MANAGEMENT OF VITREAL LOSS FROM POSTERIOR CAPSULAR RUPTURE DURING CATARACT OPERATION: Posterior Versus Anterior Vitrectomy.

PURPOSE: To compare the efficacy between 23-gauge sutureless pars planar vitrectomy (PPV) and anterior vitrectomy in the management of vitreous loss associated with posterior capsular rupture during cataract surgery. METHODS: Medical records of 139 eyes which sustained posterior capsular rupture and vitreal prolapse to anterior chamber during cataract surgery were retrospectively reviewed. Thirty-two eyes which underwent 23-gauge sutureless PPV (group PPV) and 107 eyes which underwent anterior vitrectomy (group AntV) were compared in postoperative visual and anatomical outcomes, operation time, and complications. RESULTS: No significant differences were found between the groups in final best-corrected visual acuity of 20/40 or better (AntV vs. PPV = 80.4 vs. 90.6%, P = 0.139). However, the visual recovery rates (20/40 or better) 1 day, 1 week, 1 month postoperatively were significantly higher in group PPV (AntV vs PPV = 22.4 vs. 44%, 32.2 vs 58.6, 51.9 vs. 78.1%). Postoperative intraocular pressure-related complications requiring medication were less evident in group PPV (AntV vs. PPV = 52.3 vs. 6.3%, P < 0.001). Twelve cases (11.2%) of group AntV and 0 cases of group PPV underwent secondary operation during follow-up. Although no postoperative complications occurred in group PPV, complications such as endophthalmitis, retinal detachment, cystoid macular edema, intraocular lens instability were observed in the AntV group (none vs. 14%, P = 0.022). CONCLUSION: Twenty-three-gauge sutureless PPV is a safe and reliable solution for managing vitreous loss during cataract surgery. Therefore, it is expected to be considered primarily in institutes with vitreoretinal surgeons.

A novel color vision test for detection of diabetic macular edema.

PURPOSE: To determine the sensitivity of the Seoul National University (SNU) computerized color vision test for detecting diabetic macular edema. METHODS: From May to September 2003, a total of 73 eyes of 73 patients with diabetes mellitus were examined using the SNU computerized color vision test and optical coherence tomography (OCT). Color deficiency was quantified as the total error score on the SNU test and as error scores for each of four color quadrants corresponding to yellows (Q1), greens (Q2), blues (Q3), and reds (Q4). SNU error scores were assessed as a function of OCT foveal thickness and total macular volume (TMV). RESULTS: The error scores in Q1, Q2, Q3, and Q4 measured by the SNU color vision test increased with foveal thickness (P < 0.05), whereas they were not correlated with TMV. Total error scores, the summation of Q1 and Q3, the summation of Q2 and Q4, and blue-yellow (B-Y) error scores were significantly correlated with foveal thickness (P < 0.05), but not with TMV. CONCLUSIONS: The observed correlation between SNU color test error scores and foveal thickness indicates that the SNU test may be useful for detection and monitoring of diabetic macular edema.

A novel computerized visual acuity test for children.

PURPOSE: To investigate the efficacy of a computerized visual acuity test, the SNU visual acuity test for children. METHODS: Fifty-six children, ranging from 1 to 5 years of age, were included. In a dark room, children gazed at and followed a circular dot with 50% contrast moving at a fixed velocity of 10 pixels/sec on a computer monitor. Eye movement was captured using a charge coupled device camera and was expressed as coordinates on a graph. Movements of the eye and dot were superimposed on a graph and analyzed. Minimum visualized dot diameters were compared to the Teller visual acuity. RESULTS: Ten eyes (8.9%) of six children failed to perform the Teller visual acuity test, and two eyes (1.8%) of one patient failed to perform the SNU visual acuity test. The observed Teller visual acuity and SNU visual acuity were significantly correlated (p < 0.001). Visual angle degrees converted from the Teller visual acuity and SNU visual acuity were also significantly correlated (p < 0.001). CONCLUSION: The SNU visual acuity using moving targets correlated well with Teller visual acuity and was more applicable than the Teller acuity test. Therefore, the SNU visual acuity test has potential clinical applications for children.

