Soo Geun Joe

The therapeutic effects of bevacizumab in patients with polypoidal choroidal vasculopathy.

Purpose To evaluate the efficacy and safety of intravitreal bevacizumab for polypoidal choroidal vasculopathy (PCV). Methods In this retrospective interventional pilot study, 12 eyes of 11 patients with active PCV were treated with intravitreal bevacizumab (1.25 mg) alone or in combination with photodynamic therapy (PDT) depending on the informed patients choice. Intravitreal bevacizumab was repeated at 6-week intervals until the regression of active lesion was detected on fluorescein angiography (FA) which was done on a regular basis, Indocyanine green angiography (ICGA) and optical coherence tomography (OCT) analyses. Results Intravitreal bevacizumab was given alone in 8 eyes (Group 1) and in combination with PDT in 4 eyes (Group 2). Mean follow-up duration was 17 weeks in group 1 and 15 weeks in group 2 after bevacizumab treatment. The mean number of bevacizumab injections was 2.2 in group 1 and 2.5 in group 2. Mean BCVA improved from 20/63 to 20/40 in group 1 and 20/63 to 20/32 in group 2. Of all eyes, the BCVA improved by ≥2 lines in seven (58%) eyes and resolution of fluid and hemorrhages in clinical examination, an absence of leakage on repeat FAs, or resolved pigment epithelial detachment (PED) and/or subretinal fluid (SRF) on OCT exam was confirmed in 10 (83%) eyes. Partial or complete regression of the polypoidal vessels and interconnecting vessels was reported for most cases at the last follow-up. No significant ocular or systemic side effects were observed in both groups. Conclusions Short-term results indicate that intravitreal bevacizumab (1.25 mg) alone or in combination with PDT is well tolerated and associated with improvement in BCVA and reduced angiographic leakage in most patients. Further evaluation of intravitreal bevacizumab therapy for the treatment of PCV is warranted.

Changes in the clinical features and prognostic factors of endogenous endophthalmitis: fifteen years of clinical experience in Korea.

Purpose: To identify changes in the clinical features, management, and prognostic factors of endogenous endophthalmitis in Korea from 1996 through 2010. Methods: We conducted a retrospective review of medical records of patients diagnosed with endogenous endophthalmitis from January 1996 to December 2010, which was divided into 3 periods: 1996 to 2000, 2001 to 2005, and 2006 to 2010. Variables included age, source of infection, systemic conditions, initial and final visual acuities, causative organisms, and treatment. Results: Endophthalmitis was identified in 80 patients (97 eyes). Diabetes (42.5%) and liver cirrhosis (20%) were the common systemic problems in these patients. Liver abscess (25%) was the most common infection focus of the endophthalmitis. Klebsiella pneumoniae (48.4%) was the common causative agent, although more recently, endophthalmitis caused by gram-positive cocci has increased in frequency. The use of vitrectomy as an initial treatment has increased during the past 5 years. Good initial visual acuity greater than counting fingers (P < 0.001), early vitrectomy in patients with initially good visual presentation (P = 0.035), and gram-positive cocci (P = 0.033) as a causative agent were significantly related to a successful visual outcome. Conclusion: Although the prognosis of endogenous endophthalmitis is generally poor in most patients, some eyes can have relatively good visual outcomes if treated appropriately and early enough.

Assessment of Macular Function for Idiopathic Epiretinal Membranes Classified by Spectral-Domain Optical Coherence Tomography

