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The Korean Intermittent Exotropia Multicenter Study (KIEMS), which was initiated by the Korean Association of Pediatric Ophthalmology and Strabismus, is a collaborative multicenter study on intermittent exotropia in Korea. The KIEMS was designed to provide comprehensive information, including subjective and objective findings of intermittent exotropia in a large study population. A total of 65 strabismus specialists in 53 institutions contributed to this study, which, to date, is one of the largest clinical studies on intermittent exotropia. In this article, we provide a detailed methodology of the KIEMS to help future investigations that may use the KIEMS data.

Background/aimsThis study aimed to establish a wide-field optical coherence tomography (OCT) deviation map obtained from swept-source OCT (SS-OCT) scans. Moreover, it also aimed to compare the diagnostic ability of this wide-field deviation map with that of the peripapillary and macular deviation maps currently being used for the detection of early glaucoma (EG).MethodsFour hundred eyes, including 200 healthy eyes and 200 eyes with EG were enrolled in this retrospective observational study. Patients underwent a comprehensive ocular examination, including wide-field SS-OCT (DRI-OCT Triton; Topcon, Tokyo, Japan). The individual wide-field scan was converted into a uniform template using the fovea and optic disc centres as fixed landmarks. Subsequently, the wide-field deviation map was obtained via the comparison between individual wide-field data and a normative wide-field database that had been created by combining images of healthy eyes into a uniform template in a previous study. The ability of the new wide-field deviation map to distinguish between EG and healthy eyes was assessed by comparing it with conventional deviation maps based on the area under the receiver operating characteristic curve (AUC).ResultsThe wide-field deviation map obtained using the normative wide-field database showed the highest diagnostic ability for the diagnosis of EG (AUC=0.980 and 961 for colour-coded pixels presenting ConclusionThe wide-field SS-OCT deviation map exhibited good performance for distinguishing between eyes with EG and healthy eyes. The visualisation of the wider damaged area on the wide-field deviation map could be useful for the diagnosis of EG in clinical settings.

Prcis Recognizing the shortcomings of poor consistency of the fovea-disc relationship at different time points and comparing PanoMaps may well facilitate the understanding of the spatial relationship between parapapillary and macular areas in glaucoma. Purpose The aims of this study are to analyze the spatial distribution of the frequently damaged areas in early glaucoma, compare the patterns between nonprogressors and progressors using the combined wide-field parapapillary and macular deviation maps (PanoMap), and to evaluate the consistency of the fovea-disc relationship in PanoMap. The fovea-disc distance (FDD) and fovea-disc axis (FDA) were compared at baseline and at the last follow-up. Materials and methods In total, 118 patients with early glaucoma and a minimum follow-up period of 3 years were included in this retrospective observational study. The pattern of structural changes was evaluated by averaging the PanoMaps of the enrolled patients at baseline and last follow-up. Longitudinal comparison of the FDD and FDA was performed at baseline and the last follow-up. Patients were divided into nonprogressor (n=44) and progressor (n=74), and the patterns of glaucoma progression in PanoMaps were compared between them. Results At baseline, the glaucomatous damage was found more frequently in the macular compared with the parapapillary area. The spatial distribution of frequently damaged areas was similar between the nonprogressor and progressor. At the last follow-up, compared with the baseline structural change on the PanoMap, the progressive structural changes extended toward the fovea at both the parapapillary and macular areas in the progressor. The FDD and FDA were significantly different between the baseline and the last follow-up. Conclusions The PanoMaps showed a clear spatial distribution of early glaucomatous changes, indicating that the damaged area was frequently observed in the macular area. As the consistency of the fovea-disc relationship in PanoMaps was not excellent, this aspect should be considered when interpreting the PanoMap.

Purpose Microvasculature dropout (MvD) is a novel finding seen in optical coherence tomography angiography (OCTA), which is characterized by a localized dehiscence of the choriocapillaris in the parapapillary atrophy area. Disc hemorrhage (DH) is an important factor often associated with the development and especially progression of glaucoma. Here, we present 2 cases of MvD progression with DH. Methods and results Case 1: A 62-year-old female patient with normal tension glaucoma in both her eyes had recurrent DH at the inferior area of her right eye. A new DH was observed in the inferotemporal area of the right eye with MvD progression on OCTA in the same direction three months from the baseline.Case 2: A 57-year-old female patient with bilateral steroid-induced secondary glaucoma also had recurrent DH in her right eye. Four months from the baseline, DH occurred in the superotemporal and inferotemporal area of the right eye, and MvD was detected on OCTA in the superotemporal corresponding direction. After 19 months from the baseline, OCTA was repeated. The DH had resolved, but the superotemporal MvD persisted. Conclusions The 2 cases presented here are the first to report on the relationship between MvD progression and DH. MvD as visualized in OCTA imaging looks to be of clinical importance, and hopefully future studies will reveal the actual connection between MvD, DH, and glaucoma progression.

The present study aimed to evaluate the diagnostic ability of wide-field optical coherence tomography angiography (OCTA) density map for detection of glaucomatous damage in high myopic (HM) eyes and to further compare the diagnostic ability of OCTA with that of conventional imaging approaches including red-free photography and swept-source OCT (SS-OCT) wide-field maps. A total of 77 healthy HM eyes and 72 HM eyes with open angle glaucoma (OAG) participated in this retrospective observational study. Patients underwent a comprehensive ocular examination, including wide-field SS-OCT scan and peripapillary area and macular OCTA scans. An integrated OCTA density map thereafter was merged by vascular landmark-guided superimposition of peripapillary and macular superficial vascular density maps onto the red-free photography (resulting in the OCTA-PanoMap). Glaucoma specialists then determined the presence of glaucomatous damage in HM eyes by reading the OCTA-PanoMap and compared its sensitivity and specificity with those of conventional images. Sensitivity and specificity of OCTA-PanoMap for HM-OAG diagnosis was 94.4% and 96.1%, respectively. Compared with other imaging methods, the sensitivity of OCTA-PanoMap was significantly higher than that of red-free photography (P = 0.022) and comparable to that of wide-field SS-OCT maps. Specificity of OCTA-PanoMap was significantly higher than those of other conventional imaging methods (except for wide-field thickness map). The OCTA-PanoMap showed good diagnostic ability for discrimination of HM-OAG eyes from healthy HM eyes. As a complementary method of an alternative imaging modality, OCTA-PanoMap can be a useful tool for detection of HM-OAG.