Partial visual rehabilitation using a toric implantable collamer lens in a patient with keratoconus: a case report with 20 months of follow-up.

We report the case of a 37-year-old man with a high myopic keratoconus eye that was treated with a posterior chamber toric implantable collamer lens (ICL) in Korea. The patient had a history of contact lens intolerance and did not want to have a corneal transplantation. His uncorrected visual acuity (UCVA) and best spectacle corrected visual acuity were 0.02 and 0.4 in the left eye, respectively. Preoperatively, the manifest refraction was -12.0 -3.5 × 30A. Postoperatively, the manifest refraction was -1.75 × 180A. UCVA improved markedly after implantation. No intraoperative or postoperative complications were observed during 20 months of follow-up. Toric ICL implantation may be a possible alternative surgical option for the visual rehabilitation of high myopic astigmatism in keratoconus patients with rigid gas permeable contact lens intolerance and in patients who do not want to get a corneal transplant.

Effects of a novel push-through technique using the implantable collamer lens injector system for graft delivery during endothelial keratoplasty.

PURPOSE: To investigate effects of a new push-through insertion method for donor lenticules using an injector system on endothelial viability ex vivo and in a clinical case series of endothelial keratoplasty. METHODS: An ex vivo delivery model was used with porcine corneoscleral rims. We compared the endothelial viability in a new push-through insertion method using the Visian Implantable Collamer Lens (ICL) injector versus that of standard forceps-assisted insertion for lenticule delivery. Twenty porcine corneal lenticules were divided into four groups by insertion method and wound size. Vital dye staining was performed and devitalized areas were semi-quantitatively assessed by digital imaging. In the clinical case series, Descemet's stripping endothelial keratoplasty (DSEK) using the push-through method was performed in seven patients and endothelial outcome was determined six months postoperatively. RESULTS: Mean devitalized areas for the push-through method were significantly lower than for forceps-assisted insertion through 3.2 mm incision (23.99 ± 2.17% vs. 50.48 ± 5.07%, p = 0.009) in the ex vivo model. Average endothelial cell counts of donor tissues of patients who underwent DSEK were 26.4% lower six months postoperatively. CONCLUSIONS: Push-through delivery of donor lenticules using the Visian ICL injector system appears to be less harmful to endothelial cells than conventional forceps-assisted delivery.

VSX1 gene and keratoconus: genetic analysis in Korean patients.

PURPOSE: The visual system homeobox 1 (VSX1) gene variants have recently been shown to be associated with keratoconus. To replicate this finding, we performed a genetic analysis of the VSX1 gene in a Korean case-control sample. METHODS: Patients with keratoconus and healthy control subjects were recruited from Seoul National University Hospital. A diagnosis of keratoconus was made based on clinical examinations and the presence of characteristic topographic features. For all patients and controls, the whole coding region and the exon-intron junctions of the VSX1 gene were analyzed by direct sequencing. RESULTS: Fifty-three patients with keratoconus and 100 healthy volunteers were included. We observed 2 novel missense substitutions (Leu17Val and Val199Leu) and 1 previously reported substitution (Gly160Val) in 6 of the 53 affected probands. Because these substitutions have been identified in unaffected individuals, they were not considered to be pathogenic. No intragenic polymorphism was associated with a significantly increased risk of keratoconus. CONCLUSIONS: We cannot confirm the previously reported association of the VSX1 gene variants with keratoconus. Our results suggest that the VSX1 gene and its mutations with amino acid changes do not play a major role in the pathogenesis of keratoconus.

Juvenile xanthogranuloma presenting as infiltrative conjunctival mass in an adult.