PURPOSE To evaluate the functional changes in various morphologic types of idiopathic epiretinal membrane (ERM) by multifocal electroretinography (mfERG) and spectral-domain optical coherence tomography (SD-OCT). METHODS All patients (n = 71) with unilateral idiopathic ERM underwent complete ophthalmologic examination, including measurements of best-corrected visual acuity (BCVA), SD-OCT, and mfERG for both eyes. To classify idiopathic ERM by subtype, the morphologic characteristics of the foveal area on representative scanned images were assessed. The five subtypes by foveal SD-OCT morphology included fovea-attached ERM with outer retinal thickening and minimal inner retinal change (Group 1A), outer retinal inward projection and inner retinal thickening (Group 1B), and prominent thickening of inner retinal layer (Group 1C) and foveal sparing ERM with formation of macular pseudohole (Group 2A) and with schisislike, intraretinal splitting (Group 2B). RESULTS On mfERG, P1 amplitude density in the central ring (R1) and inter-eye (affected eye/fellow eye) response ratio of P1 amplitude density in R1 differed significantly among five groups (P = 0.032 and P = 0.022, respectively). In Group 1 patients, central subfield thickness (CST) and inner retinal layer thickness (IRT) on SD-OCT were strongly correlated with BCVA and P1 amplitude density in R1. A receiver operating characteristic (ROC) curve analysis showed that IRT had high predictive accuracy in distinguishing Groups 1A and 1B (area under the ROC curve [AUROC] = 0.966) and Groups 1B and 1C (AUROC = 1.000). CONCLUSIONS Multifocal electroretinography can be used to investigate the pathophysiology of ERM and to evaluate the degree of functional demise in the fovea on SD-OCT.

Effect of combined cataract surgery and ranibizumab injection in postoperative macular edema in nonproliferative diabetic retinopathy.

Purpose: To evaluate whether intravitreal ranibizumab injection at cataract surgery prevents postoperative diabetic macular edema (PME) in patients with stable diabetic retinopathy without significant macular edema. Methods: Eighty patients with cataract, stable diabetic retinopathy, and no significant macular edema were randomized to a sham group (cataract surgery only) or a group undergoing cataract surgery plus intraoperative ranibizumab injection. Best-corrected visual acuities, central subfield thickness, and total macular volume were assessed at baseline and 1 week, 1, 3, and 6 months postoperatively by spectral domain optical coherence tomography. Clinically meaningful PME (central subfield thickness increase >60 &mgr;m relative to baseline) was computed. Results: The groups did not differ in baseline best-corrected visual acuity, central subfield thickness, and total macular volume. Compared with the ranibizumab injection group, the sham group had significantly larger central subfield thickness increases relative to baseline at 1 week and 1 month; larger total macular volume increases at all time points (P = 0.012, P = 0.005, P < 0.001, P < 0.001, P = 0.005, P = 0.017, respectively); higher PME frequency at 1 month (P = 0.019); and poorer best-corrected visual acuity improvement from baseline to 6 months after surgery (P = 0.046). Conclusion: In patients with stable diabetic retinopathy without significant macular edema, intravitreal ranibizumab injection at cataract surgery may prevent the postoperative worsening of macular edema and may improve the final visual outcome without affecting safety.

Optical Coherence Tomography Evaluation of Detached Macula from Rhegmatogenous Retinal Detachment and Central Serous Chorioretinopathy

PURPOSE To compare structural changes using optical coherence tomography (OCT) and visual acuity (VA) loss in patients with shallow macula-off rhegmatogenous retinal detachment (RD) and central serous chorioretinopathy (CSC) involving the macula. DESIGN Retrospective, comparative observational study. METHODS Fifteen eyes with rhegmatogenous RD and 21 eyes with CSC with comparable height of macular detachment (< or = 550 microm) were evaluated retrospectively. All eyes were subjected to complete ophthalmologic examination, including OCT analysis, and were followed up until complete resolution of RD. RESULTS The mean height +/- standard deviation at the fovea was 290 +/- 153 microm in rhegmatogenous RD and 310 +/- 141 microm in CSC. Although the duration of symptoms was longer in CSC than in rhegmatogenous RD (35.0 +/- 38.0 days vs 8.3 +/- 8.0 days), initial (0.25 vs 0.64 logarithm of the minimum angle of resolution [logMAR] units; P = .001) and final VA (0.09 vs 0.49 logMAR units; P < .001) were significantly better in CSC. OCT analysis of rhegmatogenous RD showed intraretinal cyst formation, intraretinal separation, and undulation of outer detached retina in 10 (67%), nine (60%), and six (40%) eyes, respectively. Eyes with two or more preoperative structural changes had poorer initial VA than eyes with none or one structural change. In comparison, none of the 21 CSC eyes showed any of these changes (P < .001). CONCLUSIONS Compared with CSC, macula-involving rhegmatogenous RD resulted in more rapid visual loss, despite similar height of foveal detachment. Structural changes on OCT may be correlated with different levels of visual function in these two conditions.

