Microstructure of the corneal endothelial transition zone in different laboratory animals.

Purpose: To compare the microstructure of the corneal endothelial transition zone in different laboratory animals. Methods: Flat-mount corneas of rabbits, rats, and mice were stained with Alizarin Red S (ARS) and observed using scanning electron microscopy (SEM). The progenitor cell markers p75 neurotrophin receptor (p75NTR), SRY-box transcription factor 9 (SOX9), leucine-rich repeat-containing G protein-coupled receptor 5 (Lgr5), telomerase reverse transcriptase (TERT), and proliferation marker Ki-67 were examined in the flat-mounted corneas of three laboratory animals using immunofluorescence microscopy. Results: On flat mounts, proximity to the trabecular meshwork correlated with weaker ARS staining and greater polymorphism of endothelial cells in the transition zone in all animals. On SEM, distinct and smooth structures of the transition zone were negligibly detected in all animals. The endothelial cells in the transition zone had irregular shapes, with less dense, less wavy intercellular junctions, especially in murine corneas, exhibiting unique intercellular cystic spaces. In the transition zone of the rabbit cornea, progenitor cell markers p75NTR, SOX9, Lgr5, TERT, and proliferation marker Ki-67 were expressed, in contrast to those in other murine corneas. Conclusions: Although the transition zone was not identified clearly, irregular cell morphology and loss of cell-cell contact were observed in all animal corneal endothelial cells. The proliferative capacity and the presence of progenitor cells were confirmed in the transition zone, especially in the rabbit cornea.

Analysis of ocular fluid in patients with ranibizumab-recalcitrant neovascular age-related macular degeneration who have serum anti-ranibizumab antibodies.

PURPOSE: To evaluate whether anti-drug antibodies (ADAs) are present in the ocular fluid of patients with ranibizumab-recalcitrant neovascular age-related macular degeneration (nAMD). METHODS: Two serum ADA-positive ranibizumab-recalcitrant patients and two serum ADA-negative controls were recruited from patients with nAMD treated with ranibizumab monotherapy. Recalcitrance was defined as persistent fluid after ≥6 monthly ranibizumab injections. Serum and aqueous humor ADAs were detected by enzyme-linked immunosorbent assay and immunoprecipitation, respectively. RESULTS: Two of 156 ranibizumab-treated patients were ADA-positive. The patients received six and 14 ranibizumab injections, respectively, up to 4 weeks prior to blood collection. The serum ADA concentration was estimated to be approximately 50,000 ng/mL. Neutralizing ADAs were confirmed in both samples. A specific band was detected by immunoprecipitation only in ADA-positive samples, consistent with the results of enzyme-linked immunosorbent assay. Based on an assessment of the degree of sensitivity of commercially available anti-ranibizumab antibodies, it was estimated that the immunoprecipitation method could detect ADA levels >30 ng. Nevertheless, ADAs were not detected in the aqueous humor of either the experimental or control group. CONCLUSION: In the aqueous humor, ADAs are either not present or are present at a lower concentration than that which can be detected by immunoprecipitation. This presumably reflects the fact that blood ADA is the product of systemic circulation clearance through anterior elimination of intravitreal ranibizumab. Based on our results, ADAs do not return to the eye in sufficient quantities to interfere with the action of ranibizumab in the vitreous cavity.

LONGITUDINAL ASSESSMENT OF CHOROIDAL STRUCTURE IN PATIENTS WITH MACULAR NEOVASCULARIZATION.

PURPOSE: To investigate morphologic changes of choroidal structure through chronologic aspect in progression of macular neovascularization (MNV) with pachychoroid features. METHODS: One hundred seventy-one MNV participants above 50 years old with or without pachychoroid features were included in the analysis. Age-matched 132 normal patients were analyzed as control group. The total choroidal area and ratio of Sattler's layer area to total choroidal area, derived by summing 25 horizontal raster scans of the 30° × 20° scan area on enhanced depth imaging optical coherence tomography, were calculated to compare the difference among the normal eyes and the MNV eyes with/without pachychoroid features. RESULTS: The mean ratio of Sattler's layer area to total choroidal area is maintained at around 40% in normal eyes and MNV eyes without pachychoroid features. In MNV with pachychoroid features, the ratio of Sattler's layer area to total choroidal area changes according to the disease activity. Ratio of Sattler's layer area to total choroidal area is 34.1 ± 4.4% at the time of onset, 37.2 ± 4.8% at the time of remission, and decreases during recurrence from 36.8 ± 3.8% to 33.4 ± 3.8% (all P < 0.001). CONCLUSION: MNV with pachychoroid features is a disease whose development and progression are related to a change in the choroidal interlayer area ratio following the relatively larger dilation of Haller's layer vessels.

