Hae Jung Paik

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.

A Silastic Sheet found during Endoscopic Transnasal Dacryocystorhinostomy for Acute Dacryocystitis

Purpose To report the case of a silastic sheet that was found during an endoscopic transnasal dacryocystorhinostomy for treatment of acute dacryocystitis with necrosis of the lacrimal sac. Methods A thirty-two year old male presented with painful swelling on the nasal side of his left lower lid two weeks prior to visiting this clinic. Fourteen years ago, the patient was involved in a traffic accident and underwent surgery to reconstruct the ethmoidal sinus. Lacrimal sac massage showed a regurgitation of a purulent discharge from the left lower punctum. Therefore, the patient was diagnosed with acute dacryocystitis and an endoscopic transnasal dacryocystostomy was performed the next day. Results The surgical finding showed severe necrosis around the lacrimal sac and a 20 × 15-mm sized silastic sheet was found crumpled within the purulent discharge. The sheet was removed, the lacrimal sac was irrigated with an antibiotic solution, and a silicone tube was intubated into the lacrimal pathway. After surgery, the painful swelling on the nasal side of left lower lid resolved gradually, and there were no symptomatic complications three months later. Conclusions We report the first case where a silastic sheet applied during a facial reconstruction had migrated adjacent to the lacrimal sac resulting in severe inflammation.

Effects of botulinum a toxin injection on the extraocular muscle fiber layers: Comparison between subtenon injection and intramuscular injection

PurposeTo 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.MethodsTwelve 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.ResultsThe 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.ConclusionSubtenon 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.

Effect of horizontal rectus surgery for the correction of intermittent exotropia on sub-A or sub-V pattern

We evaluated effect of horizontal rectus surgery on sub-A or sub-V pattern intermittent exotropia. We enrolled patients with sub-A or sub-V pattern intermittent exotropia. The sub-A pattern was diagnosed when the eyes diverged less than 10 prism diopters (PD) from upgaze to downgaze, and sub-V pattern when the divergence was 14 PD or less from downgaze to upgaze. Patients had undergone horizontal rectus surgery without vertical transposition of horizontal rectus muscle or oblique muscle weakening. The patients were divided into two groups: sub-A pattern (group A) and sub-V pattern (group V). The outcome measures were change of amount of pattern and rate of collapse of pattern postoperatively. The amount of pattern (vertical incomitance) was amount of difference in exodeviation between upgaze and downgaze. Collapse of pattern was defined as disappearance of difference in exodeviation between upgaze and downgaze. In groups A and V, preoperative amounts of pattern were 4.9 PD and 6.8 PD, respectively. A significant reduction in amount of pattern was observed in both groups throughout the follow-up period (p<0.05). At postoperative 6 months, the amounts of pattern were 1.0 PD and 1.2 PD and the extents of reduction in amount of pattern were 4.4 PD and 5.9 PD. The rates of collapse of pattern at postoperative 6 months were 77.8 and 60.0%, respectively. In the patients with sub-A or sub-V pattern exotropia, horizontal rectus surgery without vertical transposition or oblique muscle weakening can successfully collapse the pattern.

A case of orbital lipoma with exophthalmos and visual disturbance

Cholesterol granuloma is a pathological term used to describe an infl ammatory response to cholesterol crystals. It appears to represent the end result of a variety of pathways for cholesterol deposition. The fi rst description is thought to be that made by Meyer, who in 1893 described a lesion in the peritoneum. It is a rare lesion and has been more frequently described in the middle ear cavity, especially in the mastoid air cells and tympanic cavity. The fi rst orbital case was reported by Denig in 1902. The pathogenesis of cholesterol granuloma is still unclear. It is thought to be due to ventilatory obstruction of the pneumatized bone resulting in local tissue breakdown. The important precipitating factor in the development of cholesterol granuloma may be hemorrhage within an obstructed, unaerated bony cavity. Resorption of air in the obstructed sinus creates negative pressure, leading to exudation and hemorrhage from the sinus mucosa. The subsequent anaerobic breakdown of blood products results in the formation of cholesterol crystals. The densely packed cholesterol crystals incite a localized infl ammatory reaction, characterized by granulation tissue, with granulocyte and foreign-body giant cell accumulation. Therefore, histopathological examination of the lesion shows cholesterol clefts with a surrounding foreign-body giant cell reaction and granulation tissue formation, together with evidence of old and recent hemorrhage. In addition, there is a dense infi ltrate of lymphocytes and plasma cells (Fig. 1D). The typical fi ndings of cholesterol granuloma on MRI scans are lesions that show areas of high signal intensity on both T1-weighted and T2-weighted images (characteristic of chronic hemorrhage) interspersed by either septations or foci of low signal intensity. However, differentiating a cholesterol granuloma from other lesions may be diffi cult both clinically and by imaging. In such cases, percutaneous imaging-guided biopsy can be used safely and effectively to obtain a defi nitive diagnosis. In conclusion, our case displayed the typical clinical features of compressive optic neuropathy and the characteristic histopathology to establish the diagnosis of cholesterol granuloma. We reported a case of sphenoid sinus cholesterol granuloma, which, although extremely rare, should be considered as a possible cause of compressive optic neuropathy.

