Jen-Shang Huang

Foveola nonpeeling technique in internal limiting membrane peeling of myopic foveoschisis surgery.

Foveola Nonpeeling Technique in Internal Limiting Membrane Peeling of Myopic Foveoschisis Surgery Myopic foveoschisis is a unique complication of posterior staphyloma in highly myopic eyes. The formation of macular hole and posterior retinal detachment are well-known consequences of this unstable condition. Early stages of such degenerative changes can only be detected using the high-resolution imaging technique optical coherence tomography (OCT). Tangential traction is believed to be one of the main causes of the disease, along with anteroposterior traction. The significant role of vitreous and internal limiting membrane (ILM) traction is confirmed by the good results obtained by vitrectomy with gas tamponade and facedown positioning. However, postoperative development of full-thickness macular hole in some of the cases required surgery, jeopardizing the central fovea tissue, which existed preoperatively. The present report describes an ILM peeling technique that leaves the epifoveolar tissue in situ and thus prevents the development of macular hole.

Central retinal artery occlusion caused by expansion of intraocular gas at high altitude.

PURPOSE To report a case of central retinal artery occlusion caused by expansion of intraocular gas during mountain travel at high altitude. DESIGN Interventional case report. METHODS A 46-year-old man underwent vitrectomy with intraocular gas tamponade for rhegmatogenous retinal detachment, right eye. During his trip to Mountain Ali with an altitude of 6,210 feet, he felt a sensation of fullness and noted loss of vision in his right eye. When he came down to sea level, an intraocular pressure of 54 mm Hg was present in the right eye. He visited our clinics 2 weeks after the episode, and the right eye had best-corrected visual acuity of counting fingers, intraocular pressure of 14 mm Hg, attenuated retinal arteries, and a pale optic disk. RESULTS Because of irreversible damage to the retina of the right eye, he did not receive any treatment. CONCLUSIONS We should not neglect the possibility of hazard for patients with intraocular gas under low atmospheric pressure circumstances, such as mountain travel.

Ciliary detachment after pars plana vitrectomy: an ultrasound biomicroscopic study.

Purpose To determine the incidence, duration, risk factors, and clinical outcomes for ciliary detachment after pars plana vitrectomy (PPV). Methods A total of 109 eyes of 103 patients who underwent PPV for various disease entities were included. Ultrasound biomicroscopy was applied to determine the tomographic features of the ciliary body before and 1, 3, and 7 days after the surgery. All eyes were then examined once weekly for 2 months. Demographic, preoperative, intraoperative, and postoperative parameters were evaluated to assess their predictive value in the formation of postvitrectomy ciliary detachment. Results Ciliary detachment was observed in 46 eyes (42%) after surgery and persisted for less than 3 weeks in 40 of 46 eyes. It most frequently occurred in eyes of patients with proliferative diabetic retinopathy (PDR) (64%) or retinal vascular obstructive diseases (RVO) (47%). Extensive retinal photocoagulation and retinal cryopexy positively predisposed to its formation whereas fluid–gas exchange had a protective effect. No clinical complications were observed in eyes with postoperative ciliary detachment. Conclusion Ciliary detachment occurred frequently after PPV. A diagnosis of PDR or RVO and surgical procedures with extensive retinal photocoagulation and retinal cryopexy may have a higher incidence of its occurrence.

Visual Outcome in Primary Macula-Off Rhegmatogenous Retinal Detachment Treated With Scleral Buckling

BACKGROUND AND PURPOSE To evaluate the visual outcome of primary macula-off rhegmatogenous retinal detachment after successful scleral buckling. METHODS A retrospective, non-controlled case series study was conducted in 93 patients (93 eyes) who underwent primary successful scleral buckling procedure for retinal detachment. Factors including duration of macular detachment, patient age, preoperative best-corrected visual acuity (VA), surgical management of subretinal fluid, and refractive error were analyzed statistically to determine their association with final visual outcome. RESULTS Postoperative VA of 20/50 or better was found in 53.6% of eyes with duration of macular detachment within 7 days, and 29.7% of eyes with macular detachment for more than 7 days (Fishers exact test, p = 0.019). VA better than 20/50 was found in 61% of eyes with preoperative VA better than 20/400 and in 33.9% with preoperative VA worse than 20/400 (Fishers exact test, p = 0.008). Patients aged 30 years or less achieved better mean postoperative VA than those aged 31 to 50 and those aged 50 years and older (ANOVA, p = 0.003). Patients with low-grade myopia (< -6D) regained significantly better mean postoperative VA as compared with high myopia (> -6D) and emmetropic eyes (0 to +3D) (ANOVA, p < 0.001). Subretinal fluid drainage procedure did not affect postoperative visual result. Multivariate logistic regression analysis revealed that the duration of macular detachment was the only variable affecting the visual result. CONCLUSION Scleral buckle surgery performed within the first week, preoperative vision more than 20/400, age younger than 30 years old, and low-grade myopia were associated with significantly better visual recovery from macular-off rhegmatogenous retinal detachment.

