Eun Min Kang

Estimated Trans-Lamina Cribrosa Pressure Differences in Low-Teen and High-Teen Intraocular Pressure Normal Tension Glaucoma: The Korean National Health and Nutrition Examination Survey.

Background To investigate the association between estimated trans-lamina cribrosa pressure difference (TLCPD) and prevalence of normal tension glaucoma (NTG) with low-teen and high-teen intraocular pressure (IOP) using a population-based study design. Methods A total of 12,743 adults (≥ 40 years of age) who participated in the Korean National Health and Nutrition Examination Survey (KNHANES) from 2009 to 2012 were included. Using a previously developed formula, cerebrospinal fluid pressure (CSFP) in mmHg was estimated as 0.55 × body mass index (kg/m2) + 0.16 × diastolic blood pressure (mmHg)—0.18 × age (years)—1.91. TLCPD was calculated as IOP–CSFP. The NTG subjects were divided into two groups according to IOP level: low-teen NTG (IOP ≤ 15 mmHg) and high-teen NTG (15 mmHg < IOP ≤ 21 mmHg) groups. The association between TLCPD and the prevalence of NTG was assessed in the low- and high-teen IOP groups. Results In the normal population (n = 12,069), the weighted mean estimated CSFP was 11.69 ± 0.04 mmHg and the weighted mean TLCPD 2.31 ± 0.06 mmHg. Significantly higher TLCPD (p < 0.001; 6.48 ± 0.27 mmHg) was found in the high-teen NTG compared with the normal group. On the other hand, there was no significant difference in TLCPD between normal and low-teen NTG subjects (p = 0.395; 2.31 ± 0.06 vs. 2.11 ± 0.24 mmHg). Multivariate logistic regression analysis revealed that TLCPD was significantly associated with the prevalence of NTG in the high-teen IOP group (p = 0.006; OR: 1.09; 95% CI: 1.02, 1.15), but not the low-teen IOP group (p = 0.636). Instead, the presence of hypertension was significantly associated with the prevalence of NTG in the low-teen IOP group (p < 0.001; OR: 1.65; 95% CI: 1.26, 2.16). Conclusions TLCPD was significantly associated with the prevalence of NTG in high-teen IOP subjects, but not low-teen IOP subjects, in whom hypertension may be more closely associated. This study suggests that the underlying mechanisms may differ between low-teen and high-teen NTG patients.

Lattice corneal dystrophy type IIIA with hyaline component from a novel A620P mutation and distinct surgical treatments.

Purpose: The aim of this study was to report a lattice corneal dystrophy (LCD) family with a novel mutation of A620P in the TGFBI gene, its long-term treatment, follow-up data, and related pathologic findings. Methods: A total of 28 family members were clinically examined, and blood samples or buccal epithelial cells were taken for DNA analysis. All exons from the entire TGFBI gene coding region were analyzed for mutations in 3 affected members. Exon 14 was amplified in other family members and in 100 normal Korean persons as control. Corneal tissues from 1 affected family member were examined using light and electron microscopy. Results: Clinical examination revealed relatively late-onset LCD with asymmetric progression and recurrent corneal erosion. The affected family members have been treated with penetrating keratoplasty, deep lamellar keratoplasty, and phototherapeutic keratectomy for up to 19 years. Screening of the TGFBI gene revealed a novel A620P mutation, which was found in all affected members. The amyloid origin of deposits was confirmed by Congo red and was also partially stained with Masson trichrome. Although there were no electron-dense bodies as in granular dystrophy, transmission electron microscopy demonstrated that the stromal deposits were not homogenous and contained a variety of constituents with different electron densities. Conclusions: We present the characteristics and surgical treatment of corneas with a novel A620P mutation in TGFBI showing LCD type IIIA with hyaline component.

Relationship between Peripapillary Retinal Nerve Fiber Layer Thickness Measured by Optical Coherence Tomography and Visual Field Severity Indices

Purpose Though there are many reports regarding the structure-function relationship in glaucoma, they are too complicated to apply to the routine clinical setting. The aim of this study was to investigate the direct relationship between peripapillary retinal nerve fiber layer (RNFL) thickness measured by optical coherence tomography (OCT) and visual field (VF) severity indices computed by standard automated perimetry. Methods This cross-sectional comparative study included 104 glaucomatous patients and 59 healthy subjects. Peripapillary RNFL thickness was measured by spectral domain (SD) and time domain (TD) OCTs. Four glaucoma VF severity indices, including mean deviation (MD), pattern standard deviation (PSD), Collaborative Initial Glaucoma Treatment Study (CIGTS) VF score, and Advanced Glaucoma Intervention Study (AGIS) VF score, were calculated using standard automated perimetry. The Pearsons correlation coefficients (r) between the average and quadrants of peripapillary RNFL thicknesses and the four VF severity indices were calculated. Results In glaucomatous eyes, the r value between the average RNFL thickness measured by SD OCT and each VF severity index were 0.562, -0.514, -0.577, and -0.567 for the MD, PSD, CIGTS VF score, and AGIS VF score, respectively (all p < 0.001). Among each quadrant, the inferior RNFL thickness showed the largest r value; 0.587, -0.552, -0.613, and -0.598 for the MD, PSD, CIGTS VF score, and AGIS VF score, respectively (all p < 0.001). Measurements by TD OCT showed similar strengths of association with SD OCT. Conclusions Moderate correlation was identified between peripapillary RNFL thicknesses measured by SD/TD OCT and glaucoma VF severity indices. Among each quadrant, the inferior RNFL thickness showed the greatest association with glaucoma VF severity indices. There was no significant difference according to the type of VF severity index or the type of OCTs.

