Moonjung Choi

Prevalence and risk factors of visual impairment and blindness in Korea: the Fourth Korea National Health and Nutrition Examination Survey in 2008-2010.

To describe the age, gender specific prevalence and risk factors of visual impairment and blindness in Korea.

Comparison of the Conventional Dresden Protocol and Accelerated Protocol With Higher Ultraviolet Intensity in Corneal Collagen Cross-linking for Keratoconus

Purpose: To compare the accelerated corneal cross-linking (CXL) protocol and the conventional Dresden protocol in patients with keratoconus in terms of visual acuity, keratometric values, and topographic parameters. Methods: Twenty-eight eyes of 25 patients with primary keratoconus were divided into 2 groups; 15 eyes in group 1 received CXL under the standard Dresden protocol (3 mW/cm2 for 30 min, dose 5.4 J/cm2) and 13 eyes in group 2 were treated with the accelerated protocol (30 mW/cm2 for 3 min 40 s, dose 6.6 J/cm2). Visual acuity, refractive error, keratometry values obtained by both Pentacam and Auto Kerato-Refractometer, corneal thickness, and topometric indexes were compared 6 months postoperatively. Results: The visual acuity improved significantly from 0.17 ± 0.16 to 0.08 ± 0.09 logarithm of the minimum angle of resolution in group 1 (P = 0.009). The cylindrical refractive error improved in both groups (P = 0.05 in group 1 and P = 0.011 in group 2), and the spherical equivalent increased in group 1 (P = 0.021). In group 1, the maximum keratometry value decreased by 0.55 ± 0.89 diopters (P = 0.03), and the mean keratometry value decreased by 0.44 ± 0.63 diopters (P = 0.017), whereas the changes in visual acuity, spherical and spherical equivalent refractive errors, and keratometric values in group 2 were not statistically significant. The corneal thickness at the apex decreased significantly in group 1 (P = 0.001), but the change was not significant in group 2. Conclusions: Despite a higher UV dose (6.6 J/cm2), accelerated CXL with higher UV intensity and reduced irradiation time showed a smaller topographic flattening effect than did the conventional Dresden protocol in primary keratoconus with documented progression.

Refractive Errors in Koreans: The Korea National Health and Nutrition Examination Survey 2008-2012

Purpose Our study provides epidemiologic data on the prevalence of refractive errors in all age group ≥5 years in Korea. Methods In 2008 to 2012, a total of 33,355 participants aged ≥5 years underwent ophthalmologic examinations. Using the right eye, myopia was defined as a spherical equivalent (SE) less than -0.5 or -1.0 diopters (D) in subjects aged 19 years and older or as an SE less than -0.75 or -1.25 D in subjects aged 5 to 18 years according to non-cycloplegic refraction. Other refractive errors were defined as follows: high myopia as an SE less than -6.0 D; hyperopia as an SE larger than +0.5 D; and astigmatism as a cylindrical error less than -1.0 D. The prevalence and risk factors of myopia were evaluated. Results Prevalence rates with a 95% confidence interval were determined for myopia (SE <-0.5 D, 51.9% [51.2 to 52.7]; SE <-1.0 D, 39.6% [38.8 to 40.3]), high myopia (5.0% [4.7 to 5.3]), hyperopia (13.4% [12.9 to 13.9]), and astigmatism (31.2% [30.5 to 32.0]). The prevalence of myopia demonstrated a nonlinear distribution with the highest peak between the ages of 19 and 29 years. The prevalence of hyperopia decreased with age in subjects aged 39 years or younger and then increased with age in subjects aged 40 years or older. The prevalence of astigmatism gradually increased with age. Education was associated with all refractive errors; myopia was more prevalent and hyperopia and astigmatism were less prevalent in the highly educated groups. Conclusions In young generations, the prevalence of myopia in Korea was much higher compared to the white or black populations in Western countries and is consistent with the high prevalence found in most other Asian countries. The overall prevalence of hyperopia was much lower compared to that of the white Western population. Age and education level were significant predictive factors associated with all kinds of refractive errors.

