Long Term Corneal Endothelial Cell Density Loss after Iris-fixed Phakic Intraocular Lens Implantation

PURPOSE: To report three cases of severe endothelial cell density loss after iris claw phakic intraocular lens (Artisan® lens) implantation. CASE SUMMARY: A 32-year-old woman underwent iris claw intraocular lens implantation in both eyes. Preoperative corneal endothelial cell count was 2,556 cells/mm² in the right eye and 2,674 cells/mm² in the left eye. After 4 years, the corneal endothelial cell count was 1,968 cells/mm² in the right eye and 1,997 cells/mm² in the left eye. A 27-year-old woman underwent iris claw intraocular lens implantation in both eyes. Preoperative corneal endothelial cell count was 3,222 cells/mm² in the right eye and 3,122 cells/mm² in the left eye. After 4 years 8 months, the corneal endothelial cell count was 2,729 cells/mm² in the right eye and 2,488 cells/mm² in the left eye. A 39-year-old woman underwent phakic intraocular lens implantation in other clinic, and the lens of left eye was removed the same day because of elevated intraocular pressure. She underwent iris claw intraocular lens implantation in the left eye. Preoperative corneal endothelial cell count was 2,500 cells/mm² in the left eye, which decreased to 1,873 cells/mm² after 8 years. Six months after intraocular lens removal and cataract surgery, her cornea endothelial cell count was 1,412 cells/mm². CONCLUSIONS: Although iris-fixed intraocular lens implantation is safe and effective for correcting myopia, at least 4 years of long-term observation for evaluating corneal endothelial cell density maybe necessary.

A Case of Surgical Diagnosis and Treatment of Idiopathic Orbital Myositis with Sudden Vision Loss

PURPOSE: We report a case of idiopathic orbital myositis with sudden onset of unilateral visual loss and hypertrophy of the lateral rectus muscle at the apex of the orbit that was diagnosed using orbital biopsy and treated with intravenous corticosteroids. CASE SUMMARY: We examined a 20-year-old woman who complained of decreased visual acuity and binocular diplopia for 2 weeks. She showed 40-prism diopter left esotropia at the primary position. Her visual acuity with eyeglasses was 0.7 and 0.2 in the right and left eyes, respectively. Brain magnetic resonance imaging (MRI) revealed a round mass on the left lateral rectus muscle at the apex of the orbit with optic nerve compression. We planned orbital biopsy to exclude orbital lymphoma and other biopsy-requiring diseases. After 3 weeks, the visual acuity of her left eye decreased to 0.02. Repeated MRI revealed enlargement of all extraocular muscles on the left orbit. With biopsy showing several lymphocytes infiltrating muscle fibers, we made a diagnosis of idiopathic orbital myositis. Intravenous injection of corticosteroids was administered during hospitalization. After 2 weeks of corticosteroid therapy, the visual acuity of her left eye was improved to 0.63, the esotropia disappeared, and the enlargement of the left lateral rectus muscle was improved on orbital MRI. CONCLUSIONS: For non-specific idiopathic orbital myositis located at the apex of the orbit and enlargement of the extraocular muscle in a short period with decreased visual acuity, administration of intravenous injection of corticosteroids before orbital biopsy could help restore vision.

A Comparative Histopathological Study of Lens Capsule and Epithelial Cells in Various Types of Cataract

PURPOSE: To evaluate the histopathological changes of anterior capsule and lens epithelial cells in various types of cataract. METHODS: Patients scheduled for cataract surgery of phacoemulsification with intraocular lens implantation were enrolled in this study. Anterior capsule tissues sized 5 mm were obtained at the time of continuous curvilinear capsulorhexis during surgery. Histological examination of the obtained tissue was performed by transmission electron microscope. RESULTS: Nuclear cataract showed a uniform cuboidal monolayer of epithelial cells firmly attached to the anterior capsule. But, the mitochondria, Golgi apparatus, and endoplasmic reticulum were damaged and replaced with vacuoles. Anterior subcapsular cataract showed multilayers of epithelial cells with irregular intracellular structures. Epithelial cells of mature cataract were severely damaged and detached from the anterior capsule, accompanied by expansion of intra-cellular space and a large amount of vacuoles. Epithelial cells were irregular and severely damaged, and intracellular structures were hardly observed in traumatic cataract. Deposition of pseudoexfoliation materials on the anterior capsule was observed in pseudoexfoliation cataract. CONCLUSIONS: Changes in epithelial cells caused by fluid accumulation and electrolyte imbalance in the lens attributes more to cataract formation than do changes the in lens capsule.

