Electroretinography in congenital nystagmus patients with a normal fundus examination.

PURPOSE: To identify the ophthalmic causes of congenital nystagmus with normal eye examination by electroretinography (ERG). STUDY DESIGN: Retrospective observational study. METHODS: We reviewed the medical records of patients younger than 6 months of age who presented between June 2008 and November 2011 with nystagmus and no other neurological signs following an otherwise normal eye examination. A complete ophthalmic examination and ERG (Nicolet Bravo system; Nicolet Biomedial & RETIscan; Roland Instruments), fundus photography, and Ishihara color test were performed to identify any ophthalmic causes of congenital nystagmus. RESULTS: Thirty-three patients met the criteria. Rod dysfunction was diagnosed in 4 patients (12.1%), cone dysfunction in 2 patients (6.1%), and cone-rod dysfunction in 1 patient (3.0%). The results of ERG were negative in 2 patients (6.1%). Idiopathic infantile nystagmus was diagnosed in the remaining 24 patients (72.7%) based on their normal ERG examination. CONCLUSIONS: In Korean congenital nystagmus patients with a normal fundus examination, achromatopsia and Leber's congenital amaurosis are uncommon causes. ERG is needed to make a definite diagnosis and provide prognostic information in congenital idiopathic nystagmus patients with a normal fundus examination.

Association between refractive errors and horizontal strabismus: the Korea National Health and Nutrition Examination Survey.

PURPOSE: To investigate the association between refractive error and horizontal strabismus based on a Korean population-based survey. METHODS: The study included 22,887 participants >5 years of age who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2011. Refractive error was classified into myopia, hyperopia, astigmatism, and anisometropia. The association between refractive error and exodeviation or esodeviation was assessed using multivariate logistic regression analysis. RESULTS: After adjusting for potential confounders, the analyses revealed an increased odds ratio (OR) for exodeviation with an increasing trend according to the severity of myopia (mild myopia, OR = 1.36 [95% CI, 1.11-1.66]; moderate myopia, OR = 1.75 [95% CI, 1.36-2.26]; severe myopia, OR = 2.01 [95% CI, 1.50-2.69]; Ptrend < 0.001). Hyperopia was not associated with exodeviation (P = 0.273). There were also significant associations for exodeviation with astigmatism (OR = 1.36 [95% CI, 1.16-1.59; P < 0.001]) and anisometropia (OR = 1.78 [95% CI, 1.38-2.30; P < 0.001]) In comparison, esodeviation was significantly associated with hyperopia (OR, 10.24 [95% CI, 4.43-23.70; P < 0.001]) and anisometropia (OR, 5.16 [95% CI, 2.27-11.76; P < 0.001]), while no significant association was found with myopic degree (P = 0.170) or astigmatism (P = 0.816). CONCLUSIONS: Refractive error was closely associated with exodeviation and esodeviation. These risk associations should be considered when managing refractive errors.

Frontline treatment with chemoimmunotherapy for limited-stage ocular adnexal MALT lymphoma with adverse factors: a phase II study.

BACKGROUND: Radiotherapy is a commonly used treatment for limited-stage ocular adnexal mucosa-associated lymphoid tissue lymphoma (OAML) but showed a substantial relapse risk if the disease involves beyond-conjunctiva or bilateral conjunctivae. Systemic chemoimmunotherapy may be an alternative frontline therapy for the limited disease with those adverse prognostic factors. PATIENTS AND METHODS: We designed a multicenter, phase II study of the chemoimmunotherapy, rituximab, cyclophosphamide, vincristine, and prednisolone (R-CVP) for the treatment of patients with limited-stage OAML with bilateral or beyond-conjunctival involvement. Thirty-three patients with Ann Arbor stage I OAML with the adverse factors were enrolled. Patients received six cycles of R-CVP followed by two cycles of rituximab therapy. RESULTS: At the end of treatment, all the enrolled patients had responded. The cumulative complete response achievement was 93.9% at 2 years. At a median follow-up of 50.6 months, three patients had progressed. Progression-free survival and overall survival at 4 years was 90.3±5.3% and 100%, respectively. CONCLUSIONS: This phase II study demonstrated durable efficacy of R-CVP chemoimmunotherapy, which has promise as an alternative frontline therapy for the limited-stage OAML patients with adverse prognostic factors. CLINICAL TRIAL REGISTRATION: NCT01427114.

Measuring the differences in work ratios between pediatric and adult ophthalmologic examinations.

