Yonguk Kim

Comparison of aqueous concentrations of angiogenic and inflammatory cytokines based on optical coherence tomography patterns of diabetic macular edema

Purpose: The purpose was to compare aqueous inflammatory and angiogenic cytokine levels in diabetic macular edema (DME). Materials and Methods: Aqueous samples were obtained from 50 eyes with DME and 12 normal eyes (control group). DME was classified according to the morphologic pattern based on optical coherence tomography: Diffuse retinal thickening (DRT; n = 19), cystoid macular edema (CME; n = 17), or serous retinal detachment (SRD; n = 14). Aqueous samples were collected just before intravitreal injection and at the beginning of cataract surgery in the control group. Interleukin (IL)-6, IL-8, interferon-induced protein (IP)-10, monocyte chemotactic protein (MCP)-1, platelet-derived growth factor (PDGF)-AA, and vascular endothelial growth factor (VEGF) levels were measured by multiplex bead assay. Results: The IL-6, IL-8, IP-10, and PDGF-AA levels differed significantly among the three groups of DME (P = 0.014, P = 0.038, P = 0.021, and P = 0.041, respectively). However, there were no differences between groups in aqueous concentration levels of MCP-1 and VEGF (P = 0.205 and P = 0.062, respectively). IL-6 (P = 0.026) and IL-8 (P = 0.023) correlated positively with central foveal thickness (CFT) in the CME group. None of the cytokine levels correlated significantly with CFT in any of the DRT and SRD groups. Conclusions: Aqueous concentrations of cytokines varied according to the morphologic pattern of DME, which might explain the variable response to treatments such as intravitreal bevacizumab or triamcinolone injection.

AGE-RELATED CLINICAL OUTCOME AFTER MACULAR HOLE SURGERY.

Purpose: To evaluate functional and anatomical retinal recovery according to patient age using spectral domain optical coherence tomography in eyes with surgically closed macular holes. Methods: We retrospectively studied 83 eyes with anatomically closed idiopathic macular holes after surgery confirmed by spectral domain optical coherence tomography. Patients were divided into four subgroups based on age (Group 1: ⩽ 60, Group 2: 61–65, Group 3: 66–70, Group 4: > 70). Best-corrected visual acuity and reconstruction of the external limiting membrane and ellipsoid zone after surgery were documented for 12 months. Results: Mean patient age was 64.5 ± 9.8 years (range 44–81). Mean visual improvement in logMAR units (ETDRS letter score) at 12 months was worse in older age subgroups (Group 1: 0.4 ± 0.3 [20], Group 2: 0.4 ± 0.3 [20], Group 3: 0.2 ± 0.3 [10], Group 4: 0.1 ± 0.3 [5], P = 0.001). When age was more than 65 years, total number of eyes with restored retinal microstructure after surgery was lower (22 eyes, 53.7%; 32 eyes, 76.2%; P = 0.018) and time (months) to structural recovery was longer (10.2, 7.1, P < 0.001) than age under 65 years. Visual improvement corresponded to recovery of the outer retinal layers. In multivariate analysis, patients of older age (odds ratio, 0.91; 95% CI, 0.89–0.93) had less visual improvement at month 12. Conclusion: Poor visual outcomes and delayed microstructural recovery occurred in older subjects after anatomically closed macular hole surgery. Older age may be indicative of poor clinical outcome in repaired macular holes.

En Face Spectral-Domain Optical Coherence Tomography Imaging of Outer Retinal Hard Exudates in Diabetic Macular Edema Based on Optical Coherence Tomography Patterns.

BACKGROUND AND OBJECTIVE To evaluate en face spectral-domain optical coherence tomography (SD-OCT) findings of the outer retinal hard exudates in diabetic macular edema (DME). PATIENTS AND METHODS Exploratory analyses of prospective and consecutive case series. Fifty-five eyes treated with intravitreal ranibizumab (IVR) (Lucentis; Genentech, South San Francisco, CA) for 12 months were classified according to OCT features of DME: diffuse retinal thickening (DRT), cystoid macular edema (CME), and serous retinal detachment (SRD). Area fraction of outer nuclear layer (ONL) hard exudates (HEs) was assessed from en face OCT images. RESULTS Area fraction of ONL HEs increased from 1.45% ± 1.22% to 2.24% ± 1.31% in DRT and from 2.24% ± 1.85% to 3.25% ± 1.52% in CME. HE gain was greatest during first 3 months (DRT = 0.83%; CME = 1.25%). SRD showed no difference in HEs (P = .462). CONCLUSIONS ONL HEs increased in DRT and CME at month 12 following IVR. Rapid gain of HEs was found during the initial loading phase of IVR.