PURPOSE: To report on the clinical and histopathologic findings of a conjunctival juvenile xanthogranuloma in an adult. METHODS: Case report and literature review. RESULTS: A 43-year-old man developed 2 yellowish conjunctival lumps not associated with other ocular or systemic findings. A half-corneal diameter-sized main mass was located at the 2-o'clock position, and the other 1/8-corneal diameter-sized mass was located at the 4-o'clock position. The masses were vitelliform in appearance with poor supplying vessels. The masses were removed en bloc by conjunctivectomy. Cryotherapy was done along the excision margin. Histopathologic examination revealed dense infiltration by histiocytes with background of multiple lymphocytes and Touton giant cells. Immunohistochemical staining was positive for CD3 (T-cell marker) and CD68 (histiocytic marker) but negative for CD1a and S-100 (Langerhans cell marker). CONCLUSION: Juvenile xanthogranuloma may present as conjunctival infiltrative masses in adults. Immunophenotyping is helpful in differentiating it from a more malignant lesion.

Cysteamine prevents the development of lens opacity in a rat model of selenite-induced cataract.

PURPOSE: The activation of transglutaminase 2 (TG2) by oxidative stress through TGFß has been reported to play a crucial role in cataract formation. The authors investigated whether TG2 is involved in selenite-induced cataract formation in rats and whether cysteamine, a chemical inhibitor of TG2, can prevent cataract formation in this model. METHODS: Intracellular TG2 activity was monitored in a human lens epithelial cell (HLE-B3) line and cultured rat lenses after treatment with selenite. Rat pups (13 days old) were injected subcutaneously with sodium selenite (Na(2)SeO(3); 20 µmol/kg) and intraperitoneally with cysteamine (30, 40, and 60 mg/kg) for 14 days. Lenses were evaluated photographically at days 7 and 14. The concentrations of malondialdehyde and glutathione in the lenses were determined. RESULTS: In HLE-B3 cells or rat lenses, selenite induced intracellular TG activity, which was inhibited by cysteamine. In selenite-treated rats, the rate of cataract formation was significantly reduced by cysteamine (P < 0.001). The mean cataract area in the lenses of cysteamine-treated rats was smaller than that of control rats (P < 0.01). The levels of total and reduced glutathione in the lenses of cysteamine-treated rats extracted at day 14 were higher than those of control rats. CONCLUSIONS: Cysteamine suppresses cataract formation induced by selenite in rats, suggesting that cysteamine can be used as a pharmaceutical intervention to prevent or delay cataract formation.

Vortex keratopathy in a patient receiving vandetanib for non-small cell lung cancer.

We report a case of vortex keratopathy in a patient treated with vandetanib for non-small cell lung cancer (NSCLC). A 44-year-old female who underwent two cycles of chemotherapy for NSCLC complained of visual blurring in both eyes after the initiation of vandetanib, an anti-epidermal growth factor receptor (EGFR) and anti-vascular endothelial growth factor receptor 2 protein tyrosine kinase inhibitor. On ophthalmic examination, visual acuities were 20 / 20 OU and, with the exception of diffuse vortex keratopathy in both eyes, other findings were unremarkable. Vandetanib is believed to have caused vortex keratopathy in this patient. Anti-EGFR properties affecting normal corneal epithelial cell migration and wound healing or drug associated metabolite deposition, which is the case in numerous drug-associated vortex keratopathies, may be possible underlying mechanisms in the formation of this corneal complication.

Cosmetic improvement of nevus of Ota by scleral allograft overlay.

OBJECTIVE: To report surgical outcome of a new therapeutic technique for nevus of Ota by scleral allograft overlay. DESIGN: Noncomparative clinical interventional study. PARTICIPANTS: Eight eyes of 7 patients with scleral nevus of Ota. METHODS: Patients underwent subconjunctival scleral allograft overlay between September 2005 and June 2007 at Seoul National University Hospital. Preoperative neval extent, postoperative cosmesis, complications, and visual acuity change were evaluated. RESULTS: Most of the patients showed satisfying cosmetic improvement. There were no significant complications in a follow-up period of more than 3 years. CONCLUSIONS: Scleral allograft overlay is a safe and effective procedure for cosmetic improvement of nevus of Ota.

Five-year results of corneal tattooing for cosmetic repair in disfigured eyes.