Correlations between spectral-domain OCT measurements and visual acuity in cystoid macular edema associated with retinitis pigmentosa.

PURPOSE To evaluate the characteristics of spectral-domain optical coherence tomography (SD-OCT) findings associated with visual outcome and compare OCT measurements according to presence of cystoid macular edema (CME) in retinitis pigmentosa (RP) patients. METHODS Patients with typical RP who underwent SD-OCT were included. We compared OCT measurements such as central retinal thickness (CRT), photoreceptor thickness, and photoreceptor inner segment/outer segment (IS/OS) junctional status at the fovea between the CME and non-CME groups. Also, correlations between best-corrected visual acuity (BCVA) and each parameter were determined. RESULTS Among a total of 220 eyes in 128 RP patients, 46 eyes of 30 patients (20.9%) had CME. CRT was 303.1 ± 81.8 μm and 209.2 ± 46.8 μm in the CME and non-CME groups, respectively (P < 0.001). BCVA did not differ between the two groups (P = 0.690). However, among a subgroup with unilateral CME, BCVA was significantly worse in CME eyes than in the fellow eyes (P = 0.046). In the CME group, eyes with increased CRT showed worse BCVA (P = 0.010). Among 12 eyes with severe CME, defined as 350 μm or more CRT, 10 (83.3%) showed an absent IS/OS junction. In the non-CME group, in contrast, eyes with decreased CRT showed worse BCVA (P < 0.001). In both groups, severe IS/OS disruption was correlated with worse BCVA (P < 0.001). The risk of IS/OS disruption was higher in the CME group (P = 0.016). CONCLUSIONS The presence of CME in RP patients was not necessarily correlated with loss of visual acuity. In eyes with CME, however, severe CME was strongly correlated with IS/OS disruption and visual impairment. Thus, severe CME seemed to be a predictor of poor visual outcome in RP patients.

Inner retinal layer thickness is the major determinant of visual acuity in patients with idiopathic epiretinal membrane

Editor, I diopathic epiretinal membrane (ERM) may be asymptomatic until the tangential tractional forces on the retina cause significant thickening and intraretinal structural distortion at the macula (Pournaras et al. 2000). In clinical practice, we often witness asymptomatic patients with prominent ERM. It is unclear whether central subfield thickness (CST), inner retinal layer thickness (IRLT), outer retinal layer thickness (ORLT) or photoreceptor inner segment ⁄outer segment (IS ⁄OS) disruption is the major contributing factor to reduced visual acuity in ERM (Michalewski et al. 2007; Arichika et al. 2010). Medical records for 123 patients (134 eyes: 107 phakic eyes and 27 pseudophakic eyes) with idiopathic ERM were reviewed. Cases of ERM secondary to other diseases or accompanied by lens opacity of N3, C3, P3 or greater (LOCS III) (Chylack et al. 1993) were excluded. Fluorescein angiography was performed in all eyes to exclude associated vascular occlusive disease. Best-corrected visual acuity (BCVA) was converted to the logMAR scale. SD-OCT examinations were performed using a Cirrus SD-OCT system (Carl Zeiss Meditec Inc., Dublin, CA, USA) with software version 4.0. CST was measured automatically. Inner retinal layer thickness (length from the vitreoretinal interface to the outer border of the inner nuclear layer) and ORLT (length from the inner border of the outer plexiform layer to the photoreceptor IS ⁄OS junction) were measured manually on the horizontal raster image passing through the foveal centre. The mean age was 65.1 ± 8.5 years. The CST values ranged from 189 to 661 lm, and BCVA in

Prevalence and Risk Factors of Early-Stage Age-Related Macular Degeneration in Patients Examined at a Health Promotion Center in Korea

