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Purpose: To compare differences between the original criteria for diagnosis of ocular sarcoidosis (OS) (first International Workshop for OS [IWOS] 2009) and the revised criteria (sixth IWOS 2017), and their clinical usefulness when assessing OS in Korean patients. Methods: We analyzed patients with suspected OS who visited our tertiary referral ophthalmological and pulmonary clinic from 2007 to 2018. We diagnosed patients using both sets of criteria. Blood test and biopsy data (collected by physicians) and slit-lamp, fundus, and fluorescein angiography data (collected by ophthalmologists) were reviewed. Results: Thirty-four patients were diagnosed using both criteria. Of 32 patients who underwent biopsies, 31 had OS (96.87%). Using either set of criteria, 31 patients were diagnosed with definite OS and two with presumed OS. One patient diagnosed with possible OS using the previous criteria was diagnosed with presumed OS using the revised criteria. The new criteria add the lysozyme level, the CD4/CD8 ratio, and positron emission tomography imaging data to the old criteria and add the descriptors “presumed OS” and “probable OS”. There is no need to use the revised criteria in Korea; the biopsy and imaging data are adequately diagnostic. Conclusions: IWOS revised the OS diagnostic criteria by adding new parameters. However, this was unnecessary for Korea, where the biopsy and imaging data are adequately diagnostic.

Purpose We report a case of intraocular involvement in diffuse large B-cell lymphoma masquerading as Vogt-Koyanagi-Harada disease. Methods A 48-year-old woman presented with blurred vision in both eyes, fever, and hearing disturbance and underwent a complete ophthalmologic and systemic evaluation. Results Ophthalmologic examination showed bilateral exudative retinal detachment and signs of Vogt-Koyanagi-Harada disease. However, considering her generalized symptoms, systemic evaluation was performed before administering systemic steroid pulse therapy. In a systemic investigation, the patient was diagnosed with intraocular involvement in diffuse large B-cell lymphoma. After systemic chemotherapy, her bilateral visual acuity improved to 20/25 and the bilateral serous retinal detachment resolved. Conclusion In cases with prominent systemic symptoms, comprehensive systemic evaluation should be performed to rule out severe systemic conditions, such as malignancies.

This population-based, retrospective cohort study aimed to evaluate the association between glaucoma surgery and all-cause and cause-specific mortality among Korean elderly patients with glaucoma. A total of 16210 elderly patients (aged ≥ 60 years) diagnosed with glaucoma between 2003 and 2012 were included, and their insurance data were analyzed. The participants were categorized into a glaucoma surgery cohort (n = 487), which included individuals who had diagnostic codes for open angle glaucoma (OAG) or angle closure glaucoma (ACG) and codes for glaucoma surgery, and a glaucoma diagnosis cohort (n = 15,723), which included patients who had codes for OAG and ACG but not for glaucoma surgery. Sociodemographic factors, Charlson Comorbidity Index score, and ocular comorbidities were included as covariates. Cox regression models were used to assess the association between glaucoma surgery and mortality. The incidence of all-cause mortality was 34.76/1,000 person-years and 27.88/1,000 person-years in the glaucoma surgery and diagnosis groups, respectively. The adjusted hazard ratio (HR) for all-cause mortality associated with glaucoma surgery was 1.31 (95% confidence interval [CI], 1.05–1.62, P = 0.014). The adjusted HR for mortality due to a neurologic cause was significant (HR = 2.66, 95% CI 1.18–6.00, P = 0.018). The adjusted HRs for mortality due to cancer (HR = 2.03, 95% CI 1.07–3.83, P = 0.029) and accident or trauma (HR = 4.00, 95% CI 1.55–10.34, P = 0.004) associated with glaucoma surgery for ACG were significant as well. Glaucoma surgery was associated with an increase of mortality in elderly patients with glaucoma. In particular, the risk of mortality associated with glaucoma surgery due to neurologic causes was significant.

PURPOSE The purpose of this study was to investigate and compare the prevalence and clinical characteristics of epiretinal membrane (ERM) in patients with pseudoexfoliation glaucoma (PXG) and primary open-angle glaucoma (POAG). METHODS In this retrospective observational study, 211 PXG eyes, 210 age-matched normal eyes, and 220 POAG eyes were included. The presence and staging of ERM (stage 1, 2, and 3 or greater) were independently assessed by 2 observers. Univariate and multivariate linear regression analyses were performed to assess the factors associated with visual field (VF) mean deviation (MD) in PXG eyes. RESULTS Among 211 PXG eyes, 40 (19.0%) had an ERM, while 4.1% of POAG and 2.4% of normal eyes had an ERM (P

Purpose: To report the anatomical and functional outcomes of Argus II retinal prosthesis implantation in Korean patients. Methods: We included 5 consecutive patients with end-stage retinitis pigmentosa (RP) who underwent Argus II retinal prosthesis implantation and were followed for at least 12 months. The transcorneal electrical evoked response was utilized for patient selection. We used intraoperative optical coherence tomography (OCT) for optimal placement of the array and provided specialized vision rehabilitation training. A morphological evaluation using SD-OCT and a functional evaluation using computer-based visual function tests, a letter-reading ability test, and the Functional Low-Vision Observer Rated Assessment (FLORA) were conducted. Results: Postoperatively, the array was completely apposed to the retinal surface in all eyes, except for one eye which had a preexisting macular concavity. Fibrosis-like tissues of ≥50-μm thickness developed at the interface in 2 eyes. All of the patients showed improvement in computer-based visual function tests and could read ETDRS letters at a distance of 50 cm. Three patients could read Korean words. FLORA was improved in all patients, mainly in tasks of visual mobility, daily activities, and social interactions. Conclusions: Along with good anatomical outcomes and specialized rehabilitation practices, recipients of the Argus II implant showed profound improvements in functional vision and mobility.

Due to the genotype–phenotype heterogeneity in retinitis pigmentosa (RP), molecular diagnoses and prediction of disease progression is difficult. This study aimed to report ocular and genetic data from Korean patients with PDE6B-associated RP (PDE6B-RP), and establish genotype–phenotype correlations to predict the clinical course. We retrospectively reviewed targeted next-generation sequencing or whole exome sequencing data for 305 patients with RP, and identified PDE6B-RP in 15 patients (median age, 40.0 years). Amongst these patients, ten previously reported PDE6B variants (c.1280G > A, c.1488del, c.1547T > C, c.1604T > A, c.1669C > T, c.1712C > T, c.2395C > T, c.2492C > T, c.592G > A, and c.815G > A) and one novel variant (c.712del) were identified. Thirteen patients (86.7%) experienced night blindness as the first symptom at a median age of 10.0 years. Median age at diagnosis was 21.0 years and median visual acuity (VA) was 0.20 LogMAR at the time of genetic analysis. Nonlinear mixed models were developed and analysis revealed that VA exponentially decreased over time, while optical coherence tomography parameters linearly decreased, and this was related with visual field constriction. A high proportion of patients with the c.1669C > T variant (7/9, 77.8%) had cystoid macular edema; despite this, patients with this variant did not show a higher rate of functional or structural progression. This study will help clinicians predict functional and structural progression in patients with PDE6B-RP.