Purpose: To quantitatively investigate the microstructural properties of the optic nerve (ON) in vivo using diffusion magnetic resonance imaging (dMRI) tractography in an elderly population and to determine the differences between the ON diffusion properties stratified by basic demographics.Methods: We measured fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) of the intraorbital ON in cognitively normal controls selected from the Alzheimer's Disease Neuroimaging Initiative 3 database (n =104; mean age = 73. 8 ± 8.1 years) using dMRI probabilistic tractography and evaluated the correlation between diffusion parameters and demographic factors. Diffusion parameters were measured in 20 equidistant nodes along the tract, and the data from proximal 70% (14 nodes) of the intraorbital ON were averaged.Results: The mean FA of the intraorbital ON was 0.392 ± 0.063, and the mean MD was 1.163 ± 0.165 μm2/s. The mean RD was 0.882 ± 0.152 μm2/s, and the mean AD was 1.693 ± 0.183 μm2/s. The multiple linear regression model showed a negative correlation between FA and age. FA in females was significantly higher than males, whereas RD in female was significantly lower.Conclusions: We measured the diffusion properties of the intraorbital ON using dMRI tractography in an elderly cognitively normal population. The diffusion properties detected by dMRI tractography may substantially reflect the microstructure of the ON.

PRECIS We investigated changes of intraocular pressure (IOP) according to eye gaze. IOP was significantly elevated in adduction, abduction, and supraduction. However, there was no significant difference between glaucoma and control groups. PURPOSE We assessed changes in IOP according to eye gaze and identified their correlations with various risk factors of glaucoma. PATIENTS AND METHODS In this prospective observational study that included 56 glaucoma patients and 34 healthy participants, we measured IOP in the primary position with a Goldmann applanation tonometry and rebound tonometer. Then, this IOP was measured in abduction, adduction, supraduction using a rebound tonometer. IOP changes according to eye gaze were measured based on the baseline IOP, and IOP changes between glaucoma and the control groups were compared. Correlations between IOP changes and risk factors of glaucoma were evaluated. RESULTS The baseline IOP was not significantly different between glaucoma and the control groups. Compared with the IOP in the primary position, a significant increase in IOP was 2.3±2.7 mm Hg during abduction (P

Purpose We investigated the microRNAs (miRNAs) expression in the anterior lens capsules of patients with senile cataract and compared it to that in the anterior lens capsules of healthy controls. Moreover, we compared the differences in miRNAs expression according to the types of cataracts. Methods Individual lens epithelium samples were collected from 33 senile patients and 10 controls. The cataract patients were classified into cortical, nuclear, posterior and anterior subcapsular and mixed. The expression of 12 different miRNAs in lens epithelium was measured using real-time polymerase chain reaction and compared between the senile cataract patients and controls. The differences of miRNA levels according to cataract type were analyzed. Results The expression levels of let-7g-5p, miR-23a-3p, miR-23b-3p, and miR-125a-5p were significantly upregulated in patients with senile cataract when compared with those in the control group (P < 0.05). The expressions of let-7a-5p, let-7d-5p, miR-16-5p and miR-22-3p were significantly downregulated in the senile cataracts (P < 0.05). Let-7a-5p, let-7d-5p, let-7g-5p and mir-23b-3p had significant difference in expression between nuclear and anterior subcapsular cataracts. Conclusions The eight differentially expressed miRNAs may be involved in the pathogenesis of senile cataract, in particular, related to oxidative stress and autophagy. Translational Relevance We infer that several miRNAs in lens epithelial cells are promising candidate biomarkers of senile cataracts.

Background To quantitatively compare short-term hard exudates (HEs) alteration in patients with diabetic macular edema (DME) after intravitreal triamcinolone, dexamethasone implant or bevacizumab injections. Methods This retrospective study enrolled DME eyes with HEs that underwent a single-dose intravitreal injection of triamcinolone (25 eyes), dexamethasone implant (20 eyes), or three monthly injections of bevacizumab (25 eyes) and completed at least three months of follow-up. All patients were examined before and after 1, 2 and 3 months of injections. Using color fundus photographs, the amount of HEs was quantified by two masked graders. The difference in HEs area between baseline and each follow-up visit was compared among the three groups. Results After three months, HEs area was reduced to 52.9 ± 4.21% (P

Purpose Deregulated expression of several microRNAs (miRNAs) in sera or salivary glands of patients with Sjogren syndrome (SS) has been reported. However, none have investigated miRNAs in samples that can represent lacrimal glands. We compared the miRNAs expression in the tears of SS patients and healthy controls. Moreover, we investigated the correlation between miRNAs expression and ocular staining score (OSS). Methods Individual tear samples were collected from 18 SS patients and 8 age-matched controls. Clinical ophthalmologic assessments included Schirmer I test, tear film breakup time (tBUT), and OSS. The expression of 43 different miRNAs in tears was measured using real-time polymerase chain reaction, and compared between the SS patients and controls. And we also compared between the three groups of control, primary SS, and secondary SS patients. The correlation between the miRNA expression and OSS was evaluated. Results The expression levels of miR-16-5p, miR-34a-5p, miR-142-3p, and miR-223-3p were significantly upregulated in patients with SS when compared with those in the control group (P < 0.05). The expression of 10 miRNAs (miR-30b-5p, miR-30c-5p, miR-30d-5p, miR-92a-3p, miR-134-5p, miR-137, miR-302d-5p, miR-365b-3p, miR-374c-5p, miR-487b-3p) was significantly downregulated in the SS patients (P < 0.05). Eight miRNAs showed statistically significant differences between the three groups of control, primary SS and secondary SS. All 14 miRNAs with significant differences in SS patients and control group were not significantly correlated with OSSs. Conclusions The 14 differentially expressed miRNAs may be involved in the pathogenesis of SS, in particular, related to autoimmunity and neuropathy.

