Changes in Aqueous Concentrations of Various Cytokines after Intravitreal Bevacizumab Injection for Chronic Central Serous Chorioretinopathy

Purpose@#This study aimed to investigate changes in cytokine levels after intravitreal bevacizumab injection in patients with chronic central serous chorioretinopathy (CSC). @*Methods@#In a prospective interventional trial, 12 eyes from 12 patients with chronic CSC and six eyes from six patients who underwent cataract surgery were included as controls. Patients diagnosed as with CSC received a single intravitreal injection of bevacizumab (1.25 mg/0.05 mL). Aqueous humor samples were collected from the patients and controls. Best-corrected visual acuity and foveal thickness were evaluated, and aqueous samples were obtained before and 4 weeks after injection. The aqueous concentrations of interleukin (IL)-6, IL-8, interferon-induced protein (IP)-10, monocyte chemotactic protein (MCP)-1, platelet-derived growth factor (PDGF)-AA, and vascular endothelial growth factor (VEGF) were measured using a multiplex bead assay. @*Results@#After injection, the foveal thickness decreased significantly from 328.08 μm (range, 210–477 μm) to 283.91 μm (range, 168–356 μm; p = 0.048), but the best-corrected visual acuity was not significantly different (p = 0.066). The aqueous levels of IL-8 increased significantly from 3.3 pg/mL (range, 1.5–8.3 pg/mL) to 4.7 pg/mL (range, 2.2–11.6 pg/mL) at 4 weeks after the injection (p = 0.046). The aqueous levels of VEGF decreased significantly from 31.4 pg/mL (range, 17.0–53.3 pg/mL) to 15.2 pg/mL (range, 7.7–21.5 pg/mL; p < 0.01). No significant changes in levels of IL-6 (p = 0.455), IP-10 (p = 0.055), MCP-1 (p = 0.076), and PDGF-AA (p = 0.339) were noted 4 weeks after injection. @*Conclusions@#In this study we found intravitreal bevacizumab injection decreased VEGF and increased IL-8 in the eyes of patients with chronic CSC. This study suggests the possibility that the pathogenesis of CSC may be related to abnormal circulation of the choroidal blood vessels through VEGF and IL-8 cytokine level changes.

Clinical Effects of Non-damaging Retinal Laser Therapy in Chronic Central Serous Chorioretinopathy

Purpose@#This study analyzed the effects of non-damaging retinal laser therapy (NRT) in patients with chronic central serous chorioretinopathy. @*Methods@#A retrospective study was conducted on patients with chronic central serous chorioretinopathy who were undergoing follow-up with NRT from November 2016 to February 2018. NRT was performed in patients who underwent intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection at least two times with no improvement in visual acuity and a reduced amount of subretinal fluid. Before and after treatment, logMAR best-corrected visual acuity (BCVA) evaluation and subretinal fluid (SRF) according to thickness measurements of the macula determined from optical coherence tomography imagery were performed over a period of at least 6 months. @*Results@#Eighteen eyes of 18 patients (11 male and 7 female) with chronic central serous retinopathy were treated with NRT. The mean age of patients was 54.6 ± 13.19 years old and the mean duration of follow-up was 9.75 ± 3.20 months. The central macular thickness decreased from 375 to 246 nm (p < 0.001) and BCVA improved from 0.48 to 0.40 (p = 0.028). SRF completely resolved in 55.56% of the patients after NRT. @*Conclusions@#In patients with chronic central serous chorioretinopathy, which did not improve even after intravitreal anti-VEGF injection, NRT is a relatively safe and effective treatment.