To investigate and compare the clinical features of cytomegalovirus (CMV) retinitis after solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) and to determine the poor prognostic factors. Patients consulted to the ophthalmology department for CMV viremia after transplantation between March 2008 and February 2018 and followed for more than 6 months were analyzed. Medical records regarding demographic, serologic, and ocular characteristics were compared between the SOT and HSCT groups. Factors associated with poor visual outcomes were determined with logistic regression. CMV retinitis developed in 11.3% of patients with CMV viremia following transplantation. In the SOT group (25 eyes/18 patients) and the HSCT group (33 eyes/21 patients), CMV retinitis occurred at 5.8 months and 3.7 months post-transplantation, respectively. Mortality was significantly higher in the HSCT group (52.4% vs. 5.6%, P < 0.001). During the mean 11.7 months of follow-up, visual acuity tended to be aggravated (P = 0.087) despite antiviral treatment, which was especially notable in the SOT group (P = 0.028). Six eyes (10.3%) underwent vitrectomy due to retinal detachment, most of which (5 eyes) were in the SOT group. Multivariate logistic regression analysis showed that the presence of concurrent CMV disease (OR = 14.11, P = 0.009) and foveal involvement (OR = 114.85, P = 0.001) were poor prognostic factors. Clinical manifestations of CMV retinitis differed between the HSCT and SOT group. Concurrent CMV diseases and foveal involvement were associated with poor visual outcomes in CMV retinitis following transplantation.

We investigated the microvascular changes in eyes with lamellar macular holes (LMHs) using optical coherence tomography angiography (OCTA), compare them between two subtypes of LMH. Tractional and degenerative LMH were differentiated based on the morphological characteristics of OCT. In OCTA images, foveal and parafoveal vessel density (VD) in the superficial and deep capillary plexus (SCP, DCP) and foveal avascular zone (FAZ) area were measured. Eyes that underwent vitrectomy for LMH were included in subgroup analysis. We analysed 63 LMH (42 tractional and 21 degenerative) eyes and 63 control eyes. Compared with degenerative LMH, tractional LMH had better BCVA (p = 0.010), smaller FAZ area (p = 0.001), and higher foveal VD in the SCP (p = 0.130) and DCP (p = 0.002). In degenerative LMH, better BCVA was associated with greater foveal VD in the SCP (p = 0.040) and DCP (p = 0.005), and parafoveal VD in the SCP (p = 0.006). In subgroup analysis, only the tractional LMH group showed significant increases in foveal and parafoveal VDs in the SCP after vitrectomy (p = 0.001 and p = 0.026, respectively). Significant differences in microvascular changes were noted between tractional and degenerative LMH, suggesting that two subtypes are distinct pathogenetic entities.

We evaluated the incidence and characteristics of eyes with cytomegalovirus (CMV) retinitis according to the occurrence of cystoid macular edema (CME) and identified the risk factors of its occurrence. Patients diagnosed with CMV retinitis and examined using optical coherence tomography were classified according to the development of CME. The CME group was further divided according to the presence of active retinitis at the time of CME development. The demographics, serologic findings, ophthalmic presentations, ocular treatments, and visual prognosis were compared. CME was identified in 25 eyes (17 eyes with active retinitis and 8 eyes with inactive retinitis) out of the 67 eyes with CMV retinitis. Visual acuity was worse in the CME group than in the non-CME group. The CME group had longer CMV viremia duration, zone 1 involvement, and larger extent of CMV retinitis. While CME with concurrent active retinitis developed in eyes with direct foveal involvement of retinitis in the acute phase and required more ganciclovir injections after CME development, CME without active retinitis developed in eyes with larger extents of involvement and more intravitreal ganciclovir injections before CME development. Zone 1 involvement and longer CMV viremia duration were independently associated with the occurrence of CME. CME, which caused visual deterioration, developed in considerable patients with CMV retinitis and had different characteristics according to the presence of active retinitis.

We conducted targeted next-generation sequencing (TGS) and/or whole exome sequencing (WES) to assess the genetic profiles of clinically suspected retinitis pigmentosa (RP) in the Korean population. A cohort of 279 unrelated Korean patients with clinically diagnosed RP and available family members underwent molecular analyses using TGS consisting of 88 RP-causing genes and/or WES with clinical variant interpretation. The combined genetic tests (TGS and/or WES) found a mutation in the 44 RP-causing genes and seven inherited retinal disease (IRD)-causing genes, and the total mutation detection rate was 57%. The mutation detection rate was higher in patients who experienced visual deterioration at a younger age (75.4%, age of symptom onset under 10 years) and who had a family history of RP (70.7%). The most common causative genes were EYS (8.2%), USH2A (6.8%), and PDE6B (4.7%), but mutations were dispersed among the 51 RP/IRD genes generally. Meanwhile, the PDE6B mutation was the most common in patients experiencing initial symptoms in their first decade, EYS in their second to third decades, and USH2A in their fifth decades and older. Of note, WES revealed some unexpected genotypes: ABCC6, CHM, CYP4V2, RS1, TGFBI, VPS13B, and WDR19, which were verified by ophthalmological re-phenotyping.

Purpose. Retinitis pigmentosa (RP) shows great diversity between genotypes and phenotypes, and it is important to identify the causative genes. This study aimed to analyze the molecular profiles, associated ocular characteristics, and progression of RP in Korean patients. Methods. All the genetic variants in patients with RP, identified using targeted next-generation sequencing (NGS) with a panel of 88 RP-related genes between November 2018 and November 2019, were retrospectively reviewed. All the patients underwent comprehensive ophthalmological evaluations, and their clinical and family histories were recorded. The best-corrected visual acuity (BCVA) deterioration and photoreceptor disruption progression rates were determined based on the major causative mutational genes using nonlinear mixed models, and the differences among them were investigated using the interaction effect. Results. Among the 144 probands, 82 variants in 24 causative genes were identified in 77 families (53.5%). Most of the RP cases were associated with autosomal recessive variants (N = 64 (44.4%)), followed by autosomal dominant (N = 10 (6.9%)) and X-linked variants (N = 3 (2.1%)). The four most frequently affected genes were EYS (N = 15 (10.4%)), USH2A (N = 12 (8.3%)), PDE6B (N = 9 (6.3%)), and RP1 (N = 8 (5.6%)). Epiretinal membranes and cystoid macular edema were frequently noted in the patients with USH2A (75.0%) and PDE6B (50.0%) variants, respectively. During the follow-up period, the BCVA and photoreceptor disruption changes were significantly different among the patients carrying the four common causative genes ( P = 0.014 and 0.034, resp.). Patients with PDE6B variants showed faster BCVA changes (0.2 LogMAR/10 years), and those with USH2A variants showed the fastest ellipsoid zone disruptions (−170.4 µm/year). Conclusion. In conclusion, our genetic analysis using targeted NGS provides information about the prevalence of RP-associated mutations in Korean patients. Delineating clinical characteristics according to genetic variations may help clinicians identify subtype features and predict the clinical course of RP.

