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   2014| October-December  | Volume 4 | Issue 4  
    Online since October 1, 2014

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Current concepts and cutting-edge techniques in myopic macular surgeries
Yasushi Ikuno
October-December 2014, 4(4):147-151
Myopic foveoschisis and macular hole with a retinal detachment are two major diseases associated with posterior staphyloma that are specific to high myopia. The pathogenesis is a combination of various types of traction from the vitreous cortex, epiretinal membrane (ERM), internal limiting membrane (ILM), and microvessels. Foveoschisis typically starts with retinoschisis, and a retinal detachment subsequently develops as a result of traction on the inner retina. The stress on the fovea eventually opens a small hole and leads to retinal detachment from a macular hole; thus, both are closely related. These two pathologies can be treated with vitrectomy. A foveal detachment is the best indication for surgery because of the greatest visual improvement. The routine surgical procedures are vitreous cortex removal with triamcinolone acetonide, ERM peeling, ILM peeling stained with Brilliant Blue G, and gas tamponade. The necessity for ILM peeling and gas tamponade for myopic foveoschisis remains controversial. A postoperative macular hole is a severe complication in foveoschisis, and a photoreceptor inner/outer segment defect seen on optical coherence tomography images obtained preoperatively is a risk factor for macular hole. A foveal nonpeeling can be considered to avoid foveal trauma. The inverted ILM peeling technique is a new option to enhance macular hole closure. Both techniques seem to enhance retinal restoration; however, the visual benefit has not been confirmed. A long-shaft forceps facilitates precise maneuvers. Vitrectomy for highly myopic macular diseases remains challenging; however, an understanding of the pathogeneses and innovations in vitreous surgical instruments and techniques will facilitate safer surgeries.
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Role of genetic factors in the pathogenesis of exudative age-related macular degeneration
Peng Zhou, Xiao-Xin Li
October-December 2014, 4(4):152-155
Exudative age-related macular degeneration (AMD) is one of the leading causes of irreversible blindness worldwide. Many recent genetic association studies on large case–control cohorts have helped in drawing an outline of the pathogenesis of AMD. The majority of the associations observed in oxidative stress and lipid peroxidation (complement factor H or CFH), complement (CFH, C3, complement factor I, C2, complement factor B), and neovascularization (vascular endothelial growth factor A, high-temperature requirement factor A1) genes have been replicated in diverse populations worldwide. In this review, we have provided an overview on the genetic factors in the pathogenesis of AMD, and highlight their underlying molecular genetic mechanisms. Further comprehensive research is needed to verify this outline, to explore the treatment target, and to develop the effective primary and secondary prevention of AMD.
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A novel view of punctate inner choroidopathy: Characterizing the serial changes by high resolution spectrum-domain optical coherence tomography
Yu-Bai Chou, Yu-Chien Chung, Shih-Jen Chen, Fenq-Lih Lee, Chang-Sue Yang
October-December 2014, 4(4):179-183
We report a case of punctate inner choroidopathy (PIC) treated with oral prednisolone and intravitreous bevacizumab injection (IVB). The case was studied and followed for 5 months by serial spectrum-domain optical coherence tomography (SD-OCT). At the early active phase of PIC, SD-OCT showed dome-shaped retinal pigment epithelium (RPE) elevation with underlying intact Bruch’s membrane (BM), overlying photoreceptor inner/outer segment junction (PRJ) disappearance, and homogenous hyperreflective sub-RPE signals. After oral prednisolone and IVB, SD-OCT showed resolution of RPE changes with overlying intact PRJ. Further, the localized outer retinal layers were found to gradually move outward. Our case of PIC was followed by SD-OCT and was successfully treated with oral prednisolone and IVB. SD-OCT may play an important role in early identification of PIC and evaluation of disease progression. According to the serial changes in SD-OCT, we hypothesize that the origin of PIC is most likely to be localized at the RPE level. Early detection and intervention may prevent the progression of PIC to choroidal neo-vascularization and may lead to good prognosis.