Background Traumatic optic neuropathy (TON) is a form of optic nerve injury that occurs secondary to trauma and is etiologically associated with acute axonal loss with severe vision loss. Here, we reported longitudinal changes in the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC) using wide-field swept source optical coherence tomography (SS-OCT) in two cases of TON and identified the source of the damage. Case presentation (Case 1) A 65-year-old man was admitted to the hospital due to an injury in the right eye (OD) and was subsequently diagnosed with indirect TON. He was then treated with high-doses of intravenous steroids. Wide-field SS-OCT was performed at the baseline and after 1 day, 2 days, 1 week, 1 month, and 4 months. The wide-field deviation map detected thinning earlier in the macular GCC than in the peripapillary RNFL. (Case 2) A 63-year-old man was admitted to the hospital with a fractured left maxilla-zygomatic complex attributed to blunt-force trauma to the head and loss of vision in his left eye (OS). He was diagnosed with indirect TON and treated with high-doses of intravenous steroids. Wide-field SS-OCT was performed at the baseline and after 1 week, 2 weeks, 2 months 5 months, and 7 months. The wide-field deviation map detected thinning earlier in the peripapillary RNFL than in the macular GCC. Conclusions Wide-field SS-OCT facilitated the identification of various sequential progression patterns in patients with TON. Furthermore, the area in which the structural damage was first detected was seen differently in the peripapillary and macular deviation maps for each case. Thus, wide-field imaging, which includes the macular and peripapillary areas, are useful in monitoring TON.

PURPOSE: To determine the range of eye movement in normal human subjects and to investigate the effect of age and gaze direction on eye movement. PATIENTS AND METHODS: A prospective observational study. We enrolled 261 healthy subjects, 5–91 years of age. Photographs were obtained in the cardinal gaze positions and processed using Photoshop. The processed images were analyzed using the Image J program to measure the angle of eye movement. The angle of eye movement was quantified using a modified limbus test. We measured the angle of eye movement in adduction, abduction, elevation, and depression. RESULTS: The ranges of eye movement were 44.9 ± 7.2° in adduction, 44.2 ± 6.8° in adduction, 27.9 ± 7.6° in elevation, and 47.1 ± 8.0° in depression. The ranges of eye movement in the younger group were higher than that in the older group in adduction, abduction, and elevation (P

[This corrects the article DOI: 10.1371/journal.pone.0204069.].

Purpose One purpose of this study was to collect wide-field swept-source optical coherence tomography (SS-OCT) data from healthy eyes and build a wide-filed normative database. Another purpose was to compare the glaucoma diagnostic ability of new parameters based on this normative database to the parameters that are currently in use, such as the peripapillary retinal nerve fiber layer (RNFL), macular ganglion cell-inner plexiform layer, and ganglion cell complex (GCC) thickness. Methods This study had 220 healthy eyes and 292 eyes with early-stage glaucoma (EG) and moderate-stage glaucoma (MG) enrolled. Using the wide-field SS-OCT images (12 × 9 mm) of healthy eyes, a wide-field normative database was constructed by transforming and combining the individual images into a uniform template using the fovea and optic disc centers as fixed landmarks. Adjustment for the disc size was conducted. With this normative database, new parameters based on the ratio of the fovea-disc distance (FDD) consisting of the fovea-disc relationship were evaluated. The glaucoma diagnostic ability was assessed based on the area under the receiver operating characteristic curve (AUC). Results Among the new peripapillary parameters, the RNFL of the circumference of the circle with diameter 0.8 FDD showed the highest AUC value for EG and MG, but the value was not significantly superior to that of the initial RNFL (AUC = 0.940 vs. 0.937, P = 0.631). Among the macular parameters, the GCC of the area of the circle of 1.5 FDD showed the highest AUC value for EG and MG, and the value was significantly superior to that of initial GCC (AUC = 0.929 vs. 0.919, P = 0.033). However, there was no significant difference between the initial and adjusted GCC thickness in patients included in the EG or MG groups separately. Conclusions A wide-field normative database was built to consider the relationship between the fovea and the optic disc. Considering this aspect, we found that the GCC analysis using a broader area presented a significantly greater glaucoma diagnostic performance for EG and MG in the macula than the initial parameter for the GCC. Translational relevance Based on this wide-field normative database, the clinical use of a wide-field deviation map may help diagnose the patients with EG and MG in the future.

Purpose To measure the degree of compensatory torsional eye movement during head tilt using a fundus photography method. Methods We enrolled 55 healthy subjects who were 20–66 years of age. Fundus photographs were obtained in the presumed baseline position and in stepwise head tilt positions to evaluate ocular torsion using a non-mydriatic fundus camera. Horizontal marks on the nose were photographed simultaneously to evaluate head tilt. Images were analysed using Photoshop to measure the degree of ocular torsion and head tilt. Results A consistent compensatory torsional eye movement was observed in all subjects during head tilt. The degree of compensatory torsional eye movement showed a positive correlation with the angle of head tilt. Ocular torsional disconjugacy was observed during head tilt, with larger excycloductional eye movement than incycloductional eye movement (4.88 ± 2.91° versus 4.50 ± 2.76°, p

