Macular superficial vascular density on optical coherence tomography angiography in children with unilateral anisometropic and bilateral hyperopic amblyopia.

We analyzed whether macular superficial vascular density (SVD) and foveal vascular zone (FAZ) on optical coherence tomography angiography (OCTA) can distinguish between bilateral ametropic and anisometropic amblyopia. We included 42, 33, and 50 eyes in the bilateral ametropic amblyopia, anisometropic amblyopia, and normal control groups, respectively. Using macular swept-source optical coherence tomography angiography, we measured and analyzed the superficial FAZ areas and five sectoral macular SVDs after magnification correction. The anisometropic amblyopic eye group showed significantly increased foveal SVDs (p < 0.001) and significantly decreased superficial FAZ areas (p < 0.001), compared with the remaining groups. Additionally, the bilateral ametropic amblyopia group had significantly decreased nasal SVDs. SVDs and superficial FAZ areas differed among hyperopic amblyopia subtypes. These findings may reflect vascular distribution differences and macular changes in hyperopic amblyopia subtypes compared with normal eyes.

Two cases of myotonic dystrophy manifesting various ophthalmic findings with genetic evaluation.

We report two cases of myotonic dystrophy in one family; both diagnosed from genetic analysis following ophthalmic indications, but before the manifestation of systemic symptoms. A 39-year-old female visited our clinic for routine examination. Mild ptosis, sluggish pupillary response, and bilateral snowflake cataracts were found. Fundus examination revealed an increased cup-to-disc ratio (CDR) in both eyes and a defect in the retinal nerve fiber layer in the right eye. Intraocular pressure was low, but within the normal range in both eyes. Because cataracts are characteristic of myotonic dystrophy, we suggested that her 14-year-old daughter, who did not have any systemic complaints, undergo ophthalmic examination. She also had mild ptosis and snowflake cataracts. Both patients underwent genetic evaluation and were diagnosed with myotonic dystrophy caused by unstable expansion of cytosine-thymine-guanine trinucleotide repeats in the dystrophia myotonica-protein kinase gene. Ophthalmologists can diagnose myotonic dystrophy based on clinical and genetic findings, before the manifestation of systemic abnormalities.

Lower Lid Laxity is Negatively Correlated with Improvement of the Ocular Surface Disease Index in Dry Eye Treatment.

PURPOSE: To compare the responses to dry eye treatment of patients sorted by the degree of lower lid laxity. METHODS: Sixty patients were grouped into three groups according to the degree of lower lid laxity. Tear break-up time (TBUT), Schirmer test (ST) scores, ocular surface disease index (OSDI) scores, and changes in OSDI score in each group were compared, before and at 3 months after treatment. RESULTS: TBUT, ST, and OSDI scores were not different among the three groups at baseline. TBUT improved in each group at 3 months after treatment, and no differences between groups were found. ST scores were not increased after treatment, while OSDI were improved to 22.57 ± 5.243, 31.16 ± 11.353, and 37.85 ± 13.342 in the no, moderate, and high laxity groups, respectively; these improvements were statistically significant (p = 0.003, <0.001, <0.001, respectively). Patients with greater than moderate lower lid laxity saw the smallest improvement in response to dry eye treatment, as assessed by change in OSDI score (p = 0.005 versus moderate laxity group, p = 0.005 versus no laxity group). CONCLUSIONS: Lower lid laxity is one of the factors contributing to the responses to dry eye treatment assessed by change in OSDI score, independent of TBUT and ST scores.

The Association Between Aqueous Connective Tissue Growth Factor and the Severity of Age-related Cataracts as Graded by the Lens Opacities Classification System III.