Non-human Immunodeficiency Virus-related Ocular Syphilis in a Korean Population: Clinical Manifestations and Treatment Outcomes

Purpose To describe the clinical manifestations and treatment outcomes of ocular syphilis in patients without human immunodeficiency virus (HIV) infection. Methods A total of 45 eyes from 39 patients with ocular syphilis confirmed by serologic tests were reviewed retrospectively. The included cases were all non-HIV-infected patients presenting with intraocular inflammation from 2002 to 2014 at Kyung Hee University Hospital. Medical records of 45 eyes were analyzed and included best-corrected visual acuity and ophthalmologic examination findings of the anterior and posterior segments to determine the focus of inflammation. Optical coherence tomography and fluorescein angiography findings as well as both medical and surgical management were also analyzed. Results The mean patient age was 61.0 years (range, 37 to 89 years). Bilateral ocular involvement occurred in 6 patients (15.4%), and diagnoses at presentation were most frequently related to posterior uveitis (38%), followed by panuveitis (29%) and optic neuritis (11%). Isolated interstitial keratitis and intermediate uveitis were uncommon (4%, both). Twenty-eight eyes (62.2%) were treated with penicillin, and 11 eyes (24.4%) underwent surgical treatment. The mean baseline best corrected visual acuity was 0.79 ± 0.59 (mean ± standard deviation, logarithm of the minimum angle of resolution) and significantly improved to 0.60 ± 0.63 at the final follow-up after treatment (p = 0.019). Mean visual improvement was significantly greater in the penicillin-treated group (p = 0.001). Visual impairment at the final visit occurred in 11 eyes (24.4%). Among the visual impairment group, 10 eyes (90.1%) had posterior segment-involving uveitis. Conclusions Visual outcomes of treated, non-HIV-related ocular syphilis were favorable regardless of time to presentation. Posterior segment-involving uveitis at presentation was associated with poor visual outcome.

Learning curves for strabismus surgery in two ophthalmologists

Purpose: To identify the average turning point by comparing the learning curves of two surgeons learning to perform strabismus surgery. Materials and Methods: Patients who underwent procedures to correct exotropia between January 2010 and December 2014 followed for at least 3 months were retrospectively assessed. The first 70 patients on whom each of two ophthalmologists (A and B) performed surgery to treat strabismus were divided into 7 cohorts comprising 10 patients each based on the chronological order of the surgery. Factors, including patient age, preoperative angle of deviation, operative time, and success or failure of the operation, were compared between the two surgeons. Learning curves were calculated based on changes in operative time and operation success rate. Operation success was determined by measuring the angle of deviation at a distance of 5 m 3 months after the operation. Results: A turning point was observed after 40 cases for Surgeon A and 50 cases for Surgeon B based on the operative time learning curve. No turning point was observed in the operation success rate learning curve based on the absence of a specific trend. Success rate by cohort was not significantly different between the two surgeons (P > 0.05). Surgeon B had a significantly longer mean operative time than Surgeon A (P = 0.045). Conclusions: Approximately 50 cases are required for an ophthalmologist to reach a turning point in strabismus surgery. This outcome can be used as a guideline when training surgeons to perform strabismus surgery.