Rationale: Optic disc melanocytoma is an ophthalmic tumor that arises from melanocytes, and is a variant of the melanocytic nevus. Here we report 2 cases of optic disc melanocytoma in Asian patient: one associated with normal tension glaucoma (NTG), and the other associated with angle closure glaucoma (ACG). Patient concerns: Case 1 is a 57-year-old Asian female presented to our department for a general ophthalmic examination. Incidentally, brownish pigmented lesion was found on dilated fundus examination of her right eye. The fundus examination and optical coherence tomography (OCT) examination revealed a mass within optic disc, and superotemporal retinal nerve fiber layer (RNFL) thinning. The Humphrey visual field test showed corresponding visual field defect. Fluorescein angiography showed no leakage around the lesion. Case 2 is a 78-year-old Asian woman presented with complaints of acute bilateral ocular pain. The initial examination revealed shallow anterior chamber. Under the impression of intermittent angle closure attack, prophylactic laser peripheral iridotomy were performed. On dilated fundus examination, black pigmented lesion was found at superior sector of optic disc. Further examination revealed bilateral superotemporal, inferotemporal RNFL thinning on OCT, and spatially corresponding visual field defects. Diagnoses: Clinical diagnosis of NTG was made for case 1 patient. Although it was a little distant from typical glaucomatous changes, nevertheless she had RNFL defect compatible with visual field defects. Considering her normal IOP and angle structures, we believe NTG was a probable diagnosis for the patient. In case 2, we made diagnosis of ACG presenting as intermittent angle closure attack because of her presenting symptoms, narrowing of anterior chamber and angle structures found on gonioscopic and slit lamp examinations. Interventions: In Case 1, we prescribe 0.005% latanoprost ophthalmic solution. In Case 2, at first prophylactic laser peripheral iridotomy was performed. Then, topical eyedrops administration was started, and the patient was examined periodically. Outcomes: In Case 1, at 6 months’ follow-up, OCT and visual field test showed no progression. In Case 2, to this date, the optic disc melanocytoma remains stable for over a 6-year-follow-up period. Lessons: The fact that NTG and ACG can coexist in patients with melanocytoma of optic disc should be recognized, and the possibility of such should appropriately be evaluated.

In this cross-sectional study, we examined age-related changes in the retinal vessels of 100 healthy participants, aged from 5 to 80 years, and divided into four groups (G1, under 20 years of age, G2, from 20 to 39 years of age, G3, from 40 to 59 years of age, G4, age 60 years or older). All subjects underwent swept-source optical coherence tomography (SS-OCT) and OCT angiography (OCTA). The vascular density (VD) of the superficial (SCP) and deep capillary plexus (DCP), and choriocapillaris (CCP) were measured using OCTA. The vascular density of each capillary layer, foveal avascular zone (FAZ) area, ganglion cell-inner plexiform layer (GC-IPL) thickness, retinal thickness (RT), and choroidal thickness (CT) were compared between age groups. Most OCT variables were correlated with OCTA variables. The FAZ area, VD of the SCP, DCP, and CCP, GC-IPL thickness, RT, and CT showed significant difference (p &lt, 0.001) between G1 + G2 and G3 + G4, except for central GC-IPL thickness (p = 0.14) and central RT (p = 0.25). Density of the retinal capillary vasculature reduced and FAZ area increased after age 40, which represents the onset of middle age.

Aim To investigate the performance of a newly developed three-dimensional (3D) biomechanical model in various transposition procedures for correction of complete sixth nerve palsy with educational purpose. Methods A 3D biomechanical eye model was created using Hyperworks software based on geometry data and the biochemical properties of the eyeball and extraocular muscles. A complete sixth nerve palsy model was achieved via modification of lateral rectus muscle strength. Four different muscle transposition procedures (the Hummelsheim, Jensen, Foster, and muscle union procedures) were set up, and the objective surgical effect of each procedure was calculated using 3D model simulation. Results In the 3D simulation, sixth nerve palsy was modeled by rotating the eye 34.16 degrees in the medial direction, consistent with 70 prism diopter (PD) esotropia. In surgical model simulation, the Hummelsheim procedure resulted in a 28 PD reduction of total deviation, the Jensen procedure achieved a 34 PD reduction, the Foster procedure led to a 57 PD reduction, the muscle union procedure yielded a 57 PD reduction in esotropia in sixth nerve palsy. Conclusion The 3D simulation provided a consistent model of sixth nerve palsy and objective data excluding the potential for variation of surgical skill. It could also help predict surgical outcomes.

To investigate the choroidal changes that occur in hydroxychloroquine (HCQ) retinopathy using multimodal imaging including fluorescein angiography, indocyanine green angiography, and optical coherence tomography (OCT) angiography and to correlate these changes with retinal findings obtained using OCT and fundus autofluorescence.In 20 patients (n = 40 eyes) with systemic lupus erythematosus or rheumatoid arthritis diagnosed to have HCQ retinopathy, imaging modalities including swept-source OCT, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, and OCT angiography were used to evaluate retinal and choroidal changes associated with retinopathy. The assessments included specific findings such as presence of hyperfluorescent or hypofluorescent lesions on angiography and signal void zones on OCT angiography, their frequencies, and the correlations among the retinal and choroidal findings. These findings were also correlated with the severity of retinopathy. Retinopathy progression was defined using fundus autofluorescence and OCT and correlated with the retinal/choroidal findings.Fluorescein angiography demonstrated a hyperfluorescent area, which reflects a defective retinal pigment epithelium, with multiple tiny dark spots within the area. Indocyanine green angiography showed a hypofluorescent area with dark spots, which was matched to the hypoautofluorescent area on fundus autofluorescence. Although there were no specific morphologic abnormalities in the choroid layers using en face choroidal imaging, OCT angiography demonstrated signal void areas on the choriocapillaris in the areas of the retinal pigment epithelium defect. Even after cessation of HCQ, there was progression of retinopathy in eyes with choroidal involvement, particularly on the area of choroidal findings.Multimodal imaging demonstrates choriocapillaris degeneration in eyes with HCQ retinopathy, particularly those with severe retinopathy. The choroidal change was associated with outer retinal toxicity of HCQ.