PURPOSE: To evaluate the relationship between aqueous humor concentrations of connective tissue growth factor (CTGF) and the severity of age-related cataracts. MATERIALS AND METHODS: We conducted a prospective clinical study on 43 eyes of 43 patients with senile cataracts scheduled to undergo routine phacoemulsification surgery. Before surgery, all patients were graded for cataract severity using the Lens Opacities Classification System III in terms of four features: nuclear opalescence (NO), nuclear color (NC), cortical cataracts (C), and posterior sub-capsular cataracts (P). During surgery, aqueous humor samples were obtained from all patients, and sandwich enzyme-linked immunosorbent assays (ELISAs) were used to determine CTGF concentrations. To assess any relationship between cataract severity and CTGF levels of the aqueous humor, various correlation analyses and multiple linear regression were used. RESULTS: We found a positive correlation between the overall cataract grade and aqueous CTGF level (p < 0.05). In addition, four features of the cataract grade (nuclear opalescence, nuclear color, cortical cataract and posterior sub-capsular cataract) were positively correlated with the aqueous CTGF concentration (p < 0.05). The final regression model identified overall cataract grade as an independent predictor of increased CTGF levels in the aqueous humor (p < 0.05). CONCLUSIONS: CTGF tends to increase in the aqueous humor as the severity of age-related cataracts increases. Therefore, this cytokine may play an important role in the pathogenesis of age-related cataracts. Additional studies are required for clarification of this finding.

Effect of diabetic retinopathy and diabetes on the intraocular straylight in pseudophakic eyes.

BACKGROUND: The aim of this study was to prove the relationship between the intraocular straylight level and diabetic retinopathy (DR) according to disease severity. Also, we aimed to evaluate whether diabetes mellitus (DM) per se could be a risk factor of increased intraocular straylight although we did not rely on a definite sign of DR in this study. METHODS: In this prospective comparative study, ninety three eyes were enrolled and divided into four groups as follows: Group 1 (26 eyes), without DR or DM; Group 2 (25 eyes), with DM but without DR; Group 3 (21 eyes), mild to moderate non-proliferative DR; and Group 4 (21 eyes), severe non-proliferative DR. To measure the intraocular straylight in an objective manner, the C-quant straylight meter was used to preoperatively and 2 months postoperatively in all patients who underwent phacoemulsification surgery. All the patients also underwent a macular optical coherence tomography and hemoglobin A1c (HbA1c) analysis. A comparison of straylight levels adjusted by age among four groups was performed postoperatively. RESULTS: The postoperative level of intraocular straylight was statistically significantly different among four groups (P <0.05). When adjusted for ages, Group 4 showed the highest straylight level when compared with Group 3 and the other two groups (P <0.05). Group 1 showed the lowest straylight level in comparison with Group 2 and the other two groups (P <0.05). There was no significant correlation between HbA1c level, duration of diabetes and postoperative straylight level. CONCLUSIONS: The level of intraocular straylight at 2 months postoperatively had a tendency to increase as the severity of DR increased. Additionally, the straylight level was higher in DM patients without DR than in patients without DM. Therefore, the severity of DR seemed to influence the intraocular straylight level. Although there is no definite sign of DR, DM per se can be a risk factor for increasing intraocular straylight. In conclusion, the level of intraocular straylight seems to be a sensitive test for detecting early retinal damage secondary to DM.

Endothelial Cell Loss after Phacoemulsification according to Different Anterior Chamber Depths.

Purpose. To compare the loss of corneal endothelial cells after phacoemulsification according to different anterior chamber depths (ACDs). Methods. We conducted a prospective study on 135 eyes with senile cataracts. Eyes with nuclear density grades of 2 to 4 were divided into three groups according to ACD: ACD I, 1.5 < ACD ≤ 2.5 mm; ACD II, 2.5 < ACD ≤ 3.5 mm; or ACD III, 3.5 < ACD ≤ 4.5 mm. Intraoperative mean cumulative dissipated energy (CDE) was measured. Clinical examinations included central corneal thickness (CCT) and endothelial cell count (ECC) preoperatively and 2 months postoperatively. Results. There were no significant differences in CDE among the ACD groups (P > 0.05). Endothelial cell loss was significantly higher in ACD I than in ACD III in grades 3 and 4 cataract density groups 2 months after phacoemulsification (P < 0.05). There were also more changes in CCT in all of the cataract density groups in the ACD I group compared to the ACD II and III groups 2 months postoperatively, but the difference was not statistically significant. Conclusions. Eyes with shallow ACDs, especially those with relatively hard cataract densities, can be vulnerable to more corneal endothelial cell loss in phacoemulsification surgery.

