Kyung Eun Han

Evaluation of Dry Eye and Meibomian Gland Dysfunction After Cataract Surgery

PURPOSE To evaluate dry eye and meibomian gland dysfunction after cataract surgery. DESIGN Prospective observational case series. METHODS We studied 58 eyes of 48 patients who underwent phacoemulsification and evaluated them preoperatively and at 1 month and 3 months postoperatively. Ocular symptom scores, lid margin abnormalities, superficial punctate keratopathies (SPKs), tear film break-up time (TBUT), Schirmer test, lower tear meniscus height, depth, and area using Fourier domain optical coherence tomography, meibum expressibility and images of the meibomian glands using meibography were measured. RESULTS The ocular symptom scores were worse at 1 month and 3 months postoperatively (P < 0.001 and P < 0.001, respectively). Lid margin abnormalities were significantly increased (P < 0.001 and P < 0.001, respectively) and TBUT decreased postoperatively (P < 0.001 and P < 0.001, respectively). Meibum expressibility decreased at 3 months postoperatively (P = 0.016); however, meibography score, SPK, lower tear meniscus height, depth and area and the Schirmer test did not change significantly postoperatively (all P values >0.05). CONCLUSION Meibomian gland function may be altered without accompanying structural changes after cataract surgery.

Pathogenesis and treatments of TGFBI corneal dystrophies

Transforming growth factor beta-induced (TGFBI) corneal dystrophies are a group of inherited progressive corneal diseases. Accumulation of transforming growth factor beta-induced protein (TGFBIp) is involved in the pathogenesis of TGFBI corneal dystrophies; however, the exact molecular mechanisms are not fully elucidated. In this review article, we summarize the current knowledge of TGFBI corneal dystrophies including clinical manifestations, epidemiology, most common and recently reported associated mutations for each disease, and treatment modalities. We review our current understanding of the molecular mechanisms of granular corneal dystrophy type 2 (GCD2) and studies of other TGFBI corneal dystrophies. In GCD2 corneal fibroblasts, alterations of morphological characteristics of corneal fibroblasts, increased susceptibility to intracellular oxidative stress, dysfunctional and fragmented mitochondria, defective autophagy, and alterations of cell cycle were observed. Other studies of mutated TGFBIp show changes in conformational structure, stability and proteolytic properties in lattice and granular corneal dystrophies. Future research should be directed toward elucidation of the biochemical mechanism of deposit formation, the relationship between the mutated TGFBIp and the other materials in the extracellular matrix, and the development of gene therapy and pharmaceutical agents.

Clinical findings and treatments of granular corneal dystrophy type 2 (avellino corneal dystrophy): a review of the literature.

Objectives: To review the literature about clinical findings and treatments of granular corneal dystrophy type 2 (GCD2). Methods: Various literatures on clinical findings, exacerbations after refractive corneal surgery, and treatment modalities of GCD2 were reviewed. Results: GCD2 is an autosomal dominant disease. Mutation of transforming growth factor &bgr;-induced gene, TGFBI, or keratoepithelin gene in human chromosome 5 (5q31) is the key pathogenic process in patient with GCD2. Corneal trauma activates TGFBI and then it overproduces transforming growth factor &bgr;-induced gene protein (TGFBIp), which is main component of the corneal opacity. Refractive corneal surgery is a popular procedure to correct refractive error worldwide. However, several cases about exacerbation of GCD2 after corneal refractive surgery such as photorefractive keratectomy, laser in situ keratomileusis, and laser epithelial keratomileusis have been reported. The opacities deteriorate patients best-corrected visual acuity. Recurrence-free interval varies many factors such as the type of procedure the patient had received and the genotype of the patient. To treat the opacities in GCD2, phototherapeutic keratectomy, lamellar keratoplasty, deep lamellar keratoplasty, and penetrating keratoplasty (PKP) were used. However, the recurrence is still an unsolved problem. Conclusions: Perfect treatment of exacerbation after corneal surface ablation does not exist until now. To prevent exacerbation, refractive surgeons must do a careful preoperative examination of candidates in refractive surgeries.

Phototherapeutic keratectomy in diffuse stromal haze in granular corneal dystrophy type 2.

