Suk Woo Yang

Primary radiation therapy in patients with localized orbital marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT Lymphoma).

PURPOSEnTo evaluate the outcomes of patients with localized orbital marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT lymphoma) who were treated with radiotherapy (RT).nnnMETHODS AND MATERIALSnWe retrospectively reviewed the records of 46 patients who were treated with RT for pathologically confirmed localized stage IE marginal zone B-cell lymphoma of MALT. The radiation dose ranged from 21.6 to 45 Gy (median, 30.6 Gy) at 1.8-2.0 Gy per fraction. Median follow-up duration was 32.3 months (range, 3.1-113.6 months).nnnRESULTSnForty-three patients (93%) achieved complete remission (CR), and three patients (7%) achieved partial remission (PR). Five-year relapse-free survival, cause-specific survival, and overall survival were 93%, 100%, and 100%, respectively. Among the patients with CR, two had recurrence at three sites. One patient relapsed locally and was successfully salvaged with reirradiation. The other patient relapsed in a distant site and was successfully treated with six cycles of CHOP chemotherapy. Late complications were noted in four patients. Two patients developed cataracts at 26 and 37 months after completion of RT. The other two patients developed nasolacrimal duct obstructions at 4 and 11 months after completion of RT.nnnCONCLUSIONnOur study showed that a modest dose of RT is an excellent treatment modality with low complication and recurrence rates. We suggest that a dose of 30.6 Gy is tolerable and sufficient for treating orbital MALT lymphoma. Even following recurrence, successful salvage is possible with RT or chemotherapy.

An Overview of Ophthalmologic Survey Methodology in the 2008-2015 Korean National Health and Nutrition Examination Surveys

The Korea National Health and Nutrition Examination Survey (KNHANES) is a national program designed to assess the health and nutritional status of the noninstitutionalized population of South Korea. The KNHANES was initiated in 1998 and has been conducted annually since 2007. Starting in the latter half of 2008, ophthalmologic examinations were included in the survey in order to investigate the prevalence and risk factors of common eye diseases such as visual impairment, refractive errors, strabismus, blepharoptosis, cataract, pterygium, diabetic retinopathy, age-related macular degeneration, glaucoma, dry eye disease, and color vision deficiency. The measurements included in the ophthalmic questionnaire and examination methods were modified in the KNHANES IV, V, and VI. In this article, we provide detailed information about the methodology of the ophthalmic examinations in KNHANES in order to aid in further investigations related to major eye diseases in South Korea.

The Relationship between Visual Impairment and Health-Related Quality of Life in Korean Adults: The Korea National Health and Nutrition Examination Survey (2008–2012)

Introduction To evaluate health-related quality of life (HRQoL) in Korean adults with visual impairment(VI) using various measures based on a nationally distributed sample. Methods Using the Korea National Health and Nutrition Examination Survey (KNHANES, 2008–2012) data, we compared EuroQol five-dimensional questionnaire (EQ-5D) and EQ-visual analogue scale (VAS) scores after adjusting for socio-demographic and psychosocial factors as well as for comorbidities with VI. Logistic regressions were used to elucidate determinants for the lowest quintile HRQoL scales according to VI severity. Uncorrected visual acuity (VA) which implies vision of ordinary life was measured using an international standard vision chart based on Snellen scale. Results 28,825 participants (sum of weights; 37,562,376) were included in the analysis. The mean EQ-5D and EQ-VAS scores were significantly lower in the VI groups than in the normal vision (defined as VA 20/20-20/25) group based on the better or worse seeing eye (P<.0001 and P<.0001, respectively). Participants with moderate (VA 20/80-20/160) and severe VI (VA ≤20/200) had higher scores of multivariate-adjusted odd ratios (aORs) for the lowest quintile than did the normal vision group which was particularly evident in the results from EQ-5D, whereas the results of the mild VI (VA 20/32-20/63) group did not identify significant differences from the normal vision group independent of classification according to the better or the worse seeing eye. Conversely, EQ-VAS revealed significantly higher score of multivariate-aORs for the lowest quintile in participants with mild VI either for the better or worse seeing eye. Conclusions The severity of VI was definitely associated with impaired HRQoL compared with the normal vision population. The analyses presented here elicited even mild VI could potentially deteriorate the health-related quality of life (or subjective perception of health quality) and therefore, therapeutic approaches should also focus on the subjective perception and better management of health condition.