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Preoperative prognostic factors in vitrectomy for severe proliferative diabetic retinopathy
Shan-Jiun Lin, Po-Ting Yeh, Jehn-Yu Huang, Chung-May Yang
October-December 2014, 4(4):174-178
Purpose: To investigate the preoperative prognostic factors contributing to extremely poor visual outcome in cases of proliferative diabetic retinopathy after a successful vitrectomy and an uneventful postoperative course. Methods: We enrolled 28 consecutive eyes of 28 patients with poor preoperative visual acuity (VA), who underwent primary diabetic vitrectomy. The postoperative course was uneventful, and retinal attachment was achieved for at least 6 months in all cases. The cases were separated into the study group (postoperative VA < preoperative VA) and control group (postoperative VA ≥ preoperative VA). Preop-erative factors including systemic diseases, demographic data, proliferative diabetic retinopathy severity, and neovascularization status were compared between the two groups. Significant risk factors for poor visual results were determined by logistic regression analysis. Results: The creatinine level was significantly higher in the study group (4.07 ± 4.15 mg/dL) than in the control group (1.23 ± 0.46 mg/dL; p = 0.003). Chronic macular detachment was noted in 7/10 eyes (70%) in the study group and in 1/18 eyes (5.6%) in the control group (p = 0.001). Broad fibrovascular proliferation extending to the periphery for more than two quadrants was found in 4/10 eyes (40%) in the study group and in none of the eyes in the control group (p = 0.016). Chronic macular detachment and broad fibrovascular proliferation were significantly associated with poor visual outcome in multiple logistic regression analysis. Conclusion: Preoperative chronic macular detachment, broad fibrovascular proliferation, and poor renal function may indicate worse visual results after successful diabetic vitrectomy for cases with severe diabetic retinopathy.
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Outcome of a 10-year follow-up of laser in situ laser keratomileusis for myopia and myopic astigmatism
Takeshi Ide, Ikuko Toda, Teruki Fukumoto, Junichi Watanabe, Kazuo Tsubota
October-December 2014, 4(4):156-162
Purpose: To evaluate the results of laser in situ laser keratomileusis (LASIK) for myopia/myopic astigmatism over a 10-year period. Methods: We examined LASIK patients who received regular postoperative assessments over 10 years. We evaluated uncorrected visual acuity (UCVA), manifest refraction, best-corrected visual acuity, intraocular pressure, retreatment rate, safety, efficacy, and complications. Results: We studied 5423 eyes between December 1997 and February 2002. The study criteria were met by 346 eyes. A UCVA of 20/40 was achieved in 86.1% of the patients, with 52.0% achieving 20/20 at 10 years. Refraction within 1.00 σ of target was achieved in 76.3% of the patients, and 95.7% were within 2.00 σ at 10 years. Retreatment was required in 124 eyes (35.8%). The preoperative logMAR UCVA of 1.24 improved to −0.08 at 1 month, and slightly decreased to 0.06 at 10 years. The safety and efficacy indices were 1.0 and 0.89 at 1 month, and 0.99 and 0.71 at 10 years. Conclusion: We analyzed 6.3% of patients who regularly returned for postoperative examinations. Despite the relatively low 10-year-visit rate and the inclusion of single- and multiple-treatment cases, our results may represent the real-world picture of LASIK; furthermore, our study shows that LASIK is an effective and safe procedure.
  679 46 1
Melanoma-associated retinopathy
Chun-Hsiu Liu, Nan-Kai Wang, Ming-Hui Sun
October-December 2014, 4(4):184-188
A 63-year-old Taiwanese man with a history of cutaneous melanoma presented with a rapid onset of bilateral shimmering light and blurred vision. A fundoscopic examination was normal. However, visual field examination indicated generalized depression in both eyes. Scotopic rod-specific electroretinog-raphy (ERG) was undetectable and scotopic maximal combined-cone and rod-specific ERG showed the characteristics of negative ERG (a normal a-wave and a diminished b-wave, with the b-wave smaller than the a-wave), indicating dysfunction of the bipolar cells. Melanoma-associated retinopathy (MAR) was suspected and a systemic work-up gave a diagnosis of metastatic melanoma. This case shows the typical presentation of MAR. Greater awareness of MAR in patients with unexplained visual loss may help to identify an occult focus of metastatic melanoma.
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Low-dose propranolol for the treatment of deep infantile hemangioma with orbital involvement
Shu-Ya Wu, Chien-Cheng Chen, Ming-Chou Chiang, Yueh-Ju Tsai
October-December 2014, 4(4):191-193
Capillary hemangiomas are the second most common childhood tumor of the orbit and may cause proptosis and amblyopia if untreated. Oral propranolol has recently been reported to be an effective and safe alternative. Herein, we describe a 2-month-old boy presented with a deep capillary hemangioma of his left eye. It continued to enlarge rapidly and magnetic resonance imaging of the orbit demonstrated hemangioma infiltration over the left superonasal orbit. The patient was treated with oral propranolol starting at 0.5 mg/kg/day with an incremental increase of 0.5 mg/kg/day every 2 days, up to a maximum of 1.5 mg/kg/day. The patient continued 1.5 mg/kg/day of oral propranolol for 5 months as an outpatient without any complications. The volume of the hemangioma has decreased on the following magnetic resonance imaging and the swollen eyelid dramatically improved after treatment. Oral propranolol at 1.5 mg/kg/day may reduce the volume of deep infantile hemangioma in the proliferative stage. Relatively long duration and slow tapering are recommended to prevent relapse.
