Bi-weekly Subconjunctival Injection of Bevacizumab for Corneal Neovascularization after Burn Injury

Purpose: We report two cases of corneal neovascularization (NV) after burn injury successfully treated by subconjunctival bevacizumab injections at 2-week intervals.Case summary: Three bi-weekly subconjunctival injections of bevacizumab were administered to two patients with corneal NV after burn injury. In our first patient, corneal NV was markedly reduced by bevacizumab injection. The patient exhibited with a clear cornea and improved visual acuity (20/30) after treatment. Eleven weeks after the last injection, the cornea remained clear, with clinical regression of smaller vessels; the improvement in visual acuity was maintained. In the second case, the diameter of the vessels, hemorrhagic lesions, and corneal edema decreased/regressed, with improvement of the visual acuity to 20/25; these improvements persisted for 12 weeks after the last subconjunctival injection.Conclusions: Our results suggest that bi-weekly subconjunctival injection of bevacizumab is well-tolerated and effective for inhibiting chronic corneal NV after burn injury.

Atypical Multiple Sclerosis Presenting as Bilateral Optic Neuritis

Purpose: We report a case of multiple sclerosis with bilateral optic neuritis that was atypical in terms of both the clinical signs and symptoms.Case summary: A 34-year-old female visited the department of neurology with a complaint of sudden-onset, left lower extremity weakness and numbness that had developed 3 weeks prior, and bilateral blurred vision that had commenced 2 weeks prior. The patient was diagnosed with multiple sclerosis and prescribed high-dose intravenous methylprednisolone for 3 days, but the blurred vision did not improve. The patient was referred to the ophthalmology department. The initial best-corrected visual acuity was 0.04 in both eyes, and the relative afferent pupillary defect test was positive for the left eye. The Ishihara color test scores were 1/17 for both eyes. No optic disc swelling was evident on fundus examination. Brain and spine magnetic resonance imaging (T2-weighted) performed during the initial visit revealed lesions of high signal intensity in the frontal, subcortical white matter; the optic chiasm; the left retrobulbar optic segment; the medulla; and the spinal C2-5 processes. Aquaproin-4 immunogloblin G antibody (AQP4-IgG Ab) was not detected in serum. One month after prescription of the oral steroid, the vision improved to 1.0 in the right and 0.8 in the left eye. The patient was lost to follow-up after prescription of interferon-beta for 4 years, without recurrence.Conclusions: Binocular optic neuritis accompanied by severe visual loss is a rare form of multiple sclerosis. A thorough diagnosis (with a focus on exclusion) is required, as is appropriate treatment.

Infectious Keratitis Associated with Contact Lenses

The use of contact lenses for correcting refraction, suppressing myopia progression, and cosmetic purposes is increasing steadily. Contact lenses have various effects on the corneal surface and corneal infection can occur following obstruction of tear flow, micro-damage to corneal epithelial cells, corneal hypoxia, changes in corneal immunity, and exposure to contaminants. When a patient who used to wear contact lenses presents with keratitis, it is important to distinguish whether it is an infection; if it is an infection, it is important to find the causative strain and promptly treat it appropriately. Since improper lens care is related to infection, appropriate patient education is necessary, and the risk of contact lens infection should be reduced through regular ophthalmic examinations.

Frequently Experienced Problems in the Early Stages after Prescribing Rigid Gas Permeable Contact Lenses

Prescribing rigid gas-permeable (RGP) lenses involves a series of processes that determine the most appropriate final lens through the trial use of test lenses based on the results of slit lamp microscopy, measuring refraction and corneal curvature, and corneal topography. The final prescription is reached by judging the dynamic lens movement, adequacy of the tear layer around the lens, corrected vision, and quality of vision. Various problems are encountered soon after prescribing lenses, including foreign body sensation, tear hypersecretion, decreased visual acuity, blurring, visual acuity change, redness, dryness, sudden pain, lens centering, and lens fallout. Here, we examine these problems and how to solve them.