Purpose: To determine the minimum depth of phototherapeutic keratectomy (PTK) required for diffuse haze removal in granular corneal dystrophy type 2 and to determine whether Fourier domain optical coherence tomography (FD-OCT) can be an effective technique for predicting the exact required depth of ablation. Methods: The depth of ablation used for diffuse stromal haze removal was evaluated with the slit lamp and serially taken photographs during the PTK procedure. The depth of diffuse haze was measured preoperatively using FD-OCT. Results: Forty-three eyes of 30 patients were included in this study. The mean age of the patients was 62.0 ± 8.4 years. The mean depth of PTK required was 43.7 ± 6.2 &mgr;m (range, 31–59 &mgr;m). The mean follow-up period for 29 eyes of 22 patients, who had follow-up periods of more than 6 months, was 21.0 ± 12.0 months. The mean best spectacle-corrected visual acuity of these 29 eyes was 0.43 ± 0.15 preoperatively and 0.71 ± 0.16 (P = 0.022) 1 month postoperatively. Of the 43 eyes of 30 patients, FD-OCT was evaluated in 29 eyes of 22 patients. The mean preoperative depth of diffuse haze using FD-OCT was 44.3 ± 6.4 &mgr;m. The mean depth of ablation required to remove diffuse stromal haze was 44.5 ± 5.9 &mgr;m. The actual ablated depths correlated well with the depth of haze detected by FD-OCT preoperatively (intraclass correlation coefficient = 0.719). Conclusions: FD-OCT is an accurate method of predicting the depth of PTK required to remove visually significant diffuse haze in patients with granular corneal dystrophy type 2. We advocate the use of slit-lamp biomicroscopy after the initial 30-&mgr;m ablation to determine the necessity for any further ablation.

Comparison of Two Optical Biometers.

Purpose To compare a new optical biometer device, Galilei G6 (Ziemer, Port, Switzerland), with the present optical biometer, Lenstar LS 900 (Haag-Streit, Koeniz, Switzerland), for intraocular lens (IOL) power calculation. Methods One hundred forty eyes of 140 cataract patients were evaluated with two optical biometers: the Galilei G6 and the Lenstar. The mean keratometry (K), axial length (AL), anterior chamber depth (ACD), crystalline lens thickness (LT), white-to-white (WTW), and IOL powers using the SRK/T, Holladay 1, Hoffer Q, and Haigis formulas were compared. The intrasession repeatability of the Galilei G6 measurements was assessed in 25 eyes. Results All ocular parameters measured by the Galilei G6 were highly repeatable (all intraclass correlation coefficients > 0.980). Although K and ACD did not show statistical differences between the two devices (all p > 0.05), the measurements for AL, LT, and WTW were statistically different for the two devices. The K, AL, ACD, LT, and WTW showed good correlations (r = 0.975, 0.998, 0.973, 0.946, and 0.710, respectively; all p < 0.001); however, the agreements of LT and WTW were not good between the two devices. The IOL powers using four formulas did not show statistical differences (all p > 0.05); however, agreements between the IOL powers were not strong. The ranges of 95% limit of agreements were between 1.54 and 1.90D according to the formulas. Conclusions The ocular parameters and IOL powers using the Galilei G6 cannot be used interchangeably with those of the Lenstar in clinical practice.

Comparison of intraocular pressures after myopic laser-assisted subepithelial keratectomy: tonometry-pachymetry, Goldmann applanation tonometry, dynamic contour tonometry, and noncontact tonometry.

Purpose To compare intraocular pressure (IOP) measurements using a new tonometer–pachymeter device (Tonopachy), Goldmann applanation tonometry (GAT), dynamic contour tonometry (DCT), and noncontact tonometry (NCT) before and after myopic laser‐assisted subepithelial keratectomy (LASEK). Setting Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea. Design Prospective comparative observational study. Methods Nine IOP values were measured using 4 tonometers (6 IOPs by tonometer–pachymeter and 1 each by GAT, DCT, and NCT) and compared preoperatively and 3 months postoperatively. Of the 6 IOP values measured by the tonometer–pachymeter, 1 showed uncorrected IOP and 5 indicated central corneal thickness (CCT)–corrected IOPs through different formulas. Results Preoperatively and postoperatively, the means of 9 IOP values measured by 4 tonometers were statistically different. The IOP measurements by the tonometer–pachymeter correlated with all other IOP values preoperatively; however, there was no correlation with IOP measurements using DCT postoperatively. Some IOPs using the tonometer–pachymeter were interchangeable with those using GAT preoperatively, but not with DCT preoperatively or postoperatively. The corrected IOP values of the tonometer–pachymeter formula 3 and DCT did not change after surgery. The percentage change in CCT and corneal curvature and change in diopters correlated with the percentage change in IOP measurements by GAT and NCT but not with those using DCT and the tonometer–pachymeter. Conclusion Among the 9 IOP values, corrected IOP using the tonometer–pachymeter formula 3 showed similar IOP values after LASEK, as did DCT. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Removal of lymphangiectasis using high-frequency radio wave electrosurgery.