PURPOSE To investigate the clinical characteristics and prognostic factors of young patients with central retinal vein occlusion (CRVO). METHODS This retrospective cohort study involved treatment-naive patients with CRVO. Medical records regarding basic demographics, predisposing factors, ocular characteristics, and treatments were reviewed and compared according to age at CRVO onset. RESULTS We enrolled 263 patients, of whom 69 were younger patients. Younger patients had higher prevalence of nontraditional risk factors including physical or psychological stress (P = 0.032), hematologic abnormalities (P = 0.003), and better visual acuity at baseline and last visit (all P < 0.001) and were unlikely to undergo intravitreal injections (47.8 vs. 68.6%, P < 0.001) during follow-up. Younger patients had higher prevalence of paracentral acute middle maculopathy (28.1 vs. 4.7%, P < 0.001). Older age (odds ratio = 1.165, P = 0.028), male sex (odds ratio = 7.074, P = 0.034), coexisting renal disease (odds ratio = 7.845, P = 0.050), and poor baseline visual acuity (odds ratio = 16.069, P = 0.002) were significant risk factors for poor visual outcomes in young CRVO patients. CONCLUSION Younger CRVO patients had a milder clinical course with fewer treatments and were more likely to have nontraditional risk factors than older patients.

EVIDENCE, an automated variant prioritization system, has been developed to facilitate whole exome sequencing analyses. This study investigated the diagnostic yield of EVIDENCE in patients with suspected genetic disorders. DNA from 330 probands (age range, 0‐68 years) with suspected genetic disorders were subjected to whole exome sequencing. Candidate variants were identified by EVIDENCE and confirmed by testing family members and/or clinical reassessments. EVIDENCE reported a total 228 variants in 200 (60.6%) of the 330 probands. The average number of organs involved per patient was 4.5 ± 5.0. After clinical reassessment and/or family member testing, 167 variants were identified in 141 probands (42.7%), including 105 novel variants. These variants were confirmed as being responsible for 121 genetic disorders. A total of 103 (61.7%) of the 167 variants in 95 patients were classified as pathogenic or probably to be pathogenic before, and 161 (96.4%) variants in 137 patients (41.5%) after, clinical assessment and/or family member testing. Factor associated with a variant being regarded as causative includes similar symptom scores of a gene variant to the phenotype of the patient. This new, automated variant interpretation system facilitated the diagnosis of various genetic diseases with a 42.7% diagnostic yield., Schematic diagram showing the number of patients with and without variant identification and family member testing and the proportion of variant classification.

IntroductionTo evaluate the effects of intravitreal aflibercept injection on retinal nonperfusion in patients with diabetic retinopathy (DR) using ultrawide field (UWF) fluorescein angiography (FA).Research design and methodsThirty-eight eyes of 38 consecutive patients with DR and substantial retinal nonperfusion (nonperfusion index (NPI): nonperfused/total gradable area >0.2) without macular edema were included in this prospective case series. Monthly injections of 2 mg aflibercept were given for 6 months. UWF-fundus photography and UWF-FA images were acquired at baseline, 6 months, and 12 months and evaluated by 2 masked, independent graders for the extent of retinal nonperfusion and vascular leakage. Twenty untreated fellow eyes were analyzed as controls.ResultsInter-grader agreement was strong (r=0.875) for NPI measurements. NPI was 0.46±0.10 at baseline; NPI was decreased to 0.43±0.08 (p=0.015) after 6 monthly injections of aflibercept and then slightly increased to 0.44±0.09 (p=0.123) after 6 months of observation. Vascular leakage also significantly decreased by 21.0% at 6 months (p=0.010). Untreated fellow eyes did not show significant changes in NPI and vascular leakage during follow-up. Reduction in retinal nonperfusion was associated with severe nonproliferative diabetic retinopathy (NPDR) (vs PDR, OR 19.119, p=0.025) and higher leakage index (per 0.1, OR 15.152, p=0.020).ConclusionsIntensive aflibercept treatment was effective in reducing retinal capillary nonperfusion in patients with DR without macular edema. Severe NPDR and profound vascular leakage were significantly associated with retinal reperfusion after aflibercept treatment.Trial registration numberNCT03006081.

PURPOSE To compare the functional and anatomical outcomes of central retinal vein occlusion (CRVO) according to the presence of glaucoma before the onset of CRVO, and to assess whether pre-existing glaucoma affects the prognosis of CRVO in terms of development and conversion to ischaemic CRVO. METHODS In this retrospective cohort study, patients with treatment-naive CRVO were enrolled between December 2009 and February 2019. The patients were classified into two groups according to the presence of pre-existing primary open-angle glaucoma at CRVO diagnosis. We reviewed medical records regarding basic demographics, ocular characteristics and treatments. The effects of pre-existing glaucoma on the occurrence of ischaemic CRVO were also investigated using Cox proportional hazard models. RESULTS Of 166 eyes from 166 patients, 26 (15.7%) had pre-existing glaucoma. The pre-existing glaucoma group revealed significantly older (69.4 ± 13.3 versus 56.5 ± 15.9) and lower BCVA at baseline (1.06 ± 0.75 versus 0.64 ± 0.58, logMAR) and final visits (1.56 ± 1.35 versus 0.64 ± 0.48, logMAR) (all p

Purpose. To identify the clinical characteristics and risk factors for secondary choroidal neovascularization (CNV) in central serous chorioretinopathy (CSC). Methods. In this retrospective study, we included a total of 108 eyes in 106 CSC patients. Group A was defined as patients initially diagnosed with CSC who developed secondary CNV, and group B was defined as patients who did not develop secondary CNV. Clinical and demographic characteristics, optical coherence tomography (OCT) findings at CSC diagnosis and OCT angiography (OCTA) at the time of secondary CNV diagnosis, were compared between the groups. Results. Thirty-one eyes had CNV (group A) and 77 eyes did not (group B). The mean age of group A was higher than that of group B (52.28 ± 6.87 vs. 46.78 ± 9.45 years; P<0.001). Although there was no difference in pigment epithelial detachment (PED) height, group A had larger PED width than group B at CSC diagnosis. The foveal and parafoveal choriocapillary flow densities were significantly lower in group A than group B (P=0.027 and P<0.001, respectively). Conclusion. We identified that older age, wider PED width at diagnosis, and recurrent episodes of CSC were independent risk factors for development of secondary CNV. Therefore, patients with these risk factors should be monitored to allow early detection and prompt treatment of secondary CNV.

Purpose To investigate the microstructure of cystoid macular edema (CME) in retinitis pigmentosa (RP) and the associated vascular changes using optical coherence tomography (OCT) angiography. Methods In this retrospective study, we included 42 eyes of 21 patients with RP and age-similar normally sighted controls who underwent both OCT and optical coherence tomography angiography. Using OCT, spatial distribution of CME and the retinal layer, which CME located, was examined. Optical coherence tomography angiography images of the superficial capillary plexus and deep capillary plexus were obtained. Foveal and parafoveal flow densities in each layer and foveal avascular zone area were measured. Results Of the 42 eyes with RP, 32 had CME. All CMEs were located in the inner nuclear layer and limited to the parafovea. The outer nuclear layer/ganglion cell layer was involved in 12 eyes (37.5%). Compared with RP without CME, RP with CME (RP-CME) did not show significant differences in flow density or extent of vascular disruption within the superficial capillary plexus, deep capillary plexus, or foveal avascular zone areas. Conclusion RP-CME was mostly located in the inner nuclear layer of the parafoveal macula, without vascular disruption in optical coherence tomography angiography. Our findings may support the hypothesis that the pathogenesis of RP with CME differs from retinal vascular CME triggered by compromised deep capillary plexus.