Acanthoamoeba Keratitis Induced by a Therapeutic, Soft Contact Lens: Diagnosis via Gram Staining

Purpose: We report two cases of Acanthamoeba keratitis diagnosed by Gram staining in patients who had recently worn therapeutic, soft contact lenses and had no history of lens use for visual correction.Case summary: The first patient was initially diagnosed with suspected mixed bacterial or fungal keratitis before a final diagnosis of Acanthamoeba keratitis was confirmed by Gram staining of a corneal smear. The second patient was initially diagnosed with a persistent epithelial defect caused by an earlier lid injury inflicted by a metallic foreign body, and then with a suspected mixed infection combined with herpetic uveitis. The patient was finally diagnosed with Acanthamoeba keratitis by Gram staining of a corneal smear. Both cases were treated with polyhexamethylene biguanide and chlorhexidine.Conclusions: Therapeutic, soft contact lenses are used to enhance corneal, epithelial wound healing in conjunction with antimicrobial prophylaxis. However, application of such a lens to a diseased cornea may predispose to the development of microbial keratitis caused by microorganisms resistant to the usual, prophylactic, antimicrobial eye drops. Therapeutic, soft contact lenses are associated with a risk of Acanthamoeba keratitis; early diagnosis is important. Gram staining of a corneal smear is useful in this context. Acanthamoeba is not eradicated by empirical broad-spectrum antimicrobials.

Clinical Analysis of Dry Eye Syndrome According to Anterior Displacement of the Marx Line

Purpose: To evaluate the clinical characteristics of patients with dry eye syndrome according to anterior displacement of the Marx line.Methods: This retrospective study involved 127 eyes in 127 patients with dry eye, who were divided into three groups: group 1, aqueous-deficient, including Sjögren syndrome; group 2, meibomian gland dysfunction (MGD) dry eye; and group 3, other tear layer instability. A detailed assessment was conducted, involving the Ocular Surface Disease Index, corneal fluorescein staining (score: 0-15), conjunctival Lissamine green staining (score: 0-12), measurement of tear breakup time, and Schirmer’s test.Results: The proportion of patients with MGD was highest in the group with anterior displacement of the Marx line (p < 0.05). The correlation between anterior dislocation of the Marx line and Schirmer’s test, an objective indicator of dry eye syndrome, was significantly weaker when there was anterior displacement of the Marx line.Conclusions: Anterior dislocation of the Marx line was more common in patients with MGD. The Marx line is a useful marker for diagnosing MGD.

Severe Intraocular Pressure Fluctuation following Hemodialysis after Cataract Surgery in a Patient with Chronic Renal Failure

Purpose: To report a case of severe intraocular pressure fluctuation following hemodialysis after cataract surgery in a patient with chronic renal failure.Case summary: A 51-year-old female patient on hemodialysis for chronic renal failure, who was seen regularly by our retina clinic for proliferative diabetic retinopathy and right eye cataract, presented with decreased visual acuity in her right eye. During phacoemulsification under the diagnosis of right eye cataract, zonular dialysis and posterior capsule rupture occurred and intraocular lens ciliary sulcus insertion was performed. Following hemodialysis 3 days after the surgery, the patient complained of headache and right eye pain. The intraocular pressure of the right eye had increased to 44 mmHg. Mild inflammation in the anterior chamber was found with remnant lens material present at the inferior anterior angle. The use of glaucoma eye drops, anterior chamber paracentesis, and anterior chamber irrigation reduced the intraocular pressure and improved the patient’s symptoms. However, a severe increase in intraocular pressure recurred with the above symptoms, again following hemodialysis. Intraocular pressure fluctuation was repetitively present after serial hemodialysis treatments for 1 month, at which point cataract and glaucoma surgeries were considered. However, the intraocular pressure stabilized afterwards; thus, the patient remained under observation and was treated with glaucoma eye drops.Conclusions: Inflammation and a decrease in the aqueous outflow facility due to remnant lens material and the use of an ophthalmic viscoelastic device in cataract surgery may cause severe intraocular pressure fluctuations in patients undergoing hemodialysis for chronic renal failure.

