Clinical application of 3D display device in ophthalmology: measurement of metamorphopsia.

PURPOSE: To develop a new tool for detecting metamorphopsia. METHOD: Evaluation of diagnostic test. Novel tool for measuring metamorphopsia was developed using commercial 3D display. Fifty-eight patients diagnosed with macular disease, which included epiretinal membrane, age-related macular degeneration, central serous chorioretinopathy and macular hole, as confirmed by macular optical coherence tomography were tested with Amsler grid and novel method. The subjective perception of metamorphopsia and its effect on the lives of the participants with macular disease was also evaluated using a brief questionnaire. The sensitivity and specificity to subjective perception of metamorphopsia were compared. RESULTS: The sensitivity and specificity were 66.7% and 97.7%, respectively, using the Amsler grid test, and 100% and 90.7%, respectively, using the 3D novel metamorphopsia test developed for this study. CONCLUSIONS: The detection rate of metamorphopsia in macular disease using novel metamorphopsia test was significantly higher than that using the Amsler grid test. This novel approach to detecting for metamorphopsia can also be used at home for self-assessment.

Measurement of subfoveal choroidal thickness in normal-tension glaucoma in Korean patients.

PURPOSE: To evaluate subfoveal choroidal thickness (CT) in eyes with normal-tension glaucoma (NTG) in patients who were visualized by enhanced depth imaging optical coherence tomography. METHODS: In this observational, comparative case series, subfoveal CT was measured with enhanced depth imaging optical coherence tomography in 35 eyes of normal individuals and 32 eyes of patients with NTG. Subfoveal CT in each eye was analyzed by measuring the vertical distance from Bruch membrane to the innermost sclera layer. RESULTS: The mean subfoveal CT in the normal individual group and the NTG patient group were 300.0±52.7 and 289.5±100.4 µm, respectively. There was no difference in subfoveal CT in the 2 groups (P=0.60). The mean subfoveal CT in all subjects was significantly correlated negatively with age only (P=0.03). CONCLUSIONS: The subfoveal CT does not differ between the eyes of the normal individual group and the eyes in the NTG patient group, suggesting that CT may not play a role in the pathogenesis of NTG.

Change in subfoveal choroidal thickness after argon laser panretinal photocoagulation.

AIM: To evaluate changes in subfoveal choroidal thickness (SFCT) and macular thickness as measured by enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) after argon laser panretinal photocoagulation (PRP) in patients with severe diabetic retinopathy. METHODS: This prospective, comparative case series included 21 patients (28 eyes) with severe diabetic retinopathy. All patients underwent three sessions of PRP. The SFCT and macular thickness were measured using EDI-OCT at baseline and one week after completion of 3 sessions of PRP. RESULTS: SFCT before PRP was (318.1±96.5)µm and increased to (349.9±108.3)µm (P=0.001) after PRP. Macular thickness significantly increased at one week after PRP (from 273.1±23.9µm at baseline vs 295.8±25.3µm at one week; P<0.001). No significant relationship between the changes in macular thickness and SFCT was observed (r=-0.13, P=0.52). CONCLUSION: PRP induced increases in both SFCT and macular thickness. Changes in SFCT did not correlate with changes in macular thickness.

Engorgement of vortex vein and polypoidal choroidal vasculopathy.

PURPOSE: The purpose of this study was to identify a correlation between engorgement of the vortex vein and the development of polypoidal choroidal vasculopathy (PCV). METHODS: Engorgement of the vortex vein was evaluated by masked observers using a montage of indocyanine green angiography images. Sixty-three eyes with PCV, 27 uninvolved fellow eyes with PCV, and 30 eyes of age-matched control subjects were included. The incidence and distribution pattern of engorgement were evaluated. RESULTS: Thirty-three eyes (52.4%) of PCV evidenced engorgement of the vortex vein, whereas such engorgement was detected in only 7 of the 30 eyes (30.4%) of the control subjects (P = 0.016). Among 27 fellow eyes with PCV, it was detected in 11 (40.7%) (P = 0.706 vs. control eyes). In all groups, it was most frequently detected at the inferior temporal quadrant. In eyes with PCV, mean (±standard deviation) choroidal thickness of the eyes evidencing vortex vein engorgement was 338.1 ± 131.3 µm and the thickness of those not evidencing vortex vein engorgement was 275.1 ± 107.7 µm. When the choroidal thickness increased to 10 µm in the eyes with PCV, the odds of detecting the engorgement was multiplied by a factor of 1.05 (P = 0.042). The incidence of the engorgement of vortex vein was correlated with the presence of choroidal vascular hyperpermeability (P = 0.009). CONCLUSION: This study demonstrates that engorgement of the vortex vein was observed more frequently in the eyes with PCV. Such a finding was associated with choroidal thickening and choroidal vascular hyperpermeability. These indicate that the engorgement of the vortex vein might be involved in the pathogenic mechanisms of PCV.