Younger generations of learners want to have a sense of ownership and play active roles in their own learning processes. While many innovative pedagogical approaches in higher education aim to provide learning experiences that empower students as partners in their educational experience, assessment can fail to offer that ownership. In this chapter, we describe how bringing play into assessment could transform both educators’ and students’ roles in assessment processes, and how a playful take on assessment could introduce social, iterative, and democratised assessment processes. We further illustrate how play could be integrated with assessment using the case of MetaRubric, a playful assessment design tool that educators can play to learn about the features of good rubrics, or have students play to co-create rubrics in a playful way. We conclude the chapter by discussing the potential benefits of playful assessment for assessment of and with younger generations.

Background: EVIDENCE, an automated variant prioritisation system, has been developed to facilitate whole exome sequencing analyses. This study investigated the diagnostic yield of EVIDENCE in patients with suspected genetic disorders. Methods: DNA from 330 probands (age range, 0–68 years) with suspected genetic disorders were subjected to whole exome sequencing. Candidate variants were identified by EVIDENCE and confirmed by testing family members and/or clinical reassessments. Findings: EVIDENCE reported a total 245 variants in 216 (65·5%) of the 330 probands. The average number of organs involved per patient was 4·5 ± 5·0. After clinical reassessment and/or family member testing, 197 variants were identified in 172 probands (52·1%), including 116 novel variants. These variants were confirmed as being responsible for 147 genetic disorders. A total of 109 (55·3%) of the 197 variants were classified as pathogenic or likely to be pathogenic before, and 147 (74·6%) after, clinical assessment and/or family member testing. Factors associated with a variant being regarded as causative include rules, such as PVS1, PS1, PM1, PM5, and PP5, and similar symptom scores of a gene variant to the phenotype of the patient. Interpretation: This new, automated variant interpretation system facilitated the diagnosis of various genetic diseases with a 52·1% diagnostic yield. Funding: Institute for Information and Communications Technology Promotion (IITP) grant funded by the Korean government (MSIT) (2018-0-00861, Intelligent SW Technology Development for Medical Data Analysis). Competing Interest Declaration: The authors declare no conflicts of interest. Ethical Approval: The study was approved by the Institutional Review Board for Human Research of the Asan Medical Center (IRB numbers: 2018-0574 and 2018-0180).

There is increasing interest in using data to design digital games that serve the purposes of learning and assessment. One game element, difficulty, could benefit vastly from applying data-driven methods as it affects both players’ overall enjoyment and efficiency of learning and qualities of assessment. However, how difficulty is being defined varies across the learning, assessment, and game perspectives, yet little is known about how educational difficulty can be balanced in educational games for each of the potentially conflicting goals. In this paper, we first review varying definitions of difficulty and then we discuss how we came up with a difficulty metric and used it to refine our game-based assessment Shadowspect. The design guidelines, metrics and lessons learned will be useful for designers of learning games and educators interested in balancing difficulty before they implement these tools in the classroom.

To investigate the differences in the progression of diabetic retinopathy (DR) in both eyes of patients with axial anisometropia.A retrospective review was conducted on diabetic patients who had different axial lengths (difference greater than 1 mm) in each eye. The primary objective of this study was to analyze the differences in the progression of DR in both eyes of patients with axial anisometropia. Fundus images (fluorescein angiography and photographs of the fundus covering the Early Treatment Diabetic Retinopathy Study seven fields) were graded using the Early Treatment Diabetic Retinopathy Study DR grading system. Also, the severity of diabetic retinopathy was analyzed based on the axial length and subfoveal choroidal thickness.Thirty-four of 6,963 patients with DR were included after applying the exclusion and inclusion criteria. The mean age was 53.53 ± 12.20 years and duration of diabetes was 9.63 ± 7.73 years. The mean axial length of the longer and shorter eye was 26.21 ± 2.04 mm and 23.21 ± 1.73 mm, respectively (P0.001). In shorter eyes, 61.7% (21 of 34) of the eyes had proliferative diabetic retinopathy. In contrast to the shorter eye, only 8 of the longer eyes (8 of 34, 23.5%) had proliferative diabetic retinopathy (McNemar test, P0.001). In eyes with thin subfoveal choroidal thickness (250 µm), the proliferative diabetic retinopathy ratio was significantly lower (P = 0.007).In patients with axial anisometropia, the longer eye had a lower degree of DR progression than the shorter eye. This result showed that elongation of the axial length had a protective effect against the progression of DR without individual confounding factors.

Objective Machine learning in healthcare, and innovative healthcare technology in general, require complex interactions within multidisciplinary teams. Healthcare hackathons are being increasingly used as a model for cross-disciplinary collaboration and learning. The aim of this study is to explore high school student learning experiences during a healthcare hackathon. By optimizing their learning experiences, we hope to prepare a future workforce that can bridge technical and health fields and work seamlessly across disciplines. Methods A qualitative exploratory study utilizing focus group interviews was conducted. Eight high school students from the hackathon were invited to participate in this study through convenience sampling Participating students (n = 8) were allocated into three focus groups. Semi structured interviews were completed, and transcripts evaluated using inductive thematic analysis. Findings Through the structured analysis of focus group transcripts three major themes emerged from the data: (1) Collaboration, (2) Transferable knowledge and skills, and (3) Expectations about hackathons. These themes highlight strengths and potential barriers when bringing this multidisciplinary approach to high school students and the healthcare community. Conclusion This study found that students were empowered by the interdisciplinary experience during a hackathon and felt that the knowledge and skills gained could be applied in real world settings. However, addressing student expectations of hackathons prior to the event is an area for improvement. These findings have implications for future hackathons and can spur further research into using the hackathon model as an educational experience for learners of all ages.

Background Limited data are available regarding the long-term effects of pancreas transplantation on the progression of diabetic retinopathy (DR) and the incidence and associated risk factors for early worsening of DR. Methods Patients who underwent successful pancreas transplantation between January 2007 and October 2015 and were followed for 1 year or longer were consecutively enrolled. Variables regarding demographic, systemic, metabolic, and surgical factors were reviewed for each patient. DR progression was defined as (i) development or aggravation of macular edema requiring intravitreal anti-VEGF injections and/or (ii) progression of DR severity requiring panretinal photocoagulation (PRP) and/or pars planar vitrectomy (PPV). Early worsening was defined as progression within 1 year of posttransplant. Results Three hundred three eyes of 153 patients were included in the analysis. At the pretransplant ocular evaluation, 221 eyes (72.9%) showed advanced DR with history of PRP and/or PPV. During a mean follow-up period of 4.2 years, 62 eyes (20.5%) experienced DR progression, and early worsening was noted in 57 eyes (18.8%). DR with recent PRP within pretransplant 1 year and pancreas transplant alone were significant risk factors for early worsening. Conclusions In 4 of 5 patients who received pancreas transplant, the degree of DR remained stable over time after transplantation. Meanwhile, early worsening of DR could occur in patients at risk, particularly within the first posttransplant year. We suggest that physicians should have a high index of suspicion and carefully monitor for early worsening of DR and timely manage possible ocular deterioration.

