Joo Young Shin

Comparison of efficacy and safety between half-fluence and full-fluence photodynamic therapy for chronic central serous chorioretinopathy.

Purpose: To compare the efficacy and safety of half-fluence photodynamic therapy (PDT) and conventional PDT in chronic central serous chorioretinopathy. Methods: A multicenter retrospective comparison study. Retrospective review of 60 patients including 29 patients (34 eyes) who received half-fluence PDT and 31 patients (33 eyes) who received conventional PDT for the treatment of chronic central serous chorioretinopathy. Best-corrected visual acuity, central fovea retinal thickness and resolution of subretinal fluid on optical coherence tomography, and choroidal perfusion decrease on indocyanine green angiography were assessed. Choriocapillaris perfusion decrease was quantified as mean gray value ratio of treated and nontreated areas using commercial imaging software. Results: Treatment success without recurrence was achieved in 32 of 34 eyes (94.1%) treated with half-fluence PDT and 33 of 33 eyes (100%) treated with conventional PDT (P = 0.493). There was no difference in final best-corrected visual acuity (logarithm of the minimal angle of resolution) between the 2 groups (0.17 ± 0.32 vs. 0.21 ± 0.39; P = 0.603). Choriocapillaris perfusion decrease quantified from post-PDT indocyanine green angiography was significantly more severe in the conventional PDT group (P = 0.006), and it showed a positive correlation with retinal thinning after PDT (R2 = 0.380; P < 0.001). Conclusion: Half-fluence PDT is as effective as conventional PDT, while minimizing the deleterious effect on choriocapillaris perfusion and retinal thickness.

Association Between Low Serum Free Thyroxine Concentrations and Coronary Artery Calcification in Healthy Euthyroid Subjects

BACKGROUND Considerable evidence suggests that hypothyroidism could promote atherosclerotic vascular changes. We planned this study to investigate whether serum free thyroxine (FT4) or thyroid-stimulating hormone (TSH) levels are associated with coronary artery calcification measured in healthy euthyroid subjects. METHODS A cross-sectional analysis was performed among subjects who visited our hospital for a health checkup. Among 1849 subjects, 669 (mean age 55.3±8.8 years; 392 men) with FT4 and TSH in the normal ranges were included after excluding those with diabetes, a history of current smoking and cardiovascular disease (CVD), or the use of drugs for hypertension, antithyroid drugs, or thyroid hormone preparations. Coronary artery calcium scores (CACS) were measured by multi-detector computed tomography. RESULTS Subjects with a CACS >100 had lower FT4 levels than those with a lower CACS (p=0.017), whereas no difference was observed in the TSH levels among CACS categories. FT4 levels had an odds ratio of 0.06 for high CACS (95% confidence interval=0.01-0.74; p=0.028) after the adjustment for CVD risk factors. In multivariate regression analysis, CACS was negatively correlated with FT4 levels (β=-0.823, p=0.032), and the inverse association between FT4 and CACS remained significant only in men (p=0.011). CONCLUSION FT4 levels were inversely associated with coronary artery calcification in euthyroid healthy subjects, especially in men independent of conventional CVD risk factors. Further studies are needed to validate whether subjects with decreased FT4 levels within the normal reference range are at a high CVD risk and have poor cardiovascular outcomes.

Genetic factors associated with response to intravitreal ranibizumab in Korean patients with neovascular age-related macular degeneration.

Purpose: To investigate the association between genetic risk variants for age-related macular degeneration (AMD) and response to intravitreal ranibizumab in Korean patients with neovascular AMD. Methods: This prospective study included 273 treatment-naive patients (273 eyes) who underwent 5 monthly injections (Months 0, 1, 2, 3, and 4) of intravitreal ranibizumab for neovascular AMD. Patients were genotyped for 23 single-nucleotide polymorphisms within 12 AMD-relevant genes. For each polymorphism, genotypic association with good response at Month 5, predetermined as visual improvement of ≥8 Early Treatment Diabetic Retinopathy Study letters from baseline, was investigated with logistic regression analysis adjusted for age, gender, smoking, baseline Early Treatment Diabetic Retinopathy Study letter, central retinal thickness, lesion area, and type of choroidal neovascularization. Results: At Month 5, visual acuity improved by 9.1 ± 17.6 letters from baseline, and 136 patients (49.8%) were classified as good responders. In logistic regression, no tested polymorphism showed statistically significant association with favorable visual outcome at Month 5. When unadjusted for multiple tests, AA genotype for VEGF rs699947 had an increased chance of good response compared with other genotypes (odds ratio, 3.61; 95% confidence interval, 1.42–9.18; P = 0.0071). Conclusion: In this Korean neovascular AMD cohort, there was no statistically significant effect of genotype on early visual outcome after ranibizumab treatment.

Optical coherence tomography-based ranibizumab monotherapy for retinal angiomatous proliferation in Korean patients.