Main Reasons for and Associated Factors of the First Fundus Examination in Diabetic Patients

PURPOSE: To determine the major reasons that diabetics decide to undergo their first fundus examination, and the factors influencing such reasons. METHODS: Of the patients with type II diabetes who presented to the Department of Ophthalmology in Gachon University Gil Medical Center, 164 patients who underwent their first fundus examination after being diagnosed with diabetes were included in the study. Face-to-face and phone interviews with these patients were conducted. RESULTS: The average prevalence period from the diagnosis of diabetes to the first fundus examination was 8.3 ± 7.5 years. Of the diabetics who underwent their first fundus examination, 52.4% had diabetic retinopathy, with no significant difference in prevalence between the male and female patients (p = 0.118). The most common reason for deciding to undergo the first fundus examination was recommendation by a doctor (53.7%). For those patients who received their first fundus examination after recommendation by a doctor, the prevalence period from diabetes was the shortest among all patients (p < 0.001), and the prevalence and severity of diabetic retinopathy were the lowest (p < 0.001 and p = 0.017, respectively). The number of fundus examinations conducted following recommendation by a doctor was significantly higher in secondary and tertiary hospitals than in primary hospitals (p < 0.001). Education on diabetes and knowledge of diabetic ocular complications were found to be significantly correlated (p < 0.001). CONCLUSIONS: For patients who are diagnosed with diabetes and treated in primary hospitals, who are older, or who did not receive education on diabetes, recommendation by a doctor for early fundus examination is particularly important regardless of subjective visual disturbance. Moreover, patient education should be offered and ophthalmic examination should be recommended in primary hospitals.

Treatment of Acute Central Retinal Artery Occlusion with Ocular Ischemic Syndrome

PURPOSE: We report a case of treatment of acute central retinal artery occlusion (CRAO) with ocular ischemic syndrome (OIS). CASE SUMMARY: A 72-year-old man presented with acute loss of vision in the right eye on that day. At initial examination, visual acuity tested positive for light sensitivity in the right eye. Fundus examination demonstrated a visible embolus at the central retinal artery overlying the optic disc head and a cherry-red spot in the fovea. Fluorescein angiography revealed that filling of the choroidal circulation was delayed, and the arteriovenous transit time was even further delayed. Carotid angiography showed marked stenosis within the right internal carotid artery. Laboratory tests included blood tests for hypercoagulability evaluation, for which the results were non-specific. To treat acute CRAO with OIS in the right eye, transluminal Nd:YAG laser embolectomy (TYE) was performed twice, and carotid angioplasty with stenting was conducted within the stenosed internal carotid artery. One month after the TYE procedure and carotid stenting, the patient's visual acuity improved to 0.06 and the arteriovenous transit time was within normal limits on fluorescein angiography. CONCLUSIONS: The visual prognosis in eyes with CRAO plus an associated choroidal circulatory disturbance is extremely poor. However, we experienced and reported a case of CRAO with OIS treated successfully through a prompt TYE procedure and carotid angioplasty with stenting.

Pars Plana Ahmed Implantation Combined with 23-gauge Vitrectomy for Refractory Neovascular Glaucoma in Diabetic Retinopathy

PURPOSE: To evaluate the efficacy and safety of a pars plana Ahmed valve implantation combined with 23-gauge sutureless vitrectomy in the treatment of patients with medically uncontrolled neovascular glaucoma (NVG) in proliferative diabetic retinopathy (PDR). METHODS: The authors retrospectively reviewed the records of 11 consecutive patients with refractory NVG in PDR who underwent a 23-gauge sutureless vitrectomy combined with pars plana placement of an Ahmed valve implant. Control of intraocular pressure (IOP), pre- and postoperative best-corrected visual acuity and the development of intra- and postoperative complications were evaluated during the follow-up. RESULTS: The mean follow-up was 12.2 months (range, 8 to 25 months). Mean preoperative IOP was 35.9 +/- 6.3 mmHg and mean postoperative IOP at the last visit was 13.3 +/- 3.2 mmHg. Control of IOP (8 to 18 mmHg) was achieved in all patients, but 91% (10 of 11 patients) needed antiglaucoma medication (mean number of medications, 1.2 +/- 0.6). Postoperative visual acuity improved in 11 eyes, and the logarithmically to the minimum angle of resolution mean visual acuity in these eyes improved from 1.67 +/- 0.61 to 0.96 +/- 0.67. The complications that occurred were transient hypotony in one case, transitory hypertension in two cases, and postoperative vitreous hemorrhage which spontaneously cleared in two cases. CONCLUSIONS: We suggest the combination of 23-gauge pars plana vitrectomy and Ahmed valve implantation is safe and effective in PDR patients with refractory NVG.