This population-based, retrospective cohort study aimed to evaluate the association between glaucoma surgery and all-cause and cause-specific mortality among Korean elderly patients with glaucoma. A total of 16210 elderly patients (aged ≥ 60 years) diagnosed with glaucoma between 2003 and 2012 were included, and their insurance data were analyzed. The participants were categorized into a glaucoma surgery cohort (n = 487), which included individuals who had diagnostic codes for open angle glaucoma (OAG) or angle closure glaucoma (ACG) and codes for glaucoma surgery, and a glaucoma diagnosis cohort (n = 15,723), which included patients who had codes for OAG and ACG but not for glaucoma surgery. Sociodemographic factors, Charlson Comorbidity Index score, and ocular comorbidities were included as covariates. Cox regression models were used to assess the association between glaucoma surgery and mortality. The incidence of all-cause mortality was 34.76/1,000 person-years and 27.88/1,000 person-years in the glaucoma surgery and diagnosis groups, respectively. The adjusted hazard ratio (HR) for all-cause mortality associated with glaucoma surgery was 1.31 (95% confidence interval [CI], 1.05-1.62, P = 0.014). The adjusted HR for mortality due to a neurologic cause was significant (HR = 2.66, 95% CI 1.18-6.00, P = 0.018). The adjusted HRs for mortality due to cancer (HR = 2.03, 95% CI 1.07-3.83, P = 0.029) and accident or trauma (HR = 4.00, 95% CI 1.55-10.34, P = 0.004) associated with glaucoma surgery for ACG were significant as well. Glaucoma surgery was associated with an increase of mortality in elderly patients with glaucoma. In particular, the risk of mortality associated with glaucoma surgery due to neurologic causes was significant.

PurposeEVIDENCE, an automated interpretation system, has been developed to facilitate the entire process of whole exome sequencing (WES) analyses. This study investigated the diagnostic yield of EVIDENCE in patients suspected genetic disorders.MethodsDNA from 330 probands (age range, 0–68 years) with suspected genetic disorders were subjected to WES. Candidate variants were identified by EVIDENCE and confirmed by testing family members and/or clinical reassessments.ResultsThe average number of overlapping organ categories per patient was 4.5 ± 5.0. EVIDENCE reported a total 244 variants in 215 (65.1%) of the 330 probands. After clinical reassessment and/or family member testing, 196 variants were identified in 171 probands (51.8%), including 115 novel variants. These variants were confirmed as being responsible for 146 genetic disorders. One hundred-seven (54.6%) of the 196 variants were categorized as pathogenic or likely pathogenic before, and 146 (74.6%) after, clinical assessment and/or family member testing. Factors associated with a variant being confirmed as causative include rules, such as PVS1, PS1, PM1, PM5, and PP5, and similar symptom scores between that variant and a patient’s phenotype.ConclusionThis new, automated variant interpretation system facilitated the diagnosis of various genetic diseases with a 51% improvement in diagnostic yield.

To compare optical coherence tomography angiography (OCT-A) parameters between type 1 and type 2 diabetic patients with diabetic retinopathy (DR). A total of 70 patients with type 1 diabetes and 70 with type 2 diabetes were retrospectively analyzed. DR was graded as no DR, mild nonproliferative DR (NPDR), moderate NPDR, severe NPDR, and proliferative DR (PDR). Using OCT-A, the foveal avascular zone (FAZ) area (mm2) and vascular density (VD) (%) were calculated in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). In both type 1 and 2 diabetes patients, the FAZ area (mm2) in both capillary plexuses (CP) increased with DR progression, whereas the VD (%) progressively decreased. The changes in the FAZ area and the VD were significantly greater in the DCP than in the SCP in both types of diabetes patients(p

Purpose: To evaluate the 1-year results of 25-gauge microincision vitrectomy surgery (MIVS25) combined with intraoperative dexamethasone (DEX) implant for persistent diabetic macular edema (DME). Methods: This study enrolled patients who had a history of DME for ≥12 months and underwent MIVS25 and DEX implant injection. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) were assessed postoperatively. Results: Eighteen eyes were included in the analysis. Preoperatively, logMAR BCVA was 0.90 and CRT was 594 µm on average. CRT decreased until the 3-month follow-up visit and tended to increase at 6 months, but stabilized at 12 months with additional treatments in five eyes at 5 months postoperatively. Statistically significant improvement in BCVA was noted 1 month after treatment and at each subsequent follow-up visit (p < 0.001). Conclusion: MIVS25 combined with DEX implant injection might be utilized as an effective and safe alternative treatment for intractable DME.

Purpose To investigate macular microvasculature changes using optical coherence tomography angiography (OCTA) and analyze their correlation with the structural parameters in highly myopic eyes. Methods We measured the area of the foveal avascular zone (FAZ) and the parafoveal vessel density in the superficial and deep retinal plexuses using OCTA. The magnification effect of the FAZ area was corrected using Bennett's formula. Retinal thickness measured at each corresponding area of the OCTA parameters, subfoveal choroidal thickness, and ocular characteristics were reviewed, and the relationships between the microvasculature measurements and the ocular structural characteristics were explored. Results Fifty-two eyes with high myopia and 52 normal sex- and age-matched controls were included in the analysis. The FAZ area was significantly larger in the myopic eyes (p = 0.023). The superficial parafoveal vascular density was significantly decreased (p = 0.007) in the myopic eyes compared with the normal eyes, whereas there was no significant difference in the deep parafoveal vascular density (p = 0.226). Regarding the retinal thickness, only the parafoveal inner retinal thickness was significantly smaller in the myopic eyes than in the normal eyes (p = 0.023). The FAZ and subfoveal choroidal thickness were significantly correlated with the axial length, and the parafoveal inner retinal thickness was significantly correlated with the superficial parafoveal vascular density (all p < 0.05). Conclusions The FAZ was enlarged and the parafoveal vascular density was reduced in the highly myopic eyes. The decrease was prominent in the superficial capillary plexuses and well-correlated with the retinal thickness profiles. The macular microvascular network alteration may be attributed to the ocular axial elongation that occurs with myopia.

Background/AimTo analyse ultrawide-field fluorescein angiography (UWF-FA) images of diabetic retinopathy using a novel software that automatically calculates microaneurysm (MA) and non-perfusion area.MethodsTwo hundred UWF-FA images of treatment-naïve diabetic retinopathy (38 proliferative diabetic retinopathy and 162 non-proliferative diabetic retinopathy) from 120 patients (mean age 54.22; 80 male) were analysed using novel software to determine the number of MAs, area of capillary non-perfusion (ischaemic index) and number of neovascularisations. Each result was compared according to its retinal regions.ResultsFor the total retina, the mean number of MAs was 292.02 (±175.57) and the ischaemic index was 59.42% (±14.78%). Most MAs were located in the mid-peripheral retina (80.54%); however, the density of MAs was highest in the posterior pole (pConclusionThe automated software allowed prompt and quantitative analysis of UWF-FA images of DMR. MAs were most frequent in the nasal and mid-peripheral retina, with their density being highest in the posterior pole and nasal retina. Ischaemic index increased with distance from the posterior pole, showing strong correlation with central foveal thickness in all retinal areas except the posterior pole.