A three-year follow-up of intravitreal triamcinolone acetonide injection and macular laser photocoagulation for diffuse diabetic macular edema.

PURPOSE: To report the three-year outcomes of macular laser photocoagulation following intravitreal injection of triamcinolone acetonide (IVTA) for diffuse diabetic macular edema (DME). METHODS: A prospective, randomized controlled study was completed. Eighty-six eyes of 74 patients with diffuse DME were randomized into two groups. Eyes assigned to the combination group (n = 48) were subjected to macular laser photocoagulation three weeks after IVTA. Eyes in the IVTA group (n = 38) underwent IVTA alone. Central macular thickness was measured by optical coherence tomography, and the number of additional treatments and mean time to recurrence were assessed. RESULTS: Thirty-seven eyes in the combination group and 26 eyes in the IVTA group completed the three-year follow-up. Recurrence of DME after initial treatment was not observed for nine of the 37 (24.3%) eyes in the combination group or for one of the 26 (3.9$) eyes in the IVTA group (p = 0.028). DME was absent for 19.9 months after treatment in the combination group compared to 10.3 months in the IVTA group (p = 0.027). The mean number of additional treatments was 0.92 in the combination group and 1.88 in the IVTA group (p = 0.001). CONCLUSIONS: Results in the subset of subjects who completed the three-year follow-up demonstrated that laser photocoagulation following IVTA is more effective than IVTA monotherapy for diffuse DME. Combination therapy required fewer additional treatments and resulted in a lower recurrence rate than IVTA monotherapy.

Development of polypoidal choroidal vasculopathy in unaffected fellow eyes.

PURPOSE: To assess longitudinal changes and determine their angiographic risk factors in the fellow eyes of patients with unilateral polypoidal choroidal vasculopathy (PCV). METHODS: We reviewed the medical records of 47 patients with unilateral PCV, all of whom had completed at least 12 months of follow-up. The angiographic features were evaluated including the development of active PCV over time, choroidal vessel dilation, choroidal vascular hyperpermeability, the branching vascular network (BVN) and late geographic hyperfluorescence (LGH), which was defined as a well-demarcated geographic hyperfluorescent lesion on late-phase on indocyanine green angiography (ICGA). RESULTS: The mean follow-up period was 30.3 ± 12.2 months. Among 47 fellow eyes, 24 (51.1%) had choroidal vascular dilation, 27 (57.4%) had choroidal vascular hyperpermeability, six (12.8%) had BVN and 23 (48.9%) had LGH. The development of active PCV was noted in nine fellow eyes (19.1%), all of which had exhibited LGH at baseline. However, PCV did not develop in eyes without features of LGH at baseline (p<0.001). The development of PCV was noted in three eyes with notification of BVN at baseline; however, PCV also developed in six eyes without apparent features of BVN (p=0.08). CONCLUSION: The presence of LGH on ICGA in the fellow eye appears to be a significant risk factor for the development of active PCV and may constitute the diagnosis of preclinical PCV.

Combination of vitrectomy, IVTA, and laser photocoagulation for diabetic macular edema unresponsive to prior treatments; 3-year results.