Presumed Intraocular Natural Killer/T-cell Lymphoma Combined with Nasal Lymphoma

PURPOSE: To report a case of presumed intraocular natural killer/T-cell lymphoma (NKTL). CASE SUMMARY: A 61-year-old male presented with visual disturbance of the left eye for duration of 3 years. He had been treated with systemic chemotherapy and radiotherapy for nasal NKTL 1 year prior. Inflammatory reaction in the anterior chamber and vitreous opacity were observed in the left eye. The patient was diagnosed with uveitis in the left eye at a local clinic 3 years prior to visiting us. Because the patient did not respond to anti-inflammatory therapy, we performed diagnostic and therapeutic vitrectomy. Intraoperatively, vitreous opacity was thin sheet like in appearance. The vitreous specimen contained few lymphoid cells and was positive for Epstein Barr virus-encoded RNA (EBER). Systemic workups showed no metastasis to other organs. The patient was treated with systemic methotrexate chemotherapy and intravitreal methotrexate injected 3 times (once per week). During the 12-month follow-up period after the last intravitreal injection, the recurrence of lymphoma and related uveitis was not observed.

Comparison between Retinal Tear and Rhegmatogenous Retinal Detachment as the Cause of Dense Vitreous Hemorrhage

PURPOSE: To analyze retinal tears and to compare the clinical outcomes between retinal tear and rhegmatogenous retinal detachment (RRD) as the cause of dense non-diabetic vitreous hemorrhage in patients who underwent vitreoretinal surgery. METHODS: In a retrospective case series, the medical records of patients who presented dense non-diabetic vitreous hemorrhage and who underwent vitreoretinal surgery between January 2005 and June 2009 were reviewed. Among the 134 patients, 27 patients had dense vitreous hemorrhage caused by retinal tears. The first group had retinal tears only and the second group had accompanying RRD. A comparison of clinical features and postoperative prognoses between the two groups was performed. RESULTS: Among the 27 eyes with non-traumatic retinal tear and RRD, 18 were categorized into the retinal tear group and 9 to the RRD group. The demographic findings between the two studied groups exhibited no significant differences except for time between onset of symptoms and diagnosis. However, the time to diagnosis was significantly delayed in the group with RRD (22.67 +/- 37.47 days) compared to the retinal tear group (5.00 +/- 3.41 days) (p = 0.035). The amount of visual improvement was also greater in the retinal tear group than the RRD group (p = 0.002). CONCLUSIONS: Retinal tears are a major cause of non-diabetic vitreous hemorrhage. Vitreous hemorrhage caused by retinal detachment may result in delayed diagnosis and poor visual recovery. Therefore, early examinations in suspicion of RRD and appropriate treatments are needed in non-diabetic vitreous hemorrhage.