Factors associated with ocular surface epithelial damage in patients with primary Sjögren's syndrome.

BACKGROUND: The aim of this study was to evaluate the effects of systemic parameters, laboratory findings, oral parameters, and other ocular surface parameters on ocular surface epithelial damage in patients with primary Sjögren's syndrome (pSS). METHODS: A total of 82 dry eye disease (DED) patients with pSS were enrolled in this study. Ocular surface epithelial damage was measured by ocular staining score (OSS). Systemic parameters, laboratory findings including serologic markers, oral parameters, and other ocular surface parameters were collected. Other ocular surface parameter assessments such as the Schirmer's test, fluorescein tear breakup time, meibomian gland examinations, noninvasive keratographic tear film break-up time measurements using the Keratograph® 5 M were performed, and the Ocular Surface Disease Index was determined. RESULTS: In a multivariate analysis, decreased age and increased duration of pSS were significantly related to increased logarithm-transformed OSS (ß = -0.011, P = 0.043 and ß = 0.003, P = 0.008). Among the ocular surface parameters, decreased fluorescein tear breakup time and increased MGD grade were significantly associated with increased logarithm-transformed OSS (ß = -0.183, P < 0.001 and ß = 0.192, P = 0.049). CONCLUSIONS: Ocular surface epithelial damage in patients with pSS was associated with young age, long duration of disease, unstable tear film, and decreased meibomian gland function.

Assessment of meibomian glands and tear film in post-refractive surgery patients.

IMPORTANCE: Corneal refractive surgery may impact meibomian gland and tear film in post-refractive surgery patients. BACKGROUND: To compare ocular surface parameters between post-refractive surgery patients and normal controls. DESIGN: Cross-sectional single centre study. PARTICIPANTS: A total of 120 eyes of 120 subjects were divided into three groups: (i) 60 controls and 60 patients underwent corneal refractive surgery at least 12 months ago; (ii) 30 post-laser in-situ keratomileusis (LASIK) patients and (iii) 30 post-laser epithelial keratomileusis (LASEK)/photo-refractive keratectomy (PRK) patients. METHODS: Tear meniscus height, non-invasive keratographic tear film break-up time and meibography were measured using the Keratograph® 5M. Fluorescein break-up time, ocular surface staining, examination of lid margins and meibomian glands, Schirmer's test and Ocular Surface Disease Index questionnaire were performed. MAIN OUTCOME MEASURES: Ordinary logistic regression was performed to evaluate the impact of clinical variables including refractive surgery on the meiboscores. RESULTS: In post-LASIK patients, ocular surface parameters including Ocular Surface Disease Index scores, fluorescein break-up time and staining scores, except Schirmer's scores, were significantly worse than those in controls (P < 0.050). Ocular surface staining scores in post-LASEK/PRK patients was higher than that in the controls (P = 0.001). In post-refractive surgery patients, grade of meibomian gland parameters and meiboscores were worse than those of controls (all P < 0.050). Histories of refractive surgery were associated with high meiboscore (ß = 1.100, P = 0.043 for LASIK and ß = 1.039, P = 0.042 for LASEK/PRK). CONCLUSIONS AND RELEVANCE: Corneal refractive surgery may adversely affect the ocular surface, and a reduction of functional meibomian glands can contribute to chronic tear film dysfunction after corneal refractive surgery.

Effect of sulodexide in patients with non-proliferative diabetic retinopathy: diabetic retinopathy sulodexide study (DRESS).