Depression and anxiety in age-related macular degeneration

Dear editor We read with great interest the article titled “Treatment satisfaction of patients undergoing ranibizumab therapy for neovascular age-related macular degeneration in a real-life setting” by Gohil et al.1 We are in agreement with their findings. We congratulate the authors for their well-organized study and would like to contribute to their findings. Anxiety and depression that affect the state of physical, mental, and social well-being completely account for a patient’s quality of life. Severe depression has been revealed to have worse effect on the prognosis of diseases such as breast cancer, cardiovascular disease, and diabetes,2–4 whereas concurrent supportive management of depression may improve the treatment outcome in these diseases. According to the recent report from Mathew et al,5 vision impairment and consequent functional disability caused by age-related macular degeneration (AMD) may cause high levels of clinical depression in patients, which has direct or indirect adverse effects on their quality of life. Indeed, anxiety and depression affect the quality of life in AMD patients and can bring patients to address different satisfaction to their treatment outcome. In addition, it is convinced to have an influence on maintaining the life-long treatment, which is the key to a treatment success. Therefore, it is highly recommended to assess and support the mental health problems, including neuropsychiatric evaluation when necessary, of AMD patients undergoing anti-VEGF treatment, which may be helpful in maximizing the patient’s treatment satisfaction.

Traumatic central serous chorioretinopathy in the fellow eye

Sir, Traumatic central serous chorioretinopathy (CSC) is very rare, and there is a few previous report of traumatic CSC worldwide.[1,2] We recently experienced a case of CSC after blunt trauma in the fellow eye, thus, herein report the case. A 39-year-old male presented with ocular pain in his right eye following blunt trauma by a plastic ball hitting his eye 1-day earlier. At initial presentation, his best-corrected visual acuities (BCVA) was 20/25 in the right eye and 20/20 in the left eye. The intraocular pressure was 19 mmHg in both eyes. Slit-lamp examination revealed no red blood cells in the anterior chamber. Fundus examination revealed no abnormality in the right eye. An orbital computed tomography scan showed a blowout fracture of the right orbital floor with a slight dislocation of the orbital contents [Fig. 1]. Optical coherence tomography (OCT) scans were performed in both eyes, which were normal, without any signs of retinal detachment. The patient was observed closely with consecutive fundus examination. Two weeks later, he experienced visual disturbance in the left eye. BCVA was 20/50 in the left eye with metamorphopsia while in right eye it was 20/20. On fundus examination, a serous macular detachment was noted in the left eye [Fig. 2a]. Fluorescein angiography showed a focal retinal pigment epithelial (RPE) leakage [Fig. 2b]. OCT performed on the same day showed elevation of the sensory retina in the macula [Fig. 2c]. One month after the trauma in the right eye, BCVA of left eye returned to 20/20 and the neurosensory retinal detachment resolved on OCT examination. Figure 1 Orbital computed tomography showing linear fracture of the inferior orbital wall with a slight dislocation of the orbital contents Figure 2 (a) Fundus photograph reveals a serous elevation of the retina in the macular area. (b) Fluorescein angiography shows a “smokestack” pattern leakage. (c) Optical coherence tomography shows a serous macular detachment CSC is a multifactorial disease of unknown etiology and has been associated with type A personality, emotional stress, pregnancy, hypertension, psychopharmacological medication, and increased levels of corticosteroids.[3] There has been a suggestion that people with type A personality, who gets intensed and overwhelmed easily by stressful situations, over stimulates sympathoadrenomeullary system, consequently overproduce catecholamine, and increase the release of cortisol resulting in CSC.[4] Our case shows no immediate ophthalmologic signs in the affected eye from the first visit, but presented CSC in the unaffected eye after few days after trauma; however, there still is a possibility that CSC has occurred regardless of trauma. During the first visit interview, many factors have been considered to rule out other factors that may have caused CSC, i.e. any stressful situation, previous diagnosis of CSC, and use of steroids (oral or any other route); however, none of these factors seemed to cause CSC. Therefore, it may conclude that the trauma in the right eye caused an increase in endogenous catecholamines, affecting the opposite eye. This is the first case of blunt trauma related CSC occurring in the unaffected eye in Korea, and it is important to notice that it took less than 1 month to recover, whereas CSC, in general, is known with its slow recovery. In conclusion, although there are no immediate signs of damage in the affected eye after blunt trauma, a careful examination of both eyes within few days followed by regular follow-up is required as CSC may occur in the opposite, unaffected eye. Financial support and sponsorship This study was supported by 2014 Research Grant from Kangwon National University (No. 120140437). Conflicts of interest There are no conflicts of interest.