Three Toxic Heavy Metals in Open-Angle Glaucoma with Low-Teen and High-Teen Intraocular Pressure: A Cross-Sectional Study from South Korea.

Background To investigate the association between heavy metal levels and open-angle glaucoma (OAG) with low- and high-teen baseline intraocular pressure (IOP) using a population-based study design. Methods This cross-sectional study included 5,198 participants older than 19 years of age who participated in the Korean National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2012 and had blood heavy metal levels available. The OAG with normal baseline IOP (IOP ≤ 21 mmHg) subjects were stratified into low-teen OAG (baseline IOP ≤ 15 mmHg) and high-teen OAG (15 mmHg < baseline IOP ≤ 21 mmHg), and the association between blood lead, mercury, and cadmium levels and glaucoma prevalence was assessed for low- and high-teen OAG. Results The adjusted geometric mean of blood cadmium levels was significantly higher in subjects with low-teen OAG than that of the non-glaucomatous group (P = 0.028), whereas there were no significant differences in blood lead and mercury levels. After adjusting for potential confounders, the low-teen OAG was positively associated with log-transformed blood cadmium levels (OR, 1.41; 95% confidence interval (CI), 1.03–1.93; P = 0.026). For high-teen OAG, log-transformed blood levels of the three heavy metals were not associated with disease prevalence. The association between log-transformed blood cadmium levels and low-teen OAG was significant only in men (OR, 1.65; 95% CI, 1.10–2.48; P = 0.016), and not in women (OR, 1.10; 95% CI, 0.66–1.85; P = 0.709). Conclusions The results of this study suggest that cadmium toxicity could play a role in glaucoma pathogenesis, particularly in men and in OAG with low-teen baseline IOP.

A Korean Woman with Reactive Lymphoid Hyperplasia of the Uvea

Dear Editor, Recently, we diagnosed a 50-year-old woman as having reactive lymphoid hyperplasia (RLH) of the uvea, and herein we report that this is the first diagnosis of this condition in a Korean patient. The patient was referred to the ophthalmology clinic with blurry vision due to choroidal mass-like lesions of the right eye for 1 month. Uncorrected visual acuity (UCVA) of the right eye was 0.2, and best-corrected visual acuity of the right eye was 0.9 (+sph 2.25, -cyl 0.75, axis 90). Slit lamp examination showed no remarkable findings in the anterior segment including the vitreous. Fundus examination via indirect ophthalmoscopy showed multiple yellow-orange colored choroidal mass-like lesions at the posterior pole in the right eye (Fig. 1A). Fluorescence angiography showed stippled hyperfluorescence (Fig. 1B) with late phase staining (Fig. 1C). On indocyanine green angiography, retinochoroidal folds radiating from the optic nerve head were seen as hypofluorescence lines upon examination (Fig. 1D and 1E). Spectral domain optical coherence tomography showed subretinal fluid in the fovea, with undulating retina due to choroidal mass both horizontally (Fig. 1F) and vertically (Fig. 1G). Ultrasound sonography showed homogenous intraocular elevation which was acoustically empty (Fig. 1H), and lesion size was base 11.93 mm with a height of 2.71 mm. On magnetic resonance imaging of the brain and orbit, the subretinal mass showed hyperintensity on T1 (Fig. 1I) and hypointensity on T2 images (Fig. 1J). Systemic evaluation including positron emission tomography revealed no primary malignancy, and ocular management was recommended by the oncologist. RLH of the uvea was suspected, and systemic steroid treatment was started with prednisolone 50 mg per day for the first week, and then 40 mg per day for the following week. After 2 weeks, UCVA of the right eye improved to 0.8, and choroidal elevation was also improved (Fig. 1K). On ultrasonography, the size of the choroidal mass was base 8.80 mm with a height of 1.87 mm (Fig. 1L). Systemic steroid administration was continued at 30 mg per day for one week, followed by 25 mg per day for an additional week. UCVA of the right eye after one month of steroid treatment was 0.6, and the choroidal mass lesion was stable, and steroid administration was further tapered off. Fig. 1 Fundus photography of the 50-year-old patient with reactive lymphoid hyperplasia of the uvea in the right eye (A). Fluorescence angiography showed stippled hyperfluorescence (B) with late phase staining (C). On indocyanine green angiography, retinochoroidal ... RLH of the uvea is a rare disease, and it is a diagnosis of exclusion. RLH usually affects middle-aged patients, with a mean age of 55 years [1]. RLH is generally unilateral, and has no apparent racial or sexual predilection [2]. Patients suffer from recurrent episodes of blurred vision and metamorphopsia secondary to serous fluid serous detachment of the macula [1,2,3,4,5]. Multifocal yellow-orange lesions by choroidal infiltration are a typical feature of RLH of the uvea, and sometimes pink, smooth-surfaced subconjunctival extensions are reported [1,2,3,4,5]. Ultrasonographic findings are especially helpful in the diagnosis of RLH in that they reveal diffuse choroidal infiltration with low internal reflectivity, a lack of choroidal/scleral excavation, and the presence of extrascleral peripapillary nodules [4,5]. RLH usually responds to steroid therapy promptly [4,5]. Before the diagnosis of RLH, several diseases should be considered including diffuse choroidal melanoma, metastatic carcinoma, inflammatory diseases such as multifocal choroiditis, uveal effusion, and malignant lymphoma [3]. Although it is rare, we experienced a Korean patient who was compatible with RLH, and this patient was successfully treated with systemic steroid treatment. Therefore, when diagnosing choroidal mass in the Korean population, RLH should be also considered.