Recurred Adenoid Cystic Carcinoma of Lacrimal Gland with Aggressive Local Invasion to the Maxillary Bone Marrow without Increased Uptake in PET-CT

Dear Editor, This report describes a patient with locally aggressive adenoid cystic carcinoma (ACC) of the lacrimal gland that recurred after neoadjuvant intra-arterial chemotherapy (IAC), local surgery and postoperative radiotherapy. A 47-year-old female presented with painless swelling of her right eyelid that had persisted for 3 months. Physical examination revealed 3-mm exophthalmos of the right eye. Orbit magnetic resonance imaging (MRI) with contrast revealed an approximately 3-cm-sized enhancing lesion in the right lacrimal gland with bony invasion (Fig. 1A). Incisional biopsy verified ACC. Neoadjuvant intracarotid adriamycin and cis-platinum was started, but the patient was switched to the intravenous regimen due to facial swelling and tenderness. After two chemoreduction cycles, the patient underwent orbital exenteration. Because the resected margin of the lateral exenterated orbit and zygoma were positive for carcinoma, additional lateral zygoma bone was removed (Fig. 1B). The pathology report verified T4bN0M0 stage ACC, cribriform type, with lymphovascular invasion (Fig. 1C). The patient then received postoperative 59.4 Gy radiotherapy. An MRI taken 1 year after exenteration revealed an approximately 7-mm, focal enhancing lesion in the right anterior maxilla bone, suggestive of possible tumor recurrence. However, positron emission tomography-computed tomography (PET-CT) did not show increased uptake of fludeoxyglucose (FDG) (Fig. 1D). The patient refused to have a bone biopsy. A repeat MRI performed 2 years after surgery indicated that there was an increase in the extent of the enhancing lesion inferior to the right orbit and right pterygomaxillary fissure and suspicious tumor spread along the right foramen rotundum, but again no increased FDG uptake was observed on PET-CT (Fig. 1E). A bone biopsy was recommended which the patient refused. A PET-CT taken 3 years postoperatively again showed a stable disease state, however, the patient presented with an elevated pigmented mass along the inferolateral margin of the exenterated orbit after 6 months. An MRI revealed a markedly increased infiltrating mass along the entire maxillary sinus wall with perineural spread to the cavernous sinus via the foramen rotundum. At that time, PET-CT finally showed consistent findings of high FDG uptake (Fig. 1F). An excisional biopsy of the elevated pigmented lesion (Fig. 1G) confirmed the pathology as recurred ACC (Fig. 1H). The patient was referred to the head and neck surgery department and a salvage operation was planned, however the patient refused to undergo the operation and she did not return until she presented to the emergency room in a confused mental status with blindness in her left eye a year later. An MRI revealed an increased right maxillary sinus mass with intracranial extension, brain edema, and infiltration into the left orbital apex compressing the optic nerve (Fig. 1I). Upon refusal of further treatment, the patient died within 1 month. Fig. 1 (A) Coronal and axial views of orbit magnetic resonance imaging (MRI) taken preoperatively, revealing an approximately 3-cm-sized enhancing lesion in the right lacrimal gland with bony invasion. (B) Photograph of the exposed lateral zygoma bone during ... ACC is an aggressive malignant neoplasm with locoregional recurrence being the most common cause of disease progression and death [1]. Surgery and radiotherapy are the conventional treatment modalities, but whether the addition of IAC improves survival and whether the risk of potential toxicities should be taken remain controversial. Tse et al. [2] reported that the cumulative 5-year carcinoma cause-specific death rate was 16.7% in the group treated with IAC and exenteration. In contrast, Fellman et al. [3] reported 2 cases of ACC recurrence and distant metastasis after IAC followed by surgery and high-dose radiation therapy. We report a case of recurring ACC that involved the contralateral eye and brain, despite multimodality treatment. The condition was not detectable on PET-CT scan for several years. ACC has been reported to be FDG avid, manifesting low FDG uptake compared to size-matched squamous cell carcinoma [4]. Cribriform or tubular histologic subtypes show even lower FDG uptake compared to the solid pattern, and therefore physicians should be meticulous when interpreting PET-CT results in ACC patients. The locally aggressive nature of the cancer and the inconsistent radiologic findings [5] which was apparent in this case highlight the need for serial MRI follow-up for monitoring of disease progression, for prompt biopsy when recurrence is suspected, and for radical local control of the disease. Also, the potential complications of IAC, such as facial tenderness and swelling that were experienced by our patient, and other factors that lead to the optimal treatment response, should be taken into consideration when deciding the treatment regimen for ACC.