PURPOSE: To assess the differences in work needed for pediatric and adult ophthalmologic examinations. METHODS: Seven ophthalmology residents conducted slit-lamp and refraction examinations on children 3-7 years of age and adults 20-69 years of age. The examiners reported the magnitude estimate (ME) of their work in relation to two references (cross-reference ME): average adult examination and average pediatric examination. The examination time was also measured. RESULTS: For the slit-lamp examination, 50 children and 58 adults were recruited. The ME was 1.45 (95% CI, 1.30-1.62) times higher for the pediatric examinations than for the adult examinations when the reference was an average adult case. With respect to time, the pediatric examinations took 1.22 (95% CI, 1.06-1.41) times longer than the adult examinations. For the refraction examinations, 58 children and 96 adults were recruited. The ME was 1.35 (95% CI, 1.21-1.52) times higher for the pediatric examinations. The pediatric examination took 1.32 (95% CI, 1.16-1.50) times longer than the adult examination. The cross-reference ME ratios measuring the pediatric over adult examinations against both the pediatric and adult reference cases were equivalent in both the slit-lamp and the refraction examinations; however, the ME and time ratios of the pediatric over the adult examinations were not equivalent for the slit-lamp or for the refraction examinations. CONCLUSIONS: The cross-reference ME showed that pediatric ophthalmologic examinations require more work than the adult examination with validity and reliability. The time estimate was insufficient as a single indicator for work estimation.

Linezolid induced retinopathy.

PURPOSE: While optic neuropathy is a well-known cause of visual disturbances in linezolid-treated patients, the possibility of linezolid-related retinopathy has not been investigated. Here, we report a case of retinopathy demonstrated by multifocal electroretinogram (mfERG) in a linezolid-treated patient. METHOD AND RESULTS: A 61-year-old man with extensively drug-resistant pulmonary tuberculosis treated with linezolid for 5 months presented with painless loss of vision in both eyes. The patient's best corrected visual acuity was 20/50 in the right eye and 20/100 in the left eye. Fundus examination revealed mild disc edema, and color vision was defective in both eyes. Humphrey visual field tests showed a superotemporal field defect in the right eye and central and pericentral field defect in the left eye. Optical coherence tomography (OCT) revealed only mild optic disc swelling. In mfERG, central amplitudes were depressed in both eyes. Four months after the cessation of linezolid, visual acuity was restored to 20/20 right eye and 20/25 left eye. The color vision and visual field had improved. The OCT and mfEFG findings improved as well. CONCLUSIONS: Although the clinical features were similar to linezolid-induced optic neuropathy, the mfERG findings suggest the possibility of a retinopathy through cone dysfunction.

Medial rectus muscle anchoring in complete oculomotor nerve palsy.

The management of exotropia resulting from complete oculomotor nerve palsy is challenging. Conventional therapeutic interventions, including supramaximal resection and recession, superior oblique tendon resection and transposition, and several ocular anchoring procedures have yielded less-than-adequate results. Here we describe a novel surgical technique of anchoring the medial rectus muscle to the medial orbital wall in combination with lateral rectus disinsertion and reattachment to the lateral orbital wall.

Relationship between Cornea and Lid Margin Position on the Appearance of Strabismus.

PURPOSE: Previous strabismus appearance studies using images from real face photographs could not preclude the effect of other facial landmarks, such as position and contour of brow, nose, and facial outline, from pure effect of ocular deviation itself. With conceptualized drawings of eyes, we simulated strabismus deviation and collected the responses of observers. METHODS: The experiments consisted of three sessions: (1) one-eye, (2) two-eye cornea, and (3) two-eyelid deviation simulations. On a monitor, eight different ocular deviations in increments of 6 prism diopters of horizontal or vertical deviations were simulated. Nine ophthalmology residents were asked to choose between esotropia and exotropia for horizontal simulations and hypotropia or hypertropia for vertical simulations. Psychometric function fitting was performed. Detection sensitivity, point of subjective equality, and 95% thresholds were calculated. RESULTS: Between cornea and lid deviation simulations, there was no difference in 95% thresholds, points of subjective equality, and sensitivity (all p values > 0.10), reflecting that the relative location of cornea and lid was the determinant factor in recognizing ocular deviation. The sensitivities of vertical deviation simulations were higher than that of horizontal in two-eye cornea and lid comparisons (p values < 0.04) but not in one-eye (p value = 0.37). CONCLUSIONS: Our results suggest that the appearance of strabismus depends not on the absolute ocular alignment but rather on the reciprocal relationship of cornea and lid margin. Vertical misalignment was more apparent than horizontal misalignment.

