Hee Yoon Cho

Quantitative Assessment of Inferior Oblique Muscle Overaction Using Photographs of the Cardinal Positions of Gaze

PURPOSE To report a novel method for measuring the degree of inferior oblique muscle overaction and to investigate the correlation with other factors. DESIGN Cross-sectional diagnostic study. METHODS One hundred and forty-two eyes (120 patients) were enrolled in this study. Subjects underwent a full orthoptic examination and photographs were obtained in the cardinal positions of gaze. The images were processed using Photoshop and analyzed using the ImageJ program to measure the degree of inferior oblique muscle overaction. Reproducibility or interobserver variability was assessed by Bland-Altman plots and by calculation of the intraclass correlation coefficient (ICC). The correlation between the degree of inferior oblique muscle overaction and the associated factors was estimated with linear regression analysis. RESULTS The mean angle of inferior oblique muscle overaction was 17.8 ± 10.1 degrees (range, 1.8-54.1 degrees). The 95% limit of agreement of interobserver variability for the degree of inferior oblique muscle overaction was ±1.76 degrees, and ICC was 0.98. The angle of inferior oblique muscle overaction showed significant correlation with the clinical grading scale (R = 0.549, P < .001) and with hypertropia in the adducted position (R = 0.300, P = .001). The mean angles of inferior oblique muscle overaction classified into grades 1, 2, 3, and 4 according to the clinical grading scale were 10.5 ± 9.1 degrees, 16.8 ± 7.8 degrees, 24.3 ± 8.8 degrees, and 40.0 ± 12.2 degrees, respectively (P < .001). CONCLUSIONS We describe a new method for measuring the degree of inferior oblique muscle overaction using photographs of the cardinal positions. It has the potential to be a diagnostic tool that measures inferior oblique muscle overaction with minimal observer dependency.

Depression of Late Age-Related Macular Degeneration Patients in Korea.

Purpose The aim of study was to investigate the relationship between depression and age-related macular degeneration (AMD) in Korea treated with intravitreal ranibizumab. Methods This was a cross-sectional study. This study included 107 patients diagnosed with AMD treated with intravitreal ranibizumab. All patients answered the Korean version of the Geriatric Depression Scale (GDS-K), and the prevalence of depression was evaluated. The patients from 1 center were classified into groups with and without depression according to GDS-K. Visual acuity (VA), duration, bilaterality, history of previous treatment for AMD, and comorbidities were assessed and compared between groups. The correlations between GDS-K and other variables were investigated. Results The prevalence of depression was 26.2% with AMD treated with intravitreal ranibizumab in this study. In subanalysis, the 23 depressed patients (33.3%) were older (P = 0.022) than the nondepressed. Positive correlations were observed between GDS-K and age, VA of injected eye, VA of better eye, duration of AMD, and the number of previous treatments for AMD. Conclusions This is the first study evaluating the relationship between depression and AMD in Koreans treated with intravitreal ranibizumab. The prevalence of depression in AMD is substantial and similar to those in previous reports. Interventions to diagnose and treat depression in AMD patients are necessary.

The effect of pattern scan laser photocoagulation on peripapillary retinal nerve fiber layer thickness and optic nerve morphology in diabetic retinopathy.

Purpose To evaluate the effect of pattern scan laser (PASCAL) photocoagulation on peripapillary retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), and optic nerve morphology in patients with diabetic retinopathy. Methods Subjects included 35 eyes for the PASCAL group and 49 eyes for a control group. Peripapillary RNFL thickness, cup-disc area ratio and CMT were measured before PASCAL photocoagulation and at 2 and 6 months after PASCAL photocoagulation in the PASCAL or control groups. Results The average RNFL thickness had increased by 0.84 µm two months after and decreased by 0.4 µm six months after PASCAL photocoagulation compared to baseline, but these changes were not significant (p = 0.83, 0.39). The cup-disc area ratio was unchanged after PASCAL photocoagulation. CMT increased by 18.11 µm (p = 0.048) at two months compared to baseline thickness, and partially recovered to 11.82 µm (p = 0.11) at six months in the PASCAL group. Conclusions PASCAL photocoagulation may not cause significant change in the peripapillary RNFL thickness, CMT, and optic nerve morphology in patients with diabetic retinopathy.