Bilateral macular coloboma and pigmented paravenous retinochoroidal atrophy.

A patient had bilateral macular coloboma with aggregations of pigment clumps located perivascularly, predominantly paravenously, and in other parts of the retina. The Toxoplasma IgG antibody was negative. The diagnosis of bilateral macular coloboma with pigmented paravenous retinochoroidal atrophy was made and seemed to be a developmental abnormality in origin.

Vitreous Levels of Reactive Oxygen Species in Proliferative Diabetic Retinopathy

OBJECTIVE To investigate vitreous levels of reactive oxygen species (ROS) in patients with proliferative diabetic retinopathy (PDR) and analyze ROS levels among different groups of PDR patients. DESIGN Retrospective case-control study. PARTICIPANTS Thirty-nine eyes of 39 patients with PDR and 16 eyes of 16 non-PDR patients (control group) that underwent primary vitrectomy for complications of PDR and other conditions (control group), with a follow-up time > or = 12 months. METHODS Proliferative diabetic retinopathy patients were classified into 3 groups according to the extent of fibrovascular proliferation: (1) no or focal adhesions at < or =3 sites (n = 17); (2) > or =1 broad adhesions or vitreous-retinal adhesions around disc, macula, and arcade (n = 12); and (3) vitreous-retinal attachment extending to the periphery or no posterior vitreous detachment with or without retinal detachment (RD) (n = 10). The control group (n = 16) contained non-PDR patients. Vitreous samples were obtained during measurement of vitrectomy and vitreous levels of ROS by luminol-enhanced chemiluminescence assay. MAIN OUTCOME MEASURES Reactive oxygen species levels were recorded as mean (+/- standard deviation) chemiluminescence counts per 10 seconds. Correlations of vitreous levels of ROS among the 3 PDR groups and anatomic prognosis were evaluated. Multiple linear regression analysis of selective potential risk factors was performed to investigate the main determinants of ROS levels. RESULTS Vitreous ROS levels were significantly higher in patients with PDR (125.76+/-351.72 chemiluminescence counts per 10 seconds) than in control patients (0.37+/-0.72 chemiluminescence counts per 10 seconds; P<0.0001). Reactive oxygen species levels were 1.86+/-1.63 (group 1), 24.47+/-22.68 (group 2), and 457.94+/-597.01 (group 3); the difference among groups was significant (P = 0.001). Regression analysis indicated that only patient grouping (according to the severity of fibrovascular proliferation) had a strong dependent association with ROS levels (P = 0.001). Final anatomic results revealed that recurrent untreatable RD occurred in 3 patients of group 3, who also had the highest ROS levels. CONCLUSIONS Reactive oxygen species levels were significantly elevated in the vitreous fluid of PDR patients, and patients with a more advanced clinical PDR appearance had higher ROS levels. These findings suggest an association between ROS and the pathogenesis of PDR. Reactive oxygen species might be correlated with PDR severity.

Early-onset severe donor-related Candida keratitis after descemet stripping automated endothelial keratoplasty.

Donor-related keratitis is a rare complication in cornea transplantation. Only a few cases of Candida keratitis after Descemet stripping automated endothelial keratoplasty (DSAEK) have been reported, with varying onsets and outcomes. We report a case of early-onset severe Candida albicans interface keratitis and endophthalmilitis after DSAEK. A 45-year-old woman had bilateral corneal edema and a cataract with 20/200 vision in her right eye. She underwent uneventful DSAEK, phacoemulsification, and implantation of a posterior intraocular lens in her right eye. Infiltrates at the lenticular edge and a strong anterior chamber reaction were observed on postoperative Day 1. Anterior chamber paracentesis for cultures and an intracameral injection of 0.1 mL of 0.5% moxifloxacin were performed. Infiltrates developed at the graftehost interface on Day 3 (Fig. 1A). Cultures from the donor corneal rim and paracentesis both yielded C. albicans (þ2). Topical voriconazole (1%) hourly and systemic fluconazole (400 mg daily) were administered on Day 3. Removal of the donor lenticule, anterior chamber irrigation with 0.2%

Severe ocular complications following facial calcium hydroxylapatite injections: Two case reports

Dermal soft-tissue augmentation using a filler is a technique widely used for facial cosmetic enhancement. However, potential complications following facial cosmetic injections have heightened the possibility of iatrogenic visual loss. We report two cases of severe ocular complications after nasal cosmetic enhancement. Both cases had poor visual outcomes in spite of emergency management. The second patient is a rare case with bilateral anterior ischemic optic neuropathy after dermal soft-tissue augmentation. The visual outcome was correlated with the location and the extent of the arterial embolization. Unfortunately, there is still no standard treatment protocol for vision-threatening complications. Clinicians should always keep in mind that embolic arterial occlusion may occur after augmentation.

Effects of lid suturing and trans-scleral cryotherapy on ocular growth in a piglet model.

