Hyung Woo Kwak

Iatrogenic Occlusion of the Ophthalmic Artery After Cosmetic Facial Filler Injections A National Survey by the Korean Retina Society

IMPORTANCE Iatrogenic occlusion of the ophthalmic artery and its branches is a rare but devastating complication of cosmetic facial filler injections. OBJECTIVE To investigate clinical and angiographic features of iatrogenic occlusion of the ophthalmic artery and its branches caused by cosmetic facial filler injections. DESIGN, SETTING, AND PARTICIPANTS Data from 44 patients with occlusion of the ophthalmic artery and its branches after cosmetic facial filler injections were obtained retrospectively from a national survey completed by members of the Korean Retina Society from 27 retinal centers. Clinical features were compared between patients grouped by angiographic findings and injected filler material. MAIN OUTCOMES AND MEASURES Visual prognosis and its relationship to angiographic findings and injected filler material. RESULTS Ophthalmic artery occlusion was classified into 6 types according to angiographic findings. Twenty-eight patients had diffuse retinal and choroidal artery occlusions (ophthalmic artery occlusion, generalized posterior ciliary artery occlusion, and central retinal artery occlusion). Sixteen patients had localized occlusions (localized posterior ciliary artery occlusion, branch retinal artery occlusion, and posterior ischemic optic neuropathy). Patients with diffuse occlusions showed worse initial and final visual acuity and less visual gain compared with those having localized occlusions. Patients receiving autologous fat injections (n = 22) had diffuse ophthalmic artery occlusions, worse visual prognosis, and a higher incidence of combined brain infarction compared with patients having hyaluronic acid injections (n = 13). CONCLUSIONS AND RELEVANCE Clinical features of iatrogenic occlusion of the ophthalmic artery and its branches following cosmetic facial filler injections were diverse according to the location and extent of obstruction and the injected filler material. Autologous fat injections were associated with a worse visual prognosis and a higher incidence of combined cerebral infarction. Extreme caution and care should be taken during these injections, and physicians should be aware of a diverse spectrum of complications following cosmetic facial filler injections.

Diurnal variation in choroidal thickness in relation to sex, axial length, and baseline choroidal thickness in healthy Korean subjects.

Purpose: To investigate diurnal variations in choroidal thickness (CT) in relation to various factors in healthy Korean subjects using spectral-domain optical coherence tomography. Methods: A prospective study was conducted on 100 healthy volunteers who each underwent measurements of CT in the same subfoveal area using an enhanced depth imaging technique with spectral-domain optical coherence tomography at 8 AM, 11 AM, 2 PM, and 5 PM. Possible correlations between the diurnal variation of CT and other factors, such as sex, axial length (AL), baseline CT (8 AM), blood pressure, and intraocular pressure, were evaluated. Results: One hundred volunteers with a mean age of 30.1 years were scanned. A significant pattern of diurnal variation was observed, with a mean CT of 278.28 ± 91.78 &mgr;m at 8 AM, 271.57 ± 89.08 &mgr;m at 11 AM, 266.39 ± 86.18 &mgr;m at 2 PM, and 264.92 ± 87.10 &mgr;m at 5 PM in a right eye. Right eye and left eye had a similar trend of diurnal cycle. Based on sex, AL, and baseline CT, the pattern of diurnal variation was greater and the amplitude significantly was greater in men, AL ⩽ 24 mm and baseline CT ≥ 300 &mgr;m (men vs. women: P = 0.048, AL ⩽ 24 mm vs. AL > 24 mm: P = 0.036, baseline CT ≥ 300 &mgr;m vs. baseline CT < 200 &mgr;m: P = 0.002, baseline CT ≥ 300 &mgr;m vs. 200 &mgr;m ⩽ baseline CT < 300 &mgr;m: P = 0.008). There were no significant correlations between the diurnal variation of CT and systolic blood pressure, diastolic blood pressure, or intraocular pressure. Conclusion: In men as well as in those with a shorter AL and thick baseline CT, a greater pattern of diurnal variation with significantly greater amplitude was observed.

