Christopher Seungkyu Lee

Posterior Vitreomacular Adhesion and Risk of Exudative Age-related Macular Degeneration: Paired Eye Study

PURPOSE To evaluate posterior vitreomacular adhesion as a risk factor for choroidal neovascularization (CNV) in age-related macular degeneration (AMD). DESIGN Retrospective, observational case series. METHODS We retrospectively reviewed optical coherence tomography (OCT) and fluorescein angiography (FA) of 251 consecutive patients with unilateral exudative AMD. Fellow eyes had no sign of exudative AMD. Vitreomacular adhesion was defined when posterior hyaloid line attached to inner retinal surface was seen in OCT. We compared the incidence of posterior vitreomacular adhesion between the 2 eyes and the association between CNV location and vitreomacular adhesion. RESULTS We found posterior vitreomacular adhesion in 56 patients (22.3%), and 3 cases in which it was present in both eyes. CNV was mostly present in eyes with vitreomacular adhesion (44/53, 83%), and rarely found in eyes without vitreomacular adhesion (6/53, 11.3%; P = .0007). The location of vitreomacular adhesion was always observed over the area of the CNV in exudative eyes (50/50). CONCLUSIONS Posterior vitreomacular adhesion is associated with CNV in AMD. Chronic vitreomacular traction may be a risk factor for the development of exudative AMD.

Efficacy and safety of intravitreal bevacizumab compared with intravitreal and posterior sub-tenon triamcinolone acetonide for treatment of uveitic cystoid macular edema.

Purpose: To demonstrate the effect of bevacizumab compared with triamcinolone acetonide for the treatment of persistent cystoid macular edema in noninfectious uveitis. Methods: The medical records of 31 eyes of 31 patients with uveitic cystoid macular edema that had persisted despite conventional treatment were reviewed. Ten eyes received 1.25 mg of intravitreal bevacizumab (IVB), 11 eyes received 4 mg of intravitreal triamcinolone acetonide (IVTA), and 10 eyes received 40 mg of posterior sub-Tenon triamcinolone acetonide (PSTA). Changes in visual acuity with a logarithmic minimal angle of resolution and central foveal thickness measured with optical coherence tomography were analyzed. Results: The mean follow-up was 22.3 weeks. The best improvement in visual acuity and reduction in central foveal thickness was achieved at 4 weeks in all groups but worsened with time until 12 weeks (visual acuity improved from baseline by 0.19, 0.27, and 0.16 and central foveal thickness decreased from baseline by 167.4 μm, 327.6 μm, and 166.4 μm with IVB, IVTA, and PSTA, respectively; P < 0.001). The results with IVTA were better than those with IVB or PSTA, although the difference did not reach statistical significance. Intravitreal bevacizumab provided a significantly better effect in visual acuity gain in Behcet uveitis than in non-Behcet uveitis (P = 0.045). Kaplan-Meier survival analysis showed that the median period of effect were 16 weeks with IVB, 30 weeks with IVTA, and 12 weeks with PSTA. An increase in intraocular pressure (>5 mmHg greater than baseline) was observed in 1 eye (10%) with IVB, 5 eyes (45.5%) with IVTA, and 4 eyes (40%) with PSTA. Conclusion: Intravitreal bevacizumab was a well-tolerated and effective supplementary therapy for persistent uveitic cystoid macular edema, especially in Behcet uveitis and for patients with the risk of an increase in intraocular pressure. However, reinjection may be required because of the limited potency and duration of the positive effects of IVB.

Combined Transconjunctival and Transcaruncular Approach for Repair of Large Medial Orbital Wall Fractures

OBJECTIVES To describe the combined transcaruncular and transconjunctival approach in isolated large medial orbital wall fractures and to study the implications of uncorrected posterior orbital volume on postoperative enophthalmos. METHODS A retrospective medical record review was performed of 23 consecutive patients who underwent reduction surgery for isolated large medial orbital wall fractures using the combined transcaruncular and transconjunctival approach between February 1, 2003, and October 31, 2007. The unaffected contralateral orbital volume was assumed to represent the pretrauma volume of the affected orbit, and the uncorrected posterior orbital volume after reduction was determined using a software program. RESULTS The mean (SD) volume of the affected orbit changed from 26.00 (2.01) cm3 to 24.08 (2.06) cm3 after reduction, which was still larger than the contralateral unaffected orbit by 1.48 (0.83) cm3. Despite the uncorrected volume in the most posterior portion of the medial wall, the mean (SD) postoperative enophthalmos measured only 0.17 (0.29) mm using Hertel exophthalmometry at a mean follow-up of 8.5 months. CONCLUSIONS The combined transconjunctival and transcaruncular approach results in excellent outcomes in terms of prevention of postoperative enophthalmos of the large medial wall fracture without substantial complications. The far posterior medial volume may not contribute significantly to the development of posttraumatic enophthalmos.

Level of vascular endothelial growth factor in aqueous humor and surgical results of ahmed glaucoma valve implantation in patients with neovascular glaucoma.