Novel Technique to Overcome the Nonavailability of a Long Needle 9-0 Polypropylene Suture for Sutured Scleral Fixation of the Posterior Chamber Intraocular Lens Using a Single Fisherman’s Knot

Purpose To describe a method to overcome the nonavailability of a long needle 9-0 polypropylene suture for sutured scleral fixation of the posterior chamber intraocular lens (PC-IOL) using a single fishermans knot (SFK). Methods First, a 10-0 polypropylene suture was passed from the sclera to the ciliary sulcus using a long needle. A 9-0 suture was tied to the unpassed portion of the 10-0 suture with an SFK. We pulled the 10-0 suture to pass the SFK through the sclera, and then we cut the knot and removed the 10-0 suture. IOL fixation with 9-0 sutures used the conventional techniques used for sutured scleral-fixated IOL. Preoperative and postoperative visual acuity, corneal astigmatism, and endothelial cell count and intraoperative/postoperative complications were evaluated. Results An SFK joining the two sutures was passed through the sclera without breakage or slippage. A total of 35 eyes from 35 patients who underwent sutured scleral fixation of the IOL. An intraoperative complication (minor intraocular hemorrhage) was recorded in four cases. Knot exposure, IOL dislocation, subluxation, and retinal detachment were not observed. Conclusions The SFK offers the opportunity to use 9-0 sutures for the long-term safety and may not require the surgeon to learn any new technique.

The Effect of Optic Disc Center Displacement on Retinal Nerve Fiber Layer Measurement Determined by Spectral Domain Optical Coherence Tomography

Purpose To investigate the effect of optic disc center displacement on retinal nerve fiber layer (RNFL) measurement determined by spectral domain optical coherence tomography (SD-OCT). Methods The optic disc center was manipulated at 1-pixel intervals in horizontal, vertical, and diagonal directions. According to the manipulated optic disc center location, the RNFL thickness data were resampled: (1) at a 3.46-mm diameter circle; and (2) between a 2.5-mm diameter circle and 5.4-mm square. Error was calculated between the original and resampled RNFL measurements. The tolerable error threshold of the optic disc center displacement was determined by considering test-retest variability of SD-OCT. The unreliable zone was defined as an area with 10% or more variability. Results The maximum tolerable error thresholds of optic disc center displacement on the RNFL thickness map were distributed from 0.042 to 0.09 mm in 8 directions. The threshold shape was vertically elongated. Clinically important unreliable zones were located: (1) at superior and inferior region in the vertical displacement; (2) at inferotemporal region in the horizontal displacement, and (3) at superotemporal or inferotemporal region in the diagonal displacement. The unreliable zone pattern and threshold limit varied according to the direction of optic disc displacement. Conclusions Optic disc center displacement had a considerable impact on whole RNFL thickness measurements. Understanding the effect of optic disc center displacement could contribute to reliable RNFL measurements.

Simple method to restore a fractured 10-0 polypropylene suture using a single fisherman's knot

During 2010 and 2011, we reported a rate of endophthalmitis of 0.14 per 1000 in the Diablo Service Area of Kaiser Permanente; this low rate corresponded to adoption of intracameral injections at the end of cataract surgery among all patients treated in that medical center. In recent years and in response tomounting evidence of the effectiveness and safety of intracameral injections of antibiotic in preventing cataract surgery–related endophthalmitis, our network of surgeons across the entire Northern California region of Kaiser Permanente (including the Diablo Service Area and 15 other service areas) has increased adoption of intracameral antibiotics at the end of cataract surgery. Some surgeons currently prefer cefuroxime as a first-line drug; others use moxifloxacin. In cases of allergy, a small percentage of patients receive vancomycin. Following publication of our 2010–2011 experience and as part of our mission to provide high-quality care to our patients, we took steps to increase implementation of intracameral injections systemwide. From January 1 to December 31, 2013, an increasing proportion of our cataract surgery patients received intracameral antibiotics, with an average proportion of 79% for the calendar year, similar to the proportion reported in Europe. Using the same case definition that we used in our previous report, we calculated the rate of endophthalmitis for the calendar year 2013 in the entire Northern California region. Among 32 562 routine phacoemulsification procedures, we observed 3 cases of endophthalmitis. One of these occurred among 6891 procedures performed without intracameral injections (rate 0.14 per 1000; 95% confidence interval [CI], 0.00-0.80 per 1000); the pathogen was methicillinresistant Staphylococcus aureus. The 2 other cases occurred among 25671 procedures with intracameral injections (rate 0.08 per 1000; 95% CI, 0.00-0.28 per 1000). One case that received intracameral moxifloxacin occurred the day after surgery; the etiology was coagulase-negative Staphylococcus species. The second case, which received intracameral cefuroxime, involved Enterococcus faecalis endophthalmitis following removal of sutures 30 days after uneventful cataract surgery. This resulted in a Seidel-positive wound; a contact lens was placed and ofloxacin drops were prescribed 2 days prior to clinical signs of infection. Arguably, this second case would not have been affected by