Acquired Brown Syndrome Treated With Traction of Superior Oblique Tendon.

Brown syndrome is a rare strabismic disease characterized by a limited elevation in adduction of the eye. The lengthening/weakening of superior oblique muscle is the main way of surgical intervention for this disease. A 7-year-old boy was diagnosed as having acquired Brown syndrome in his right eye after injury in his face. We experienced successful release of this Brown syndrome through mere pulling outward of superior oblique tendon during surgical exploration. We briefly discuss why this manipulation of superior oblique tendon that we performed was successful.

Postoperative changes of intermittent exotropia type as classified by 1-hour monocular occlusion

Purpose To evaluate postoperative changes of the intermittent exotropia type as classified by 1-hour monocular occlusion test. Design Institutional, retrospective study. Methods We retrospectively reviewed the medical records of 179 patients who had undergone surgery for intermittent exotropia with a postoperative follow-up of 6 months or more. We evaluated the exodeviation obtained before and after 1-hour monocular occlusion preoperatively and again at postoperative 1, 3 and 6 months. Intermittent exotropia was divided into 4 types according to Burian’s classification. The main outcome measure was the distribution of intermittent exotropia type based on 1-hour monocular occlusion in both pre- and postoperative periods. Results Of the 179 patients, 152 (84.9%) were assigned preoperatively to the basic type, 14 (7.8%) to the pseudo-divergence excess type, and 13 (7.8%) to the convergence insufficiency type. At postoperative 1, 3, and 6 months, the exotropia-type distribution was shifted predominantly to the basic type (p<0.001, p = 0.004, p = 0.029, respectively). Among the preoperative basic-type patients, 96.9% maintained that type postoperatively. However, only 18.2 and 11.1% of the pseudo-divergence excess and convergence insufficiency types maintained the same type. The proportions of the basic type had increased at postoperative 6 months, from 87.8 to 95.7% for bilateral lateral rectus (BLR) recession, from 73.7 to 92.3% for unilateral recess-resect (R&R), and from 88.0 to 95.0% for unilateral lateral rectus (ULR) recession. Conclusion The type of intermittent exotropia changed mostly to the basic type postoperatively even as classified after 1-hour monocular occlusion. This finding was consistent regardless of the surgical methods (BLR, ULR recession and R&R).

The Effect of Preoperative Occlusion Therapy on Long-term Outcome after Surgery for Early-onset Exotropia

Purpose To investigate the effect of preoperative part-time occlusion therapy on long-term surgical success in early-onset exotropia. Methods The medical records of patients who underwent surgery for exotropia with onset before the first year of age and who were followed for ≥3 years were reviewed. Patients were divided into two groups according to the degree of compliance with part-time occlusion therapy: the good compliance group (>50% adherence rate) and the poor compliance group (≤50% adherence rate). Surgical success was defined as orthophoria to exodeviation less than 10 prism diopters both at distance and near. The level of postoperative stereopsis was compared between the two study groups among total enrolled patients and among those with constant exotropia. Results Of the 51 patients, 26 were assigned to the good compliance group and the remaining 25 patients to the poor compliance group. The surgical success rate was significantly higher in the good compliance group than in the poor compliance group (80.8% vs. 52.0%, p = 0.040). Among 24 constant exotropia patients (12 patients for each group), the success rate was insignificantly higher in the good compliance group than in the poor compliance group (75.0% vs. 58.3%, p = 0.448). The good compliance group had a better level of stereopsis than the poor compliance group (p = 0.045 for all 44 patients, p = 0.020 for 19 patients with constant exotropia). Conclusions Preoperative part-time occlusion therapy was useful for improving the surgical outcome of early-onset exotropia and postoperative stereopsis.