Radiotherapy With or Without Surgery for Patients With Idiopathic Sclerosing Orbital Inflammation Refractory or Intolerant to Steroid Therapy

PURPOSEnTo evaluate the outcomes of patients with idiopathic sclerosing orbital inflammation (ISOI) treated with radiotherapy with or without surgery.nnnMETHODS AND MATERIALSnWe retrospectively reviewed 22 patients with histopathologically confirmed ISOI who had been refractory or intolerant to steroid therapy and treated with radiation with or without surgery. The radiation dose ranged from 20 to 40 Gy (median, 20 Gy) at 2xa0Gy per fraction. Presenting signs and treatment outcomes were assessed.nnnRESULTSnProptosis was the most common sign at presentation, seen in 19 (86.3%) patients, followed by restriction of extraocular movements in 10 (45.4%) patients. Response to radiotherapy was complete in 15 (68.1%) patients, partial in 3 (13.6%) patients, and none in 4 (18.2%) patients. At the median follow-up of 34 months, 14 (63.6%) patients had progression-free state of symptoms and signs, with the progression-free duration ranging from 3 to 75 months (median, 41.5 months), whereas 8 (36.4%) patients had recurrent or persistent disease although they hadxa0received radiotherapy. Of the 14 progression-free patients, 6 underwent a bimodality treatment of debulking surgery of ocular disease and radiotherapy. They had had no recurrent disease. Cataract was the most common late complications, and 2 patients experienced a Grade 3 cataract.nnnCONCLUSIONnOur study suggests that for patients with ISOI who are refractory or intolerant to steroid therapy, 20 Gy of radiotherapy appears to be effective for the control of disease with acceptable complications, especially when it is combined with surgery.

Microscopic Characteristics of Lower Eyelid Retractors in Koreans

Purpose To identify the microscopic characteristics of lower eyelid retractors in Korean individuals and to elucidate age-related changes in lower eyelid retractors. Methods Eighteen Korean lower eyelids from formalin-fixed cadavers were stained with Massons trichrome. Specimens were divided into two groups based on age at death (group A, ≤65 years; group B, >65 years), and the microscopic findings were analyzed and compared by light microscopy. Results The capsulopalpebral fascia (CPF) had distinct junctions and no fusion with orbital septum in 14 eyelids (77.8%). The CPF was fused with the orbital septum in only two eyelids (11.1%). Although not significant, the inferior tarsal muscle was closer to the tarsus in group A (1.24 ± 0.71 mm) than group B (2.14 ± 1.18 mm, p = 0.07), and the tarsal height tended to be longer in group B (4.71 ± 0.55 mm) than group A (4.16 ± 1.01 mm, p = 0.20). Tarsal fatty infiltration was more evident in group B. Conclusions The CPF was rarely fused with the orbital septum in our sample of Korean lower eyelids. Although we did not identify any remarkable age-related changes in lower eyelid structures, there was a tendency for the lower retractor to loosen from the tarsus and for increased fatty infiltration in the lower eyelids from elderly individuals.

Analysis of treatment outcomes for primary tonsillar lymphoma.

Purpose Although each Waldeyer’s ring sub-site is considered an independent prognostic factor, few studies have assessed the prognosis and treatment of tonsillar lymphoma. Treatment outcomes were analyzed in patients with primary tonsillar lymphoma who were treated with chemotherapy and radiotherapy (RT). Materials and Methods Nineteen patients with diffuse large B-cell lymphoma were evaluated, with a median follow-up of 53 months. Age, sex, and histology, amongst other factors, were reviewed. Progression-free survival (PFS) and overall survival (OS) rates were analyzed. Results Most patients had Ann Arbor stage I-II (94.7%), IPI score of 0 (89.5%), and complete remission after chemotherapy (89.5%). The 5-year PFS and OS rates were 74.6% and 80%, respectively. In univariate analysis, the rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen resulted in a better PFS than the cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) regimen (88.9% vs. 50.0%; p = 0.053). RT dose was related to the survival outcome (p = 0.010 for PFS, p = 0.044 for OS). Patients were classified into the CHOP + RT (>40 Gy) group and R-CHOP + RT (≤40 Gy) group. The 5-year PFS rates were 50% in the CHOP + RT group, and 100 % in the R-CHOP + RT group (p = 0.018). The 5-year OS rates were 66.7% and 100%, respectively (p = 0.087). Conclusion Primary tonsillar lymphoma patients typically have favorable outcomes. Chemotherapy (R-CHOP) combined with relatively lower dose consolidative RT may be safe and effective for primary tonsillar lymphoma.