Change in quality of life of patients undergoing silicone stent intubation for nasolacrimal duct stenosis combined with dry eye syndrome.

AIMS: To investigate the effect of silicone stent intubation (SI) on the quality of life of patients diagnosed with nasolacrimal duct stenosis and dry eye syndrome. METHODS: This study is a prospective, interventional case series. Consecutive 30 patients diagnosed with nasolacrimal duct stenosis and reflex tearing due to dry eye syndrome were included. Eligible subjects underwent SI and were asked to complete the Glasgow Benefit Inventory (GBI) questionnaire. Surgical outcomes and GBI scores were investigated 6 months postoperatively. RESULTS: The surgical success rate determined by the patients' subjective symptoms was 76.7% (23/30). Mean total GBI score was +17.19 (95% CI 8.34 to 26.03). The general subscale score was +20.36 (95% CI 10.19 to 30.54), the social support scale score was +21.54 (95% CI 11.37 to 31.71) and the physical health score was -0.56 (95% CI -8.92 to 7.80). CONCLUSIONS: SI could be an effective treatment option for reflex tearing in patients diagnosed with dry eye syndrome and nasolacrimal duct stenosis.

Bilateral simultaneous angle-closure glaucoma associated with septic condition of Korean hemorrhagic fever (KHF).

PURPOSE: To report a case of bilateral simultaneous angle-closure glaucoma caused by septic condition of Korean hemorrhagic fever. METHODS: A 62-year-old man visited our emergency center with signs of sepsis (fever, leukocytosis, and oliguria). After 4 days of hospitalization, the patient reported blurred vision. Upon ophthalmologic examination, elevated intraocular pressure, edematous cornea, closed anterior chamber angle, and shallow anterior chamber without iris bowing were found in both eyes in slit-lamp examination and in Pentacam (Oculus, Wetzlar, Germany) Scheimpflug images. Bilateral choroidal effusion was observed on an ultrasound B scan as well. The serologic test for anti-hantaan virus immunoglobulin G (IgG) was positive. RESULTS: Along with the sepsis treatment, intravenous hyperosmotic agent, antiglaucoma eye drops, and 1% atropine eye drop were administered immediately. To control the choroidal effusion, systemic steroid was also administered. After 4 months, anterior chamber depth and choroidal effusion were normalized. CONCLUSIONS: Systemic causes should be considered in patients with bilateral angle-closure glaucoma, and Korean hemorrhagic fever can be one of the causes in endemic areas.

Strabismus surgery outcomes after scleral buckling procedures for retinal reattachment.

OBJECTIVE: To investigate the outcomes of strabismus surgery in patients with a prior history of a scleral buckling procedure for retinal reattachment. METHODS: We reviewed the medical records of 18 patients who underwent strabismus surgery following a scleral buckling procedure and investigated the effect of multiple variables on postoperative alignment after strabismus surgery including gender, age, surgeon, number of strabismus surgeries, adjustable suture use, previous pars plana vitrectomy, preoperative best-corrected visual acuity, and scleral buckle removal. Outcomes were considered successful if there was ≤ 10 prism diopters (PD) residual horizontal and/or ≤ 4 PD residual vertical deviations. Statistical analyses were performed using Fisher's exact test, Mann-Whitney test, and nominal logistic regression. RESULTS: Success using our criteria of motor alignment was achieved in 6 of 18 eyes (33%). A higher rate of success was found in the scleral buckle removal group (success with buckle removal, 62.5%; success without buckle removal, 10.0%; p = 0.04). Nominal logistic regression analysis showed scleral buckle removal was the most significant factor associated with successful surgical alignment (p = 0.03; odds ratio = 16.67). Although the success rate was higher in the adjustable suture group (50% in adjustable group vs 14.3% in non-adjustable group: Fisher's exact test, p = 0.30), this difference was not statistically significant. No retinal redetachments occurred after scleral buckle removal. CONCLUSIONS: These results suggest that scleral buckles can be safely removed in selected patients with strabismus following retinal reattachment surgery and scleral buckle removal may improve ocular alignment following strabismus surgery.

Toxocariasis of the optic disc.

A healthy 46-year-old man presented with decreased vision in the right eye after ingestion of raw meat. On funduscopic examination, a cystic lesion was found on an edematous right optic disc with adjacent serous retinal detachment. Optical coherence tomography confirmed a peripapillary serous retinal detachment and a well-demarcated cystic lesion (200 × 200 × 500 µm) in the right eye. The patient had moderate eosinophilia and was seropositive for anti-Toxocara IgG antibody. Diagnosed with ocular toxocariasis, he was treated with systemic corticosteroids and albendazole with improvement in vision and fundus appearance.

