Soh Eun Ahn

Peripapillary choroidal thickness in patients with early age-related macular degeneration and reticular pseudodrusen

PurposeThe purpose of this study was to investigate peripapillary and macular choroidal thickness (CT) in patients with early age-related macular degeneration (AMD) with or without reticular pseudodrusen (RPD).MethodsWe investigated the medical records of 89 patients (89 eyes) with early AMD. The eyes were grouped into three categories according to the extent of RPD: no RPD, localized RPD, and diffuse RPD. Peripapillary and macular CT were measured with images obtained by spectral domain optical coherence tomography. CT in the peripapillary and macular areas was compared among groups.ResultsBoth RPD groups exhibited an older subject age and a greater female predominance compared to the non-RPD group (P = 0.007 and P = 0.030, respectively). Macular and peripapillary CT were different among the three groups (all, P < 0.001), and both RPD groups showed a thinner choroid in all areas compared to the non-RPD group after adjusting for age and sex (all, P ≤ 0.016). Temporal peripapillary and nasal macular CT at 500 μm and 1500 μm, respectively, from the fovea in eyes with diffuse RPD were significantly thinner than that in eyes with localized RPD (P = 0.008, P = 0.016 and P < 0.001, respectively).ConclusionsIn addition to the macular area, the peripapillary CT, including the area outside the macula, was thinner in eyes with RPD than in those without RPD. Significant differences in the papillomacular choroid were observed based on RPD distribution type, which suggests that variation in CT is based on the extent of RPD.

Three-dimensional configuration of subretinal fluid in central serous chorioretinopathy.

PURPOSE The purpose of this study was to characterize the 3-dimensional (3D) configuration of subretinal fluid (SRF) in idiopathic central serous chorioretinopathy (CSC) using spectral-domain optical coherence tomography (SDOCT). METHODS The OCT images of patients with CSC were reviewed retrospectively. The 3D configurations of SRF were assessed using a modified segmentation algorithm of SDOCT. The differences of the configurations between acute and chronic CSC were compared. For the patients with acute CSC, we investigated a possible relationship between early change in 3D configuration and disease prognosis. RESULTS We included 69 eyes of 68 patients in this study. The mean volume, the greatest basal diameter (GBD), and the area of SRF were not different between acute and chronic CSC. The mean peak height (PH) of SRF and the ratio of PH to GBD in acute CSC (298.13 ± 92.67 μm, 9.44 ± 2.57%) were significantly greater than those in chronic CSC (192.97 ± 71.05 μm, 5.97 ± 1.90%; P < 0.001, P < 0.001, respectively). In patients with acute CSC, the early changing pattern of 3D configurations was significantly different according to the SRF prognosis (P = 0.003). In situ decrease of SRF was observed in 94.7% of the spontaneously resolving group. However, downward elongation of SRF was observed more frequently in the persistent group (58.3%) than in the spontaneously resolving group (6.3%). CONCLUSIONS The 3D configurations of SRF were different between acute and chronic CSC. In patients with acute onset, the early change of 3D configuration was different and varied according to the SRF prognosis.

Hyperreflective external limiting membranes after successful macular hole surgery.

Purpose: To evaluate changes in external limiting membranes (ELMs) in the foveae of patients with surgically closed macular holes. Methods: In this retrospective observational case series, spectral-domain optical coherence tomography scan images were obtained from eyes of patients with macular holes closed after vitrectomy. The integrity of the ELMs was evaluated at the fovea. In eyes with a restored ELM, the reflectivity of the ELM was estimated. Results: At a mean of 19 months (range, 3.0–59.7 months) after surgery, the integrity of the ELM was restored in 21 (77.8%) of 27 eyes with closed macular holes. The ELM was not restored in six eyes with glial sealing, in which glial tissues were present in the entire retinal layer. All 21 eyes with restored ELMs had an area of hyperreflectivity within the ELM observed at the thinnest part of the fovea; this was associated with an underlying photoreceptor defect. Conclusion: Abnormally hyperreflective ELMs were frequently observed at the thinnest point of the fovea after macular hole surgery. These hyperreflective ELMs may be newly formed after surgery.

The effect and applications of acellular dermal allograft (AlloDerm®) in ophthalmic plastic surgery

PURPOSE To describe the use and efficacy of AlloDerm in ophthalmic plastic and reconstructive surgery. METHODS A retrospective review was conducted of 31 eyes of 25 patients who underwent an AlloDerm graft procedure for correction of lower lid retraction, anophthalmic socket contraction, superior sulcus deformity, implant exposure, or skin defect. Clinical outcomes were measured by the degree of improvement and incidence of complications. Operation success and reoperation rates were also evaluated. RESULTS There were 15 cases of lower lid retraction, 10 anophthalmic socket contractions, 2 superior sulcus deformities, 2 orbital implant exposures, and 2 periorbital skin defects. The mean age of the patients was 44.7 (±2.8) years. The mean follow-up period was 16.7 (±2.5) months. Twenty-seven eyes (87.1%) had successful outcomes and 4 eyes of 4 patients required further surgery. Three of those were due to undercorrection, and the other was due to severe adhesion. Applications of AlloDerm skin substitute were satisfactory at the 6-month follow-up examination. There were no statistically significant factors, such as underlying causes or degrees and locations of defects that impacted on outcome. CONCLUSIONS AlloDerm is an excellent material for correction of lid retraction, contracted socket, superior sulcus deformity, and implant exposure. In patients for whom periorbital skin grafts or flaps are inappropriate or difficult to perform, the use of AlloDerm to cover skin defects may be a good option.