Clinical Manifestations of Extruded Conjunctival Melanocytic Mass

PURPOSE: To investigate the clinical manifestations and characteristics of extruded conjunctival melanocytic mass. METHODS: A total of 33 patients who had extruded conjunctival melanocytic mass and who underwent excisional biopsy were retrospectively reviewed. RESULTS: Based on the excisional biopsy results, 13 patients (40%) were diagnosed with compound nevus, nine patients (27%) with subepithelial nevus, eight patients (24%) with primary acquired melanosis without atypia, and three patients (9%) with malignant melanoma. Compound nevus was located on the temporal side of the cornea in 54% of affected cases, bulbar conjunctival in 77%, and was partially pigmented (brown) in 61%. The average size of the melanocytic mass was 24 mm when histological analysis showed melanin nevus cells in the conjunctival epithelial layer and subepithelial stromal layer. Subepithelial nevus was located on the temporal side of the cornea (56%) and in the bulbar conjunctival (78%) and had a brown color (78%). The average size of the melanocytic mass was 28 mm when histological analysis showed melanin nevus cells located only in the subepithelial stromal layer and forming nest shapes. Primary acquired melanosis without atypia was located on the temporal side of the cornea (62.5%) and bulbar conjunctival (75%) and had brown color (75%). The average size of melanin nevus cells located only in the basement membrane of the epithelial layer was 30 mm. Three of these masses were malignant melanoma, and all cases were located on the superior side of the cornea and palpebral conjunctiva. All cases were black and had an average size of 53 mm, with malignant cells observed in all layers of the conjunctiva and connective tissue. CONCLUSIONS: A conjunctival melanocytic mass located on the palpebral conjunctiva, extruding onto the surface, and large in size should be suspected as malignant melanoma. In such cases, early biopsy and aggressive resection are required.

Clinical Features Associated with the Direction of Deviation in Sensory Strabismus

PURPOSE: To assess the clinical features associated with the direction of deviation in sensory strabismus and postoperative stability of strabismus angles. METHODS: The authors retrospectively reviewed the medical records of 98 patients diagnosed with sensory strabismus who were treated surgically. Among the factors analyzed were sex, age, direction of strabismus, preoperative visual acuity, age at onset of visual loss, cause of primary sensory deficit, refractive error, age at operation, deviation angle at 1 and 6 months postoperatively and after at least 5 years. RESULTS: At baseline, 20 patients (20.4%) had esotropia and 78 (79.6%) had exotropia. Common causes of primary sensory deficit were corneal opacity (25.5%), vitreoretinal disorder (23.5%), and congenital cataracts (16.3%). The proportion of esotropia increased significantly as the refractive error of the sound eye became more hyperopic. The older the patients were when they lost their vision, the higher the proportion of exotropia. Patients with longer duration of vision loss were more likely to have a larger deviation angle with exotropia, but the association was not significant with esotropia. CONCLUSIONS: Patients with sensory strabismus tend to develop exotropia. Refractive error of the sound eye and age at onset of vision loss were associated with the direction of strabismus. Despite poor sensory fusion even after surgery, more than 50% of patients maintained a stable eye position.

A Case of Iatrogenic Horner's Syndrome after Video-Thoracoscopic Surgery for Primary Pneumothorax

PURPOSE: To report a case of iatrogenic Horner's syndrome after video-thoracoscopic surgery for primary pneumothorax. CASE SUMMARY: An 18-year-old man with ptosis in the right eye was referred to our clinic. The patient had undergone wedge resection via video-thoracoscopic surgery for primary pneumothorax three weeks previously. On ocular examination, the palpebral fissure width was 7 mm in the right lid and 8 mm in the left lid, the marginal reflex distance 1 (MRD 1) was 2 mm in the right lid and 3 mm in the left lid, and the bilateral levator muscle function was good. Anisocoria was present, and pupil size in a dark room was 2.5 mm in the right eye and 4 mm in the left eye. The patient complained of facial anhidrosis on the right side of the face. CONCLUSIONS: Although iatrogenic Horner's syndrome is rare complication of video-thoracoscopic surgery for primary pneumothorax, diagnosis after surgery of the thoracic cavity should be made carefully.

Histologic Serial Changes of Obliterating Materials in the Rat Temporal Dorsal Bullae / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Mastoid obliteration surgery is a modern trend for otitis media either with or without cholesteatoma. The aim of our study is to evaluate histologic changes and effectiveness over time resulting from different obliterating materials and the existence of mucosa in the temporal dorsal bullae in rats. MATERIALS AND METHOD: Rats were divided into two groups. One group had the mucosa removed and was treated with trichloroacetic acid (TCA). The other group with mucosa remaining was untreated. The temporal dorsal bullae of the two groups of rats were obliterated with Mimix(R) (hydroxyapatite cement), Regenafil(R) (demineralized bone matrix), cartilage chip, and bone chip. Three months and again six months after the implantation, 5 animals in each group were examined. A histological study was performed to evaluate inflammation, new bone formation, and mucocele formation within the bullae. RESULTS: The group that had Mimix(R) implanted had a high inflammatory reaction, low implanted material resorption and cyst formation. The group with Regenafil(R) implanted had high cyst formation and more cyst formation with the passage of time. The group with bone chip implanted had high new bone formation, but also high cyst formation. The group that had cartilage chip implanted had high new bone formation, low implanted material resorption and low cyst formation. CONCLUSION: Cartilage chip is the only material that should be used in the air cell with mucosa remaining. Demineralized bone matrix and bone chip should not be used in the air cell with mucosa remaining. Hydroxyapatite cement should not be used due to severe inflammation.