The 23-Gauge Sutureless Vitreoretinal Surgery in Previously Vitrectomized Eyes

PURPOSE: To investigate the incidence and risk factors of major complications including postoperative hypotony after 23-gauge transconjunctival sutureless vitrectomy in previously vitrectomized eyes. METHODS: The authors retrospectively reviewed medical records of 52 eyes, which underwent 23-gauge transconjunctival sutureless vitrectomy of previously vitrectomized eyes by a single surgeon. Major outcomes were postoperative hypotomy (<6 mmHg), intraoperative sclera shrinkage during sclerotomy,and other postoperative complications. Multiple logistic regression analysis was performed that included 212 eyes with primary vitreoretinal surgery in order to validate secondary vitreoretinal surgery as a significant risk factor of postoperative hypotony. RESULTS: Postoperative hypotony occurred in 4 eyes (7.7%) out of 52 eyes that underwent a second vitrectomy. The odds ratio of the second vitreoretinal surgery (OR=1.15, p=0.283) was not significant by multiple logistic regression analysis that included age, sex, axial length of globe, and the number of surgeries as the independent variables. Choroidal detachment occurred in one eye but disappeared three days later. The intraocular pressure was normalized within one week in all cases. Scleral shrinkage during sclerotomy occurred in five eyes (9.6%), and there were no other major complications, such as endophthalmitis. CONCLUSIONS: A 23-gauge transconjunctival sutureless vitrecomy of previously vitrectomized eyesshowed a 7.7% incidence of postoperative hypotony and favorable prognosis.

Anterior Ischemic Optic Neuropathy Following Periocular Autologous Fat Injection

PURPOSE: To report an unusual case of anterior ischemic optic neuropathy and choroidal ischemia after injection of autologous fat into the periorbital region due to embolism of the short posterior ciliary artery without involving the retinal artery. CASE SUMMARY: A 39-year-old female presented with sudden blurred vision, diplopia and ptosis of her left eye immediately after receiving an autologous fat injection into the periorbital area. The first ophthalmologic examination revealed that the patient s left eye had decreased visual acuity, relative afferent pupillary defect, exotropia, and hypertropia. Fundus examination of the left eye showed disc edema. Fluorescein angiography showed multiple choroidal vascular filling defects at the early phase and wedge-shaped or geographic fluorescein staining at the superior, inferior, and temporal peripheral areas at late phase. Humphrey visual field test results disclosed an inferior visual field defect. On the follow-up visit after oral steroid therapy (prednisolone 30 mg) for 7 days, diplopia disappeared and visual acuity recovered to 1.0. The inferior visual field defect and relative afferent pupillary defect were still present.

A Case of Intraoperative Floppy Iris Syndrome in a Patient Using Tamsulosin

PURPOSE: To report a case of Intraoperative Floppy Iris Syndrome (IFIS) experienced during pars plana vitrectomy and phacoemulsification in a patient using tamsulosin, which is a selective alpha 1 adrenergic antagonist. CASE SUMMARY: A 77-year-old male who had used tamsulosin for the previous month for prostate cancer visited our clinic with left visual disturbance, that had developed a week earlier. The best-corrected visual acuity of the left eye was 0.02 and both pupils showed incomplete mydriasis. Pars plana vitrectomy and phacoemulsification with PCL implantation were performed on his left eye to correct a left cataract and retinal vein occlusion with vitreous hemorrhage. Phacoemulsification idenfied a billowing iris and progressive pupillary constriction. Therefore, we administered an intracameral epinephrine injection and applied an iris hook. The procedure was completed successfully without any complications. The best-corrected visual acuity of the left eye was good as at 0.9, and iris depigmentation and atrophy were checked two months postoperatively in the right eye, which had not had any previous surgical history. CONCLUSIONS: A detailed medical history taking is essential because IFIS may raise the risk of intraoperative complications, such as posterior capsule rupture, especially when the small pupil is small. Safe procedures must be planned with cessation of tamsulosin at least a week preoperatively.

Sclerotomy-related Retinal Breaks in Vitrectomy for Proliferative Diabetic Retinopathy: 20- vs 23-Gauge Systems

PURPOSE: To compare the rate of intraoperative sclerotomy-related retinal breaks (SRRB) between 20- and 23-gauge vitrectomy for proliferative diabetic retinopathy (PDR). METHODS: Medical records of 62 consecutive eyes of 54 patients who underwent 20-gauge pars plana vitrectomy (PPV) and 63 consecutive eyes of 55 patients who received 23-gauge transconjunctival sutureless vitrectomy were retrospectively reviewed. RESULTS: Three (4.8%) out of 62 eyes in the 20-gauge group had SRRB and 1 (1.6%) eye developed retinal detachment at 4 months postoperatively, while 2 (3.2%) out of 63 eyes in the 23-gauge group had SRRB and 1 (1.6%) eye developed retinal detachment at 3 months postoperatively. CONCLUSIONS: There were no significant differences in the rates of sclerotomy-related retinal breaks and sclerotomy-related retinal detachments between 20-gauge PPV and 23-gauge PPV for PDR.