PURPOSE: To evaluate the long-term effects of combined therapy of vitrectomy, intravitreal triamcinolone, and macular laser photocoagulation on diabetic macular edema (DME) unresponsive to prior treatment. METHODS: Medical records of 46 eyes of 41 subjects who underwent sequential combined therapy consisting of vitrectomy, intravitreal triamcinolone, and macular laser photocoagulation for refractory DME of non-tractional origin were reviewed. Best-corrected visual acuity (BCVA), central subfield thickness (CST) of macula, and number of additional treatments were analyzed. RESULTS: Forty eyes of 35 patients completed a 3-year follow-up. The mean (± SD) CSTs before and 6 months, 1 year, 2 years, and 3 years after the administration of combined therapy in these eyes were 499.1 ± 174.9, 224.2 ± 110.2, 273.4 ± 173.5, 237.5 ± 84.2 and 219.4 ± 66.6 µm, respectively (p < 0.001). The mean (± SD) logMAR BCVA before and 6 months, 1 year, 2 years, and 3 years after the combined therapy were 0.82 ± 0.32, 0.69 ± 0.40, 0.63 ± 0.39, 0.61 ± 0.46, and 0.55 ± 0.44, respectively (p < 0.001). Thirty-one of 40 eyes (77.5%) exhibited no recurrence of DME after the combined therapy. No visually significant complications other than progression of lens opacity and elevation of intraocular pressure were noted during the study period. CONCLUSIONS: This study demonstrated the long-term stability and efficacy of the combined therapy described herein for the treatment of refractory DME.

Clinical features of idiopathic juxtafoveal telangiectasis in Koreans.

PURPOSE: To describe the clinical characteristics of idiopathic juxtafoveal telangiectasis (IJT) in Koreans. METHODS: Medical records of 16 patients with IJT were analyzed during the period from 1997 to 2009. Diagnosis was based on biomicrosopic and fluorescein angiographic findings and the group was determined according to the Gass and Blodi classification. RESULTS: We analyzed eight patients in group 1A (50%), two in group 1B (12.5%), and six in group 2A (37.5%). Diverse treatment modalities, such as macular laser photocoagulation, photodynamic therapy, intravitreal antiangiogenic agent, and steroid injection, were applied for macular edema in nine eyes; however, only two eyes showed visual improvement. CONCLUSIONS: In this case series, group 1A was the most common. For macular edema related to IJT, current treatment strategies had no consistent effect.

Vitreous surgery for impending macular hole.

PURPOSE: In a study conducted 15 years ago, the "Vitrectomy for Prevention of Macular Hole Study Group" was not able to prove the benefits and advantages of vitrectomy for treatment of impending macular holes; however, during the interim period, notable improvements have been achieved concerning diagnosis and efficacy of treatment. This study aims to identify the effect of current vitreous surgery for treatment of symptomatic impending macular holes. METHODS: Nineteen eyes of 17 consecutive patients who had undergone vitrectomy with internal limiting membrane peeling and short-acting gas tamponade for treatment of symptomatic impending macular holes were reviewed. Outer foveal defects on preoperative optical coherence tomography were demonstrated in all cases. We analyzed visual outcome and postoperative change in foveal appearance on optical coherence tomography. RESULTS: The follow-up period ranged from 3 months to 41 months, with a mean of 13.5 months. Mean logarithm of the minimum angle of resolution best-corrected visual acuity improved postoperatively from 0.42 ± 0.18 to 0.11 ± 0.11 (P < 0.01). Postoperative optical coherence tomography examination revealed anatomical closure with complete disappearance of outer foveal defects in all patients. CONCLUSION: In symptomatic patients with impending macular holes, current vitreous surgery may prevent progression to a full-thickness macular hole and improve visual outcome. A randomized trial is warranted.

Choroidal thickness in polypoidal choroidal vasculopathy and exudative age-related macular degeneration.

PURPOSE: To compare choroidal thickness between eyes with polypoidal choroidal vasculopathy (PCV) and eyes with age-related macular degeneration (AMD). DESIGN: Observational, comparative case series. PARTICIPANTS: Twenty-five eyes with PCV, 14 uninvolved fellow eyes with PCV, 30 eyes with exudative AMD, 17 eyes with early AMD, and 20 eyes of age-matched normal subjects. METHODS: Choroidal thickness was measured using enhanced-depth imaging optical coherence tomography. Subfoveal choroidal thickness in each eye was analyzed by measurement of the vertical distance from the Bruch's membrane to the innermost scleral layer. Nasal, superior, temporal, and inferior choroidal thicknesses, 1500 µm apart from the foveal center, were also evaluated in all eyes. MAIN OUTCOME MEASURES: Choroidal thickness in each group. RESULTS: Mean (± standard deviation) subfoveal choroidal thickness in eyes with PCV and in their uninvolved fellow eyes was 438.3±87.8 µm and 372.9±112.0 µm, respectively, which was significantly greater than in eyes of age-matched normal subjects (224.8±52.9 µm) (P<0.001 and P = 0.003, respectively). Subfoveal choroidal thickness of eyes with exudative AMD (171.2±38.5 µm) and eyes with early AMD (177.4±49.7 µm) was thinner than that of age-matched normal subjects (P = 0.004 and P = 0.078, respectively). Choroidal thickness at each of the other 4 points showed a similar tendency. CONCLUSIONS: This study demonstrates thickening of choroid in the eyes with PCV, in contrast with choroidal thinning observed in eyes with AMD. These findings suggest involvement of different pathogenic mechanisms in PCV from those in exudative AMD.