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Central corneal thickness measurement by Fourier domain optical coherence tomography, ocular response analyzer and ultrasound pachymetry
Shu-Wen Chang, Po-Fang Su, Andy Y Lo, Jehn-Yu Huang
October-December 2014, 4(4):163-169
Purpose: To assess the repeatability, reproducibility, and agreement of central corneal thickness (CCT) measured by non-contact Fourier domain optical coherence tomography (FD-OCT; OptoVue) with the other two contact devices, ocular response analyzer (ORA; Reichert Ophthalmic Instruments) and Ultrasound Pachymetry (USP; DGH Technologies). Methods: This observational cross-sectional study measured CCT sequentially using FD-OCT, ORA and USP. The first 16 volunteers (32 eyes) received three measurements by two independent examiners in a single session to determine intra-observer repeatability and inter-observer reproducibility. An additional 27 volunteers (54 eyes) received one measurement by the same examiner. The measurements of all 86 eyes were analyzed for the difference, correlation, and agreement among the three devices. Results: FD-OCT measured the thinnest while USP measured the thickest CCT (548.6 ± 28.3 μm, 556.9 ± 28.8 μm, and 560.0 ± 28.8 μm by FD-OCT, ORA, and USP, respectively, p < 0.001). The mean differences (lower/upper limit of agreement) for CCT measurements were 8.4 ± 7.6 |μm (-6.5/23.2) between ORA and FD-OCT, 11.4 ± 7.3 |μm (-2.8/25.7) between USP and FD-OCT, and 3.1 ± 5.1 |μm (-6.9/13.1) between ORA and USP. The intra-class correlation coefficients were above 0.98 for all tested groups. FD-OCT had the lowest intra-examiner variability (coefficient of repeatability of 0.64%) and lowest inter-examiner variability (coefficient of reproducibility of 1.16%). Conclusion: FD-OCT, ORA, and USP demonstrated good inter-observer reproducibility and intra-observer repeatability. The three measurements were highly correlated; however, systematic differences between the three tested devices did exist. FD-OCT was a reliable and examiner-independent method in CCT measurement.
  643 43 1
Foveoschisis with focal choroidal excavation
Chih-Kang Hsu, Chun-Cheng Liu, Jiann-Torng Chen, Yun-Hsiang Chang
October-December 2014, 4(4):189-190
We report a rare case with a focal choroidal excavation (FCE) associated with foveoschisis. We describe the patient’s medical records and review the pertinent literature. A 51-year-old man had an FCE, which was considered to be associated with foveoschisis. Although the patient was treated with repeated intravitreal injection of perfluoropropane, foveoschisis persisted. FCE-linked foveoschisis may be noted in a low myopic patient. Gas tamponade failed to induce retinal reattachment, and aggressive surgical therapy may be needed in this condition.
  652 29 1
Proper indications for vitrectomy–Myopic foveoschisis and proliferative diabetic retinopathy
Shih-Jen Chen
October-December 2014, 4(4):145-146
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Use of a T-flex toric intraocular lens to correct clinically significant astigmatism
Shao-Wei Weng, Jia-Kang Wang, Shu-Wen Chang, Elsa L.C Mai
October-December 2014, 4(4):170-173
Purpose: To investigate the stability and effectiveness of T-flex toric intraocular lenses (IOLs) for the correction of regular corneal astigmatism during cataract surgery. Methods: From October 2009 to January 2014 we enrolled patients receiving phacoemulsification and T-flex toric IOL implantation in the capsular bag at the Far Eastern Memorial Hospital. The uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), corneal astigmatism, refractive astigmatism, and the degree to which the IOL axis deviated from the demanded axis were recorded both before the operation and 6 months postoperatively. Results: We enrolled 24 eyes of 24 consecutive patients in this study. The mean spherical power of the implanted toric IOLs was 17.13 ± 4.21 D (range 6.0–24.0 D) and the mean cylindrical power of the IOLs was 3.0 ± 0.86 D (range 2.0–5.0 D). At the 6-month follow up examination, the refractive astigmatism had improved from 3.21 ± 1.50 D to 0.77 ± 0.47 D (p < 0.001) and the spherical equivalence had improved from 4.47 ± 5.43 D to 0.63 ± 0.49 D (p = 0.007). The CDVA improved from 0.81 ± 0.45 logMAR to 0.09 ± 0.11 logMAR (p < 0.001). The mean improvement from the preoperative CDVA to the postoperative UDVA was 5.3 lines on the Snellen chart. Ninety-two percent of our patients achieved a postoperative UDVA >20/40 and 67% achieved a postoperative UDVA >20/25. Conclusion: The T-flex toric IOL can effectively reduce visually significant corneal astigmatism and improve uncorrected distance visual acuity during cataract surgery.
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