Effect of Accommodation on Vaulting and Movement of Posterior Chamber Phakic Lenses in Eyes with Implantable Collamer Lenses

PURPOSE To investigate and compare vaulting and movement changes during accommodation in eyes with the V4c and V4 implantable collamer lenses (ICL). DESIGN Comparative, observational case series. METHODS The medical records of 35 eyes (18 patients) with the V4 ICL and 51 eyes (26 patients) with the V4c ICL were retrospectively examined and included in analyses. Anterior chamber depth (ACD), posterior corneal surface-to-ICL distance (endo-ICL distance), pupil size, and postoperative vaulting were evaluated using the Visante anterior chamber optical coherence tomography system. Images were taken during the nonaccommodative and accommodative states 3 months after ICL implantation. Refractive error, keratometry values, axial length, intraocular pressure, and central corneal thickness were evaluated at 3 months postoperatively. RESULTS ICL vaulting did not significantly change during accommodation in eyes with either the V4 or V4c ICL (P = .532 for V4 ICL and P = .415 for V4c ICL). However, significant reductions in ACD, endo-ICL distance, and pupil size were observed during accommodation in both groups. In eyes with a V4 ICL, the change in [Δ] ACD was 0.2 ± 0.1 mm (P < .001), Δendo-ICL distance was 0.2 ± 0.1 mm (P < .001), and Δpupil size was 0.5 ± 0.9 mm (P = .021). For eyes with the V4c ICL, ΔACD was 0.2 ± 0.2 mm (P < .001), Δendo-ICL distance was 0.2 ± 0.2 mm (P < .001), and Δpupil size was 0.8 ± 1.2 mm (P < .001). The mean reductions of each parameter were not statistically different between eyes with the V4 ICL and the V4c ICL. CONCLUSIONS Contrary to the light stimulation response, accommodation does not significantly affect ICL vaulting differently in eyes with either the V4 or V4C ICLs.

Fundus autofluorescence findings in central serous chorioretinopathy using two different confocal scanning laser ophthalmoscopes: correlation with functional and structural status

PurposeTo compare autofluorescence (AF) findings using wide-field (Optomap) and conventional (HRA-AF) confocal scanning laser ophthalmoscopy (cSLO) systems in patients with central serous chorioretinopathy (CSC), and to investigate the correlations between AF findings and functional and anatomical status.MethodsOptical coherence tomography (OCT) and AF images were compared in 73 eyes with serous retinal detachment (SRD) (group A) and 30 eyes without SRD (group B). We evaluated AF findings from the SRD region, atrophic area, and foveola. Correlations between AF findings and outer retinal abnormalities in OCT and visual acuity (VA) were analyzed.ResultsOptomap-AF was more effective than HRA-AF in identifying the margins of a detached area (P = 0.001) in group A, and for monitoring mild outer retinal damage (P = 0.041) in group B. The foveolar AF grades in both instruments were significantly correlated with VA and central foveal thickness (CFT) in both group A (Optomap, VA rs = 0.33, P = 0.012; CFT rs = −0.38, P = 0.002; HRA, VA rs = 0.62, P < 0.001; CFT rs = −0.70, P < 0.001) and group B (Optomap, VA rs = 0.71, P < 0.001, CFT rs = −0.78, P < 0.001; HRA, VA rs = 0.40, P = 0.026, CFT rs = −0.40, P = 0.030).ConclusionsOptomap-AF was found to be advantageous for monitoring subretinal status in eyes with SRD, and more accurately reflected mild outer retinal changes in eyes without SRD. Foveolar AF grades of both imaging modalities were significantly correlated with functional and anatomical status.