PURPOSE: To investigate the 5-year results of corneal tattooing for cosmetic repair in disfigured eyes and identify the risk factors associated with complications. METHODS: Corneal tattooing was performed in patients with stable corneal opacity and blind eyes. A total of 147 eyes of 147 patients who were followed up for at least 5 years after tattooing were enrolled in the study. The following valuables were included as potential risk factors for long-term complications: age, sex, duration of opacity before tattooing, and the presence of calcific plaque. Corneal tattooing was also performed in 6 rabbit eyes, and the stained eyes were enucleated at 6 months postoperatively for histological analysis. RESULTS: The average follow-up time after surgery was 65 ± 5 months. Long-term complications such as reopacification or increased opacity, fading of color, and epithelial growth developed in 12% of the tattooed eyes between 2 and 4 years after surgery and most required reoperation. Univariate analysis of risk factors affecting recurrence or complications revealed no statistically significant differences among candidate factors. Histological results of the tattooed rabbit eyes showed that clumps of blackish granules were present in the anterior half of the stroma without any infiltration of inflammatory cells to the adjacent layers. CONCLUSIONS: Corneal tattooing in disfigured eyes provided a good cosmetic outcome more than 5 years after surgery.

Long-term outcome and prognostic factor analysis for keratolimbal allografts.

PURPOSE: To evaluate the long-term results of keratolimbal allograft (KLAL) and elucidate the prognostic factors of KLAL survival. METHODS: Twenty-four eyes of 22 patients underwent KLAL one or more times, and were followed up more than 1 year postoperatively. Their medical records were reviewed. The success of KLAL and penetrating keratoplasty (PKP) was evaluated. KLAL success was defined as absence of persistent corneal epithelial defect, corneal conjunctivalization, or neovascularization on the corneal edge of the graft. Prognostic factors for survival of KLAL were analyzed, including preoperative diagnosis, history of graft rejection, symblepharon, concurrent surgery, immunosuppressant dose, and interval for full epithelialization time. The prognostic factors were evaluated by univariate survival analysis or multivariate Cox proportional hazards survival regression. RESULTS: KLAL had been successful in 33.3% of the eyes over an average of 47.9 months. Fifteen episodes of KLAL rejection developed in ten eyes (41.7%), but 13 cases (86.7%) were reversible. Of 45 KLAL procedures, eyelid deformity, symblepharon, and the interval of full epithelialization were significantly associated with KLAL success by univariate analysis, and the presence of symblepharon was identified by multivariate Cox regression analysis as the most important prognostic factor to affect KLAL outcome (p = 0.010). CONCLUSIONS: KLAL has been partly successful for reconstruction of limbal stem cell deficiency, and symblepharon has been identified as a significant prognostic factor for KLAL survival. Surgical correction of symblepharon is important before KLAL and PKP.

Efficacy of a computerized optokinetic nystagmus test in prediction of visual acuity of better than 20/200.

PURPOSE: To evaluate the efficacy of a computerized optokinetic nystagmus (OKN) test in detecting visual acuity (VA) of >20/200. METHODS: This was a combined retrospective and prospective, noninterventional study. In phase I of the study, data from 168 eyes of 154 subjects who underwent the computerized objective VA test using OKN responses at Seoul National University Bundang Hospital were reviewed and reanalyzed, and a table for predicting the range of subjective VA for each step of objective VA was made. From the table, the cutoff value for detecting VA of >20/200 was determined. In phase II of the study, the distribution of subjective VA according to each objective VA step was determined for 80 eyes of 40 subjects at Seoul Veteran's Hospital. The sensitivity and the specificity of our cutoff value were evaluated in the two groups. RESULTS: No significant difference was found in the distribution of subjective VA according to objective VA steps between the two groups. For the subjects in phase I of the study, the sensitivity of our cutoff value was 91.7% and the specificity was 88.3%. For patients in phase II of the study, the sensitivity of our cutoff was 86% and the specificity was 96.7%. CONCLUSIONS: This study shows that an objective VA test using OKN responses can be effective in predicting real VA and detecting VA of >20/200.