We aimed to correlate the visual function and structural characteristics of the retina and choroid in advanced retinitis pigmentosa (RP) patients. A cross-sectional, retrospective review was conducted of medical records of 149 RP patients who reported visual field constriction on a central 30-2 Humphrey visual field chart. Using spectral domain-optical coherence tomography, central foveal thickness (CFT), ellipsoid zone (EZ) length, macular volume (MV), and submacular choroidal thickness (SMChT) were measured. A control cohort (68 eyes of 68 patients) was included for comparing the macular structure. Quantitative correlations between visual function indices [visual field index (VFI) and best-corrected visual acuity (BCVA)] and structural indices (CFT, EZ length, and SMChT) were evaluated. Mean age was 46.3 ± 15.5 years; mean illness duration was 60.7 ± 60.0 months. SMChT was thinner than that in normal controls. Per Pearson’s correlation, BCVA and VFI exhibited a progressive worsening related to age and disease duration. In multivariate linear regression, BCVA and VFI were significantly correlated with CFT, EZ length, and MV at the central 1-mm area. Among RP patients with visual field constriction within 30°, VFI and BCVA closely correlate with the degree of retinal structural change, including the CFT, EZ length, and MV. SMChT uniformly decreased in this study population and exhibited no significant correlation with BCVA or VFI degree.

Background The present study describes our 10-year experience with uveoretinal adverse events that manifest because of chemotherapy. Methods A retrospective chart review was performed for all patients who presented to the ophthalmologic department while undergoing systemic chemotherapy between July 2005 and June 2015. Results A total of 55 patients (mean age, 51.2 years, 38 women [69.1%]) suspected of having uveoretinal disease owing to the use of chemotherapeutic agents alone were enrolled. Breast cancer was the predominant disease (36.4%); noninfectious anterior uveitis (21.8%) was the most common condition. Bilateral involvement was observed in 16 patients (29.1%). Although cisplatin (21.8%) was the most commonly used drug, daunorubicin, cytarabine, tamoxifen, toremifene, and imatinib were also frequently used. The median duration until ophthalmologic diagnosis was 208.5 days (range, 19–5,945 days). The proportion of patients with final visual acuity (VA) < 20/40 Snellen VA (0.5 decimal VA) was 32.7%. However, no relationship was observed between final VA < 20/40 and age, sex, therapeutic agents, and metastasis. Conclusion Uveoretinal complications were mostly mild to moderate and exhibited a favorable response to conservative therapy. A considerable number of patients exhibited significant irreversible loss of vision after cessation of the causative chemotherapeutic agent. Ophthalmological monitoring is required during chemotherapy., Graphical Abstract

AimsTo investigate the structural changes of the superficial capillary plexuses (SCP) and deep capillary plexuses (DCP) using optical coherence tomography (OCT) angiography (OCTA) in patients with idiopathic macular hole (MH) after surgery, determine the factors related to changes of macular capillary plexuses and evaluate its association with postoperative visual outcomes.MethodsThirty-three patients with unilateral MH who were followed for ≥6 months after surgery were included. Ophthalmologic evaluations included best corrected visual acuity (BCVA) and spectral-domain OCT before surgery and 6 months postsurgery. En face OCTA images were obtained for both eyes at 6 months postsurgery, and the postoperative foveal avascular zone (FAZ) area and parafoveal vascular density were identified.ResultsCompared with fellow eyes, eyes after MH surgery had a smaller FAZ area in both SCP and DCP (pConclusionAssessment of macular capillary plexuses using OCTA may be useful for monitoring retinal structural and functional changes in MH.

Purpose: The aim of this study was to determine the correlation between the duration of myopic choroidal neovascularization (CNV) and treatment outcome after anti-vascular endothelial growth factor (VEGF) injections. Methods: We performed a retrospective review of treatment-naïve myopic CNV patients who were treated with anti-VEGF and followed for at least 24 months to identify factors predicting final outcome and recurrence. Results: Among 106 eyes, a shorter duration of CNV was a significant predictor of a better final best-corrected visual acuity, even after controlling for other factors (p = 0.042). When divided into 3 groups according to CNV duration before treatment (p = 0.006) and number of injections (3.5, 4.0, and 5.5, respectively; p = 0.021) were significantly lower in eyes with a shorter duration of CNV. Conclusions: Early anti-VEGF treatment of myopic CNV decreased the recurrence rate and number of injections and improved visual outcome.

The relationship between video gameplay, video game genre preference, personality, and GPA was investigated in an online correlational study with university students. In addition to administering self-report measures of GPA and personality, we asked three different questions regarding styles of video gameplay. The first asked the average time spent playing video games per week (habitual players), the second asked the total time spent playing favorite video games (selective players), and the third asked the number of different video games played in a year (diverse players). Students who were medium in selective player style (spent 11-50h) had significantly higher GPAs than students low on selective player style (spent 0-10h). Students high on habitual playing style (7 or more hours a week) showed significantly lower levels of Conscientiousness compared to students low on habitual playing style (0-1h a week). Students who were high on the diverse style (i.e., 7 or more games played a year) showed significantly higher Openness scores than students low on the diverse style (0-3 games a year). Finally, several notable relations were found between video game genre preference, GPA, and personality. Results are discussed in terms of the positive implications of video gameplay on academic performance.

Purpose To evaluate the outcome of Ahmed glaucoma valve (AGV) implantation in eyes with refractory secondary glaucoma following pars plana vitrectomy (PPV) and the associated prognostic factors. Methods A total of 146 eyes in 146 patients who underwent AGV implantation after PPV (followed up for ≥1 year) were included. AGV implantation was considered successful when the intraocular pressure (IOP) was 6 to 21 mmHg regardless of using IOP-lowering medication. The hazard ratios (HRs) associated with surgical failure were determined with Cox proportional analysis. Results The most common cause for PPV was complications of proliferative diabetic retinopathy (50%). The mean and peak IOPs between PPV and AGV implantation were 26.9 ± 6.6 and 35.9 ± 10.2 mmHg, respectively. AGV implantation was performed on average 18.7 months after PPV, and its overall success rate was 80.1% during a mean follow-up period of 43.6 months. In multivariate analyses, rubeosis observed before AGV implantation (HR, 4.07; 95% confidence interval, 1.57 to 10.6; p = 0.004) and higher peak IOP before AGV (HR, 1.04; 95% confidence interval, 1.00 to 1.07; p = 0.034) were predictive of failure. However, no PPV-related factors were associated with the surgical outcome of AGV implantation. Conclusions The outcome of AGV implantation is good in refractory glaucoma following PPV. Rubeosis after PPV and higher peak IOP before AGV are risk factors for poor outcomes. Patients who undergo PPV should be followed for the development of rubeosis and IOP control.