A Case of Middle Ear Effusion due to Lipoma on the Eustachian Tube / 대한이비인후과학회지

Lipoma of the head and neck region rarely occurs, if any, on the posterior triangle of neck. We have experienced a lipoma on Eustachian tube, which caused recurrent middle ear effusion. A 42-year-old female patient was presented with right aural fullness and hearing disturbance. She had a history of several cases of right middle ear effusion in the past and insertions of ventilation tubes to relieve each of them. A yellowish round mass was found on the pharyngeal orifice of the right Eustachian tube by fiberoptic nasopharyngoscopy. It was removed via endoscopic endonasal approach and there is no evidence of recurrence along about 3 months after the surgery. This would be a good case for the importance of nasopharyngeal examination in patient with middle ear effusion.

A Case of Empty Sella Syndrome with Cerebrospinal Fluid Rhinorrhea / 대한이비인후과학회지

The empty sella syndrome is defined as the intrasella herniation of the chiasmal cistern resulting from a congenitally incompetent diaphragma sellae. In idiopathic or primary empty sella syndrome, sella remodelling occurs as a result of an anatomical variation in the diaphragma sella. The secondary empty sella syndrome occurs following surgery or irradiation of an intrasellar lesion. Empty sella syndrome is known to be rarely associated with Cerebrospinal fluid (CSF) rhinorrhea. We experienced a case of secondary empty sella symdrome with CSF rhinorrhea in a 56-year old female who complained of persistent rhinorrhea through the roof of the sphenoid sinus after brain surgery due to meningioma. The CSF rhinorrhea was treated successfully with transseptal trans-sphenoidal approach.

Epitympanoplasty with Mastoid Obliteration Technique: 38 Months Follow-Up Results of 283 Cases / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: There have been heated controversies over the choice of the canal wall down mastoidectomy and canal wall up mastoidectomy, which are operational methods used to eliminate the lesion of chronic otitis media including cholesteatoma. Combining the advantages of both methods, we devised a new operational method in 1994. This study reports the surgical results of the epitympanoplasty employing the mastoid obliteration technique after a follow-up 38 months in 283 cases. SUBJECTS AND METHOD: A retrospective review was made of 283 cases (273 patients) on which this technique was performed by the first author between Dec. of 1994 to Mar. of 2004. The follow-up period varied from 8 to 104 months, with the average period of 38 months. We analyzed postoperative complications including cavity problems, the recurrent cholesteatoma, residual cholesteatoma cases in the mastoid cavity, residual cholesteatoma in the tympanic cavity and postoperative otorrhea and hearing results. RESULTS: The overall incidence of postoperative complications was 21.9%. The results of postoperative complications in the above listed order were 0%, 0%, 1.0%, 4.3% and 5.7%, respectively. Air-bone gap (ABG) closure was 4.73 dB HL and the statistical analysis revealed that the postoperative ABG was significantly lower than the preoperative ABG (p=0.0023). CONCLUSION: The present study suggests that this procedure prevents the cavity problem, helps reduce recurrence and effectively manages the residual cholesteatoma. Also, this procedure achieves good audiologic results.

Epitympanoplasty with Mastoid Obliteration Technique in Children with Cholesteatoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Cholesteatoma in children has a more aggressive growth pattern than observedin adults and often involves the entire mastoid and tympanic cavity, which necessitates early surgical treatment. The rapid tissue growth, the greater degree of infection and inflammation brought on by the Eustachian tube, and well pneumatized mastoid are the major contributing factors for cholesteatoma being so extensive in children. In this study, we evaluated the result of epitympanoplasty and mastoid obliteration in cholesteatoma of children. SUBJECTS AND METHOD: The operation was performed in 28 children patients under the age of 15 from May 11, 1995 to August 13, 2003. They were 3 congenital and 25 acquired cholesteatoma cases, which were accompanied by 4 cases of adhesive otitis media, 1 case of external auditory canal cholesteatoma, and 1 case of congential aural atresia that developed after two operations of canaloplasty. RESULTS: Of the 28 cases, 6 underwent one-staged operation and 8 underwent second-look operations, respectively. In 3 of the 8 cases that underwent second look operation, there was residual cholesteatoma in the tympanic cavity, and cholesteatoma was removed. After operation, there was no recurrent cholesteatoma. Among the 13 cases of ossiculoplasty, 9 could have the test of pure tone audiogram, and 5 cases could preserve postoperative air-bone gap within 30 dB. CONCLUSION: It is expected that epitympanoplasty with the mastoid obliteration technique reduces the air-burden of E-tube in children of cholesteatoma, and the technique probably can prevent the formation of retraction pocket and recurrence of cholesteatoma.

