Tsung-Tien Wu

Risk factors for endogenous endophthalmitis secondary to klebsiella pneumoniae liver abscess: 20-year experience in Southern Taiwan.

Purpose: To identify the risk factors for endogenous endophthalmitis secondary to Klebsiella pneumoniae liver abscess. Methods: We conducted a retrospective review of medical records of 602 patients admitted with K. pneumoniae liver abscess from January 1991 to November 2009. Variables included age, sex, history, month of onset, systemic condition, initial and final visual acuities, slit-lamp biomicroscopy, intraocular pressure, fundus, course and treatment. Results: Endophthalmitis was identified in 42 patients (53 eyes). Nineteen eyes (35.8%) had final vision of counting fingers or better. Diabetes was significantly associated with the development of endophthalmitis (P = 0.003) and poor visual outcome (P = 0.019). Poor initial vision (worse than counting fingers) was also significantly related to the poor visual outcome of endophthalmitis (P < 0.001). Subgroup analysis of 9 vitrectomy cases showed that progressive anterior chamber reaction might be related to poor visual outcome. Moreover, patients whose disease onset was in winter were slightly more likely to develop endophthalmitis (P = 0.088). Conclusion: Although the prognosis of endogenous K. pneumoniae endophthalmitis is generally poor, some eyes might be saved if treated early enough. Diabetes is a significant risk factor for the development of endogenous endophthalmitis and poor visual outcome in patients with K. pneumoniae liver abscess. Early vitrectomy might be considered in patients whose anterior chamber inflammation did not respond well to intravitreal antibiotics.

Ocular Uveitis as the Initial Presentation of Syphilis

Background: To document the characteristics of syphilitic patients who present with ocular uveitis clinically and are diagnosed by an ophthalmologist first. Methods: Retrospective chart review of uveitis patients in the department of ophthalmology between 1992 and 2004 was done. We included only those patients with positive serologic tests, active ocular uveitis, and record of detailed examination. Results: There were 8 syphilitic patients (14 eyes) who presented with ocular syphilis clinically and who were diagnosed by an ophthalmologist first. The ocular diagnosis included panuveitis (11 eyes, 78.6%), anterior uveitis (2 eyes, 14.3%), and posterior uveitis (1 eye, 7.1%). Two patients (25%) had unilateral eye involvement, and 6 patients (75%) had involvement in bilateral eyes. One patient (2 eyes) with panuveitis also had bilateral exudative retinal detachment and chronic angle closure glaucoma. All 8 patients were negative for human immunodeficiency virus. Dark field examination of aqueous humor in 2 cases revealed Treponema pallidum, which was confirmed by immunofluorescent test. Treatment included systemic penicillin in 7 patients and oral tetracycline in 1 patient (due to penicillin allergy). Visual function and uveitis improved after treatment in all patients. Conclusion: Syphilis can be presented initially as ocular uveitis without obvious systemic manifestation. Ophthalmologists play an important role in the early diagnosis and treatment of syphilis. If treated early enough, the response is good, even if the patient is allergic to penicillin. Awareness of the multiple manifestations of ocular syphilis is the key to early detection of the disease.

Vitreous hemorrhage complicating intravitreal tissue plasminogen activator and pneumatic displacement of submacular hemorrhage.

Purpose: To evaluate the clinical factors associated with vitreous hemorrhage (VH) complicating intravitreal tissue plasminogen activator and pneumatic displacement of submacular hemorrhage, and analyze visual outcomes. Methods: In this retrospective, comparative study, 120 consecutive eyes underwent intravitreal tissue plasminogen activator (50 μg) and perfluoropropane (0.3 mL) injection for submacular hemorrhage secondary to different causes. We recorded their demographic data, visual acuity, complications, and further treatment after VH. Two groups created according to the occurrence of VH were compared to identify possible risk factors. Results: Breakthrough VH occurred in 18 eyes (15%). The size of submacular hemorrhage was significantly positively related to the occurrence of VH (P for trend <0.001). Among etiology, idiopathic polypoidal choroidal vasculopathy (IPCV) was associated with a significantly higher incidence of VH (odds ratio, 15.63; 95% confidence interval, 2.30–106.15; P = 0.005). Age-related macular degeneration was much less likely than other causes to result in VH (odds ratio, 0.121; 95% confidence interval, 0.023–0.642; P = 0.013). Best and final visual acuity improved significantly from initial visual acuity in both groups (P < 0.05). Conclusion: A large area of submacular hemorrhage (≥10 disk areas) and IPCV were risk factors for VH after injection. The occurrence of VH did not affect final visual outcome.