Letter by Lee et al Regarding Article, “Spontaneous Resolution of Central Serous Chorioretinopathy in a Patient With Congenital Retinal Macrovessel”

To the Editor: We read the article by Ascaso entitled, “Spontaneous Resolution of Central Serous Chorioretinopathy in a Patient with Congenital Retinal Macrovessel” published in Volume 124 of Circulation with great interest.1 In our opinion, the images provided in the article do not seem to show what we can see in typical central serous chorioretinopathy (CSCR). In the images provided, the leakage seen on fundus fluorescein angiography definitely appears to be originating from an anastomotic site at the congenital retinal macrovessels (CRMs). The retinal vessels are visible below the leakage point, which …

Bilateral acute myopia and angle closure glaucoma induced by Ma-huang (Ephedra): A case report

Rationale: Cases of bilateral acute angle closure have been reported after use of various drugs. Patient concerns: A 52-year-old woman visited the emergency room and complained of acute bilateral ocular pain and decreased vision accompanied by headache, nausea, and vomiting. One day before, she had started a herbal medicine containing Ma-huang for weight loss. On examinations, myopic shift, edematous cornea, increased intraocular pressure, shallow anterior chamber, and thickened choroid on both eyes were observed. Diagnoses: Angle closure glaucoma induced by drug (Ma-huang). Interventions: To promptly quit the offending drug and apply ocular hypotensives and cycloplegics. Outcomes: Her symptoms and signs were relieved after antiglaucoma medications and no significant recurrence has been occurred. Lessons: Physicians prescribing weight loss medications containing Ma-huang must be aware of the potentially sight-threatening adverse effect of bilateral acute angle closure.

Depressive Symptoms and Quality of Life in Age-related Macular Degeneration Based on Korea National Health and Nutrition Examination Survey (KNHANES)

Purpose This study was conducted to investigate the depressive symptoms and quality of life (QOL) in patients with age-related macular degeneration (AMD) using data obtained from the Korea National Health and Nutritional Examination Survey V-2 (KNHANES V-2) conducted in 2011. Methods This was a population-based, cross-sectional study that selected 329 participants from the fifth KNHANES (2011) who were diagnosed with AMD by an ophthalmologist based on fundus photography. The prevalence of depressive symptoms and the health-related QOL (using EuroQol indices) in this cohort were also estimated. Factors associated with depressive symptoms, including socioeconomic status, QOL indices, and associated chronic diseases, were investigated using multivariate regression models. Results Depressive symptoms were observed more frequently in AMD patients than in non-AMD controls (p = 0.013). Among the total 329 AMD participants, 65 (19.8%) had depressive symptoms. There were 16 males (24.6%) and 49 females (75.4%). Upon multivariate analysis, significant factors found to be associated with depressive symptoms were female gender (odds ratio [OR], 2.082; 95% confidence interval [CI], 1.001 to 4.330), being in the “dependent” group for activities of daily living (OR, 4.638; 95% CI, 2.061 to 10.435), and having “some problems” in the “anxiety-depression” dimension of the EQ-5D (OR, 7.704; 95% CI, 1.890 to 31.408). Conclusions Female gender and being dependent on others for activities of daily living increased the association of depressive symptoms in this cohort of AMD participants. Screening for depressive symptoms in East Asian AMD patients with these characteristics should be an important component of their care.