Anterior dislocation of an empty capsular bag in a pseudophakic eye: A rare case report.

Spontaneous intraocular lens (IOL) dislocation is uncommon in the absence of any ocular areas with zonular weakness or trauma. There have been no reports of spontaneous capsular bag dislocation into the anterior chamber without an IOL. We report a rare, interesting case of spontaneous capsular bag anterior dislocation, without an IOL, into the anterior chamber with no history of genetic disease, ocular trauma, or pseudoexfoliation that might predispose to a zonular abnormality.

Beneficial effects of adjuvant intravitreal bevacizumab injection on outcomes of Ahmed glaucoma valve implantation in patients with neovascular glaucoma: systematic literature review.

PURPOSE: We evaluated the effects of adjuvant intravitreal bevacizumab injection on the outcomes of Ahmed glaucoma valve (AGV) implantation in patients with neovascular glaucoma (NVG) through a systematic literature review. METHODS: An extensive search of PubMed, EMBASE, and the Cochrane Library was performed in November 2014 for selection of relevant studies. The weighted mean difference of the percentage of intraocular pressure reduction (IOPR%) from baseline to endpoint was used as the primary efficacy estimate, and Mantel-Haenszel odds ratios and 95% confidence intervals (CIs) of the success rate were used as the secondary efficacy estimates. The incidence of adverse events was also documented through a review of the studies. RESULTS: Six studies involving 252 patients (256 eyes) were included in this systematic review. The differences in the means and 95% CIs of the IOPR% of 6 studies showed that adjuvant bevacizumab treatment tended to be more effective than AGV implantation alone. Comparison of the outcomes of AGV implantation only with those of AGV implantation+adjuvant bevacizumab showed a success rate in favor of AGV implantation+adjuvant bevacizumab. The incidence of bleeding-associated complications such as hyphema, vitreous hemorrhage, and suprachoroidal hemorrhage was lower in association with combination treatment than with AGV implantation only. Combination treatment seemed to be associated with a lower incidence of other adverse effects such as hypotony, flat chamber, choroidal detachment/effusion, tube-associated complications, and corneal decompensation. CONCLUSION: AGV implantation with adjuvant bevacizumab was more effective and had a higher success rate than surgery alone for lowering IOP in patients with NVG. The combined procedure tended to show a lower incidence of bleeding-associated complications, such as hyphema.

The effect of baicalin in a mouse model of retinopathy of prematurity.

Baicalin is a flavonoid derived from the dried root of Scutellaria baicalensis. In this study, oxygen-induced retinopathy was used to characterize the anti-angiogenic properties of baicalin in mice. Pups were exposed to a hyperbaric oxygen environment to induce retinal angiogenesis and were subjected to intraperitoneal injection of baicalin. Avascular area, neovascular tufts, and neovascular lumens were quantified from digital images. Compared to the vehicle, baicalin clearly reduced the central avascular zone and the number of neovascular tufts and lumens. High-dose baicalin (10 mg/kg) significantly reduced the expression of matrix metalloproteinase-2 (MMP-2), MMP-9, angiotensin II, and vascular endothelial growth factor (VEGF). These results show that baicalin is a powerful antiangiogenic compound that attenuates new vessel formation in the retina after systemic administration, and is a candidate substance for therapeutic inhibition of retinal angiogenesis.

Sulodexide inhibits retinal neovascularization in a mouse model of oxygen-induced retinopathy.