Purpose To investigate the distribution of outer retinal changes in hydroxychloroquine (HCQ) retinopathy and explore optical coherence tomography (OCT) protocols to maximize the sensitivity of HCQ retinopathy detection in Asian patients. Design Diagnostic validity assessment. Methods Setting: Institutional. Patient Population: Forty-eight eyes (24 patients) with HCQ retinopathy underwent 6-mm horizontal and vertical line scans and 6 × 6-mm 2 volume scans using spectral-domain OCT (SD-OCT), and 9-mm line scans and 6 × 6-mm 2 and 12 × 9-mm 2 volume scans using swept-source OCT (SS-OCT). Observation Procedures: Distances from the fovea to the defective photoreceptors were measured in the temporal, nasal, superior, and inferior directions from line scan OCT images. The sensitivity of retinopathy detection, indicated by photoreceptor defects, was compared among protocols. Main Outcome Measures: Detection of photoreceptor defects and distances from the fovea to the defects. Results The average minimum distance from the fovea to an area of photoreceptor defects was 1.84 ± 1.26 mm (mean ± standard deviation). The distances were greater than 3 mm horizontally and vertically in 15 (31.3%) and 17 (35.4%) eyes with HCQ retinopathy, respectively, and only wide-field line or volume scans could detect defects in the eyes. The 9-mm line scans detected HCQ retinopathy significantly better than 6-mm scans ( P P = .001). The 12 × 9-mm 2 volume scan detected retinopathy with the greatest sensitivity (100%). Conclusions Our study recommends a wide-field OCT scan to screen Asian patients taking HCQ medications.

Background Hydroxychloroquine (HCQ) retinopathy can accompany other retinal complications such as cystoid macular edema (CME), which leads to central visual loss. We report a case of CME with HCQ retinopathy that improved with the use of oral acetazolamide, and discussed the possible mechanisms of CME in HCQ retinopathy using multimodal imaging modalities. Case presentation A 62-year-old patient with systemic lupus erythematosus (SLE) and HCQ retinopathy developed bilateral CME with visual decline. Fluorescein angiography (FA) showed fluorescein leakage in the macular and midperipheral area. After treatment with oral acetazolamide (250 mg/day) for one month, CME was completely resolved, best corrected visual acuity (BCVA) improved from 20/50 to 20/25, and FA examination showed decreased dye leakage in the macular and midperipheral areas. Conclusions In cases of vision loss in HCQ retinopathy, it is important to consider not only progression of maculopathy, but also development of CME, which can be effectively treated with oral acetazolamide.

Purpose To determine the range of eye movement in normal human subjects and to investigate the effect of age on eye movement. Methods We enrolled 261 healthy subjects, 5–91 years of age for this prospective observational study. Photographs were obtained in the cardinal gaze positions and processed using Photoshop. The processed images were analyzed using the Image J program to measure the angle of eye movement. The angle of eye movement was quantified using a modified limbus test. We measured the angle of eye movement in adduction, abduction, elevation, and depression. Results The normal ranges of eye movement were 44.9 ± 7.2° in adduction, 44.2 ± 6.8° in adduction, 27.9 ± 7.6° in elevation, and 47.1 ± 8.0° in depression. There were significant negative correlations between the angles of horizontal and upward gazes and age (R = −0.294 in adduction, R = −0.355 in abduction, and R = −0.506 in elevation, all p

Purpose To investigate the effect of eye movement on the optic nerve head (ONH) using swept-source optical coherence tomography (SS-OCT), and to measure the degree of ONH changes. Methods We enrolled 52 healthy subjects, 20 to 40 years of age, and performed a prospective observational study. Both ONH and macula were imaged simultaneously using wide volume scan of the SS-OCT in the primary and different gaze positions. Horizontal eye movements were used to obtain OCT images in abducted and adducted eyeball positions. Multilateral 3-dimensional registration was used to process and analyze the images to measure the degree of ONH changes. Results The mean axial length (AXL) was 25.73 ± 1.42mm and the mean spherical equivalents was -4.49 ± 2.94 D (The proportion of high myopia was 39.4%). Significant morphologic changes were observed in the ONH during both abduction and adduction. In abduction, the overall ONH tissues were elevated, and the mean area of elevation was 115,134 ± 9,424 μm2 (p

Purpose: To identify the anatomy of the levator aponeurosis (LA) and Whitnall’s ligament (WL) in Korean subjects using cadavers. Methods: Orbital exenteration was performed in ten cadavers (20 eyeballs) that had no history of trauma near the eyeball. We observed characteristics of WL (tension, density, and shape) and the relationship between the superior rectus muscle (SR) and the levator palpebrae superioris. We measured the distance from both the eyelid margin and the upper border of the tarsal plate to the insertion of the LA medially, centrally, and laterally. Results: The WLs we observed showed several shapes. In 12 eyes, we saw clear, white fibrotic bands, while in four others, we found thin, less taut bands. In four eyes, we were unable to identify the precise shape of the band. The insertions of the LA showed nasal dehiscence in 13 eyes and parallel attachment in seven eyes. The distances from the eyelid margin to the insertion of the LA medially, centrally, and laterally were 8.31 mm, 5.57 mm, and 5.15 mm, respectively. The distances from the upper border of the tarsal plate to the insertion of the LA medially, centrally, and laterally were 2.75 mm, 4.82 mm, and 4.29 mm, respectively. Conclusions: This study examined the anatomy of WL and the LA in Korean subjects and may be helpful as a reference in levator muscle surgery. Korean J Ophthalmol 2009;23:183-187 ⓒ 2009 by the Korean Ophthalmological Society.

Flashes of light or phosphenes are the sensation of light without light actually entering the eye. This phenomenon can be evoked by stimulation of the retina or the visual cortex of the brain and can appear unilaterally or bilaterally. From an ophthalmologic perspective, phosphenes can arise from photoreceptor induction by mechanical,1,2 inflammatory,3 or vascular4 stimuli. Therefore, it is necessary to determine the origin of phosphenes for further management. We encountered a patient who reported having phosphenes while moving his eyes laterally. We performed various ophthalmologic imaging studies to identify the origin of these phosphenes.