VISUAL AND MORPHOLOGIC OUTCOMES OF INTRAVITREAL RANIBIZUMAB FOR DIABETIC MACULAR EDEMA BASED ON OPTICAL COHERENCE TOMOGRAPHY PATTERNS.

Purpose: To evaluate the visual and morphologic outcomes of intravitreal ranibizumab (IVR) in eyes with diabetic macular edema (DME) based on the morphologic pattern on optical coherence tomography. Methods: A prospective and consecutive series of 55 eyes with DME was classified according to OCT features: diffuse retinal thickening (DRT), cystoid macular edema (CME), and serous retinal detachment (SRD). Patients received three consecutive monthly injections of IVR and as needed thereafter. The primary outcome was the number of treatments undertaken by DME type over 12 months. Best-corrected visual acuity, retinal thickness, and microstructural changes were also evaluated. Results: The eyes were classified as DRT (n = 23), CME (16), or SRD (16). The mean number of injections over 12 months was significantly different among the groups: DRT (3.69), CME (5.33), and SRD (5.09; P = 0.028). Best-corrected visual acuity of SRD (20/60) was significantly worse than that of the other types (DRT = 20/38; CME = 20/43; P = 0.015) after 12 months. Conclusion: Vision gains and retinal anatomy improvement were maintained in all three types during the first year of IVR administration. Especially, DRT maintained a good response to ranibizumab in a fewer number of injections. Disruption of the photoreceptor integrity at the baseline was correlated with poorer visual outcome and occurred more frequently in SRD.

Changes of parafoveal retinal nerve fiber layer thickness analyzed by spectral-domain optical coherence tomography after pars plana vitrectomy.

Purpose: To use spectral-domain optical coherence tomography to evaluate the postoperative retinal nerve fiber layer (RNFL) thickness changes in eyes undergoing vitrectomy. Methods: This is a retrospective study of 44 patients (44 eyes) who underwent monocular vitrectomy for an epiretinal membrane (19 eyes), macular hole (12 eyes), or vitreous hemorrhage (13 eyes). Quantitative analysis of the peripapillary RNFL by spectral-domain optical coherence tomography was performed before surgery and for 6 months postoperatively on both eyes. Results: Mean patient age was 62.72 ± 9.11 years. Mean preoperative RNFL thickness did not differ significantly between vitrectomized eyes (88.33 ± 13.23 &mgr;m) and nonvitrectomized fellow eyes (87.49 ± 13.18 &mgr;m; P > 0.05). In vitrectomized eyes, the preoperative mean RNFL thickness in the superior quadrant was significantly different from that at 6 months after surgery (P = 0.02). Vitrectomized eyes with a macular hole showed significant changes in the mean RNFL thickness in the inferior quadrant (P = 0.04). Conclusion: Retinal nerve fiber layer thickness was reduced in some of the quadrants of the vitrectomized eye during the 6-month postoperative follow-up period. Spectral-domain optical coherence tomography can be clinically useful for detection of localized RNFL defects in patients who underwent vitrectomy. Future prospective studies with more patients and longer follow-up duration are required.

Laser Photocoagulation Enhances Adeno-Associated Viral Vector Transduction of Mouse Retina

Laser photocoagulation is a well-established treatment modality for retinal disease. Discrete laser burns can be placed anywhere in the retina, singly or multiply, and the burn intensity is controllable. This study investigates the effect of prior laser photocoagulation on the retinal transduction properties of intravitreally administered adeno-associated viral (AAV) vectors. C57BL/6J mice were subjected to unilateral laser photocoagulation 48 hr before bilateral intravitreal injection of self-complementary cytomegaloviral enhanced green fluorescent protein (EGFP) vectors packaged in AAV type 2, 5, and 8 capsids. The eyes were enucleated 4 weeks after injection and examined by histochemistry and quantitative image analysis. Laser pretreatment resulted in substantially increased localized transduction around the burn site for all AAV capsid types. Without laser pretreatment, the vectors transduced only ganglion cells (AAV2) or sporadic cells around the optic nerve head (AAV5 and AAV8). Laser pretreatment increased AAV2 vector expression throughout the entire retina and focally at the burn site. Transduced cells at the burn site included retinal pigment epithelium (RPE), photoreceptors, Müller cells, inner nuclear layer cells, and retinal ganglion cells. The AAV5 vector showed increased RPE transduction at the burn site only. The AAV8 vector showed augmented expression in RPE, photoreceptors, and Müller cells around the burn site. Migrating RPE cells, present in the neural retina near the burn site, were also transduced by all three capsid types as evidenced by colocalization of EGFP and cytokeratin. Laser photocoagulation can be used to precisely direct AAV vector transduction to discrete locations in the retina. A combination of laser and AAV-mediated gene expression may allow the development of improved therapies for diabetic retinopathy, branch and central vein occlusion, and age-related macular degeneration.