Effects of a high level of illumination before sleep at night on chorioretinal thickness and ocular biometry

ABSTRACT The choroid is affected by many factors. One of the factors, change in illumination has been suggested to influence choroidal thickness. However, the effects of bright light before sleep at night on the human eye are not well established. The purpose of this study was to investigate the effects of a high level of illumination in the evening on ocular measurements. Twenty‐seven men with myopia spent seven consecutive nights in the sleep laboratory. During the first two nights, subjects were exposed to light at 150 lux between 20:00 and midnight. Then, for five consecutive nights, they were exposed to ambient light at 1000 lux between 20:00 and midnight. Ocular parameters and their diurnal variations were compared between the two periods and the effects of a high level of illumination were analyzed. After subjects were exposed to 1000 lux of illumination, axial length increased with borderline significance (p = 0.064). Macular volume and retinal thickness did not change. However, subfoveal choroidal thickness after exposure to 1000 lux of illumination (245.37 ± 52.84 &mgr;m) was significantly lower than that after 150 lux of illumination (268.00 ± 57.10 &mgr;m), (p < 0.001). Significant diurnal variations were found in mean keratometry (p = 0.039), intraocular pressure (IOP, p = 0.003), ocular perfusion pressure (OPP, p < 0.0001), macular volume (p = 0.019), and subfoveal choroidal thickness (p < 0.0001). A high level of illumination had significant effects on only IOP and OPP (p = 0.027 and 0.017, respectively). Bright light exposure before sleep at an intensity as high as 1000 lux reduced subfoveal choroidal thickness in healthy young men. In conclusion, diurnal variation in choroidal thickness can be affected by bright light exposure before sleep. HighlightsAfter bright light exposure, axial length was increased and choroidal thickness was decreased.Choroidal thickness has diurnal variation.Diurnal variation of choroidal thickness has no change after bright light exposure.

Demographic Features of Idiopathic Macular Telangiectasia in Korean Patients

Purpose To investigate the clinical and demographic features of idiopathic macular telangiectasia (MacTel) in Korean patients since the introduction of spectral domain optical coherence tomography (SD-OCT). Methods We reviewed medical records of patients who were diagnosed with MacTel from 2009 to 2013. All patients underwent fluorescein angiography and SD-OCT and were classified as type 1 or type 2 according to the classification system proposed by Yannuzzi. Results Over a period of 5 years, 4 (18.2%) patients were diagnosed with type 1 MacTel and 18 (81.8%) patients were diagnosed with type 2 MacTel. All patients with type1 MacTel were male, and their mean age was 51 ± 8.6 years. Among patients with type 2 MacTel, 3 (16.7%) were male, 15 (83.3%) were female, and the mean age was 60 ± 13.6 years. Whereas all type 1 MacTel patients had either metamorphopsia or mild scotoma, of the 18 patients with type 2 MacTel, only 4 (22.2%) had those symptoms, 10 (55.6%) complained of only mild visual impairment, and the other 4 (22.2%) had no symptoms. Intraretinal cystoid spaces were observed in 26 (72.2%) of 36 eyes with type 2 MacTel by SD-OCT. These cystoid spaces had irregular boundaries and did not correspond to angiographic leakages. Conclusions Type 2 MacTel was most common in the present study. The wider availability of SD-OCT may have contributed to the diagnosis of type 2 MacTel. Type 2 MacTel may be more prevalent than type 1 in Koreans, which corresponds to the results of Western countries.

Ultra-wide-field green (532 nm) and red (633 nm) reflectance imaging of the "sunset glow" fundus in chronic Vogt-Koyanagi-Harada disease.