Purpose: To evaluate the visual outcome of optical coherence tomography–based ranibizumab monotherapy in Korean patients with retinal angiomatous proliferation and identify prognostic factors of visual outcome. Methods: A prospective single-arm clinical study of 31 retinal angiomatous proliferation patients who underwent 3 consecutive monthly intravitreal ranibizumab injections was conducted. Additional treatment was given based on optical coherence tomography at monthly follow-ups over 24 months. Results: Best-corrected visual acuity improved from 48.7 ± 19.3 to 56.3 ± 19.1 letters at 24 months (P = 0.010). Total cumulative numbers of injection were 5.5 ± 2.2 and 7.7 ± 3.4 times at 12 and 24 months, respectively. Older age, larger choroidal neovascularization size, and poor initial best-corrected visual acuity were associated with poor visual outcome. Final best-corrected visual acuity was significantly worse with Stage 3 disease (70.4 ± 5.1, 62.3 ± 11.6, 46.2 ± 22.3 letters improved in each stage; P = 0.015). Among factors associated with poor visual outcome, only the stage of retinal angiomatous proliferation remained statistically significant on multiple linear regression analysis (P = 0.006). Although baseline best-corrected visual acuity was similar, Stage 3 patients exhibited limited visual improvement despite anatomical improvement, and more recurrences requiring more injections. Conclusion: Retinal angiomatous proliferation may be successfully managed with ranibizumab monotherapy in Korean patients, with the number of treatments required comparable to other forms of neovascular age-related macular degeneration. However, visual improvement was limited in late-stage RAP.

Visual prognosis and spectral-domain optical coherence tomography findings of myopic foveoschisis surgery using 25-gauge transconjunctival sutureless vitrectomy.

Purpose: To identify spectral-domain optical coherence tomography findings related to visual outcome in myopic foveoschisis after 25-gauge transconjunctival sutureless vitrectomy. Methods: Thirty-eight eyes with myopic foveoschisis were prospectively followed-up to 6 months after vitrectomy. Best-corrected visual acuity (BCVA), axial length, and spectral-domain optical coherence tomography findings were analyzed for identification of factors affecting visual outcome. Results: Best-corrected visual acuity improved significantly (preoperative 0.841 ± 0.534 logarithm of minimal angle of resolution to postoperative 0.532 ± 0.536 logarithm of minimal angle of resolution, P = 0.001), and central retinal thickness showed significant reduction (preoperative 409 ± 143 μm to postoperative 259 ± 72 μm, P < 0.001) with surgery. Anatomical success was achieved in 34/38 eyes (89.5%). Photoreceptor layer disruption was found in 20 of 38 eyes (52.6%) preoperatively and persisted after surgery in 18 of 20 eyes (90.0%). Patients with preoperative photoreceptor layer defects had significantly more associated foveal detachments and irregular choroidal surfaces and worse preoperative and final best-corrected visual acuity. Preoperative best-corrected visual acuity showed significant correlation with final best-corrected visual acuity (Pearson correlation coefficient = 0.555, P = 0.001). Patients with irregular choroidal surfaces and photoreceptor layer disruption had significantly worse final best-corrected visual acuity (P = 0.035, 0.005). Conclusion: Twenty-five-gauge transconjunctival sutureless vitrectomy showed favorable results for the management of myopic foveoschisis. Photoreceptor layer defects and irregular choroidal surfaces on spectral-domain optical coherence tomography persist despite surgery, limiting visual outcome.

Eye-Preserving Therapy in Retinoblastoma: Prolonged Primary Chemotherapy Alone or Combined with Local Therapy

Purpose To evaluate the efficacy of primary chemotherapy combined with local therapy in the treatment of retinoblastomas not treatable with a single therapeutic method. Methods We performed a retrospective chart review of 227 patients diagnosed with retinoblastoma. Sixty-five eyes in 52 patients had tumors not treatable with a single therapeutic method and received primary chemotherapy combined with local therapy as needed. Results Tumor control and eye salvage was achieved in 34 of the 65 eyes; the probability of ocular survival was 46.56% using the Kaplan-Meier method. Forty-three of the 65 eyes were group D or E tumors, in which tumor control and eye salvage was achieved in 16 eyes. Twenty eyes were treated with chemotherapy only, while 28 eyes received one additional modality of local therapy, and 17 eyes received two modalities of local therapy. Of the eyes treated with chemotherapy only, tumor control was achieved in 5 eyes. Conclusions Primary chemotherapy combined with local therapy can be effective and safe in the treatment of retinoblastomas otherwise untreatable with other therapeutic methods, such as group D and E retinoblastomas. More vigorous treatment with more local therapeutic methods combined may yield even better results.

Complications of Pathologic Myopia.

Abstract: Pathologic myopia (PM) is one of the leading causes of visual impairment worldwide. The pathophysiology of PM is not fully understood, but the axial elongation of the eye followed by chorioretinal thinning is suggested as a key mechanism. Pathologic myopia may lead to many complications such as chorioretinal atrophy, foveoschisis, choroidal neovascularization, rhegmatogenous retinal detachment, cataract, and glaucoma. Some complications affect visual acuity significantly, showing poor visual prognosis. This article aims to review the types, pathophysiology, treatment, and visual outcome of the complications of PM.