Segmentation error and macular thickness measurements obtained with spectral-domain optical coherence tomography devices in neovascular age-related macular degeneration

Purpose: To evaluate frequency and severity of segmentation errors of two spectral-domain optical coherence tomography (SD-OCT) devices and error effect on central macular thickness (CMT) measurements. Materials and Methods: Twenty-seven eyes of 25 patients with neovascular age-related macular degeneration, examined using the Cirrus HD-OCT and Spectralis HRA + OCT, were retrospectively reviewed. Macular cube 512 × 128 and 5-line raster scans were performed with the Cirrus and 512 × 25 volume scans with the Spectralis. Frequency and severity of segmentation errors were compared between scans. Results: Segmentation error frequency was 47.4% (baseline), 40.7% (1 month), 40.7% (2 months), and 48.1% (6 months) for the Cirrus, and 59.3%, 62.2%, 57.8%, and 63.7%, respectively, for the Spectralis, differing significantly between devices at all examinations (P < 0.05), except at baseline. Average error score was 1.21 ± 1.65 (baseline), 0.79 ± 1.18 (1 month), 0.74 ± 1.12 (2 months), and 0.96 ± 1.11 (6 months) for the Cirrus, and 1.73 ± 1.50, 1.54 ± 1.35, 1.38 ± 1.40, and 1.49 ± 1.30, respectively, for the Spectralis, differing significantly at 1 month and 2 months (P < 0.02). Automated and manual CMT measurements by the Spectralis were larger than those by the Cirrus. Conclusions: The Cirrus HD-OCT had a lower frequency and severity of segmentation error than the Spectralis HRA + OCT. SD-OCT error should be considered when evaluating retinal thickness.

TOPOGRAPHIC CHANGES IN MACULAR GANGLION CELL-INNER PLEXIFORM LAYER THICKNESS AFTER VITRECTOMY WITH INDOCYANINE GREEN-GUIDED INTERNAL LIMITING MEMBRANE PEELING FOR IDIOPATHIC MACULAR HOLE.

Purpose: To evaluate the topographic changes in macular ganglion cell–inner plexiform layer (GCIPL) thickness after vitrectomy with indocyanine green–guided internal limiting membrane (ILM) peeling in eyes with idiopathic macular hole. Methods: This is a retrospective analysis of 58 consecutive eyes with surgically closed macular hole after vitrectomy with indocyanine green–guided ILM peeling. Further, 31 eyes that had undergone vitrectomy without ILM peeling were used as the control group. The macular GCIPL thickness was measured with spectral domain optical coherence tomography before vitrectomy and at 1 month and 6 months after vitrectomy. Results: The preoperative mean GCIPL thickness was 78.79 &mgr;m and mean thickness at 1 month and 6 months after surgery significantly reduced progressively to 70.93 &mgr;m and 67.64 &mgr;m (P < 0.001 and P < 0.001, respectively). The postoperative mean GCIPL thickness was significantly lower than that of the group without ILM peeling at 1 month and 6 months postoperatively (P < 0.001, P < 0.001, respectively). The GCIPL thickness in the temporal area was significantly lower than in the nasal area at 1 month and 6 months postoperatively (P < 0.001, P < 0.001, respectively). Conclusion: A reduction of the macular GCIPL thickness was observed after vitrectomy with indocyanine green–guided ILM peeling for idiopathic macular hole, especially in the temporal area.