PurposeTo determine the associations between the levels of growth factors in aqueous humor and the surgical outcomes of Ahmed glaucoma valve implantation in patients with neovascular glaucoma (NVG). MethodsFrom 19 NVG eyes of 19 patients, a sample of aqueous humor was taken just before Ahmed glaucoma valve implantation. Levels of vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-β1, and TGF-β2 in aqueous humor aspirates were measured using a sandwich enzyme-linked immunosorbent assay method. When the postoperative intraocular pressures were ≥21 mm Hg with or without antiglaucoma medications at 2 successive visits or when any other surgical interventions were needed to lower intraocular pressure, that surgery was considered a failure. After patients were classified into success versus failure groups, the levels of the growth factors between the 2 groups was compared. The cumulative probability of success according to Kaplan-Meier analysis was also determined. ResultsMean postoperative follow-up period was 40.9±19.6 months and cumulative probability of success was 43% at 57 months after surgery. Mean VEGF level in the failure group was higher than that of the success group (P=0.014). However, there was no statistical difference in the levels of TGF-β1, TGF-β2, and protein between 2 study groups (all P>0.05). ConclusionsThe level of VEGF in aqueous humor was significantly higher in the failure group after the Ahmed glaucoma implantation compared with the success group. Our results imply that VEGF may play a role in determining surgical success after Ahmed valve implantation in patients with NVG.

Retinal Artery Occlusion and the Risk of Stroke Development: Twelve-Year Nationwide Cohort Study

Background and Purpose— Our aim was to evaluate the risk of subsequent stroke development after retinal artery occlusion (RAO). Methods— National registry data were collected from the Korean National Health Insurance Service, comprised 1 025 340 random subjects. Patients diagnosed with RAO in 2002 and 2003 were excluded. The RAO group was composed of patients with an initial diagnosis of either central or other RAO between January 2004 and December 2013 (n=401). The comparison group was composed of randomly selected patients (5 per RAO patient; n=2003) who were matched to the RAO group according to sociodemographic factors and year of RAO diagnosis. Each sampled patient was tracked until 2013. Cox proportional hazard regression was used. Results— Stroke occurred in 15.0% of the RAO group and in 8.0% of the comparison group (P < 0.001). RAO was associated with an increased risk of stroke occurrence (hazard ratio, 1.78; 95% confidence interval, 1.32–2.41). The magnitude of the RAO effect for stroke was larger among younger adults aged <65 years (hazard ratio, 3.11) than older adults aged ≥65 years (hazard ratio, 1.26). However, the risk of subsequent stroke was significantly increased in older adults aged ≥65 years at the 4-year follow-up (hazard ratio, 1.58; 95% confidence interval, 1.01–2.48). Conclusions— RAO was significantly associated with subsequent stroke after adjusting for comorbidities and sociodemographic factors. These findings are limited by uncontrolled confounding factors and need to be replicated by other observational studies.

Clinical and spectral-domain optical coherence tomography findings in patients with focal choroidal excavation.

OBJECTIVE To describe the clinical and spectral-domain optical coherence tomography (SD-OCT) findings in patients with focal choroidal excavation (FCE). DESIGN Retrospective case series. PARTICIPANTS Forty-one eyes of 38 patients with FCE identified in 2 tertiary medical centers in Korea. METHODS Clinical features, SD-OCT findings, and associated macular disorders of FCE were analyzed and detailed. MAIN OUTCOME MEASURES Statistical associations among clinical features, including lesion type, size, and choroidal thickness, and frequency of association with central serous chorioretinopathy (CSC), choroidal neovascularization (CNV), and polypoidal choroidal vasculopathy (PCV). RESULTS Mean patient age was 50.1 years (range, 25-76 years). The mean spherical equivalent of refractive error was -3.7 diopters (range, -10.0 to +1.5 diopters). Three patients (8%) had bilateral lesions, and 1 patient (3%) had 2 distinct lesions in the same eye. The mean FCE width and depth were 757 μm and 107 μm, respectively, with a positive correlation between width and depth (P = 0.003). The mean subfoveal choroidal thickness of FCE eyes was 284 μm, which was not statistically different from that of age-, sex-, and refractive error-matched normal subjects. Choroidal thickness in FCE was less in eyes with hyperreflective choroidal tissue under the excavation that was present in 22 eyes (54%) versus eyes without excavation (128 vs. 190 μm, respectively; P = 0.009). Twelve FCEs (29%) were the nonconforming type, revealing separation between the photoreceptor tips and the retinal pigment epithelium on SD-OCT. Nonconforming FCE was associated with visual symptoms (P < 0.001) and the presence of concurrent CSC (P = 0.001). Ten eyes (24%) were associated with CSC, and 9 eyes (22%) were associated with CNV, including 1 eye with PCV features. One eye with FCE and type 1 CNV developed a new excavation, and the excavated area in 1 eye with PCV enlarged slightly during follow-up. CONCLUSIONS Focal choroidal excavation is a relatively common entity and frequently associated with choroidal diseases, including CSC, CNV, and PCV. Although FCE is classically thought to be a congenital malformation, acquired FCE forms possibly exist.