Sulodexide is a mixed glycosaminoglycan composed of heparin and dermatan sulfate. In this study, the anti-angiogenic effect of sulodexide was investigated using an oxygen-induced retinopathy (OIR) mouse model. The retinas of sham-injected OIR mice (P17) had a distinctive central area of nonperfusion, and this area was significantly decreased in sulodexide-injected mice. The number of neovascular tufts measured by SWIFT_NV and mean neovascular lumen number were significantly decreased in sulodexide-injected mice. Hyperbaric oxygen exposure resulted in increased levels of VEGF, MMP-2 and MMP-9, and when mice were treated with sulodexide, a dose-dependent reduction in VEGF, MMP-2 and MMP-9 levels was observed. Our results clearly demonstrate the anti-angiogenic effect of sulodexide and highlight sulodexide as a candidate supplementary substance to be used for the treatment of ocular pathologies that involve neovascularization.

An unusual case of an orbital abscess secondary to contralateral sinusitis.

Orbital complications secondary to acute rhinosinusitis can result in permanent blindness or death if not treated promptly and appropriately. Many authors have reported that almost all such patients had abscesses adjacent to the infected sinuses. However, the authors experienced an orbital abscess secondary to contralateral sinusitis. Here, the authors report an 8-year-old patient who had a left superior orbital abscess secondary to a right ethmoidomaxillary sinusitis.

Correlation between disc damage likelihood scale and optical coherence tomography in the diagnosis of glaucoma.

PURPOSE: To investigate the relationship between the Disc Damage Likelihood Scale (DDLS), visual field and various optical coherence tomography (OCT) parameters for glaucoma diagnosis. METHODS: The study comprised 149 eyes from 149 patients. The patients were categorized as normal, glaucoma suspect or with glaucoma. They were clinically examined and graded according to the DDLS system. OCT was performed to acquire both a retinal nerve fibre layer analysis and an optic nerve head analysis. The relationships between DDLS score, visual field and OCT parameters were analysed using multiple correlation analysis. RESULTS: The normal, glaucoma suspect and glaucoma groups had average DDLS scores of 1.58 +/- 1.40, 2.55 +/- 1.93 and 5.33 +/- 1.39, respectively. Evaluating the area under the receiver operator characteristic curve, the DDLS had the best predictive power (0.917), followed by corrected pattern standard deviation. CONCLUSION: The DDLS is a useful parameter in the diagnosis of glaucoma and it showed a close correlation with visual field, cup/disc ratio and OCT parameters.

A prospective audit on the validity of written informed consent prior to glaucoma surgery: an Asian perspective.

PURPOSE: To assess the validity of written informed consent taken from patients prior to undergoing glaucoma surgery by testing their ability to understand the information offered to them during the consent-taking process. METHODS: Seventy-three patients were asked to complete a standardised confidential questionnaire after giving a written informed consent. Surgeons who were taking the consent were also requested to submit their self-evaluation form. Patients' understanding of the information they were given was evaluated using a standardised point scoring system. RESULTS: Fifty patients (68.5%) agreed that they were given enough time to make an informed decision, while 67 doctors (91.8%) claimed that they had allocated enough time to explain the procedures. Fifty-two patients (71.2%) reported that they were given adequate information on the details or diagnosis of their problems, 65 patients (89.0%) on the details of the procedure and 69 patients (94.5%) on the risks and complications. Thirty-four patients (46.6%) were not sure, or refused information on the risks and complications of the procedure. Only half of the patients (57.5%) had overall moderate understanding of their surgical problem, and only 13 patients (17.8%) were able to demonstrate a good overall understanding of their surgical problem. CONCLUSIONS: Although most patients acknowledged that they received sufficient information to give consent, few could objectively recall the information given to them. This study thus raises some doubts on the validity and quality of written informed consent, and highlights the importance of giving clear information to patients undergoing glaucoma surgery.

Effects of botulinum A toxin injection on the extraocular muscle fiber layers: comparison between subtenon injection and intramuscular injection.