Interleukin-17 in various ocular surface inflammatory diseases.

Recently, the association of Th-17 cells or IL-17 with ocular inflammatory diseases such as uveitis, scleritis and dry eye syndrome was discovered. We assessed whether interleukin (IL)-17 was present in the tears of various ocular surface inflammatory diseases and the tear IL-17 concentrations were clinically correlated with various ocular surface inflammatory diseases. We measured concentrations of IL-17 in tears of normal subjects (n = 28) and patients (n = 141) with meibomian gland dysfunction (MGD), dry eye syndrome (DES), Sjögren syndrome (SS), Stevens-Johnson syndrome (SJS), graft-versus-host disease (GVHD), filamentary keratitis, and autoimmune keratitis associated with rheumatoid arthritis or systemic lupus erythematosus. Clinical epitheliopathy scores were based on the surface area of corneal and conjunctival fluorescein staining. The mean concentrations of IL-17 in tears of patients with filamentary keratitis, GVHD, autoimmune keratitis, SS, DES, MGD, SJS were significantly higher in order than that in normal subjects. Tear IL-17 concentration was significantly correlated with clinical epitheilopathy scores in the patients with systemic inflammatory disease, while tear IL-17 was not correlated with clinical severity of the cornea and conjunctiva in the dry eye patients without any systemic inflammatory disease. Tear IL-17 is likely to correlate clinically with corneal disease severity only in the patients with systemic inflammatory disease.

Intraocular lens power calculation using IOLMaster and various formulas in short eyes.

PURPOSE: To evaluate the predictability of intraocular lens (IOL) power calculations using the IOLMaster and four different IOL power calculation formulas (Haigis, Hoffer Q, SRK II, and SRK/T) for cataract surgery in eyes with a short axial length (AL). METHODS: The present study was a retrospective comparative analysis which included 25 eyes with an AL shorter than 22.0 mm that underwent uneventful phacoemulsification with IOL implantation from July 2007 to December 2008 at Seoul National University Boramae Hospital. Preoperative AL and keratometric power were measured by the IOLMaster, and power of the implanted IOL was determined using Haigis, Hoffer Q, SRK II, and SRK/T formulas. Postoperative refractive errors two months after surgery were measured using automatic refracto-keratometry (Nidek) and were compared with the predicted postoperative power. The mean absolute error (MAE) was defined as the average of the absolute value of the difference between actual and predicted spherical equivalences of postoperative refractive error. RESULTS: The MAE was smallest with the Haigis formula (0.37 ± 0.26 diopter [D]), followed by those of SRK/T (0.53 ± 0.25 D), SRK II (0.56 ± 0.20 D), and Hoffer Q (0.62 ± 0.16 D) in 25 eyes with an AL shorter than 22.0 mm. The proportion with an absolute error (AE) of less than 1 D was greatest in the Haigis formula (96%), followed by those in the SRK II (88%), SRK-T (84%), and Hoffer Q (80%). CONCLUSIONS: The MAE was less than 0.7 D and the proportion of AE less than 1 D was more than 80% in all formulas. The IOL power calculation using the Haigis formula showed the best results for postoperative power prediction in short eyes.

Measurement of distance objective visual acuity with the computerized optokinetic nystagmus test in patients with ocular diseases.

BACKGROUNDS: To evaluate the efficacy of a computerized optokinetic nystagmus (OKN) test for determination of objective visual acuity (VA) at distance in patients with various ocular diseases. METHODS: This is a prospective, non-interventional study that included 85 eyes of 71 patients with one or more ocular pathologies. Study patients were classified into group C (39 eyes of 30 patients with central visual damage), group P (24 eyes of 20 patients with peripheral visual defect) and group M (22 eyes of 21 patients with media opacity). Objective distance VA was measured with OKN induction and suppression methods, and the correlation between the objective and subjective VA at distance was evaluated using linear regression analysis. Mean subjective VAs were compared among each objective VA step and among the three groups. RESULTS: Significant correlation was found between subjective distance VA and objective VA determined by both OKN induction and suppression methods in all three groups and in overall patients. In overall patients, the mean subjective VA was significantly different in several objective VA steps (Welch's ANOVA, p < 0.001 for induction and suppression methods). No significant difference in subjective VA among the three groups was found in any objective VA step. CONCLUSIONS: Our objective VA test using OKN induction and suppression methods can be useful in estimating distance VA in patients with various ocular diseases.