Sir, A 55-year-old man complaining of recurring obscured vision in both eyes presented to our clinic during his second episode of Vogt–Koyanagi–Harada (VKH) disease [Fig. 1a]. At 2 months after recurrence, a “sunset glow” change of the fundus was observed [Fig. 1c]. Upon fundus autofluorescence (FAF) imaging taken 3 months after recurrence, short wavelength FAF (SW-FAF) images revealed normal background autofluorescence (AF) with multiple focal granular hyper-AF signals [Fig. 1e], while near infrared FAF (NI-FAF) images demonstrated decreased background AF with multiple focal granular hyper-AF signals [Fig. 1f]. Most of the hyper-AF lesions were similar between FAF images, except in the macular area. Numerous hypo-AF dots surrounded by a relatively hyper-AF halo were also observed on both FAF images, which suggested corresponding swollen retinal pigmented epithelium (RPE) cells resembling a target (target sign).[1] On FAF images taken 5 months after recurrence, several previous hyper-AF signals on both images had become weak or had disappeared [Fig. ​[Fig.1h1h,​,i].i]. Composite fundus imaging with the ultra-wide-field Optomap® 200Dx system (Optos, Dunfermline, Scotland, UK) at 1 year after recurrence revealed a characteristic “sunset glow” fundus with a clearly visible array of choroidal vessels [Fig. 2a]. In green (523 nm) laser separation imaging, retinal and choroidal vessels, including vortex veins, were clearly observed [Fig. 2b]. The red (633 nm) separation view appeared to penetrate deeper and demonstrated zones of sclera, but the choroidal vessels were obscured [Fig. 2c]. Figure 1 Color fundus image and a HRA2 cSLO fundus autofluorescence (FAF) image of the left eye. Multiple serous retinal detachments are observed after recurrence (a), A “sunset glow” sign is not observed 1 month after recurrence (b), “Sunset ... Figure 2 Optomap® composite images of the left eye at 1 year after recurrence showing a lightly pigmented fundus with obvious choroidal vessels (a), In a green separation image, a green laser penetrates to the choroid and captures choroidal vessels, including ... The “sunset glow” appearance of the fundus, which reflects depigmentation occurring at the RPE or choroid level, is commonly seen in eyes with chronic VKH disease that has persisted for months.[2] VKH disease is thought to be caused by autoimmune reactions against proteins related to stromal choroidal melanocytes. The initial inflammatory events occur in the choroidal stroma, and adjacent structures, such as the RPE and the retina, are secondarily involved.[3] SW-FAF and NI-FAF originate from two different fluorophores (lipofuscin and melanin). Lipofuscin does not demonstrate properties of NI-FAF that are known to be associated with melanin in RPE and the choroid.[4] Decreased background NI-FAF images of the eye may be due to the depigmented RPE and choroid. Regarding the correspondences of hyper-AF lesions between the 2 FAF images, it is not unusual that some fundus lesions may exhibit similar and dual AF patterns.[5] The exact mechanism underlying dual AF behavior is not known, but melanolipofuscin, oxidized melanin, or other inflammatory remnant fluorophores are potential causes. The Optomap® 200Dx imaging system is a scanning laser ophthalmoscope that uses dual frequency lasers (523 nm green laser and 633 nm red laser), and simultaneously obtains both green and red separation views. Unlike the longer red laser wavelength, green lasers cannot penetrate significantly deeper than the RPE.[6] For this reason, in healthy normal eyes, observation of the choroidal vessels or nevus posterior to the RPE with the green separation view is not possible. The choroidal vessels are better visualized on the red separation view. However, if the RPE and choroid are depigmented during the convalescent and chronic stages of VKH, the green laser may penetrate the depigmented RPE to the choroid and capture the choroidal vessels. These changes also enhance the penetration of the red (633 nm) laser, resulting in severe blurring of the choroidal vessels due to increased reflectance from the inner sclera. Therefore, if choroidal vessels begin to appear in the green separation view after initial treatment, subclinical choroidal inflammation may persist, resulting in RPE and choroidal depigmentation.

Esotropia Surgery Considering the Angle under General Anesthesia.

ABSTRACT Purpose: To compare the amount of esotropia corrected by surgery under general anesthesia and in a conscious state in esotropia surgery. Methods: The charts of 42 patients who underwent surgery under general anesthesia for correction of esotropia were reviewed. Angle of deviation was measured by the alternate prism cover test in awakened state one day before and after surgery. Under general anesthesia, angle of deviation was measured by Hirschberg or Krimsky test in 5 prism diopters (PD) scale 30 minutes after induction and at the end of the surgery. The amount of the angle of esodeviation corrected by surgery measured in awakened state (A-correction) and under general anesthesia (G-correction) was compared and analyzed to identify significant differences. Results: The median age was 4.0 years and the median preoperative esodeviation angle was 30.0 PD. The median amount of G-correction of 30.0 PD was significantly different compared with that of A-correction at postoperative day one (p=0.003). However, differences between A-correction and G-correction were not evident at postoperative one week, one month, and final follow-up examination (p= 0.191, 0.215, and 0.396, respectively). Conclusions: Esotropia in A-correction was comparable to that in G-correction only at postoperative day one. These results suggest that it is desirable to perform esotropia surgery according to the initial surgical plan of awakened state regardless of the divergence of eye position. When in doubt, it could be useful to confirm whether the actual amount of surgical correction under general anesthesia is consistent with the plan and modifying the surgical dose nomogram.