Purpose: To describe a novel technique using high-frequency radio wave electrosurgery (Ellman Surgitron Dual Frequency RF; Ellman International, Inc) for the management of lymphangiectasis. Methods: Ablations were performed at the lowest power setting of 1 (of 100) in the cutting mode, producing the least amount of lateral heat. To prevent conjunctival hemorrhage, ablation was initiated immediately before introducing the tip of a needle electrode into the subconjunctival tissue under the target area. After the tip of the electrode reached the target area, ablation was maintained for 1 to 2 seconds on the surrounding area and for a longer time on the dilated lymphatic vessels, until the target conjunctiva blanched. These ablations were performed cautiously with the fine electrode to avoid thermal injury to the adjacent scleral tissue. Results: Persistent lymphangiectasis accompanied by accumulated fluid was successively treated with high-frequency radio wave electrosurgery. Surgical time was less than 5 minutes. There were no intraoperative complications. Fourier domain optical coherence tomography revealed resolution of the accumulated fluid and a decrease of dilated lymphatic vessels. Postoperatively, no notable complications, such as charring, scarring of Tenon capsule, or symblepharon resulting from excessive cauterization, were observed. Conclusion: High-frequency radio wave electrosurgery may be a safe, quick, and effective modality for the treatment of symptomatic lymphangiectasis patients.

Intraocular Lens Power Calculations for Cataract Surgery After Phototherapeutic Keratectomy in Granular Corneal Dystrophy Type 2

PURPOSE To investigate the predictability of various intraocular lens (IOL) power calculation methods in granular corneal dystrophy type 2 (GCD2) with prior phototherapeutic keratectomy (PTK) and to suggest the more predictable IOL power calculation method. METHODS Medical records of 20 eyes from 16 patients with GCD2, all having undergone cataract surgery after PTK, were retrospectively evaluated. Postoperative cataract refractive errors were compared with target diopters (D) using IOL power calculation methods as follows: 1) myopic and 2) hyperopic Haigis-L formula in IOLMaster (Carl Zeiss Meditec); 3) SRK/T formula using 4.5-mm zone Holladay equivalent keratometry readings (EKRs) (single-K Holladay EKRs method); 4) central keratometry power of true net power map in the Pentacam system (Oculus Optikgeräte GmbH); and 5) clinical history, Aramberri double-K, and double-K Holladay EKRs methods. Topographic status of corneal curvature after PTK was evaluated. RESULTS Fourteen (70%) of 20 eyes showed central island formation after PTK. When central island was present, the mean absolute error (MAE) using the hyperopic Haigis-L formula was 0.25±0.15 D. When central island was not present, the myopic Haigis-L formula showed MAE of 0.33±0.16 D. When central island formation and IOLMaster keratometry underestimation were present, the hyperopic Haigis-L formula showed the least MAE of 0.26±0.08 D when switching the IOL-Master keratometry values equal to 4.5-mm zone Holladay EKRs. CONCLUSIONS In planning for cataract surgery after PTK in GCD2, topographic analysis for central island formation is necessary. With or without central island formation, the hyperopic or myopic Haigis-L formula can be applied. When IOLMaster keratometry shows underestimation, the Haigis-L formula using 4.5-mm zone Holladay EKRs can be considered.

Successful argon laser photocoagulation of diffuse epithelial ingrowth following concomitant persistent pupillary membrane removal and phacoemulsification

UNLABELLED A 57-year-old woman had concomitant surgery of persistent pupillary membrane removal and uneventful phacoemulsification through the same temporal clear corneal incision in her left eye. Short axial lengths (right eye, 21.08 mm; left eye, 20.39 mm) with shallow angles were noted bilaterally, and other findings were not remarkable. The patient experienced angle-closure attacks 3 and 7 months postoperatively. At the second angle-closure attack, diffuse epithelial ingrowth was observed. The epithelial ingrowth covered the intraocular lens surface in the interpupillary area, the iris surface surrounding the pupil, and the temporal anterior chamber angle, but did not reach the corneal endothelial incision. After observation of iris blanching with laser photocoagulation, argon laser photocoagulation was applied to the epithelium covering the iris and angle 7 times during the following month. The epithelial ingrowth was completely removed and did not recur during the 36-month follow-up. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.

Spontaneous fracture of an implanted posterior chamber polyimide intraocular lens haptic: A case report

A 57-year-old male patient visited our clinic for decreased visual acuity in the right eye for 10 days. He denied any trauma history, but recalled that the symptom developed after straining. He had undergone uncomplicated phacoemulsification and posterior chamber intraocular lens (IOL) implantation in the bag of the right eye 11 years ago. The IOL was a three-piece silicone polyimide-haptics design. On slit-lamp examination, the IOL optic and proximal part of nasal fractured haptic were found in the anterior chamber. The distal part of fractured haptic was observed in the capsular bag. He underwent IOL exchange. The fracture site of the haptic was near the optic–haptic junction. This is the unique case report of a spontaneous fracture of an implanted posterior chamber polyimide IOL haptic, which implies the possibility of IOL haptic fracture in various haptic materials.