We evaluated the prevalence and risk factors for early age-related macular degeneration (AMD) in Koreans 50 yr of age or older who were examined at a single health promotion center. We retrospectively reviewed the records of 10,449 subjects who visited the center over a 6-month period. Fundus photography was performed on all subjects, and systematic risk factor analysis was conducted using a structured questionnaire. All patients (n = 322) were initially diagnosed with drusen or early AMD using fundoscopy; the control group (n = 10,127) were those yielding normal fundoscopy findings. The age- and gender-adjusted prevalence of early AMD was 3.08%. Advanced age, male gender, smoking status, hyperlipidemia, working outdoors, and residence in rural areas were all significantly associated with an increased risk for development of early AMD. Higher-level ingestion of fruit or herbal medication and an increased amount of exercise were associated with a lower risk of early AMD development. In our Korean cohort, consisting principally of relatively healthy, middle-class urban adults, the prevalence of early AMD was 3.08% that is similar to that reported in earlier epidemiological studies. Several modifiable risk factors such as smoking and hyperlipidemia are associated with the prevalence of early AMD in our cohort.

Pericentral Hydroxychloroquine Retinopathy in Korean Patients

PURPOSE A pericentral pattern of hydroxychloroquine (HCQ) retinopathy recently has been recognized in the United States in patients of Asian heritage. We report on an investigation of this pericentral retinopathy within a Korean population. DESIGN Retrospective, observational study. PARTICIPANTS Patients taking HCQ who were referred to ophthalmology for screening of HCQ retinopathy. METHODS The medical records of patients were reviewed, including spectral domain optical coherence tomography, fundus autofluorescence, and visual fields. MAIN OUTCOME MEASURES Frequency of pericentral pattern of HCQ retinopathy and features of progression. RESULTS Among 218 patients referred, 9 (4.1%) were diagnosed with toxicity. Of these, 8 had a predominantly pericentral pattern of retinal change, whereas only 1 had the classic parafoveal distribution of retinal damage. Progression of retinopathy was documented in 3 patients followed more than 12 months while taking HCQ. No progression was seen in 2 patients without retinal pigment epithelial (RPE) damage who were followed for at least 12 months after discontinuation of HCQ. CONCLUSIONS We found that a pericentral pattern of HCQ retinopathy was predominant among Korean patients, rather than the traditional (bulls eye) parafoveal pattern of damage. Retinopathy progressed while on the drug, but the progression stopped in patients with toxicity detected before RPE damage. These observations suggest the need for new approaches when screening for HCQ toxicity in Asian patients.

Twenty–Four Hour Blood Pressure Pattern in Patients With Normal Tension Glaucoma in the Habitual Position

Purpose To investigate the relationship between blood pressure (BP) parameters in the habitual position and glaucomatous damage at initial presentation in patients with untreated normal tension glaucoma (NTG). Methods Fifty-four eyes from 54 subjects diagnosed with NTG were consecutively enrolled. BP was measured with an automated ambulatory monitoring device in the habitual position during 24-hour in-hospitalization. Patients were classified into three groups: non-dippers, dippers, and over-dippers. corresponded to the degree of reduction in their nocturnal mean arterial pressure (MAP) compared with their diurnal MAP. Regression models were used to evaluate potential risk factors, including: age, pre-admission office intraocular pressure (IOP), central corneal thickness (CCT), and BP parameters. Functional outcome variables for glaucomatous damage included mean deviation (MD) and pattern standard deviation (PSD) on a Humphrey field analyzer (HFA). Anatomic outcome variables were TSNIT score (temporal, superior, nasal, inferior, and temporal) average, superior average, inferior average, and nerve fiber indicator (NFI) score on scanning laser polarimetry with variable corneal compensation (SLP-VCC; GDx-VCC). Results Marked systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP fluctuation were noted in the over-dipper group (p<0.05). A linear regression analysis model revealed that nocturnal trough DBP and MAP, average nocturnal SBP, and MAP were all significantly associated with a decreased average TSNIT score and an increased NFI score. Conclusions Nocturnal BP reduction estimated in the habitual position was associated with structural damage in eyes with NTG. This finding may suggest systemic vascular etiology of NTG development associated with nocturnal BP reduction.