PURPOSE: To evaluate the effectiveness of sulodexide for the treatment of hard exudates (HE) in non-proliferative diabetic retinopathy (NPDR). METHODS: This was a randomized, placebo-controlled, multicenter trial involving 130 patients (65 for each group) who had mild-to-moderate NPDR with macular HE. Participants were given a daily dose of either 50 mg sulodexide or a matching dose of placebo orally for 12 months. Main outcome measure was an improvement in HE defined as a decrease in severity by at least two grades on a 10-grade severity scale. This was evaluated by fundus photography over 12-month period. RESULTS: The sulodexide group showed significantly greater improvement in HE severity than that shown by the placebo group (39.0 % vs. 19.3 %; chi square, P = 0.005). Logistic regression analysis yielded an odds ratio of 2.790 (95 % confidence interval, 1.155-6.743; P = 0.023) for the effect of treatment once adjustments were made for demographic, prognostic and disease confounders. Intention to treat and per-protocol analysis yielded similar results. Sulodexide's safety was comparable to that of the placebo. CONCLUSIONS: Oral sulodexide therapy over 12 months improved macular HE in patients with mild-to-moderate NPDR, without leading to detectable adverse events. The study protocol was registered on clinicaltrial.gov under identifier NCT01295775.

Effect of hemodialysis (HD) on intraocular pressure, ocular surface, and macular change in patients with chronic renal failure. Effect of hemodialysis on the ophthalmologic findings.

BACKGROUND: The main objective of hemodialysis (HD) is to correct the excessive accumulation and abnormal distribution of body fluid. Therefore, changes in the systemic hemodynamic parameters and in the ocular fluid volume and composition can occur during a single HD session. The aim of this study is to evaluate the short-term changes in the ophthalmologic findings after HD. METHODS: Thirty eyes of 30 patients with chronic renal failure (CRF) undergoing HD were analyzed. The subjects were categorized into two groups according to the cause of CRF. Detailed ophthalmologic examinations were performed immediately before and after HD. The relationships between the systemic hemodynamic changes and the ophthalmologic changes during a single HD session were evaluated. RESULTS: The results show that a body fluid correction after HD involves a change in the plasma colloid osmotic pressure. The mean intraocular pressure (IOP) decreased after HD with a mean decrease of 2.4 ± 2.1 mmHg and the central corneal thickness decreased with a mean change of 6.9 ± 5.4 µm. After HD, the ocular surface changed significantly; the tear break-up time (TBUT) and basal tear secretion (Schirmer's test) decreased, whereas the keratoepitheliopathy score increased. The macular thickness measured by spectral domain optical coherence tomography (SD-OCT) decreased after HD. The mean decrease in the central subfield thickness was 7.4 ± 9.9 µm. The ocular surface changes after HD affected the visual acuity and examination quality. A significant correlation was found between the changes in the systemic hemodynamic parameters and those in the ophthalmologic findings, except for the retinal thickness. CONCLUSIONS: The changes in the ophthalmologic findings after HD were consistent and significant in all CRF subjects. These changes correlated with the increase in plasma colloid osmotic pressure. HD can correct the volume and composition of ocular fluid. Therefore, it can affect the ophthalmologic findings in a short period of time. In addition, for good examination quality, it is recommended that an ophthalmologic examination in CRF patients be performed on a non-dialysis day or prior to HD on a dialysis day. Furthermore, for accurate comparison of examination results, the time interval from an HD session to an ophthalmologic examination must be considered.

Deep learning-based prediction of the retinal structural alterations after epiretinal membrane surgery.

To generate and evaluate synthesized postoperative OCT images of epiretinal membrane (ERM) based on preoperative OCT images using deep learning methodology. This study included a total 500 pairs of preoperative and postoperative optical coherence tomography (OCT) images for training a neural network. 60 preoperative OCT images were used to test the neural networks performance, and the corresponding postoperative OCT images were used to evaluate the synthesized images in terms of structural similarity index measure (SSIM). The SSIM was used to quantify how similar the synthesized postoperative OCT image was to the actual postoperative OCT image. The Pix2Pix GAN model was used to generate synthesized postoperative OCT images. Total 60 synthesized OCT images were generated with training values at 800 epochs. The mean SSIM of synthesized postoperative OCT to the actual postoperative OCT was 0.913. Pix2Pix GAN model has a possibility to generate predictive postoperative OCT images following ERM removal surgery.

Effects of Y-27632, a Rho-associated Kinase Inhibitor, on Human Corneal Endothelial Cells Cultured by Isolating Human Corneal Endothelial Progenitor Cells.