Purpose. To study whether lid suturing can induce axial myopia and explore whether trans-scleral cryotherapy can affect ocular growth in piglets or not Methods. A total of fourteen 2- to 3-week-old piglets were studied. Three groups were included: lid suture, cryotherapy, and both lid suture/cryotherapy groups. The lid suturing group (N=6) was given lid suturing to produce visual deprivation. The cryotherapy group (N=4) received transcleral cryotherapy 360° to encircle anterior to the equator. Both treatment groups (N=4) received both cryotherapy and lid suturing. The cycloplegic refraction, corneal power, biometric axial length, and intraocular pressure (IOP) were measured before the experiments and 4 months later. Results. Mild axial myopia was induced in five lid-sutured eyes of the lid suturing group. The ocular refraction and eye size of cryotherapy eyes were not different from the control eyes in the cryotherapy group. More myopia was found in all four piglets that received both cryotherapy and lid suturing. Conclusions. Lid suturing can induce axial myopia; however, cryotherapy did not affect normal eye growth and did not prevent the development of lid suturing myopia in piglets.

Oral Levofloxacin Brings Better Results in Treating Endogenous Klebsiella pneumoniae Endophthalmitis

Dear Editor: We read with great interest the recent article ‘‘Aqueous and vitreous penetration of linezolid and levofloxacin after oral administration’’ by George and associates. They concluded that single concomitant doses of linezolid and levofloxacin achieved aqueous and vitreous concentrations above the minimum inhibitory concentration for 90% (MIC) of common ocular pathogens, including Klebsiella pneumonia (KP), up to 12 h after administration. We would like to express great admiration for their work. In our opinion this treatment should be routinely administered in clinical practice. Also, we would like to present our successful experience in treating with oral levofloxacin endogenous KP endophthalmitis, one of the most disastrous types of endophthalmitis originating from liver abscess. Based on the work by George and associates and our clinical experience, the ophthalmic community should consider adjusting the treatment policy of this devastating disease. In past decades, it has been well recognized that endogenous KP endophthalmitis almost unavoidably brought an extremely poor visual outcome. As KP endophthalmitis is prevalent in Taiwan, we would like to report our successful experience in achieving good visual outcomes with improved treatment modalities. A 53-year-old male with underlying diabetes mellitus suffered from liver abscess with KP bacteremia. Endogenous endophthalmitis in the right eye developed 3 days later. Initial corrected visual acuity was counting fingers at 80 cm. Immediate intravitreal injection (IVI) of vancomycin and ceftazidime was given. Hypopyon developed and vision deteriorated to hand motion by the next day. Emergent pars plana vitrectomy (PPV) was done. In addition to systemic administration of ceftriaxone, oral levofloxacin 500 mg once daily was also given for 2 weeks. Repeated IVI of ceftazidime and a second PPV were done 1 and 3 weeks after the first surgical intervention, respectively. Intraocular inflammation completely subsided with only localized subretinal scar remaining. Unfortunately, rhegmatogenous retinal detachment occurred at 5 weeks after initial symptom onset and PPV and silicone oil injection were performed. After silicone oil removal, the patients’ vision reached 20/32. Studies of endogenous KP endophthalmitis have shown that the initial visual acuity at diagnosis and intervention is an important prognostic factor for a better visual outcome. Thus early diagnosis and intervention are believed to be crucial in treating this devastating disease. The latest case– control study revealed that the presence of hypopyon is a marker for poorer visual outcome. However, it is noteworthy that in our case of typical endogenous KP endophthalmitis with an initial visual acuity of counting fingers and documented hypopyon, a final visual acuity of 20/32 was achieved. This dramatic improvement in visual acuity was very rare compared with previous reports. Prompt surgical intervention and intravitreous administration of antibiotics should predominate, but we believe that administration of an additional systemic antibiotic, levofloxacin, a divergence from the traditional regimen, may be helpful. The use of intravenous ceftriaxone as the first choice in endogenous KP endophthalmitis is according to the result of a single study done by Sharir et al. in 1989, which showed reliable vitreal penetration of ceftriaxone through systemic administration. By contrast, good ocular penetration of fluoroquinolones has been documented in several human studies and animal models. Achieving a therapeutic level of levofloxacin against most gram-negative bacteria has also been observed in oral drug administration. Vitreous concentrations of 1.6 mg/mL can be achieved 2.5–4 h after oral intake of levofloxacin 500 mg, which is well over the MIC of KP (0.13 mg/mL). The use of systemic levofloxacin seems to be supported by more evidence. In their work, George and associates demonstrated that a single oral dose of levofloxacin 750 mg achieved an average concentration of 2.83 – 0.80 mg/mL about 602 min after administration, which is higher than needed. The past 2 decades have shown no significant improvement in the visual outcome of endogenous KP endophthalmitis. We postulated that intravenous ceftriaxone as the conventional treatment might not have a high enough intraocular concentration to be effective against KP endophthalmitis. In our case, prompt intervention and the use of systemic levofloxacin produced a good outcome. Although early detection and intervention are of most importance, we also believe modifications to the traditional systemic antibiotic treatments are worth trying. We congratulate George and associates on their work and for their clarification of the issue. Their application in