Epitympanoplasty with Mastoid Obliteration Technique in Only/Better Hearing Ears / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Sensorineural hearing loss is one of serious complications caused after the operation of chronic ear disease. In only/better hearing ears, it is important to minimize the chances of developing a severe hearing loss and to stop the progression of disease. We report the results of performing epitympanoplasty with mastoid obliteration in the only/better hearing ear with cholesteatoma. SUBJECTS AND METHOD: From February 11, 1996 to April 16, 2003, epitympanoplasty and mastoid obliteration was performed for 6 patients with the only hearing ear and 2 with a better hearing ear. In the only/better hearing ears, 7 cases had cholesteatoma and 1 case had adhesive otitis media. The other ears of the 5 cases had previously received canal wall down mastoidectomy, 2 cases sensorineural hearing loss and 1 case both epitympanoplasty and mastoid obliteration. The observation period ranged from 7 to 99 months, with the average of 45 months. RESULTS: One-staged operation was performed on all 8 patients. Four cases got total ossicular replacement prosthesis, 3 cases received partial ossicular replacement prosthesis, and 1 case received autologous cartilage short columellization. After each operation, all patients obtained a dry, safe, self-cleansing ear and recurrence did not occur. The hearing results in this series showed that the air conduction thresholds, bone conduction thresholds and air-bone gaps were preserved in 7 cases, but became worse in one patient. Two patients did not need to use hearing aids, five patients used an hearing aid of in-the-canal (ITC) type, one patient used a hearing aid of completely-in the canal (CIC) type. CONCLUSION: Epitympanoplasty with mastoid obliteration in the only/better hearing not only can stop the progression of cholesteatoma, but also can preserve hearing of patients.

Histopathologic Evaluation of Obliterating Material in the Guinea Pig Temporal Dorsal Bullae / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The present study was undertaken to determine and to compare the characteristics of bone wax, fibrofatty tissues or bone graft materials (Lubboc(R)) as obliterating materials in the guinea pig by morphological observations. MATERIALS AND METHOD: The guinea pigs were used to perform obliteration of the dorsal bullae of the temporal bone using bone wax, fibrofatty tissues or Lubboc(R). Twelve weeks after transplantation, the animals were sacrificed, and histological sections were prepared. Histological evaluations were performed to determine changes of the dorsal bullae mucosa of the temporal bone and the implanted materials. RESULTS: Where bone wax was used for obliteration, histological evidences indicated inflammatory reactions within the dorsal bullae mucosa of the temporal bone. A large amount of absorption was observed in the fibrofatty tissue. On the other hand, in the case using Lubboc(R), real bonds between the new bone and native bone were observed, as well as a mature trabecular bone traversing throughout the entire implant materials. Bone formation as induced by the Lubboc(R) implantation appeared to be a physiological reaction, which was further supported by observation of extensive neovascularization within the graft material. CONCLUSION: Based on our current observations, we consider Lubboc(R) as a superior implant material for bone wax and fibrofatty tissues.

A Case of Papillary Thyroid Carcinoma Arising in a Thyroglossal Duct Cyst with Complete Ectopic Thyroid Gland / 대한이비인후과학회지

Malignant tumor arising in a thyroglossal duct cyst is very rare, occurring in less than 1% of thyroglossal duct cysts. Papillary carcinoma is the most common histologic type. In most cases the diagnosis is only established after excision of a clinically benign thyroglossal duct cyst. The etiology and management of papillary carcinoma arising in a thyroglossal duct cyst remain controversial. Two theories of the etiology, de novo origin and spread from a primary thyroid gland tumor, have been suggested. These have important implications for therapeutic approaches. We report a case of papillary carcinoma arising in a thyroglossal duct cyst without normal thyroid gland.

A Case of Paget's Disease on Temporal Bone / 대한이비인후과학회지

Paget's disease of the bone is a chronic, progressive disease of unknown etiology, characterized by abnormal bony resorption and deposition. It is a common skeletal disease in Europe and North America, while it is very rare in Asia. Paget's disease of the temporal bone has been reported to cause hearing loss, tinnitus, and mild vestibular symptom. We report a 28-year-old man with Paget's disease, which was a first reported case of bilateral sensorineural hearing loss for the first time in Korea.