Objective Despite the availability of minimally invasive intraoperative prophylactic sclerotomy-site laser retinopexy and 360-degree laser retinopexy to reduce the incidence of retinal detachment (RD), RD is still prevalent in macular surgery. We investigated the efficacy and safety of a new prophylactic laser retinopexy method, the intraoperative septated circumferential barrier laser (SCBL), to prevent clinically significant RD during complete phacovitrectomy in macular surgery. Design Retrospective case–control study. Participants Six hundred and eighteen consecutive patients who underwent an uncomplicated phacovitrectomy between 2005 and 2011 to treat an epiretinal membrane (ERM) and macular hole (MH) were included. Methods Three hundred and forty-four patients received SCBL (group 1), and 274 patients did not receive SCBL (group 2). In the SCBL procedure, 1 or 2 rows of circumferential moderate-intensity burns were placed anteriorly to the equator with a subsequent 5–6 septate laser burns made from the circumferential laser marks to the anterior vitreous base perpendicularly at intervals of about 60 degrees. Results The SBCL procedure took an additional 208 ± 23.1 seconds in the most recent 47 patients. SCBL was associated with a significant reduction of clinically significant RD (from 2.6% in group 2 to 0% in group 1; p = 0.003). Postoperative complications related to SCBL such as anatomical failure in MH, macular edema, and ERM were not significantly different between the 2 groups ( p = 0.738, p = 0.743, and p = 0.914, respectively). Conclusions Prophylactic intraoperative SCBL produces a significant benefit by preventing postoperative RD without significant complications in ERM and MH surgery combined with phacoemulsification.

PURPOSE To analyze differences in ultra-widefield fluorescein angiography (UWFFA) findings between patients with recurrent postvitrectomy diabetic vitreous hemorrhage (PVDVH) and patients with non-PVDVH (NPVDVH). METHODS Patients were categorized as PVDVH when vitreous hemorrhage recurred after diabetic vitrectomy. Age-matched control diabetic patients in whom vitreous hemorrhage did not recur after vitrectomy were assigned to the NPVDVH group. Baseline characteristics were compared between groups. Also peripheral angiographic findings such as peripheral neovascularization, nonperfusion, and late peripheral vascular leakage were analyzed by UWFFA. RESULTS A total of 46 eyes were included this retrospective study: 22 with PVDVH and 24 with NPVDVH. Preoperative, 3-month postoperative, and final-visit best corrected visual acuity (BCVA) were not different between the two groups. The rate of peripheral neovascularization was significantly different (PVDVH 40.9%, NPVDVH 8.3%, P = 0.010). The rate of peripheral nonperfusion was significantly greater in PVDVH eyes than in NPVDVH eyes (81.8% vs. 37.5%, P = 0.002). The rate of late peripheral vascular leakage was also significantly greater in PVDVH eyes (90.9% vs. 29.2%, P < 0.001). These differences in peripheral angiographic findings were not seen within the conventional Early Treatment Diabetic Retinopathy Study (ETDRS) 7 standard fields. Ischemic index was also significantly higher in the PVDVH group than in the NVDVH group. CONCLUSIONS Compared with diabetic vitrectomized eyes that did not have recurring vitreous hemorrhage, PVDVH eyes had a higher rate of peripheral neovascularization, nonperfusion, and late peripheral vascular leakage. These differences were not found within the conventional ETDRS 7 standard fields. Therefore, it is important to assess peripheral retinal vessels by UWFFA after diabetic vitrectomy. Furthermore, in cases of peripheral neovascularization, peripheral nonperfusion, and late peripheral vascular leakage, additional treatment may be necessary to prevent PVDVH.

Assessing generally refers to the process of gathering information about a person relative to specific competencies and other attributes, in formal or informal learning contexts. This should lead to valid and reliable inferences about competency levels, which in turn may be used for diagnostic and/or predictive purposes. Too often, classroom and other high-stakes assessments are used for purposes of grading, promotion, and placement, but not to enhance learning. In this chapter, we focus on formative assessment which posits that assessment should (a) encourage and support, not undermine, the learning process for learners and teachers; (b) provide formative information whenever possible (i.e., give useful feedback during the learning process instead of a single judgment at the end); and (c) be responsive to what is known about how people learn, generally and developmentally. This type of assessment has as its primary goal improvement of learning, which is critical to support the kinds of learning outcomes and processes necessary for students to succeed in the twenty-first century. It is referred to as “formative assessment,” or assessment for learning, in contrast to “summative assessment” (or assessment of learning). This chapter overviews the role of formative assessment in education generally, and also touches on stealth assessment specifically—an ­evidence-based approach to weaving assessments directly into learning environments (Shute, Computer games and instruction. Charlotte, NC: Information Age Publishers, 2011).

PURPOSE: To evaluate the characteristics of spectral-domain optical coherence tomography (SD-OCT) findings associated with visual outcome and compare OCT measurements according to presence of cystoid macular edema (CME) in retinitis pigmentosa (RP) patients. METHODS: Patients with typical RP who underwent SD-OCT were included. We compared OCT measurements such as central retinal thickness (CRT), photoreceptor thickness, and photoreceptor inner segment/outer segment (IS/OS) junctional status at the fovea between the CME and non-CME groups. Also, correlations between best-corrected visual acuity (BCVA) and each parameter were determined. RESULTS: Among a total of 220 eyes in 128 RP patients, 46 eyes of 30 patients (20.9%) had CME. CRT was 303.1 ± 81.8 μm and 209.2 ± 46.8 μm in the CME and non-CME groups, respectively (P < 0.001). BCVA did not differ between the two groups (P = 0.690). However, among a subgroup with unilateral CME, BCVA was significantly worse in CME eyes than in the fellow eyes (P = 0.046). In the CME group, eyes with increased CRT showed worse BCVA (P = 0.010). Among 12 eyes with severe CME, defined as 350 μm or more CRT, 10 (83.3%) showed an absent IS/OS junction. In the non-CME group, in contrast, eyes with decreased CRT showed worse BCVA (P < 0.001). In both groups, severe IS/OS disruption was correlated with worse BCVA (P < 0.001). The risk of IS/OS disruption was higher in the CME group (P = 0.016). CONCLUSIONS: The presence of CME in RP patients was not necessarily correlated with loss of visual acuity. In eyes with CME, however, severe CME was strongly correlated with IS/OS disruption and visual impairment. Thus, severe CME seemed to be a predictor of poor visual outcome in RP patients.