Impact of photodynamic therapy on quality of life of patients with age-related macular degeneration in Korea

PurposeTo assess quality of life (QOL) changes in patients with age-related macular degeneration (AMD) before and after treatment with photodynamic therapy (PDT).MethodsIn 625 patients with AMD, the EuroQol Health Questionnaire (EQ-5D) for general health status and the Visual Function Questionnaire (VF-4D) for vision-related reading ability, independence, and fear for the future were used and the results compared between within 1 week before PDT and 1 year after PDT. Subscale QOL changes were also scored with the Korean versions of EQ-5D and VF-4D.ResultsEQ-5D scores of male patients were higher than those of female patients (P < 0.05), and scores of unilateral patients were higher than those of bilateral patients (P < 0.001). Among all patients, 41.2% had a higher EQ-5D score after PDT. The mean differences between before and after treatment, estimated by three different models, the Korean model, the UK model, and the Japanese model, were all statistically significant (P < 0.001). Utility measured by the VF-4D score after PDT increased by 16.1% (P < 0.001), and subscale utilities indicated significant improvements in fear for the future (21.1%), reading ability (16.6%–14.5%), and independence (11.6%).ConclusionsPDT for patients with AMD improved both general health-related QOL and vision-related QOL, as well as subscale scores, as evaluated by EQ-5D and VF-4D.

Macular Hole Formation after Pars Plana Vitrectomy for the Treatment of Valsalva Retinopathy: A Case Report

We report a case of complete surgical resolution of Valsalva retinopathy that manifested as a premacular hemorrhage involving a membrane followed by a macular hole (MH) resulting from the first vitrectomy. A 20-year-old female patient was referred to our hospital due to sudden vision loss in the left eye. Her best-corrected visual acuity (BCVA) in the left eye was hand motion. Fundus photographs and optical coherence tomography (OCT) revealed a premacular hemorrhage. Nine weeks later, the BCVA in the left eye had returned to 20 / 100 and the premacular hemorrhage had completely resolved, but residual sub-internal limiting membrane deposits and a preretinal membrane were present. The preretinal membrane was removed by core vitrectomy and preretinal membrane peeling, but the foveal deposits could not be excised. Two weeks after the first vitrectomy, the deposits resolved spontaneously, but a full-thickness MH was present. Six months after a second vitrectomy with fluid-gas exchange, the BCVA in the left eye had improved to 20 / 25 and OCT showed that the MH had closed. This case illustrates the possibility of MH formation following vitrectomy for Valsalva retinopathy.

New profiles of posterior pole retinal thickness map in healthy Korean eyes measured by spectral-domain optical coherence tomography.

Purpose: To analyze posterior pole retinal thickness using the new Spectralis HRA + OCT protocol and compare two commercially available spectral-domain optical coherence tomography instruments (Spectralis HRA + OCT and Cirrus HD-OCT) in young healthy eyes. Methods: Retinal thickness in 178 young healthy eyes was measured using the volume scan mode and Posterior Pole Asymmetry Analysis of the Spectralis HRA + OCT and the macular cube 512 × 128 protocol of the Cirrus HD-OCT. Topologic differences in posterior pole retinal thickness between the two spectral-domain optical coherence tomographies were compared, and the relationship between retinal thickness and age or refractive error/axial length was assessed. Results: Mean retinal thickness measurements in all 9 Early Treatment Diabetic Retinopathy Study Report areas were significantly greater with the Spectralis HRA + OCT than with the Cirrus HD-OCT (P < 0.001). Retinal thickness measured with the new Spectralis HRA + OCT protocol positively correlated with refractive error (P < 0.05) and negatively correlated with axial length (P < 0.05), mainly in the temporal areas. As axial length increased and refractive error decreased, retinal thickness decreased significantly at the outer temporal areas compared with the nasal areas (P < 0.05). Foveal thickness measured with the Spectralis HRA + OCT correlated significantly with refractive error (r = −0.151; P = 0.022) and axial length (r = 0.352; P < 0.001). Conclusion: Posterior pole retinal thickness measurements in young healthy eyes should provide more detailed standard values for diagnosing and managing retinal disease.