Gamma knife radiosurgery for choroidal hemangioma.

PURPOSE: Patients with choroidal hemangioma (CH), a benign ocular hamartoma, frequently presents with visual disturbance as a result of exudative retinal detachment (RD), which originates in subretinal fluid accumulation. We report our experience using the Leksell Gamma Knife in the management of symptomatic CH. METHODS AND MATERIALS: Seven patients with symptomatic CH (circumscribed form in 3 patients and diffuse form in 4) were treated with the Leksell Gamma Knife at our institution during a 7-year period. All patients presented with exudative RD involving the macula that resulted in severe visual deterioration. The prescription dose to the target margin was 10 Gy in all cases. The mean tumor volume receiving the prescription dose was 536 mm3 (range, 151-1,057). The clinical data were analyzed in a retrospective fashion after a mean follow-up of 34.4 months (range, 9-76). RESULTS: The resolution of exudative RD was achieved within 6 months, and the visual acuity of the affected eye had improved at the latest follow-up examination (p=.018) in all patients. No recurrence of exudative RD occurred. Thinning of the CHs was observed in most patients; however, symptomatic radiation toxicity had not developed in any of the patients. CONCLUSION: Symptomatic CHs can be safely and effectively managed with Gamma Knife radiosurgery using a marginal dose of 10 Gy.

Comparative study of patients with central serous chorioretinopathy undergoing focal laser photocoagulation or photodynamic therapy.

AIMS: To compare clinical outcomes for patients with central serous chorioretinopathy (CSC) undergoing either focal laser photocoagulation or photodynamic therapy (PDT). METHODS: 26 eyes of 26 patients with symptomatic CSC underwent focal laser photocoagulation or half-dose PDT, as appropriate. Best-corrected visual acuity, optical coherence tomography and multifocal electroretinography were assessed prospectively prior to treatment and at 1, 3 and 6 months after treatment. RESULTS: 12 eyes in the focal laser group and 14 eyes in the PDT group were evaluated. One month after PDT, all eyes, except one, showed complete absorption of subretinal fluid, whereas five eyes in the focal laser group showed residual subretinal fluid (p=0.022). Visual acuity and parameters of multifocal electroretinography improved from baseline at 1, 3 and 6 months after treatment, without any significant differences between the two groups. However, compared with those in the PDT group at 1 month after treatment, P1 latencies in the first annuli of the focal laser group were delayed (40.1 ± 5.5 ms and 34.9 ± 2.5 ms, respectively; p=0.047). CONCLUSIONS: Compared with focal laser, half-dose PDT may facilitate earlier resolution of macular detachment and earlier recovery of central retinal function. However, at 3 months after treatment and thereafter, no difference in anatomical and functional recovery was noted between the two modalities of treatment.

Peripheral exudative hemorrhagic chorioretinopathy in Korean patients.

BACKGROUND: Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare condition characterized by either subretinal exudates or subretinal hemorrhage outside the macula. The objective of this case report is to describe PEHCR lesions in Korean patients. CASES: Five eyes of four patients are reviewed. OBSERVATIONS: All cases were characterized by either peripheral subretinal exudates or hemorrhage with age-related degeneration. Four of the lesions appeared as subretinal masses, and the other manifested as a large retinal pigment epithelial alteration combined with subretinal exudates and subretinal fibrosis. Two of the patients evidenced serious visual impairment induced by massive subretinal hemorrhage extending to the fovea. Visual acuity in the other three eyes studied remained stable. CONCLUSION: PEHCR appears to be a variant of age-related macular degeneration that occurs in Asians. Although PEHCR is known to be self-limiting, it frequently causes subfoveal extensions of subretinal blood and fluid.

Changes in muscle fiber size and in the composition of myosin heavy chain isoforms of rabbit extraocular rectus muscle following recession surgery.