The Efficacy of Superior Inverted Internal Limiting Membrane Flap Technique for the Treatment of Full-Thickness Macular Hole:

The Efficacy of Superior Inverted Internal Limiting Membrane Flap Technique for the Treatment of Full-Thickness Macular Hole Vitrectomy for macular holes (MHs) has shown a high closure rate and evident vision improvement.1–4 Many studies have shown that the removal of a membrane at the vitreoretinal interface in patients with idiopathic MH produced good functional and anatomical results.4–7 Surgical treatment of MHs aims to relieve vitreofoveal traction because firm foveal vitreous adhesion, anteroposterior vitreomacular traction, and tangential traction are believed to be the main factors in the pathogenesis of MH.2 In 2010, Michalewska et al8 suggested an inverted internal limiting membrane (ILM) flap technique for the treatment of idiopathic large MH. This technique prevented the postoperative flat-open appearance of MHs and improved the functional and anatomical results for MHs with a large diameter (.400 mm).9 However, the spontaneous retroversion of the ILM flap, or even ILM flap loss, occurs in up to 14% to 20% of patients during fluid–air exchange.8,10 Moreover, the patients have to mostly lie face down after the surgery. Recently published studies have introduced a modification of the classic inverted ILM flap technique.11,12 In this procedure, ILM peeling was restricted to the temporal side of the fovea, and the MH was covered with the temporal ILM flap. These studies concluded that the new technique was as effective as the classic inverted ILM flap technique for repairing large MHs. However, the temporal-side ILM flap could be difficult to keep in position because of the vector sum between gravity and the ILM tangential force. Therefore, in the present study, we attempted a novel modification by changing the direction of the ILM flap to the superior side to decrease the need of staying prone after the surgery for patients who had difficulty maintaining this position. We investigated the efficacy and convenience of the superior inverted ILM flap technique for the treatment of large idiopathic fullthickness MH. To our knowledge, this is the first study reporting the surgical outcome of this modified technique.

Long-Term Outcomes Following Trabeculectomy Combined with 25-Gauge Transconjunctival Sutureless Vitrectomy in Uveitis Patients

Abstract Purpose: To evaluate the efficacy of combined trabeculectomy (TLE) and 25-gauge transconjunctival sutureless vitrectomy (TSV-25) for uveitis patients. Methods: Combined TSV-25/TLE was performed in 9 eyes of 6 patients with vitreoretinal complications and intractable glaucoma. Visual acuity, intraocular pressure (IOP), inflammatory control, and number of hypotensive medications were evaluated. Results: Visual acuity improved in 7 of 9 eyes and inflammation was controlled with a decreased oral anti-inflammatory agent dosage in all eyes. Mean IOP, which was 28.11 ± 4.83 mmHg preoperatively, was significantly reduced (15.77 ± 2.68 mmHg) 5 years after surgery (p = 0.008). The mean number of IOP-lowering medications was 3.33 ± 0.71 before surgery and 1.11 ± 0.92 5 years after surgery (p = 0.007). Two eyes required implant of an Ahmed drainage valve during the follow-up period. Conclusion: Combined TSV-25/TLE can be effective in managing vitreoretinal complications and elevated IOP in uveitis patients.

Temporary Haptic Externalization and Four-point Fixation of Intraocular Lens in Scleral Fixation to Enhance Stability

Purpose To report the results of a new technique for intraocular lens scleral fixation of temporary haptic externalization and four-point fixation for enhanced stability. Methods Two 10–0 polypropylene strands were fixed at two points 2 mm apart on each haptic of a conventional three-piece intraocular lens, using our previously reported method of temporary haptic externalization after injector implantation. Postoperative refractive outcome and stability were evaluated. Results Although the intraocular lens was fixed at a total of four points, no intraoperative difficulties were observed during the process. Patients showed successful fixation of the intraocular lens postoperatively. The fixed intraocular lens showed good centering and minimal tilting. When compared to the two-point fixation technique, postoperative astigmatism was significantly smaller in the four-point fixation group (1.80 ± 0.84 vs. 1.00 ± 0.0.50, p = 0.033). Lens-induced astigmatism calculated from subtraction of corneal astigmatism from total astigmatism was also significantly smaller in the four-point fixation group (2.23 ± 0.98 vs.1.17 ± 0.0.70, p = 0.043). No postoperative complications were identified during a mean follow-up period of 14.8 months (range, 10 to 19 months). Conclusions By fixing the intraocular lens at two points on each side of the haptics, this method minimizes the tilting of the intraocular lens and thus decreases postoperative lens-induced astigmatism. Also, the possibility of intraocular lens dislocation in the long term might be decreased by this two-point fixation technique.