Periodontal disease (PD) is associated with various systemic diseases. We investigated the association between PD and age-related macular degeneration (AMD). For this population-based, cross-sectional study, we enrolled 13,072 adults at least 40 years of age with gradable retinal fundus photographs and community periodontal index (CPI) data from the Korean National Health and Nutrition Examination Survey (KNHANES) (2008–2010 and 2012). Participants were divided into a middle age group (age ≤62 years) and old age group (age >62 years). PD was divided into 2 categories of mild and severe. Logistic regression analysis was used to evaluate the association between PD and AMD (early and late). The prevalence of PD and AMD in the study population was 37.4% ± 0.8% and 5.6% ± 0.2%, respectively. Overall, there was no significant difference in the proportion of participants with PD between those with and without AMD. Only participants with AMD in the middle age group had more any PD than those without AMD (P = 0.031). Multivariate logistic regression model after adjusting for all confounding factors showed that PD was not significantly associated with AMD (odds ratio [OR] 1.03, 95% confidence interval [CI] 0.86–1.22). However, according to degree of PD, participants with severe PD in the middle age group were 1.61 times more likely to have AMD (OR 1.61, 95% CI 1.02–2.54). Our data, collected from an Asian population, showed that only severe PD is independently associated with AMD in individuals aged 62 years or younger.

To identify the clinical features, treatment outcomes, and prognostic factors of endogenous endophthalmitis in multiple tertiary referral centers of South Korea over a 6-year period.The authors conducted a retrospective review of medical records of 57 eyes of 43 patients diagnosed with endogenous endophthalmitis from January 2005 to December 2011, which was referred to tertiary referral centers.Fifty-seven cases of 43 patients were followed for a mean of 18.7 months (range, 0.5-50 months). The common underlying diseases were diabetes mellitus (46.5%) and liver cirrhosis (20.93%). Liver abscess (39.5%) was the most common infection source. Among prognostic factors, the initial visual acuity was associated with favorable visual outcome significantly (P0.001). Endogeneous endophthalmitis with gram-negative bacteria had worse visual outcomes than gram-positive bacteria or fungus (P = 0.014).Similar to the findings of previous East Asian studies, this study showed that Klebsiella pneumoniae was the most common causative organism of endogenous endophthalmitis and liver abscess was the most common infection focus. Although endogenous endophthalmitis is generally associated with poor visual acuity outcomes, the prognosis depends mainly on the initial visual acuity and the pathogen.

Purpose To measure the maximum angle of ocular versions using photographs of the 9 cardinal positions and a modified limbus test. Design An evaluation of diagnostic technology; a prospective observational study. Participants We enrolled 104 healthy subjects, 20 to 40 years of age. Methods Photographs were obtained in the 9 cardinal positions of gaze and the images were processed using Photoshop. The images were analyzed using the Image J program to measure the angle of version. The maximum angle of the 9 cardinal positions was quantified using a modified limbus test. Main Outcome Measures We measured the maximum angle of ocular versions in the 9 cardinal positions of gaze. We also compared the results for males and females. Results The mean angles of maximum version were adduction 47.4°, abduction 46.4°, elevation 31.8°, depression 47.8°, elevation in adduction 39.7°, elevation in abduction 40.7°, depression in adduction 52.7°, and depression in abduction 49.2°. The mean angle of maximum elevation was significantly smaller than that of depression ( P 0.001). There were no correlations between the angle of maximum version and age, spherical equivalents, or axial length. The angle of maximum version for males was significantly greater than that for females, except for inferior gaze. Conclusions A modified limbus test using photographs of the 9 cardinal positions is an objective and reproducible tool for quantifying ocular movement. Considering its simplicity, ease of use, and low cost, it has clear applications in clinical practice.

To evaluate the diagnostic accuracy of Topcon 3D spectral-domain optical coherence tomography (SD-OCT) for measuring the macular inner retinal layers and the circumpapillary retinal nerve fiber layer (cpRNFL) in order to detect preperimetric glaucoma. Two hundred four eyes, including 64 healthy eyes, 68 eyes with preperimetric glaucoma, and 72 eyes with early glaucoma were analyzed. Patients had a comprehensive ocular examination including visual field testing and SD-OCT imaging (3D OCT-2000; Topcon Corporation, Tokyo, Japan) in the macular and peripapillary regions. OCT macular scans were segmented into the macular nerve fiber layer (mNFL), ganglion cell layer with the inner plexiform layer (GCIP), and ganglion cell complex (GCC) (composed of the mNFL and GCIP). Ability to discriminate preperimetric glaucoma was assessed using the area under the receiver operating curve for all macular parameters and the cpRNFL. The median visual field MD was −0.78 ± 1.19 dB for the healthy group, −1.02 ± 1.29 dB for the preperimetric glaucoma group, and −3.08 ± 1.61 dB for the early glaucoma group. There were significant differences between the preperimetric and healthy groups for GCIP and GCC and for almost all cpRNFL thickness parameters (P

Purpose: To evaluate the thickness and volume of the choroid in healthy Korean children using swept-source optical coherence tomography. Methods: We examined 80 eyes of 40 healthy children and teenagers (

Purpose: The authors report a case of bilateral simultaneous central retinal vein occlusion caused by Waldenstrom’s macroglobulinemia. Case summary: A 65-year-old man presented to our department complaining of decreased visual acuity for the duration of about 6 months. On his initial visit, best-corrected visual acuity was 0.02 in the right eye and 0.06 in the left eye. Based on the findings of a funduscopic examination, the patient had bilateral diffuse retinal hemorrhages, dilated tortuous veins, and macular edema. He had experienced recurrent spontaneous epistaxis 6 months previously and had undergone treatments such as intravitreal bevacizumab injection and intravitreal dexamethasone implantation at another hospital. Laboratory tests at that hospital showed anemia and hyperproteinemia, for which he was referred to our hemato-oncology department. Bone marrow biopsy was consistent with Waldenstrom’s macroglobulinemia/lymphoplasmacytoid lymphoma, and he was treated with systemic chemotherapy. One year after the systemic chemotherapy, his best-corrected visual acuity was 0.15 in the right eye and 0.6 in the left eye. Funduscopy showed decreased bilateral retinal hemorrhages and macular edema. Conclusions: When simultaneous bilateral central retinal vein occlusion occurs in a patient with no other underlying disease such as hypertension or diabetes, it might be a sign of serum hyperviscosity, and there should be a very high level of suspicion for presence or progression of systemic disease. If such a disease is properly and timely diagnosed, effective early systemic evaluation and therapy can be administered, and it is important to have initial general treatment as well as ophthalmic treatment. J Korean Ophthalmol Soc 2016;57(6):1012-1017