CONCLUSIONS: Y-27632 enabled the isolation and expansion of HCEPs. It also enhanced the proliferation, viability, and migration of differentiated HCEPs. METHODS: HCEPs were isolated and expanded in a medium with and without 10µM Y-27632, and then differentiated into HCECs in a medium with fetal bovine serum. The characteristics of HCEPs and differentiated HCEPs were confirmed by immunofluorescence staining. The proliferation, viability, morphology, and wound-healing ability of differentiated HCEPs were assessed in the presence of different concentrations of Y-27632. PURPOSE: Human corneal endothelial progenitor cells (HCEPs), which has been selectively isolated and differentiated into human corneal endothelial cells (HCECs), are crucial for repairing corneal endothelial damage. In this study, we evaluated the roles of a Rho-assisted kinase (ROCK) inhibitor, Y-27632, on the isolation and expansion of HCEPs, and assessed the in vitro effects of different concentrations of Y-27632 on the differentiated HCEPs. RESULTS: Y-27632 enabled the isolation and expansion of HCEPs from the corneal endothelium. The differentiated HCEPs showed an optimal increase in proliferation and survival in the presence of 10µM Y-27632. As the concentration of Y-27632 increased, differentiated HCEPs became elongated, and actin filaments were redistributed to the periphery of cells. Y-27632 also caused a concentration-dependent enhancement in the wound-healing ability of differentiated HCEPs.

Association of polymorphisms in C2, CFB and C3 with exudative age-related macular degeneration in a Korean population.

This study was to investigate the association of genetic polymorphisms in complement component 2 (C2), complement factor B (CFB) and complement component 3 (C3) with exudative age-related macular degeneration (AMD) in a Korean population and the gene-gene and gene-environment interactions in the development of AMD. A total of six SNPs that are located in the C2 (rs547154, rs9332739), CFB (rs4151667, rs641153) and C3 (rs1047286, rs2230199) genes were genotyped in 350 samples comprised of 153 cases, 197 controls. The risk allele frequencies for rs547154 in C2 were 6.54% and 8.12% in AMD patients and controls. Those for rs641153 in CFB were 6.54% and 8.63% in AMD patients and controls. The risk allele frequency for rs9332739 in C2 (AMD, 0.65%, control, 2.03%) and rs4151667 in CFB (AMD, 0.65%, control, 1.78%) was very low. The protective allele of four SNPs was not significantly associated with decreased risk for AMD (P = 0.427, P = 0.199, P = 0.312, P = 0.303, respectively). The homozygotes for the protective allele of four SNPs were not significantly associated with decreased risk for AMD (P = 0.324, P = 0.474, P = 0.309, P = 0.411, respectively). The genetic effect of two SNPs in C3 could not be investigated because the variants were not observed. There was no evidence to support an interaction of these SNPs with LOC387715/HTRA1 variants or with environmental exposure like smoking. In conclusion, the genetic effect of C2, CFB and C3 polymorphisms, which are known to be important for AMD in Caucasian, were not significant in the Korean population. The low minor allele frequency of these SNPs in Koreans might have affected the results of this study. Ethnic differences in the roles of C2, CFB and C3 in conferring a risk of AMD should be further investigated.

Frosted Branch Angiitis; Case Series and Literature Review.

PURPOSE: Frosted branch angiitis (FBA) is a rare form of retinal vasculitis. Four case series and an extensive literature review of 236 cases were conducted to clarify the characteristics of this rare condition. METHODS: Case series and literature review. RESULTS: An analysis of the reported cases revealed that a majority (54.6%) developed FBA in the presence of an underlying disease, with recurrence and complications requiring surgical intervention being rare. The frequency of bilateral occurrence (55.0%) and prevalence in female patients (45.0%) were noted to be lower than previously reported. CONCLUSION: In general, idiopathic FBAs are more likely to be bilateral and diagnosed at a younger age than secondary FBAs. In idiopathic FBA, fundus involvement is more generalized, exudates tend to be more translucent, and extensive retinal hemorrhage tends to be less frequent. However, there were no differential characteristic fundus features that clearly distinguished idiopathic FBA from secondary FBA.