New Miyake-Apple view using a nasal endoscope.

Dear Editor, It is impossible to observe the posterior surface of the iris, ciliary body, pars plana, ora serrata, lens equator, and lens zonules of the eye using ordinary clinical tests. Until now, the Miyake-Apple view technique has been used to observe the posterior view of the anterior segment ex vivo [1–3]. With this technique, after cutting the eyeball equator, we observe the structures from behind. First, the enucleated eyeball is frozen in liquid nitrogen at −70 °C. The eyeball is cut with a knife at the equator. Glue is applied to the cut edges, and the eyeball is then attached to a transparent acrylic plate. Photographs of the posterior surface of the anterior segment are taken through the transparent plate. While this technique provides a good posterior view of the anterior segment, it is cumbersome and cannot be used in vivo. We can observe the inner structure, with minimal damage, using an endoscope such as that used in gastroscopy, colonoscopy, laparoscopy, and arthroscopy. In this letter, we present a new technique for photographing the posterior view of the anterior segment using a nasal endoscope like that commonly used in oculoplasty clinics. We performed orbital exenteration in a 78-old woman with squamous cell carcinoma in the bulbar conjunctiva and lower lid. We took photographs of the Miyake-Apple view of the eyeball using a nasal endoscope (Stryker Corporation, Kalamazoo, MI, USA) to determine whether there was any clinical sign of intraocular tumor invasion before sending the specimen to the pathology laboratory. The enucleated eyeball was placed on the table. The optic nerve was held with the left hand, while a 7 mm sclerotomy was made at the posterior pole using a #11 knife, and the endoscope probe was inserted with great care (Fig. 1-1). Cataract surgery had been performed in this eye (Fig. 1-2A). A clear one-piece intraocular lens was placed in the center of the capsular bag. The two haptics were placed symmetrically in the bag. There was no ruptured posterior capsule and there was no evidence of zonulysis. There was some remnant cortex near a haptic in the capsule (Fig. 1-2B). The equator of the lens capsule could be clearly observed in 360°. The lens equator was in contact with the ciliary processes and had an uneven margin (Fig. 1-2C). Zonules connecting the lens capsule and ciliary process were not visible. We think that the zonules were too thin and transparent for this endoscope. In an academic video on hydrodissection in cataract surgery, Miyake et al. reported that they had to use dyes to visualize the zonules [4]. The posterior surface of the iris was observed through the translucent lens capsule (Fig. 1-3A). It was brown in color, and the surface was flat. The ciliary body comprised the pars plicata and pars plana. The ciliary processes of the pars plicata showed more light color than those of the other ciliary body (Fig. 1-3B). We were able to observe the circumferential fiber of the ciliary muscle between the ciliary processes. The pars planawas dark and flat, just like its name (Fig. 1-4A). The vitreous over the peripheral retina was like fog (Fig. 1-4B). We observed an ora serrata, the border of the retina, and the spars plana (Fig. 1-4C). From iris to ciliary body and peripheral retina, we found no evidence of tumor invasion. This is consistent with the findings of the pathologist. H. S. Hwang Department of Ophthalmology, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, South Korea

Suggestion of response evaluation criteria in patients with ocular adnexal mucosa-associated lymphoid tissue lymphoma (OAML)

Ocular adnexal mucosa-associated lymphoid tissue lymphoma (OAML) has been recognized as most common primary orbital malignancy. However, little was known about the response criteria for OAML. Our aim was to suggest response criteria for nonconjunctival OAML; the response evaluation of which using the conventional response criteria is inappropriate. A retrospective chart review of 34 eyes from 30 patients diagnosed with nonconjunctival OAML was conducted, focusing on the change in tumor size based on linear bi-dimensional and three-dimensional methods in magnetic resonance imaging (MRI) of the orbit. The maximum tumor response period of each case was investigated, and the expected optimal response period was calculated using regression analysis. In 30 evaluable patients, the median time taken for the maximum tumor response was 6xa0months (range, 3–18). More than 75xa0% of patients attained maximal tumor response in 6xa0months after initial therapy for follow-up period, the median value of which was 30xa0months (range, 15–77). Based on the regression analysis, it took 4.7xa0months for the maximum diameter (2r) of tumor to decrease by 50xa0% of initial lesion size. We cautiously suggest that optimal response could be defined as 50xa0% reduction of the maximum diameter in 6xa0months since the treatment was initiated, and that only observation without additional therapy is enough for nonconjunctival OAML, if optimal response is achieved.