목적: 시야검사상 반시야결손을 나타내는 녹내장 환자에서 스펙트럼영역 빛간섭단층촬영(spectral-domain optical coherence tomography, SD-OCT)으로 측정한 정상 반시야의 시신경유두주위 망막신경섬유층(circumpapillary retinal nerve fiber layer, cRNFL) 및 황반부신경절세포층(macular...

목적: 정상 소아에서 스펙트럼영역 빛간섭단층촬영(spectral domain optical coherence tomography)을 이용하여 망막신경섬유층 부피를 측정하고 망막신경섬유층 두께와의 상관관계를 알아보고자 하였다. 대상과 방법: 2012년 2월부터 11월까지 4세에서 15세 사이의 정상 소아 79안을 대상으로 스펙트럼영역 빛간섭단층촬영을...

To present the surgical outcomes of a muscle union procedure in patients with paralytic strabismus, this retrospective study included 27 patients with paralytic strabismus who underwent a muscle union procedure. In this procedure, the two vertical rectus muscles are united with the paralytic horizontal muscle without splitting the muscles. Postoperative ocular deviations, complications, surgical success rates, and reoperation rates were obtained by examining the medical records of the patients. Seventeen patients had a sixth cranial nerve palsy, seven patients had a third cranial nerve palsy, and three patients had a medial rectus muscle palsy after endoscopic sinus surgery. The mean preoperative angle of horizontal deviation in the primary position was 56 +/- 21 prism diopters. The mean follow-up period was 12 +/-+/- 9 months. The mean final postoperative ocular deviation was 8 +/- 13 prism diopters. The success rate was 74%, and the reoperation rate was 0%. No significant complications, including anterior ischemia, occurred in any of the patients. One patient exhibited an increase in intraocular pressure in the immediate postoperative period, but this resolved spontaneously within 1 week. Our muscle union procedure was effective in patients with paralytic strabismus, especially in patients with a large angle of deviation. This muscle union procedure is potentially a suitable option for muscle transposition in patients with paralytic strabismus who have large-angle deviation or a significant residual angle after conventional surgery.

목적: 비접촉경면현미경, 이중샤임플러그전안부 사진기 및 초음파 각막두께측정계를 이용하여 중심각막두께의 측정치를 비교하고자 하였다. 대상과 방법: 정상인 70명 70안을 대상으로 비접촉경면현미경, 이중샤임플러그전안부 사진기 그리고 초음파 각막두께측정계로 측정한 중심각막두께를 비교하고 상관관계를 알아보았다. 결과: 비접촉경면현미경, 이중샤임플러그전안부 사진기...

Purpose: To evaluate the clinical stability and outcomes of 3-piece intraocular lens (IOL) transscleral fixation surgery using a modified injector. Methods: We have modified and used the Sapphire unfolder injector system (Allergan, USA). This involved, cutting a slit longitudinally at the terminal part of the injector so that a thread could pass through it freely. After a conjunctival peritomy created at 2 and 8 o’clock, a long curved needle with double-armed 10-0 polypropylene is passed through the exposed sclera. Two pieces of suture are withdrawn through the 2.8 mm corneal incision and 1 suture (from 8 o’clock) is passed through the opening of the cartridge and then tied to the leading haptic. Next, the IOL was implanted with the cartridge and then inserted through the corneal incision site. The other suture (from 2 o’clock) is tied to the haptic on the opposite side and inserted. Results: The study included 20 eyes of 20 patients with a mean age of 62.8 years at the initial visit. There were no complications, such as vitreous hemorrhage, retinal detachment, glaucoma, corneal edema, or iris injury. While the knot fixed to the leading haptic of IOL passed by the cartridge, there was no change of position. During the follow-up period, IOL dislocation did not occur and the corrected visual acuity and corneal astigmatism improved significantly. Conclusions: This technique is an effective procedure for minimizing entangled thread and corneal astigmatism. J Korean Ophthalmol Soc 2015;56(3):345-350

To report a novel method for measuring the degree of inferior oblique muscle overaction and to investigate the correlation with other factors.Cross-sectional diagnostic study.One hundred and forty-two eyes (120 patients) were enrolled in this study. Subjects underwent a full orthoptic examination and photographs were obtained in the cardinal positions of gaze. The images were processed using Photoshop and analyzed using the ImageJ program to measure the degree of inferior oblique muscle overaction. Reproducibility or interobserver variability was assessed by Bland-Altman plots and by calculation of the intraclass correlation coefficient (ICC). The correlation between the degree of inferior oblique muscle overaction and the associated factors was estimated with linear regression analysis.The mean angle of inferior oblique muscle overaction was 17.8 ± 10.1 degrees (range, 1.8-54.1 degrees). The 95% limit of agreement of interobserver variability for the degree of inferior oblique muscle overaction was ±1.76 degrees, and ICC was 0.98. The angle of inferior oblique muscle overaction showed significant correlation with the clinical grading scale (R = 0.549, P.001) and with hypertropia in the adducted position (R = 0.300, P = .001). The mean angles of inferior oblique muscle overaction classified into grades 1, 2, 3, and 4 according to the clinical grading scale were 10.5 ± 9.1 degrees, 16.8 ± 7.8 degrees, 24.3 ± 8.8 degrees, and 40.0 ± 12.2 degrees, respectively (P.001).We describe a new method for measuring the degree of inferior oblique muscle overaction using photographs of the cardinal positions. It has the potential to be a diagnostic tool that measures inferior oblique muscle overaction with minimal observer dependency.