Comparison of three types of images for the detection of retinal nerve fiber layer defects.

Purpose To compare the clinical effectiveness of three types of images for detecting retinal nerve fiber layer (RNFL) defects. Methods Three image sets of 100 subjects (9 normal control subjects, 16 glaucoma suspects, and 75 glaucoma patients) were produced using color fundus photography, typical red-free RNFL photography, and blue reflectance RNFL photography with confocal scanning laser ophthalmoscopy (CSLO). A total of 300 images were rated twice in random order by five independent evaluators who were masked to the patient characteristics; each image was rated as normal, having a diffuse RNFL defect, or showing a wedge RNFL defect. Intraobserver and interobserver agreement, sensitivity, specificity, accuracy, and area under the curve were assessed. An additional analysis was performed for identifying differences in two black-and-white RNFL photographs. Results The results showed high intraobserver agreement, with relatively low interobserver agreements among the five evaluators. Blue reflectance RNFL photography with CSLO demonstrated the best performance in sensitivity, specificity, accuracy, and area under the curve. Blue reflectance RNFL images showed better accuracy than red-free RNFL images especially in subjects with wedge defects and in advanced glaucomatous cases. Conclusions The RNFL images produced using blue reflectance with CSLO showed the best performance for the detection of RNFL defects, especially in cases with wedge defects and advanced glaucoma stages.

Sociodemographic and health behavioural factors associated with access to and utilisation of eye care in Korea: Korea Health and Nutrition Examination Survey 2008–2012

Objective To determine the sociodemographic and health behavioural factors associated with access to and utilisation of eye care in Korea. Design Nationwide cross-sectional study Methods 25 752 Koreans over the age of 30 were assessed from a national representative survey. We analysed independent variables of self-reporting eye clinic visits through multivariable analyses of sociodemographic factors. The time since the last visit to an eye clinic was used to assess access to and utilisation of eye care. Results Of the 25 752 respondents, 8237 (32.0%) visited an eye clinic in the past year, 11 028 (42.8%) were seen more than 1 year ago, while 6487 (25.2%) had never seen an ophthalmologist. Eye clinic utilisation was statistically associated with older age, female sex, higher household income, higher education levels, living in an urban area, and having comorbidities including diabetes and hypertension. Middle-aged men between 30 and 49 years were found to be less likely to receive eye care compared to the rest of the population, and the proportion that did plummeted after the financial crisis of 2007. Conclusions There is a substantial sociodemographic disparity in eye care utilisation in Korea, and men with low financial income and education level are especially at risk. Use of eye care among middle-aged men has decreased since the global financial crisis that began in 2007, and therefore healthcare policies and public interventions should be targeted at vulnerable groups to promote access to medical care.