Study for analysis of the multifocal visual evoked potential.

PURPOSE: To introduce the clinical utility of the absolute value of the reconstructed waveform method in the analysis of multifocal visual evoked potential (mfVEP). METHODS: The mfVEP with 4-channel recording was performed using RETIscan® on 10 eyes of 10 normal subjects. Amplitudes were obtained from ring-shaped 6 areas and 4 sectors. The best visual evoked potential (VEP) response method and the absolute value of the reconstructed waveform method were compared in terms of analysis of the amplitudes. In order to assess the false positive rate of the examination, stimuli were administered with one-half of the cathode ray tube (CRT) monitor completely covered and the results were compared using 2 methods. RESULTS: The amplitudes in 6 areas and 4 sectors analyzed with the best VEP response method and the absolute value of the reconstructed waveform method showed no statistical difference (p > 0.05). The amplitude in the stimuli-blocked area of the absolute value of the reconstructed waveform method was smaller than that of the best VEP response method (p < 0.05) and the amplitude of the stimuli area showed no substantial difference between two methods (p > 0.05). CONCLUSIONS: The absolute value of the reconstructed waveform method has similar reproducibility and lower level of false positives relative to the best VEP response method. Therefore, it can be considered as a useful method in the analysis of the mfVEP.

Computed tomographic angiogram of an anterior communicating artery aneurysm causing acute retrobulbar optic neuropathy: a case report.

Three-dimensional computed tomographic (3D-CT) angiography is a widespread imaging modality for intracranial vascular lesions. However, 3D-CT angiograms of an anterior communicating artery aneurysm associated with acute retrobulbar optic neuropathy have not been previously described. We present 3D-CT angiograms of an aneurysm of the anterior communicating artery that caused subarachnoid hemorrhage and vision loss in a 39-year old man. The 3D-CT angiograms were consistent with findings identified directly during surgery.

Supermaximal recession and resection in large-angle sensory exotropia.

In cases of extropia with an exodeviation angle over 50 prism diopter (PD), a 3- or 4-muscle surgery is a rational option. But, in patients with sensory exotropia, there is usually a strong preference for a monocular procedure to avoid surgery on the single seeing eye. Thus, we confined surgery to visually poor eyes, and performed a medial rectus muscle resection with a mean of 10.3 mm (range, 9-11 mm) and a lateral rectus muscle recession with a mean of 12.8 mm (range, 10-14 mm) in 4 adult sensory exotropia patients who had a mean deviation of 82.3 PD (range, 75-90 PD). The mean postoperative angle of exodeviation was 2.0 PD (range, ortho-8 PD). The limitation on abduction was not disfiguring. Other expected disfigurements, such as narrowing of the palpebral fissure or enophthalmos, were not conspicuous. The mean follow-up period was 4.5 months (range, 3-7 months). In large-angle sensory exotropia, instead of additive surgery on the seeing eye, supermaximal medial rectus resection and lateral rectus recession only on the visually poor eye is a clinically feasible surgical option.

Anterior segment measurements using Pentacam and Orbscan II 1 to 5 years after refractive surgery.

PURPOSE: To compare anterior segment measurements between Pentacam and Orbscan II after laser surface ablation. METHODS: Corneal thickness, anterior elevation, posterior elevation, and anterior chamber depth more than 1 year after laser refractive surgery were measured using Pentacam and Orbscan II in 51 eyes that underwent laser epithelial keratomileusis (LASEK) and 21 eyes that underwent photorefractive keratectomy (PRK). As controls, the same comparisons were made in 52 unoperated eyes. RESULTS: Mean follow-up was 28.2 months in the LASEK group and 49.9 months in the PRK group. Mean corneal thickness using Pentacam was thicker than that using Orbscan by 10.4 microm in unoperated eyes, 22.6 microm in LASEK eyes, and 11.0 microm in PRK eyes, but the two devices showed good correlation in all groups. Mean anterior elevation was highly correlated between the two devices with 2.1-microm differences in LASEK eyes, but posterior elevation showed no correlation with significant discrepancies. Mean anterior chamber depth was 0.12-to 0.14-microm thicker with Pentacam than with Orbscan, and highly correlated in all groups. CONCLUSIONS: Pentacam and Orbscan showed good correlations in corneal thickness, anterior elevation, and anterior chamber depth despite some differences in mean values. The two devices, however, showed no correlation in posterior elevation measurements, a difference that was greater in the postoperative groups.