PURPOSE: To assess the changes in the size of muscle fibers and the composition of myosin heavy chain (MyHC) isoforms in the global layer (GL) and the orbital layer (OL) of rabbit rectus extraocular muscle (EOM) after recession. METHODS: The right superior rectus muscles of two rabbits were harvested at 3 days or 1, 2, or 4 weeks after recession (eight rabbits in total). At each time point, one muscle was used for measuring the cross-sectional area of the muscle fibers and the other for identifying the composition of MyHC. The right superior rectus muscles of three additional naïve rabbits were used as controls. RESULTS: The mean cross-sectional area of the OL fibers did not change significantly. However, that of the GL fibers significantly decreased at 3 days (P<0.001) and 1 week (P=0.024) postoperatively, and increased thereafter to reach the control levels at 2 and 4 weeks postoperatively. Three days after surgery, the total MyHC content and the proportion of type IIb MyHC (MyHCIIb) plus EOM-specific MyHC (MyHCeom) decreased and remained at its lower level for 4 weeks. CONCLUSIONS: Transient atrophy and regeneration were observed only in the GL, and the changes in the MyHCIIb plus MyHCeom appeared to be related to these changes.

Laser photocoagulation as adjuvant therapy to surgery for large macular holes.

PURPOSE: To evaluate the effectiveness of laser photocoagulation as adjuvant therapy in the treatment of large macular holes. METHODS: A randomized clinical trial. Thirty-one eyes from 29 subjects with idiopathic macular holes of diameters larger than 400 microm were randomized into a laser group and a control group. All eyes underwent vitrectomy with peeling of the internal limiting membrane. Contrary to the control group eyes, the laser group eyes underwent laser photocoagulation at the center of the macular hole before vitrectomy. Visual acuity and anatomic outcomes assessed by optical coherence tomography (OCT) were analyzed 3 months after surgery. RESULTS: On postoperative OCT, closure of the macular hole was noted in 17 of the 18 (94.4%) laser group eyes and 10 of the 13 (76.9%) control group eyes. Hole closure without bare retinal pigment epithelium was observed in 16 eyes in the laser group and 6 eyes in the control group (P < 0.05). The amount of improvement in logMAR visual acuity 3 months after surgery was 0.40 +/- 0.29 in the laser group, and 0.19 +/- 0.23 in the control group (P < 0.05). CONCLUSIONS: Laser photocoagulation constitutes a potent adjuvant therapy that may improve anatomical and visual outcomes of surgery for macular holes larger than 400 microm.

Evaluation of the influence of tilt of optic disc on the measurement of optic disc variables obtained by optical coherence tomography and confocal scanning laser ophthalmoscopy.

PURPOSE: To evaluate the relationship between optic disc variables measured by confocal scanning laser ophthalmoscopy (CSLO) and optical coherence tomography (OCT). METHODS: Fifty-one eyes in 27 non-glaucomatous patients were scanned using a CSLO-TopSStrade mark and an OCT-OCT 3000trade mark. The relationship between the following four optic disc variables-disc area (DA), cup area (CA), neuroretinal rim area (NRRA), and cup-disc area ratio (CDAR)-measured by CSLO and OCT were evaluated, and the relationship between these measurements and optic disc tilt was assessed. Horizontal (HD) and vertical diameters (VD) of the optic disc were measured from disc photographs, and by CSLO and OCT, and ratios (HD/VD) were then compared. RESULTS: There was a good correlation in DA, CA, and CDAR except NRRA between OCT and CSLO measurements. In eyes with a tilt >/=4 degrees, DA and NRRA were measured larger, and CDAR and CA were measured smaller by OCT than by CSLO. However, in the eyes with a tilt of <4 degrees, no significant differences in measurement of disc variables were observed for the two measurement systems. HD/VD measured from disc photographs was well correlated with those determined by CSLO (r = 0.741, P < 0.0001), however, it correlated poorly with those measured by OCT in whole study eyes (r = 0.410, P = 0.008) and in eyes tilted by >/=4 degrees, respectively (P = 0.280). CONCLUSIONS: Although CSLO and OCT measurements of the optic disc are highly correlated, discrepancy becomes prominent in eyes with a disc tilted >/=4 degrees. Therefore, analysis of the optic nerve head by OCT must be cautiously interpreted in eyes with a highly tilted disc.