Vitrectomy for exudative age-related macular degeneration with vitreous hemorrhage.

Purpose:The purpose of this study was to study the effect of pars plana vitrectomy (PPV) for age-related macular degeneration with vitreous hemorrhage on choroidal neo-vascularization (CNV). Methods:A retrospective interventional case series in which 92 eyes with age-related macular degeneration with vitreous hemorrhage that received PPV were studied. Among them, 60 eyes without pre- or posttreatment other than PPV were selected. Choroidal neovascularization was expressed as the incidence of bleeding 6 months before and after PPV. The status of CNV after PPV was compared and classified as worsened, remained, regressed, disappeared, or unclassified. The influence of posterior vitreous detachment was examined. Results:The incidence of bleeding was reduced dramatically after PPV (1.11 ± 0.44 in preoperative 6 months vs. 0.03 ± 0.18 in postoperative 6 months, P < 0.0001). The status of CNV improved in most cases; 40 of 54 classifiable eyes (74.1%) were categorized as “regressed” or “disappeared.” Postoperative visual acuity was significantly better than preoperative visual acuity (P < 0.0001). The status of CNV subsided more in those eyes without posterior vitreous detachment than in those with posterior vitreous detachment (odds ratio, 1.02; 95% confidence interval, −0.01−2.08; P = 0.054). Conclusion:The activity of CNV was reduced after PPV in eyes with age-related macular degeneration with vitreous hemorrhage. Visual acuity significantly improved, with only rare severe complications. The involvement of vitreomacular traction in the patho-physiology of CNV in age-related macular degeneration is possible.

One‐year outcome of two different initial dosing regimens of intravitreal ranibizumab for myopic choroidal neovascularization

To evaluate and compare the 12‐month outcomes of two different initial dosing regimens of intravitreal ranibizumab for myopic choroidal neovascularization (CNV).

Subtle Solar Retinopathy Detected by Fourier-domain Optical Coherence Tomography

Solar retinopathy is a retinal injury caused by direct or indirect sun-gazing and solar eclipse observation without protection. Subtle changes in the retinal damage might not be evident on fundus photography and fluorescein angiography. A 40-year-old veteran suffered from paracentral scotoma in his left eye shortly after unprotected solar eclipse observation about 1 month earlier. His visual acuity was 6/5 in the right eye and 6/6 in the left. Anterior segments were normal bilaterally. Dilated fundus examination, fluorescein angiography, and central visual field testing did not reveal any abnormal findings. Fourier-domain optical coherence tomography was used for evaluation, and a focal defect in the inner and outer segments of the photoreceptor layer band was noted in the paracentral region of the fovea in the left eye, with central foveal thickness of 198 microm. Solar retinopathy is preventable with adequate eye protection. Education should be reinforced to the public. In mildly affected individuals with subtle retinal damage, Fourier-domain optical coherence tomography could be a useful imaging tool to detect the disease.

RESVERATROL PROTECTS AGAINST ULTRAVIOLET A-MEDIATED INHIBITION OF THE PHAGOCYTIC FUNCTION OF HUMAN RETINAL PIGMENT EPITHELIAL CELLS VIA LARGE-CONDUCTANCE CALCIUM-ACTIVATED POTASSIUM CHANNELS

This study was undertaken to examine the protective effect of resveratrol on human retinal pigment epithelial (RPE) cell phagocytosis against ultraviolet irradiation damage. Cultured RPE cells were exposed to ultraviolet A (UVA, 20 minutes) irradiation, and treated with meclofenamic acid (30μM, 20 minutes), paxilline (100 μM, 20 minutes) or resveratrol (10μM, 20 minutes). Meclofenamic acid and resveratrol were given after exposure to UVA. Pretreatment with meclofenamic acid, resveratrol or paxilline before UVA irradiation was also performed. Fluorescent latex beads were then fed for 4 hours and the phagocytotic function was assessed by flow cytometry. UVA irradiation inhibited the phagocytic function of human RPE cells. The large‐conductance calcium‐activated potassium channel activator meclofenamic acid ameliorated the damage caused by UVA irradiation. Pretreatment with resveratrol acid also provided protection against damage caused by UVA. Posttreatment with meclofenamic acid offered mild protection, whereas resveratrol did not. In conclusion, the red wine flavonoid resveratrol ameliorated UVA‐mediated inhibition of human RPE phagocytosis. The underlying mechanism might involve the large‐conductance calcium‐activated potassium channels.

