following cataract surgery on the left eye. RESULTS: Right eye vision decreased to no light perception with clear media and normal fundus. The vision recovered to baseline in 12 hours. Left eye vision was checked and demonstrated only light perception. Fundus examination disclosed preretinal and vitreous hemorrhage. During vitrectomy of the left eye, a penetrating wound below the optic disk with retinal detachment was found. CONCLUSION: The ipsilateral globe penetration wound depicts the mechanism of contralateral amaurosis following retrobulbar anesthesia of the case.