Investigating the relationship between serum interleukin-17 levels and systemic immune-mediated disease in patients with dry eye syndrome.

PURPOSE: To investigate the association between dry eye syndrome (DE) and serum levels of interleukin (IL)-17 in patients with systemic immune-mediated diseases. METHODS: IL-17 and IL-23 levels were measured in the sera of patients whose tear production was <5 mm on the Schirmer test. Subjects included patients with chronic graft-versus-host disease (GVHD), rheumatoid arthritis (RA), Sjogren's syndrome (SS), systemic lupus erythematosus (SLE), and no systemic disease. Corneal/conjunctival fluorescein staining was scored and the correlation between the score and the IL-17 level was evaluated. RESULTS: A strong correlation existed between IL-17 level and the type of systemic disease. IL-17 was significantly elevated in patients with chronic GVHD compared to those with RA and SS. IL-17 was not detectable in patients with SLE or in those without systemic disease. IL-23 was not detected in any of the subjects. IL-17 was significantly increased in patients with high fluorescein staining scores. CONCLUSIONS: Our data suggest that IL-17 is involved in the pathogenesis of DE in patients with systemic immune-mediated diseases.

A case of retained graphite anterior chamber foreign body masquerading as stromal keratitis.

We report a case of a retained graphite anterior chamber foreign body that was masquerading as stromal keratitis. A 28-year-old male visited with complaints of visual disturbance and hyperemia in his right eye for four weeks. On initial examination, he presented with a stromal edema involving the inferior half of the cornea, epithelial microcysts, and moderate chamber inflammation. Suspecting herpetic stromal keratitis, he was treated with anti-viral and anti-inflammatory agents. One month after the initial visit, anterior chamber inflammation was improved and his visual acuity recovered to 20/20, but subtle corneal edema still remained. On tapering the medication, after three months, a foreign body was incidentally identified in the inferior chamber angle and was surgically removed resulting in complete resolution of corneal edema. The removed foreign body was a fragment of graphite and he subsequently disclosed a trauma with mechanical pencil 12 years earlier. This case showed that the presence of an anterior chamber foreign body should always be considered in the differential diagnosis of idiopathic localized corneal edema.

Secondary intraocular lens implantation in longstanding unilateral aphakia.

PURPOSE: To investigate the effect of secondary intraocular lens (IOL) implantation on binocular vision in patients with unilateral aphakia uncorrected consecutively for 3 years or more. METHODS: This study included nine patients who underwent secondary IOL implantation, but had remained in a unilateral aphakic state, without being corrected, for at least 3 consecutive years at the time of the secondary IOL implant. They also had a postoperative best-corrected visual acuity of better than 20/40 in both eyes. All patients underwent an ophthalmologic examination including best spectacle-corrected visual acuity and binocular alignment. Stereoacuity was evaluated using the Titmus Stereotest and a stereoacuity of 100 sec of arc or better was designated as "good" stereoacuity. Binocularity was determined using the polarized 4-dot test at distance and at near and the reporting of 4 dots were used to establish fusional ability. RESULTS: Four of the nine patients (44.4%) showed the highest stereoacuity of 40 sec of arc and another four patients (44.4%) showed a stereoacuity of 50 or 60 sec of arc. Only one patient showed "poor" stereoacuity of 200 sec of arc. All the patients could fuse at near and at distance on the polarized 4-dot test. Diplopia and anomalous eye movements were not found in any patient. CONCLUSIONS: Secondary IOL implantation can provide good binocular vision even in patients with unilateral aphakia who had not been corrected for 3 years or more.