Tractional Retinal Detachment After Intravitreal Bevacizumab (Avastin(R)) Injection in Proliferative Diabetic Retinopathy

PURPOSE: To report two cases of tractional retinal detachment after intravitreal bevacizumab injection. CASE SUMMARY: (Case 1) A 48-year-old female with insulin-dependent diabetes mellitus and a high HbA1c level came to our clinic for fundus evaluation. The best corrected visual acuity (BCVA) was 1.0 in the right eye and funduscopic examination of the right eye revealed proliferative diabetic retinopathy with preretinal hemorrhage and a mild fibrovascular proliferative membrane around the optic disc. Intravitreal bevacizumab injection (1.25 mg) was performed before starting panretinal photocoagulation (PRP) to prevent macular edema after PRP. Three days after the injection, visual acuity decreased to 0.3 and funduscopic findings showed tractional retinal detachment. Vitrectomy was performed and visual acuity recovered to 1.0 four months after operation. CONCLUSIONS: Intravitreal bevacizumab injection may cause tractional retinal detachment in poorly controlled insulin-dependent diabetes mellitus patients with fibrovascular proliferative membranes.

Partial Fluid-Air-Exchange at the End of 23 Gauge Sutureless Vitrectomy to Prevent Postoperative Hypotony

PURPOSE: To evaluate the efficacy and safety of partial fluid air exchange at the end of 23-gauge transconjunctival sutureless vitrectomy to prevent postoperative hypotony. METHODS: Fifty-five eyes in 49 consecutive patients who underwent partial fluid air exchange at the end of 23-gauge sutureless vitrectomy by a single surgeon at Gil Hospital between August 2007 and February 2008 were recruited for this study. Intraocular pressure (IOP), visual acuity and post-operative complications were evaluated. RESULTS: Surgical indications included proliferative diabetic retinopathy (n=31), epiretinal membrane (n=9), nondiabetic vitreous hemorrhage (n=5), vitreous opacities (n=3), and others (n=7). Two eyes showed hypotony (<6 mmHg) on postoperative day 1 and resolved within a week without any supplemental procedures. Other complications included choroidal detachment in 1 eye, hyphema in 1 eye, and transient IIOP in 2 eyes. In 38 eyes in which combined cataract surgery was performed, air bubble-related complications including iris capture by the IOL in 3 eyes (7.9%) and opacification of the posterior capsule in 11 eyes (28.9%) occurred. No case of retinal detachment or endophthalmitis was observed. The final best corrected visual acuity was 20/40 or better in 14 eyes (25.5%). CONCLUSIONS: The partial fluid air exchange shows promise as an effective and safe procedure for prevention of postoperative hypotony after sutureless vitrectomy. Air bubble-related complications after combined cataract surgery can be avoided by several techniques.

Foveal Reattachment After Scleral Buckling vs Vitrectomy for Macula-Off Retinal Detachment