Intravitreal Tissue Plasminogen Activator and Pneumatic Displacement of Submacular Hemorrhage

PURPOSE We sought to evaluate the efficacy, safety, and visual outcome of intravitreal tissue plasminogen activator (t-pa) and pneumatic displacement to treat submacular hemorrhage. METHODS In this retrospective, interventional case series, 46 consecutive eyes of 45 patients received intravitreal t-pa (50µg in 0.1 mL) and expansile gas (0.3 mL perfluoropropane) injection for submacular hemorrhage. Hemorrhages were secondary to exudative age-related macular degeneration in 28 eyes, idiopathic polypoidal choroidal vasculopathy (IPCV) in 11 eyes, retinal arterial macroaneurysm in 2 eyes, pathologic myopia in 3 eyes, and trauma in 1 eye. After surgery, patients maintained a supine position for the first 6 h and then remained prone for about 1 week. Outcome measures were visual acuity, displacement of submacular hemorrhage, and surgical complications. RESULTS Complete displacement of thick blood out of the fovea was achieved in 40 of 45 eyes (89%), and partial displacement was achieved in 5 eyes (11%). Best postoperative visual acuity improved by 2 Snellen lines or greater in 21 of 45 eyes (46.67%). At a mean follow up of 15.64 months, final visual acuity improved by 2 Snellen lines or greater in 16 eyes (35.6%). The complication of breakthrough vitreous hemorrhage occurred in nine eyes (20%). Eyes with nonage-related macular degeneration tended to have better final visual recovery, especially eyes with IPCV over extended follow up (P = 0.035). CONCLUSIONS Intravitreal injection of t-pa and expansile gas was an effective and safe treatment for submacular hemorrhage. Our study features a considerable number of patients with IPCV, and the outcomes are favorable.

Lens Siderosis Resulting from a Tiny Missed Intralenticular Foreign Body

We report a patient with clinical ocular siderosis at the time of presentation but undetectable intraocular foreign body on computed tomography (CT) and ultrasonography. A 24-year-old man suffered from right ocular injury when hammering metal on metal. Slit-lamp examination revealed a small corneal perforating wound and an iris hole, but no intraocular foreign body was found under fundus examination. There was also no evidence of intraocular foreign body on ultrasonography and orbital CT scan. About 1 month later, lens siderosis with cataract formation developed, and the patient received lens extraction with intraocular lens implantation. During the operation, a small (< 1 x 1 x 1 mm in size) intralenticular foreign body of metal material was found and removed. The patients visual acuity improved from 6/20 to 6/6 on the next day. A patient suspected to have intraocular foreign body should be followed-up closely; it is better to remove the foreign body before siderosis bulbi occurs.

Primary gas tamponade in the management of macular hole with retinal detachment in highly myopic eyes

Background: We conducted a retrospective study to investigate the role of the primary gas tamponade on the final success rate of macular hole with retinal detachment (MHRD) in highly myopic eyes. Methods: Retrospective chart review of the patients diagnosed as MHRD in highly myopic eyes between 1992 and 2008 was done. Fifty‐three highly myopic eyes (>−6.0 diopter, >26 mm of axial length, or visible posterior staphyloma) with a retinal detachment resulting from a macular hole were included. The main outcome measures were anatomic reattachment and final visual acuity. Results: Thirty‐two of the 53 eyes received primary gas tamponade, and the reattachment of retina was achieved in 8 eyes (8/32, 25%). Twenty‐one of the 53 eyes received primary pars plana vitrectomy (PPV) with or without scleral buckle, and the reattachment of retina was achieved in 12 eyes (12/21, 57.1%). The final success rate after adjunctive operations was 96.9% in the primary gas tamponade group, and 85.7% in the primary PPV group. Stability of vision (improved or maintained) was achieved in 78.1% of the primary gas group, and 66.7% in the primary PPV group. Conclusion: Our results indicate that primary gas tamponade does not decrease the final success rate in the repair of MHRD in highly myopic patients. Since it is safe and time‐saving, primary gas tamponade could be a good alternative for primary treatment in those who are not willing or eligible for more complicated surgeries.