Efficacy of Pretreatment with Preservative-Free Topical Bromfenac in Improving Post-Intravitreal-Injection Pain: A Prospective Pilot Study.

(1) Background: To determine the analgesic effect of pretreatment topical bromfenac instillation in patients undergoing intravitreal anti-VEGF treatment. (2) Methods: A prospective, non-randomized pilot study was conducted in patients scheduled to receive repeated intravitreal anti-VEGF injections at a single tertiary hospital. Before the planned second injection, the patients received topical bromfenac eye drops twice a day for 3 days. At 1, 6, and 24 h after the first and second injections, the post-injection pain scores were determined using the numerical rating scale (NRS) telephonically. (3) Results: A total of 28 patients were enrolled in this study. After the first intravitreal injection, the NRS pain scores were 4.04 ± 1.90 at 1 h, 1.57 ± 1.75 at 6 h, and 0.93 ± 1.27 at 24 h. The pain scores after the second intravitreal injection significantly decreased at each measurement time point (p = 0.002, 0.055, and 0.004, respectively) compared to the first injection. (4) Conclusions: The use of topical bromfenac eye drops before intravitreal injection can lead to a significant improvement in injection-related pain scores, which is the basis for a future large-scale randomized comparative study.

A real-world study assessing the impact of retinal fluid on visual acuity outcomes in patients with neovascular age-related macular degeneration in Korea.

To evaluate the real-world treatment outcomes in patients with neovascular age-related macular degeneration (nAMD) in Korea, focusing on retinal fluid resolution. This multi-institutional retrospective chart review study, analyzed medical records of patients with nAMD (age ≥ 50 years) who received their first anti-vascular endothelial growth factor (VEGF) treatment in ophthalmology clinics across South Korea between January 2017 and March 2019. The primary endpoint was the proportion of patients with retinal fluid after 12 months of anti-VEGF treatment. The association between fluid-free period and VA gains was also evaluated. A total of 600 patients were enrolled. At baseline, 97.16% of patients had retinal fluid; after 12 months of anti-VEGF treatment, 58.10% of patients had persistent retinal fluid. VA improvements were relatively better in patients with absence of retinal fluid compared with presence of retinal fluid (+ 12.29 letters vs. + 6.45 letters at month 12; P < .0001). Longer duration of absence of retinal fluid over first 12 months correlated with better VA gains at month 12 (P < .01). More than half of the study patients with nAMD had retinal fluid even after 12 months of treatment with their current anti-VEGF. Presence of retinal fluid was associated with relatively worse VA outcomes.

Clinical Characteristics of Lamellar Macular Hole Subtypes: Degenerative and Tractional.

PURPOSE: To analyze clinical parameters of two subtypes of lamellar macular hole (LMH): degenerative and tractional. METHODS: This retrospective chart review study included patients monitored for more than 6 months after the initial diagnosis of LMH from January 2011 to January 2018. LMH was classified in two subtypes: degenerative and tractional. The following parameters between both subtypes were assessed: central subfield thickness (CST), maximum inner diameter (MID), maximum outer diameter (MOD), MID/MOD ratio, inner and outer segment (IS/OS) junction disruption, residual retinal thickness (RRT), subfoveal choroidal thickness (SFCT), best-corrected visual acuity (BCVA), anatomical progression rate, and percentage of patients undergoing surgery. RESULTS: This study included 51 eyes with a mean follow-up period of 18.94 months: 33 eyes with tractional LMH and 18 eyes with degenerative LMH. MID was not significantly different between both subtypes but MOD was significantly greater in tractional LMH than degenerative types (tractional, 1131.6 µm; degenerative, 708.9 µm; p < 0.001). The MID were significantly increased in degenerative eyes, while the tractional eyes featured a significant increase in MOD. BCVA was not significantly different between both subtypes at baseline and the last follow-up. Epiretinal membrane presence was significantly different between the two subtypes (tractional, 96.9%; degenerative, 22.2%; p < 0.001). Ellipsoid defect and rate of receiving surgery were not significantly different between both subtypes. The anatomical progression rate in tractional eyes (81.8%) was significantly higher than that of degenerative LMH (27.7%) (p = 0.010). The SFCT was correlated to anatomical progression in the tractional LMH (correlation coefficient = 0.351, p = 0.049) but not in the degenerative LMH. During the follow-up period, 4 eyes (22.2%) of the degenerative LMH and 11 eyes (33.3%) of the tractional LMH underwent surgery. CONCLUSIONS: We found that greater SFCT at baseline was correlated to anatomical progression of tractional LMH. Therefore, it is expected that SFCT could be used as a biomarker to predict anatomical progression in tractional LMH.