Purpose: To report a case of macular hole secondary to presumptive infectious posterior uveitis involving the fovea that spontaneously resolved after medical treatment. Case summary: A 33-year-old male visited our clinic for decreased visual acuity in his left eye. He was treated with immunosuppressive therapy including steroid after bone marrow transplantation. Best corrected visual acuity (BCVA) was 0.05 in the left eye. Slit lamp examination showed mild anterior vitritis, and fundus examination showed a macular hole with surrounding whitish infiltration at the fovea. Spectral domain optical coherence tomography (SD-OCT) revealed a full thickness macular hole with surrounding hyper-reflective masses with an infiltration-like appearance involving all retinal layers. Serum anti-toxocara IgG was positive (ELISA), and eosinophil count and immunoglobulin E was elevated. Under diagnosis of presumptive ocular toxocariasis, the patient was treated with albendazole. After medical treatment for toxocariasis, the whitish foveal infiltration became smaller and more discrete. SD-OCT revealed spontaneous closure of the macular hole, and BCVA was improved to 0.4 after a 4-month follow-up. Conclusions: We report a macular hole complicated by presumptive infectious posterior uveitis that experienced spontaneous closure after medical treatment for underlying infection. J Korean Ophthalmol Soc 2016;57(1):155-160

PURPOSE To evaluate the glaucoma progression in patients with a history of refractive corneal surgery (RCS). METHODS A total of 313 eyes of 313 glaucoma patients (RCS group, 34 eyes; non-RCS group, 279 eyes) with a mean follow-up period of 2.7 years were included. Glaucoma progression was determined either by experts' stereoscopic optic disc/retinal nerve fiber layer (RNFL) photographs or by serial visual field (VF) data. Uni- and multivariate Cox's proportional hazards models were used to determine associations between potential risk factors including a history of RCS and glaucoma progression. RESULTS Among 313 eyes, 87 (27.8%) eyes showed progression either by optic disc/RNFL photographs or VF assessment during the follow-up period. Ten (29.4%) of eyes in the RCS group and 77 (27.6%) of eyes in the non-RCS group showed glaucoma progression; however, prevalence of progression did not differ between the two groups (P = 0.482). Among all participants, baseline age and VF pattern standard deviation (PSD; hazard ratios of 1.013 and 1.119; P = 0.026 and P < 0.001, respectively) were significant risk factors for progression. In both the RCS and the non-RCS group, only VF PSD was a significant risk factor for progression according to multivariate Cox proportional hazards (1.193, 1.099, P < 0.001, P < 0.001, respectively). CONCLUSIONS Baseline VF PSD and age substantially affected glaucoma progression in all study participants, although their RCS history was not a significant risk factor for glaucoma progression.

A 40-year-old woman presented with a 1-year history of left proptosis and hypoglobus. Eight years ago, she had undergone the surgical removal of left orbital cholesterol granuloma by Krönlein lateral orbitotomy. MRI showed a lesion of high T1-signal intensity and heterogeneous T2-signal intensity, which did not demonstrate gadolinium enhancement. The lesion was excised via a sub-brow skin incision, and careful drilling and curettage of the affected bony surface of the superolateral orbit were also performed. The diagnosis of orbital cholesterol granuloma was made by histopathologic examination. There was no evidence of tumor recurrence after 2 years of follow up. The authors present a rare case of recurrent cholesterol granuloma of the orbit and its successful surgical treatment with complete excision of the tumor and the surrounding bony base.

Aim To evaluate and compare retinal nerve fibre layer (RNFL) thickness measured by direct scanning (RNFL3.45 mode) and re-sampling from datasets (NHM4 mode) of RTVue-100 optical coherence tomography (OCT). Methods Thirty-six healthy subjects and 76 subjects with glaucoma were imaged with Stratus OCT (fast RNFL mode, RNFL3) and RTVue-100 OCT (NHM4 (RNFL1) and RNFL3.45 (RNFL2) modes). Measurement reproducibility was assessed in NHM4 and RNFL3.45 modes of RTVue-100 OCT (intraclass correlation coefficient (ICC)). Agreement between different RNFL measurements was analysed by Bland–Altman plot. The areas under the receiver operating characteristic (ROC) curves (AUCs) for discrimination between healthy and glaucoma were compared between the different RNFL measurements. Results Both NHM4 and RNFL3.45 modes showed excellent measurement reproducibilities (ICC 0.831–0.978). RNFL thicknesses by two different modes of the RTVue-100 OCT, and by the Stratus OCT, were correlated in all sectors, including average. There was no significant difference between RNFL1 and RNFL2 data. However, RNFL thickness in glaucomatous eyes by the RTVue-100 OCT was significantly greater than that measured by Stratus OCT. RNFL thicknesses determined by the two different modes of RTVue-100 OCT were in excellent agreement (95% limits of agreement −6.53 to 6.95 μm). All three RNFL measurements showed good glaucoma discrimination ability (AUC = RNFL1 0.970, RNFL2 0.962, RNFL3 0.971). Conclusions RNFL thickness determined by direct scanning and re-sampling from datasets of RTVue-100 OCT were in good agreement. However, both measurements in glaucomatous subjects were significantly different from those with the Stratus OCT. Those findings should be considered when a patient is followed-up using different types of OCT.

The first challenge of accomplishing the goals of any successful instructional system depends on accurately identifying characteristics of a particular learner or group of learners – such as the type and level of specific knowledge, skills, and other attributes. The second challenge is then leveraging the information to improve learning. This chapter is intended to extend current thinking about (a) educationally valuable skills and (b) instructional system design by describing an approach for analyzing key competencies and developing valid assessments embedded within an immersive game. Specifically, we will describe theoretically based research relating to stealth assessment, diagnosis, and instructional decisions, operational within an immersive game environment. Stealth assessment and diagnosis occur during the learning (playing) process, and instructional decisions are based on inferences of learners’ current and projected competency states. Inferences – both diagnostic and predictive – will be handled by Bayesian networks and used directly in student models to handle uncertainty via probabilistic inference to update and improve belief values on learner competencies. Resulting probabilities inform decision making, as needed in, for instance, the selection of instructional support based on the learner’s current state.

PURPOSE. To evaluate and compare the glaucoma discrimination ability of macular inner retinal layer (MIRL) thickness with that of peripapillary retinal nerve fiber layer (pRNFL) thickness measured by spectral-domain optical coherence tomography (RTVue-100; Optovue Inc, Fremont, CA) in patients with normal-tension glaucoma (NTG). METHODS. Sixty-five healthy subjects and 102 with NTG were enrolled. MIRL thickness provided by a ganglion cell complex (GCC) scan and two RNFL thicknesses measured by the NHM4 (RNFL1) and RNFL 3.45 (RNFL2) modes of the RTVue-100 system were analyzed. The areas under the receiver operating characteristic curves (AUCs) of MIRL and pRNFL thicknesses for discriminating patients with NTG from control subjects were determined. The AUCs were compared between patients with central visual field (VF) defects (VF; 10° of fixation) and peripheral VF defects (10° from fixation). RESULTS. The average MIRL thickness showed a strong correlation with both RNFL1 and -2 thicknesses (R 2 0.773, 0.774, both P 0.0001). The AUCs for average MIRL, RNFL1, and RNFL2 thicknesses were not significantly different at 0.945, 0.973, and 0.976, respectively. However, the AUCs of the average and superior MIRL thicknesses were significantly less than that of the pRNFL thickness in eyes with moderate-toadvanced glaucoma and eyes with peripheral VF defects. CONCLUSIONS. The average MIRL thickness showed a strong correlation with pRNFL thickness, because patients with NTG at an early stage showed paracentral VF defects near the fixation point. MIRL thickness showed glaucoma discrimination ability comparable to that of pRNFL thickness in patients with NTG with early VF defects. In eyes with advanced or peripheral VF defect, pRNFL measurement showed a better glaucoma diagnostic ability than did MIRL measurement. (Invest Ophthalmol