A Case of Paradoxical Reaction after Treatment of Eyelid Tuberculosis

Dear Editor, We hereby present a case of paradoxical reaction after treatment of eyelid tuberculosis (TB) with anti-TB medication. An 89-year-old man presented with painful eyelid swelling and erythema of his left eyelid, which initially developed one month earlier (Fig. 1A); he was otherwise in a healthy condition. No history of ocular trauma or operation was reported. At the time of his first visit, his corrected vision was 20 / 20 (Snellen visual acuity) in the right and 20 / 40 in the left eye. Low vision of the left eye was presumed to be attributed to a progressed cataract. Under slit-lamp examination, there were no definite abnormal ocular signs. He had moving pain, but no restriction of motion. On inspection, inflamed palpable mass was noted on the left upper and lower eyelid; however, he had no definite tenderness of the lesion. The laboratory data showed normal values (e.g., body temperature of 37℃) except a slightly elevated erythrocyte sedimentation rate of 25 mm/hr. For 3 days prior to referral to our hospital, his symptom had not been improved by intravenous administration of ceftriaxone 2 g/day. Orbit computed tomography scan with contrast showed no sign of abscess despite diffuse infiltration of upper and lower eyelids. We did a biopsy of the upper eyelid, where formation of granulation tissues was found. Pathology showed chronic nonspecific inflammation with granulomatous lesion without definite acid-fast bacilli. Under the diagnosis of anterior orbital inflammation, high dose steroid pulse therapy using 500 mg of methylprednisolone/day for 4 days was performed and the steroid dosage was tapered with oral prednisolone. Eyelid swelling and erythema improved by one month of steroidal treatment (Fig. 1B), however after discontinuation, symptoms recurred and became even worse. Biopsy was performed again under the suspicious of TB infection, and anti-TB medication, HERZ (isoniazid 300 mg, ethambutol 800 mg, rifampin 500 mg, and pyrazinamide 25 mg daily) was started immediately. The pathology result was caseous necrosis with few acid-fast bacilli (Fig. 1C), and the interferon gamma test showed was positive for the TB antigen 6.19 IU/mL. Anti-TB medication was administered for 3 weeks, however, the patient revisited the clinic complaining of serious pain and presenting skin necrosis with discharge (Fig. 1D). The patient was admitted for daily aseptic dressing of the wound and monitoring while on HERZ medication. Eyelid swelling improved slightly but wound dehiscence and oozing was aggravated 5 weeks after the initiation of HERZ treatment (Fig. 1E). Under the presumption of paradoxical response to anti-TB medication, 60 mg of prednisolone was begun with rapid tapering. Combined administration of steroid and anti-TB treatment for 1month improved wound dehiscence and reduced granulation (Fig. 1F). Thereafter, for the following 9 months, therapy included only anti-TB medication, resulting in complete resolution of infection and inflammation. However, fibrosis of the upper eyelid caused incomplete blinking. Fig. 1 Representative photographs showing clinical course of the patient. (A) At initial visit left upper and lower eyelids were swollen with erythema. (B) After a month treatment of steroid, eyelid swelling and erythema was partially improved

The incidence and prevalence of pterygium in South Korea: A 10-year population-based Korean cohort study

Although numerous population-based studies have reported the prevalences and risk factors for pterygium, information regarding the incidence of pterygium is scarce. This population-based cohort study aimed to evaluate the South Korean incidence and prevalence of pterygium. We retrospectively obtained data from a nationally representative sample of 1,116,364 South Koreans in the Korea National Health Insurance Service National Sample Cohort (NHIS-NSC). The associated sociodemographic factors were evaluated using multivariable Cox regression analysis, and the hazard ratios and confidence intervals were calculated. Pterygium was defined based on the Korean Classification of Diseases code, and surgically removed pterygium was defined as cases that required surgical removal. We identified 21,465 pterygium cases and 8,338 surgically removed pterygium cases during the study period. The overall incidences were 2.1 per 1,000 person-years for pterygium and 0.8 per 1,000 person-years for surgically removed pterygium. Among subjects who were ≥40 years old, the incidences were 4.3 per 1,000 person-years for pterygium and 1.7 per 1,000 person-years for surgically removed pterygium. The overall prevalences were 1.9% for pterygium and 0.6% for surgically removed pterygium, and the prevalences increased to 3.8% for pterygium and 1.4% for surgically removed pterygium among subjects who were ≥40 years old. The incidences of pterygium decreased according to year. The incidence and prevalence of pterygium were highest among 60–79-year-old individuals. Increasing age, female sex, and living in a relatively rural area were associated with increased risks of pterygium and surgically removed pterygium in the multivariable Cox regression analysis. Our analyses of South Korean national insurance claims data revealed a decreasing trend in the incidence of pterygium during the study period.