Multiple retinal haemorrhages in diabetic retinopathy after adjunctive intravitreal bevacizumab (Avastin®) with pars plana vitrectomy

Editor, R ecent reports have shown favourable short-term results with intravitreal bevacizumab (Avastin ; Genetech, San Francisco, California, USA) in the treatment of proliferative diabetic retinopathy (PDR). However, aggravation of PDR related to this relatively recent method of treatment has not been known. We encountered a case with development of multiple retinal haemorrhages after intravitreal bevacizumab as an adjunctive treatment to pars plana vitrectomy in PDR. A diabetic 65-year-old woman presented with aggravating vitreous haemorrhage after panretinal photocoagulation (PRP) with corrected vision of 20 ⁄ 400 and was scheduled for surgery. Right eye fundus showed vitreous haemorrhage and faintly visible multiple dot-shaped retinal haemorrhages (Fig. 1A). Combined pars plana vitrectomy, phacoemulsification with intraocular lens implantation, endolaser PRP and intravitreal injection of 1.25 mg bevacizumab at the end of surgery were performed. On postoperative day 7, her right eye showed newly developed multiple, extensive retinal haemorrhages at entire fundus (Fig. 1B) with corrected vision of 20 ⁄400 and intraocular pressure of 10 mmHg. Her systemic factors, including glycemic control, blood pressure and serum lipid levels, had been stable. On her visit 9 months after surgery, retinal haemorrhages were much resolved, but corrected vision still remained at 20 ⁄ 200 (Fig. 2). We are unaware of previous reports in PubMed regarding the development of multiple retinal haemorrhages after intravitreal bevacizumab. We used 1.25 mg of bevacizumab, but considering that our case was a vitrectomized eye, actual effective dose may have been less because of rapid clearance from the vitreous cavity. No postsurgical complications of combined cataract surgery and vitrectomy (such as hypotony) were present, which could otherwise explain the development of retinal haemorrhages. Risk of haemorrhage with the use of bevacizumab has been known, especially in systemic treatment in oncology. Systemic bevacizumab for cancer therapy has promoted bleeding from mucocutaneous membranes in 20–40% of patients (BC Cancer Agency 2006). The development of metrorrhagia in a healthy nulliparous 35-year-old woman after 2 weeks of intravitreal bevacizumab for the treatment of disc neovascularization with branched retinal vein occlusion has been reported recently (Rodrigues et al. 2007). Bevacizumab is a monoclonal antibody against all isoforms of vascular endothelial growth factor (VEGF). VEGF is a regulator of endothelial cell function in proliferation, migration, differentiation and even survival (Ferrara 1999). Recent experiments in animals have suggested a central role for the 165 isoform of VEGF, specifically in the pathogenesis of diabetic macular oedema (DMO) (Qaum et al. 2001). Pegaptanib sodium injection (Macugen ; Eyetech Pharmaceuticals Inc., New York, USA), which was known to selectively block the activity of VEGF165 isoform, resulted in visual acuity gain, decrease in retinal thickness and less need for focal ⁄ grid laser intervention in DMO (Macugen Diabetic Retinopathy Study Group 2005). Blocking of physiological isoforms of VEGF, as well as pathological isoforms, with bevacizumab might (A) (B)

Clinicopathological Analysis of Periocular Sebaceous Gland Carcinoma

Background: We analyzed the clinicopathological features and prognosis in patients with periocular sebaceous gland carcinoma. Methods: Retrospectively, we studied the records of 24 cases of sebaceous gland carcinoma treated in our clinic between 1999 and 2004. The reviewed data included demographic information, initial clinical and histopathological diagnosis, anatomic tumor location, details of treatment, tumor involvement of resection margin, and outcomes such as local recurrence, distant metastasis and survival. Results: Local recurrence developed in 6 cases (25%) at a median of 20 months from initial diagnosis. Only 2 patients (8.3%) died of systemic metastasis to brain and bone from primary lacrimal gland carcinoma. The local recurrence rate in the complete excision group (5.9%) was significantly lower compared with the incomplete excision with irradiation group (71.4%; Fisher’s exact test, p = 0.003). We observed a shorter duration of symptom, a higher rate of eventual exenteration and local recurrence, and a shorter time interval to local recurrence from initial management in poorly differentiated tumors compared with moderately differentiated tumors. Conclusion: It is critical to achieve a negative tumor margin in both frozen and permanent section to prevent local recurrence. Early aggressive management is required in sebaceous gland carcinoma of the lacrimal gland, as its mortality is much higher than that of eyelid origin.

Prognostic factors in vitrectomy for lamellar macular hole assessed by spectral-domain optical coherence tomography

Purpose:  To evaluate the association between the macular structure on spectral‐domain optical coherence tomography (SD‐CT) and visual outcome after vitrectomy for lamellar macular hole (LMH).

Prevalence and risk factors of visual impairment and blindness in Korea: the Fourth Korea National Health and Nutrition Examination Survey in 2008-2010.

To describe the age, gender specific prevalence and risk factors of visual impairment and blindness in Korea.