Changes in the Ganglion Cell-inner Plexiform Layer after Consecutive Intravitreal Injections of Anti-vascular Endothelial Growth Factor in Age-related Macular Degeneration Patients.

PURPOSE: To investigate the effect of intravitreal anti-vascular endothelial growth factor (VEGF) injections on ganglion cell-inner plexiform layer (GCIPL) thickness in patients with age-related macular degeneration (AMD). METHODS: This retrospective study included patients with continuous anti-VEGF treatment who were administered at least three consecutive injections for unilateral neovascular AMD. The GCIPL thickness of the study eyes was compared before and after treatment and with healthy fellow eyes using spectral-domain optical coherence tomography. We also evaluated best-corrected visual acuity, age, and intraocular pressure. RESULTS: In total, 96 eyes of 48 patients (14 females and 34 males; mean ± standard deviation [SD] age, 70.10 ± 8.89 years) with mean number of 6.29 (SD ± 3.76) anti-VEGF injections and a mean follow-up period of 24.93 months (SD ± 19.86) were included in the study. After three consecutive intravitreal injections of anti-VEGF, the mean GCIPL thickness was significantly reduced from 70.50 (SD ± 14.06) to 65.97 (SD ± 13.91) µm. Borderline or nonsignificant decrease was also observed in GCIPL thickness for each sector. At the end of the study, the mean GCIPL thickness was further reduced to 62.56 (SD ± 16.30) µm, and significant decreases were also observed in all other sectors compared with baseline. CONCLUSIONS: It has been observed that GCIPL thickness can decrease with only three consecutive anti-VEGF injections as well as with long-term treatment in AMD patients.

Eckardt keratoprosthesis for combined pars plana vitrectomy and therapeutic keratoplasty in a patient with endophthalmitis and suppurative keratitis.

This is a case report on the use of Eckardt keratoprosthesis for pars plana vitrectomy in a patient with endophthalmitis and suppurative keratitis that developed after cataract surgery. A 79-year-old woman developed acute-onset infectious endophthalmitis and suppurative keratitis after cataract surgery that failed to respond to treatment with antibiotic eyedrops and intravitreal antibiotic injection. Using a temporary keratoprosthesis that enabled sufficient visualization, vitrectomy was performed, followed by therapeutic keratoplasty using a cryopreserved donor cornea. The patient's vision was improved from light perception to counting fingers at 30 cm, 3 months postoperatively. There was no recurrence of infection or other significant complications.

Accuracy of intraocular lens power calculation formulas using a swept-source optical biometer.

PURPOSE: To compare the accuracy of the five commonly used intraocular lens (IOL) calculation formulas integrated to a swept-source optical biometer, the IOLMaster 700, and evaluate the extent of bias within each formula for different ocular biometric measurements. METHODS: The study included patients undergoing cataract surgery with a ZCB00 IOL implant, using IOLMaster 700 optical biometry. A single eye per patient was included in the final analysis for a total of 324 cases. The SRK/T, Hoffer Q, Haigis, Holladay 2, and Barrett Universal II formulas were evaluated. The correlations between the refractive prediction errors calculated using the five formulas and ocular dimensions such as axial length (AL), anterior chamber depth (ACD), corneal power, and lens thickness (LT) were analyzed. RESULTS: There were significant differences in the median absolute error predicted by the five formulas after the adjustment for mean refractive prediction errors to zero (P = 0.038). The Barrett Universal II formula had the lowest median absolute error (0.263) and resulted in a higher percentage of eyes with prediction errors within ±0.50 D, ±0.75 D, and ±1.00 D (all P < 0.050). The refractive errors predicted by only the Barrett formula showed no significant correlation with the ocular dimensions: AL, ACD, corneal power, and LT. CONCLUSIONS: Overall, the Barrett Universal II formula, integrated to a swept-source optical biometer had the lowest prediction error and appeared to have the least bias for different ocular biometric measurements for the ZCB00 IOL.