Change in ocular alignment after topical anesthetic cataract surgery.

BACKGROUND: To report the incidence of, and change in ocular misalignment following topical anesthetic cataract surgery. METHODS: Prospectively, 160 consecutive patients who were scheduled for cataract surgery under topical anesthesia were evaluated. All patients had a complete ophthalmic examination, including ocular alignment evaluation, just before and 1 day, 1 week, 3 weeks, and 2 months after cataract surgery. RESULTS: Preoperatively, 26 patients had ocular misalignment. Mean deviation in these preexisting misalignment was 7.2 +/- 6.8 prism diopters (PD). Postoperatively, the angle of deviation improved to 5.4 +/- 7.4 PD. Acquired ocular misalignment after cataract surgery occurred in 12 of 160 patients (8%) at 1 day, and seven of 131 (5%) at 2 months. None of these seven patients sought medical attention for the diplopia. CONCLUSIONS: The overall incidence of topical anesthesia-related change in ocular alignment after uneventful cataract surgery was 5%. However, no patients had symptomatic diplopia. Topical anesthetic cataract surgery could abolish the risk of postoperative diplopia and improve the heterophoric status of preexisting misalignment.

Anorexiant-induced transient myopia after myopic laser in situ keratomileusis.

We report a case of acute transient myopia associated with ciliochoroidal effusion induced by anorexiants. The patient had had myopic laser in situ keratomileusis 7 years earlier. Acute bilateral myopia associated with anterior chamber shallowing, intraocular pressure elevation, diffuse ciliochoroidal effusion, and perimacular retinal folds was relieved 14 days after discontinuation of anorexiant medications. Tropicamide and atropine were used to deepen the anterior chamber. Sympathomimetic drugs such as phendimetrazine and ephedrine are used as anorexiants and may induce transient myopia associated with ciliochoroidal effusion, shallow anterior chamber, and acute angle-closure glaucoma.

Outcome study of two standard and graduated augmented modified Kestenbaum surgery protocols for abnormal head postures in infantile nystagmus.

BACKGROUND AND PURPOSE: Since Kestenbaum and Anderson, several ophthalmologists have reported the results of different surgical procedures, for abnormal head posture in infantile nystagmus. In this study, we tried to evaluate the surgical results of Parks' original 5-6-7-8 mm modified Kestenbaum procedure and our own 6-7-6-7 mm modified Kestenbaum procedure, designed to reduce some of the problems encountered with other variations of these techniques. METHODS: Medical records of 92 patients, who had modified Kestenbaum surgery (5-6-7-8 mm or 6-7-6-7 mm) at The Yonsei Medical Center, from March 1991 to September 2001 with a follow-up period of more than 6 months, were reviewed retrospectively. We compared Parks' modified Kestenbaum surgery (5- 6-7-8 mm) performed on 51 patients with our own modified Kestenbaum surgery (6-7-6-7 mm) on 41 patients. Each procedure was done with graded augmentation according to the amount of the face turn and the null point in electro-oculography. RESULTS: In the follow-up of an average 33 months, 45 out of 51 patients (88.2%) who underwent Parks' modified procedures showed face turn less than 10 degrees. In the follow-up of an average 29 months, 36 out of 41 patients (87.8%) with 6-7-6-7 mm procedure had face turn less than 10 degrees. CONCLUSIONS: We suggest that 6-7-6-7 mm modified Kestenbaum procedures with a graded augmentation may be a safe and efficient procedure to correct abnormal head posture in infantile nystagmus with a minimum decrease in ocular motility.

Changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery.

PURPOSE: Some patients complain of a foreign body sensation, a burning sensation, or dryness after strabismus surgery. We prospectively investigated the changes in corneal and conjunctival sensitivity, tear film stability, and tear secretion after strabismus surgery. PATIENTS AND METHODS: Corneal and conjunctival sensitivity were assessed with an esthesiometer, tear film breakup time was measured, and the Schirmer test was performed prospectively (preoperatively and 1 week, 1 month, and 3 months postoperatively) in 83 patients (124 eyes) who underwent strabismus surgery at our institution. RESULTS: There were no significant changes in corneal sensitivity, tear film stability, or tear secretion after strabismus surgery (P > .05). Conjunctival sensitivity decreased significantly after strabismus surgery (P < .05). CONCLUSION: Discomfort and dryness after strabismus surgery do not seem to be related to changes in corneal sensitivity, tear film stability, or tear secretion.