PURPOSE: To compare the morphological changes following injection of botulinum A toxin to the extraocular muscle fiber layers with those following injection to the subtenon intramuscular system. METHODS: Twelve New Zealand white rabbits were divided into two groups. In the first group (six rabbits), four received injections of 10 units of botulinum A toxin into the subtenon space of the superior rectus muscle OD, and the same dose of botulinum A toxin was injected directly into the superior rectus muscle OS. The other two rabbits in the first group were labeled as control animals; 0.1 ml of normal saline was injected into the subtenon space OD, and direct intramuscular injection was performed on the opposite eye. The animals in the first group were killed after 4 weeks to measure the average diameter of the muscle fibers in both the orbital and global layer. In animals of the second group (six rabbits), the same procedures were performed and the animals were killed 12 weeks after treatment. RESULTS: The average diameter of muscle fibers in both the orbital layer and global layer was markedly reduced in all of the botulinum A toxin-injected groups at 4 weeks after treatment compared with the controls. There was no difference in the average diameter of the muscle fibers between the orbital layer of the subtenon-injected group and that of the intramuscular-injected group at 4 weeks after treatment, but the average diameter of the muscle fibers in the global layer was significantly reduced in the intramuscular-injected group compared with the subtenon-injected group at 4 weeks after treatment. At 12 weeks following treatment, there was no difference in the average diameter between the botulinum A toxin-injected group and the control group regardless of where the toxin was injected. CONCLUSION: Subtenon injection of botulinum A toxin induced similar morphological changes as direct intramuscular injection in the extraocular muscle fiber layers. These results suggest the possibility of clinical applications of subtenon botulinum A toxin injection for the treatment of strabismus.

Herbal medication aggravates cataract formation: a case report.

We report a case of complicated cataract aggravated after taking herbal medication for atopic dermatitis. An 11-yr-old boy was referred for the evaluation of decreased visual acuity in both eyes for 2 months. Past history showed that he had been diagnosed with atopic dermatitis when he was 1 yr old. He had been treated only with herbal medication for a period of 8 months prior to visiting our clinic. He had his visual acuity checked in a local ophthalmic clinic one year before, and the visual acuity was 20/20 in both eyes at that time. When attending our clinic the ophthalmologic examination showed that his best corrected visual acuity was 20/200 in both eyes. Lenses of both eyes had severe posterior subcapsular and posterior capsular opacity. Phacoemulsification, posterior chamber intraocular lens implantation, and posterior continuous curvilinear capsulectomy were performed in both eyes. After 3 months postoperatively, the best corrected visual acuity was recovered to 20/20 in both eyes without any complication. Our case suggests that there may be a risk of aggravation of cataract or development of cataract after treatment with some unidentified herbal medication in a patient with atopic dermatitis.

Acute acquired comitant esotropia after orbital cellulitis.

Acute extraocular muscle restriction in children is a rare condition; orbital myositis is the most common cause. Most neuropathic or myopathic causes of strabismus present as an incomitant deviation. We report a case of orbital cellulitis preceding acute comitant esotropia in a patient showing no evidence of myositis or neurologic pathology.

Comparison of delayed-onset glaucoma and early-onset glaucoma after infantile cataract surgery.

PURPOSE: To investigate the causes and characteristics of glaucoma in children following cataract surgery. METHODS: Twenty-four patients (37 eyes) with uncomplicated congenital cataracts who developed glaucoma after cataract surgery were studied retrospectively. Variables included cataract morphology, surgical techniques, post-operative complications, time to the onset of glaucoma, gonioscopic findings, presence of microcornea and the histopathologic characteristics of the filtration angle (in one case). RESULTS: There was a bimodal onset of glaucoma after cataract surgery. Early-onset glaucoma occurred at a mean age of 6 months in 15 eyes and delayed-onset glaucoma at a mean age of 12 years in 22 eyes. Early-onset glaucoma was significantly (p = 0.018) more likely to be due to angle closure than delayed-onset glaucoma. With delayed-onset glaucoma, the filtration angle was open in 86% of eyes and significantly (p = 0.006) more eyes in the delayed-onset group had microcornea. Medical treatment was sufficient to control intraocular pressure in the delayed-onset group while the early-onset group required surgical treatment (P < 0.001). CONCLUSIONS: The onset of glaucoma after cataract surgery during infancy follows a bimodal pattern that is correlated with the configuration of the filtration angle. The early-onset glaucoma group had high incidence of angle closure requiring surgical treatment, while in the delayed-onset group non-surgical treatment was sufficient to control intraocular pressure. Prophylactic iridectomy in eyes at risk for pupillary block is recommended. Eyes with delayed-onset glaucoma have open filtration angles yet also have findings of incomplete development of filtration structures. Microcornea is a risk factor for delayed-onset glaucoma.