Guideline development for the evaluation of visual impairment in Korea.

This guideline is developed to provide criteria for evaluating permanent impairment of the visual system as it affects an individual's ability to perform activities of daily living. This new assessment system is based on the 5th and 6th edition of American Medical Association and McBride impairment assessment system but revised on the consideration of Korean culture and simple application. This evaluation of impairment is based on an assessment of visual acuity and visual field. Especially it weighs binocular vision and binocular visual fields and the binocular vision and binocular visual fields provide 50% of weight and the right and left eye each contribute 25%. A further adjustment of the impairment rating is included at the final step of this evaluation. Functional deficits for individual adjustments include diplopia, problem of accommodation, abnormality of eyelids, tearing, cosmetic problems from cornea opacity, glare, aphakia, and dark-adaptation. The adjustment can be added to impairment rating up to 15%. Further study is necessary to revise and update of this disability evaluation that have potential problems in actual application.

Melatonin Levels in Patients With Primary Open-angle Glaucoma With High or Low Intraocular Pressure.

PURPOSE: To evaluate circulatory melatonin levels by assessing nocturnal urinary excretion of 6-sulfatoxymelatonin (aMT6s) in patients with primary open-angle glaucoma (POAG) and to compare the high-tension group and the low-tension group. METHODS: This study included 80 eyes of 41 POAG patients and 87 eyes of 44 control subjects. POAG group was further classified into high-tension group and low-tension group according to the pretreatment intraocular pressure (IOP). The first urine in the morning was collected and aMT6s were measured using a commercial ELISA kit. Urinary aMT6s levels were expressed as ng aMT6s/mg creatinine. Differences in melatonin levels among the control and POAG subgroups were evaluated by generalized estimating equation adjusting age, sex, sleep duration, and intereye correlation. RESULTS: Urinary aMT6s/creatinine ratio did not differ between POAG and control group (P=0.097). The difference in the aMT6s/creatinine ratio between the 3 groups-high-tension group with baseline IOP≥21 mm Hg (19.74±3.12 ng/mg), low-tension glaucoma group with baseline IOP<21 mm Hg (26.71±3.47 ng/mg), and control group (30.35±3.05 ng/mg)-was statistically significant (P=0.046). Post hoc analysis revealed that the difference between the control and high-tension glaucoma groups was significant (P=0.014), whereas the difference between the control and low-tension glaucoma groups was not (P=0.436). CONCLUSIONS: This study found low melatonin levels in high-tension glaucoma compared with the control.

Location and pattern of non-invasive keratographic tear film break-up according to dry eye disease subtypes.

PURPOSE: To compare the non-invasive keratographic tear film break-up time (NIKBUT) and the location and pattern of non-invasive keratographic tear film break-up between normal group and each group of three dry eye disease (DED) subtypes. METHODS: We enrolled 55 normal subjects and 250 patients with DED, who underwent tear meniscus height and NIKBUT measurements using the Keratograph® 5M. Ocular surface parameter assessments such as the fluorescein tear break-up time, ocular surface staining, Schirmer's test, and lid margin and meibomian gland examinations were performed, and the ocular surface disease index was determined. These parameters, including the proportion of the first tear film break-up location and simultaneous multiple tear film break-up pattern, were compared amongst the normal and DED subtypes. RESULTS: Aqueous-deficient dry eye disease (ADDE) and ADDE/meibomian gland dysfunction (MGD) subtypes showed lower NIKBUTs than those of the normal group, whilst NIKBUTs of the MGD subtype did not differ from those of the normal group. The NIKBUTs showed a good diagnostic ability in diagnosing dry eye except MGD only. The occurrence of the first tear film break-up in the central location was significantly higher in both the ADDE and ADDE/MGD subtypes, comprising approximately 40% in both subtypes (p < 0.001). The proportion of a simultaneous multiple tear film break-up pattern was higher in the ADDE and ADDE/MGD subtypes, at 60.9% and 45.5%, respectively (p < 0.001). CONCLUSION: The NIKBUTs and the location and pattern of non-invasive tear film break-up were different between normal group and each group of three DED subtypes.