Long-term Clinical Outcomes of Vitrectomy with 360° Laserpexy or Scleral Encircling in Rhegmatogenous Retinal Detachment

Purpose: To compare long-term clinical outcomes of pars plana vitrectomy (PPV) combined with intraoperative 360° laserpexy and pars plana vitrectomy combined with scleral encircling for the treatment of primary rhegmatogenous retinal detachment (RRD).Methods: This retrospective, comparative case study included 70 patients who had at least 1 year of follow-up after vitrectomy for primary uncomplicated RRD from 2015 to 2019. The patients were divided into two groups. Group I included 34 patients who underwent PPV + 360° laserpexy (LP), while group II included 36 patients who underwent PPV + scleral encircling (SE). Main outcome measures were the anatomical success rate, the functional success rate, final best-corrected visual acuity (BCVA), and the incidence of post-operative complications. We also examined the long-term changes in axial length, corneal curvature, and refractive error before and after surgery.Results: LP and SE groups showed no significant differences with respect to the primary anatomical success rate (97.05% and 94.44%, respectively; p = 0.592) or the functional success rate (BCVA ≥ 20/40 at final follow-up; 82.35% and 77.78%, respectively; p = 0.635). Detachment reoccurred in three cases (one in the LP group and two in the SE group) because of proliferative vitreoretinopathy; both cases in the SE group had successful anatomical re-attachment after repeating the PPV procedure. Complications included post-operative epiretinal membrane and cystic macular edema, as well as increased intraocular pressure.Conclusions: Primary vitrectomy combined with 360° laserpexy has effectiveness similar to vitrectomy combined with scleral encircling in patients with RRD in long-term clinical outcomes.

Empty Sella and Unilateral Sixth Nerve Palsy in a Pediatric Patient with Idiopathic Intracranial Hypertension

Purpose: We report the case of a child with idiopathic intracranial hypertension who presented with binocular papillary edema and monocular sixth cranial nerve palsy accompanied by empty sella syndrome evident on brain magnetic resonance imaging.Case summary: A 9-year-old, normal-weight male patient visited the emergency room complaining of headache and diplopia 4 days in duration. The alternative prism cover test revealed esotropia of 16 prism diopters and a -1 right lateral gaze limitation. A fundus examination revealed papilledema and peripapillary hemorrhages in both eyes, and a visual field examination an enlarged, physiological blind spot in the right eye. Brain magnetic resonance imaging revealed elevated cerebrospinal fluid pressure, an empty sella, and posterior scleral flattening. We diagnosed and treated idiopathic intracranial hypertension. After 4 months, the papilledema and peripapillary hemorrhages of both eyes resolved, and the right lateral gaze limitation improved. The empty sella improved on brain magnetic resonance imaging, and we noted no recurrence 8 months after treatment.Conclusions: If a child with suspected idiopathic intracranial hypertension visits a hospital, but it is difficult to perform a lumbar puncture, brain magnetic resonance imaging should be scheduled. If abnormalities are found, these help to determine the course of disease.

Cosmetic Nd:YAG Laser-assisted Maculopathy Treated with Early Anti-vascular Endothelial Growth Factor Antibody

Purpose: To report a follow up of early intravitreal anti-vascular endothelial growth factor (VEGF) antibody treatment in a patient with maculopathy after accidental exposure to a high-powered cosmetic Nd:YAG laser.Case summary: A 36-year-old female patient visited our clinic with decreased visual acuity in the right eye after accidental exposure to a high-powered cosmetic Nd:YAG laser. The best-corrected visual acuity of the right eye was 0.1 and subretinal hemorrhage on the foveal area was observed during fundus examination. Optical coherence tomography revealed serous retinal detachment with hyperreflective disruption of the ellipsoid zone and retinal pigment epithelium-Bruch’s membrane complex. Intravitreal bevacizumab (Avastin®, 1.25 mg/0.05 mL; Roche Korea, Seoul, Korea) injections were performed three times. Visual acuity was unchanged at 6 months after the first visit. However, complete resolution of the subretinal hemorrhage was observed and there were no signs of secondary choroidal neovascularization or recurrence of choroidal hemorrhage.Conclusions: Early anti-VEGF antibody treatment in a patient with subfoveal hemorrhage and choroidal rupture after high-powered cosmetic Nd:YAG laser exposure improved morphology and prevented secondary choroidal neovascularization.