Purpose: To evaluate the effect of pattern scan laser (PASCAL) photocoagulation on peripapillary retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), and optic nerve morphology in patients with diabetic retinopathy. Methods: Subjects included 35 eyes for the PASCAL group and 49 eyes for a control group. Peripapillary RNFL thickness, cup-disc area ratio and CMT were measured before PASCAL photocoagulation and at 2 and 6 months after PASCAL photocoagulation in the PASCAL or control groups. Results: The average RNFL thickness had increased by 0.84 µm two months after and decreased by 0.4 µm six months after PASCAL photocoagulation compared to baseline, but these changes were not significant (p = 0.83, 0.39). The cup-disc area ratio was unchanged after PASCAL photocoagulation. CMT increased by 18.11 µm (p = 0.048) at two months compared to baseline thickness, and partially recovered to 11.82 µm (p = 0.11) at six months in the PASCAL group. Conclusions: PASCAL photocoagulation may not cause significant change in the peripapillary RNFL thickness, CMT, and optic nerve morphology in patients with diabetic retinopathy.

Purpose: To report the efficacy of intravitreal bevacizumab injection in adult patients with Coats’disease. Case summary: Vascular telangiectasia, microaneurysms, circinate hard exudates, and macular edema were shown in the macula of two patients. Vascular abnormality was limited to≤6 clock hours in both cases. In case 1, the temporal retina demonstrates filigree-like vessels and capillary nonperfusion. In case 2, the nasal retina demonstrates aneurysmal dilatation and multiple microaneurysms. Intravitreal bevacizumab injection was administered in both cases. After 1 month, macular edema decreased. Laser photocoagulation was performed for vascular telangiectasia, microaneurysms, and capillary nonperfusion area. Then an additional decrease of macular edema was observed. Fluorescein leakage decreased, as well. After 1 month (case 1) and 2 months (case 2), macular edema increased. The second and third intravitreal reinjections were administered to each patient. Macular edema decreased. Conclusions: We report two rare cases of Coats’disease in adult patients. Intravitreal bevacizumab injection in patients with Coats’disease can result in a rapid decrease of macular edema, which will then lead to rapid visual recovery and an opportunity for effective laser photocoagulation. We recommend that intraviteal bevacizumab injection be used in combination with laser photocoagulation for the treatment of Coats’disease. J Korean Ophthalmol Soc 2009;50(4):630-634

Purpose: To report a suprachoroidal hemorrhage by Valsalva maneuver during vitrectomy under general anesthesia. Case summary: A healthy 26-year-old man had vitrectomy under general anesthesia due to rhegmatogenous retinal detachment in his right eye. During scleral indentation and endolaser photocoagulation, he took a sudden and severe bucking reflex because the effect of general anesthesia was insufficient. After the bucking reflex, suprachoroidal hemorrhage occurred in his right eye. Immediate IOP elevation and hyperfluorocarbon tamponade was performed to remove the suprachoroidal hemorrhage and reattach the retina and choroid. The patient’s corrected visual acuity was 20/50 and slender crescent‐shaped choroidal rupture remained around the temporal area of the macula, unlike traumatic choroidal rupture. Following fluorescein angiography, staining was evident at the choroidal rupture site; no fluorescein leakage was evident. Conclusions: We report a case of acute suprachoroidal hemorrhage which we investigated by fundus examination and fluorescein angiography. J Korean Ophthalmol Soc 49(6):1022-1027, 2008

Purpose: To report the relationship between the extent of rupture of the trabecular meshwork and intraocular pressure changes in traumatic hyphema patients. Methods: Ninety-five trabecular meshwork rupture patients were selected from a group of traumatic hyphema patients. Identification and measurement of the rupture of the trabecular meshwork were performed by gonioscopy, and intraocular pressure was measured by Goldmann applanation tonometry until 3 months after the trauma. Results: There were statistically significant differences of IOP between the traumatic eyes and the contralateral eyes at day 2, 3, 5, and 1 month (p=0.000, 0.018, 0.001, 0.040, respectively). IOP was highest at the 2nd day post-trauma, and dropped by the 5th day, after which it rose slightly. The relationship between the extent of trabecular meshwork rupture and the difference of IOP was positive at the 2nd day post-trauma (r=0.259) and negative at the 6th day post-trauma (r=-0.296); these differences are statistically significant (p=0.020, p=0.041, respectively). Conclusions: A rupture of the trabecular meshwork can be measured using gonioscopy, and the change of IOP in a trabecular meshwork rupture increases as the extent of the rupture of the trabecular meshwork increases.

Purpose: To investigate the characteristics of the clear oil-drop residue observed in the vitreous cavity after intravitreal injection of different brands of triamcinolone acetonide (TA), and to compare this ingredient’s effects in those products. Methods: Intravitreal injections of four different brands of triamcinolone acetonide (4 mg/0.1 mL), which are commercially available in Korea, were given to 40 eyes for the treatment of macular edema due to a variety of causes from October 2005 through February 2006. Regular slit-lamp biomicroscopy of fundus had been performed periodically with digital image acquisition equipment after injection of TA for at least two months. We analyzed the characteristics of this residue and compared the number and size of this residue in each product. Results: Four TA products commercially available in Korea were used, with vehicles composed of preservatives and suspending agents. There were differences between products in respect to ingredients and content, as well as the characteristics of the intravitreal clear oil droplet-like residue. Conclusions: Each TA product has a variable frequency and variable amounts of clear oil droplet-like residue, which seems to be a component of the vehicle. This variation could generate differences in efficacy, side effects, and retaining duration. It should be verified whether commercial TA products are consistently safe and effective.