Graded partial tenotomy of vertical rectus muscles for treatment of hypertropia.

PURPOSE: To evaluate the effectiveness of graded (adjustable intraoperatively) partial vertical rectus muscle tenotomy at the insertion in correcting small degrees of hypertropia. METHODS: All patients with best-corrected visual acuity of better than 6/30 in both eyes who over a 30-month period underwent partial tenotomy of vertical rectus muscle(s) only (no concurrent oblique muscles) were included. Improvement was evaluated 6 weeks postoperatively as change in alignment in prism diopters (PD) in primary gaze and in the field of action of the affected rectus muscle(s). Binocular function was evaluated by Titmus stereoacuity and the Worth 4-light tests. RESULTS: All 24 patients who met criteria for inclusion had diplopia preoperatively versus seven patients (29%) postoperatively (P < .005, Student's paired t test). Prisms were used by six preoperatively versus two postoperatively (P < .05, Student's paired t test). The average vertical deviation in primary gaze decreased from 8 PD to 2 PD (P < .005, Student's paired t test). In the field of action of the treated rectus muscle, hypertropia decreased from an average of 8 PD to 3 PD (P < .005, Student's paired t test). For the preoperative and the postoperative assessments available, stereoacuity improved after 10 (56%) of the 18 procedures and Worth 4-light testing showed improvement or maintenance of fusion after 15 (79%) of 19 procedures. CONCLUSIONS: Graded vertical rectus partial tenotomy can effectively reduce small degrees of hypertropia and associated diplopia, improve binocular function, and reduce or eliminate the need for prism correction.

A case of surgical repair in strabismus fixus with ptosis.

Strabismus fixus is very rare and the convergent form is rarely accompanied by blepharoptosis. We successfully treated one patient with high myopia whose convergent strabismus fixus, accompanied by blepharoptosis, became severe after cataract surgery. We report the case with a discussion of its pathology. We performed levator advancement operation, bilateral lateral rectus 11 mm resection, and bilateral medial rectus 8 mm recession. The suture was removed after maintaining temporary traction suture for 6 days. Blepharoptosis was completely corrected by postoperative 2 months. Esodeviation was 15PD, which was not increased compared with immediately after surgery. Satisfactory cosmetic outcome was obtained.

Clinical effect of early surgery in infantile exotropia.

To evaluate the effects of early surgical intervention in infantile exotropia on the motor and sensory functions, we reviewed the records of 17 subjects diagnosed with exotropia before the age of 12 months, receiving surgery before the age of 24 months, with a follow-up period greater than one year, between 1996 and 2000. Of the 17 subjects (6 intermittent, 11 constant), 14 (82%) (6 intermittent, 8 constant) had a final horizontal deviation of <10 PD, with 3 (18%) needing a re-operation. Fusion and gross binocularity were developed in 7 (4 intermittent, 3 constant), and 11 (6 intermittent, 5 constant) subjects, respectively. Seven subjects developed stereopsis of 200 seconds or better, and 5 of the 6 with intermittent exotropia (83%) being involved. In conclusion, over 80% of the successful alignments were obtained with surgery before the age of 24 months in infantile exotropia, which was similar to previous studies. Furthermore, early surgical intervention, particularly in the intermittent phase, resulted in more effective sensory function.