PURPOSE: To compare the time course of foveal reattachment after successful surgery for macula-off retinal detachments by scleral buckling or pars plana vitrectomy (PPV). METHODS: We retrospectively examined, using optical coherence tomography (OCT), the cross-sectional retinal images of 28 patients who underwent scleral buckling or PPV for macula-off retinal detachment and whose retinas reattached upon binocular stereoscopic indirect ophthalmoscopy within 4 weeks postoperatively. All eyes underwent clinical examination and OCT scan of the macula at 6 weeks after surgery. If subretinal fluid persisted, repeated OCT was obtained at every 1~2 months until no abnormality was seen on OCT. Demographic data, including detachment characteristics, was also analyzed. RESULTS: On postoperative OCT examination 6 weeks after surgery, complete foveal reattachments were detected in 14 patients (73.7%) in the PPV group (n=19), significantly higher than 3 (33.3%) patients in the buckling group (n=9). Foveal reattachment took a mean 8.31+/-5.25 weeks in the PPV group and a mean 20.89+/-11.37 weeks in the buckling group. CONCLUSIONS: Foveal reattachment after macula-off retinal detachment occurred faster after PPV than after buckle surgery.

Endogenous Candida Endophthalmitis with Bilateral Massive Submacular Abscess

PURPOSE: We present a case of endogenous endophthalmitis in which the patient presented with an overall clinical picture suggestive of bacterial endophthalmitis but was subsequently found to have Candida endophthalmitis. CASE SUMMARY: A 50-year-old man with hepatic encephalopathy and alcoholic liver cirrhosis who was treated in gastroenterology presented with reduced vision in both eyes. Indirect ophthalmoscopy showed bilateral massive submacular abscesses and surrounding retinal hemorrhage. In view of the initial fundal picture of a submacular abscess lesion, the subacute course of the disease, and a medical history of diabetes and liver cirrhosis, a provisional diagnosis of bacterial endophthalmitis was made. Treatment with topical and systemic empirical antibiotics was immediately initiated. CONCLUSIONS: Candida albicans should be considered in the differential diagnosis of endogenous endophthalmitis when massive submacular abscesses and hemorrhage are seen.

Macular Thickness in Healthy Korean Eyes Using OCT3 Comparing with Normative Data

PURPOSE: To determine whether there are significant differences between the retinal thicknesses of the macular area in eyes of healthy Koreans compared with normative data using OCT3 (version 4.0). METHODS: The study was performed in 111 eyes of 71 adults between the ages of 20 and 69 with corrected vision of 0.8 or greater and no systemic or ocular disease. The subject group was designed to have a similar age distribution to that of normative data. An OCT3 fast macular map was used to measure macular thickness. The results were further analyzed and compared with the normative data. RESULTS: The overall results from the subject group were similar to the normative data. However, the nasal parts of the outer ring were thicker than the normative data and the temporal parts of the outer ring were thinner (p<.0001). When each age group was compared, the thickness of the superior part of the inner ring and the nasal part of the inner and outer rings were thicker than the normative data in the age groups of twenties and thirties (p<.05). For the nasal parts of outer ring, the macula were thicker by OCT examination than the normative data in 25.2% of subjects, although they were clinically normal. CONCLUSIONS: Macular thickness in healthy Koreans was generally similar to the normative data of OCT3. However, a slight difference may exist and must be considered when measuring and interpreting macular thickness measurements.

2005 Survey for KSCRS Members: Current Trends in Cataract Surgery in Korea

PURPOSE: This study investigates the current state of and future trends in the field of cataract surgery in Korea. METHODS: Since 1995, the members of the Korean Society of Cataract and Refractive Surgery (KSCRS) have made annual surveys on cataract and refractive surgery. The 2005 annual survey, consisting of 76 multiple-choice questions, was mailed in February 2005 to 300 KSCRS members. Sixty-six (22.0%) members answered the questions. Current data were compared with those of previous annual surveys and with those of surveys in the United States. RESULTS: Forty-six percent of the respondents were in the fifth decade. The duration of hospital stay has decreased annually and the use of topical anesthesia (44%) did not change. Self sealing wound construction was the main wound closure technique in phacoemulsification (63%). The implantation of phakic IOL was performed by 38% of the respondents and the most preferred intraocular lenses for small incision cataract surgery were acrylic (79%). Interest in the value added IOL has increased annually. CONCLUSIONS: This survey summarized current trends and changes in cataract surgery in Korea.