Taiwan Journal of Ophthalmology

Editorial

Editorial

Pages 127-127 Chung-May Yang
High myopia has a high prevalence inTaiwan.1 Macular hole is one of the frequently seen complications of myopic maculopathy. The formation of macular hole in high myopia involves complex traction forces from various directions. At least six traction forces maycontributetothedevelopmentofmacularholeinhighmyopia. These include the following: Vitreous anterior-posterior traction, oblique or tangential traction from partially or undetached posterior hyaloid, traction from epiretinal membrane, internal limiting membrane induced tangential traction, posterior outward traction from the staphyloma, and retinal vessels traction.2e4 These factors, alone or in combination, may induce macular hole formation through mechanisms either similar to those underlying idiopathic macularhole or unique tohigh myopic condition. Idiopathic macular hole rarely cause macular detachment. Persistent and multidirectional traction after the development of macular hole plus the abnormal retinal pigment epithelium (RPE) function from chorioretinal atrophy would predispose high myopic eyes with macular hole to localized or extensive retinal detachment (RD). The extent of RD varies, and the best treatment remains controversial. Treatment options range from intravitreal gas injection to vitrectomy with or without internal limiting membrane peeling to macular buckling. For uncomplicated RD, long-acting gas injection alone is able to achieve about 55% of reattachment rate, compared with 80% obtained by vitrectomy.5 Removing the preretinal traction as completelyaspossibleisthekeyforsurgicalreattachment.However, even with vitrectomy and membrane peeling, the hole closure rate is disappointing, hovering around 10e30%. With localized RD (RD extension limited within the equator), a single or repeated gas injection may have a reattachment rate of 70% after 1 year, with persistent open hole in most treated eyes.6 Unfortunately, the high-success reattachment rate is not maintained during a longer period of follow-up, particularly in those with optical
coherence tomography (OCT)-detectable premacular traction. Several studies have shown that macular buckling may achieve a high reattachment rate and a high hole closure rate. However, the long-term effects from the eye wall distortion and compression bythebuckle remain amajorconcern.Asin other rhegmatogenous RD, RD secondary to macular hole may develop proliferative vitreoretinopathy (PVR) if left untreated. In a pseudophakic eye, RD tendstoprogressrapidly,whichmayinduceseverehypotony,leadingtociliochoroidaldetachment.PVRbecomescommonunderthis scenario. Persistent or recurrent detachment after primary vitrectomy also tends to develop PVR. Clinical studies specifically focusing on PVR associated with macular hole in high myopia havebeenrareintheliterature.Inthisissue,San-NiChenandassociates reported the clinical presentations and surgical results of macularholewithPVRchangesinhighmyopia.Theresultsshowed that with meticulous membrane dissection, high anatomical success may be obtained. However, as up to 75% of cases require long-term silicone oil tamponade and the hole closure rate is low, the treated eyes run the risk of recurrent RD when complications related to silicone oil prompt its removal. The treatment of RD secondary to macular hole in high myopia continues to be a major challenge to the vitreoretinal surgeons.
Review Articles

Vascular endothelial growth factor and its inhibitor in age-related macular degeneration

Pages 128-133 Xiying Wang, Masahito Ohji

Intraocular angiogenesis is considered the leading cause for severe loss of vision, and contributes to many ocular diseases such as neovascular age-related macular degeneration, diabetic retinopathy, and retinopathy of prematurity, the main causes of blindness in developed countries.1 An enormous body of work has demonstrated that vascular endothelial growth factor (VEGF) plays a prominent role as mediator in the procedure of pathological angiogenesis. This makes VEGF a potential target for the medical therapies of retinal angiogenesis and some clinical trials have proved the efficacy of anti-VEGF strategies. This review evaluates the role of VEGF in the pathogenesis of age-related macular degeneration and provides an overview of recent developments in therapeutic modalities. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Uveitis: A search for a cause

Pages 134-140 Arshee S. Ahmed, Jyotirmay Biswas

This article aims to review the current literature to identify the various laboratory and investigative modalities that can be used toaid in the diagnosis of patients with uveitis. Although laboratory testssuch as erythrocyte sedimentation rate, serum angiotensin-converting enzyme levels, and human leukocyte antigen typing among others have limited utility in the diagnosis of uveitis, they provide supportive evidence. Results of serological tests such as enzyme-linked immunosorbent assay have proven to be of significant importance in diagnosing diseases such as toxoplasmosis, and the use of ocular samples such as aqueous and vitreous has greatly increased the diagnostic reliability. Imaging techniques play a major rolein the diagnosis of posterior uveitis. Fundus fluorescein angiography, indocyanine greenangiography and lately, autofluorescence and optical coherence tomography provide information about the diagnosis of uveitis disorders and are also useful for monitoring progression, complications, and response to treatment. The use of ultrasonographyand ultrasound biomicroscopy provides useful information in eyes with chronic uveitis where complications such as retinal detachment and cyclitic membranes are suspected and hazy media precludes a thorough clinical examination. Radiological investigations such as computerized tomography aid in the diagnosis and management of systemic disorders such as tuberculosis or sarcoidosis. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Original Articles

Myopic macular hole-associated retinal detachment with proliferative vitreoretinopathy

Pages 141-145 San-Ni Chen, Kun-Hsien Li, Jiunn-Feng Hwang

Purpose: The objective of this study was to report the clinical characteristics and surgical results of patients suffering from retinal detachment, which was induced by a myopic macular hole and complicated by proliferative vitreoretinopathy, but without previous vitreoretinal surgery. Methods: Interventional case series of 22 eyes in 20 patients with excessive myopia and macular holeassociated retinal detachment complicated with proliferative vitreoretinopathy were scrutinized retrospectively. All eyes had undergone par plana vitrectomy, including peeling of the epiretinal membrane, internal limiting membrane around the macular hole, and silicone oil or perfluoropropane (C3F8) retinal tamponade. An encircling buckle was also inserted in some of the eyes. Eyes with previous vitreoretinal surgery were excluded from this review. Results: The average age of patients was 68.37.17 years, average duration of symptoms prior to seeing an ophthalmologist 8.36  4.14 months, and average axial length 30.01  1.81 mm. Nine of the 20 patients had bilateral retinal detachment. The average number of operations performed was 1.36  0.58. The success rate of the initial surgery was 63.3%, which improved to 90.9% in subsequent procedures. Conclusion: A macular hole with proliferative vitreoretinopathy is associated with retinal detachment for a long duration. Retinal reattachment and improved visual acuity could be achieved in most eyes after a surgical intervention. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Endogenous candida endophthalmitis in South Taiwan: A 10-year retrospective stud

Pages 146-150 Shih-Hao Wang, Jong-Jer Lee, Yung-Jen Chen, Hsi-Kung Kuo

Purpose: To investigate the clinical manifestations and the results of the management of endogenous candida endophthalmitis (ECE) at our hospital. Methods: This study was a retrospective chart review conducted between September 2002 and September 2012. Results: Ourstudyincluded24eyesof14patients.ThecultureresultsrevealedCandidaalbicansin11cases andCandidatropicalisinthreecases.Diabetesmellitus,cancer,andintravenouscatheterimplantationwere themostimportantriskfactorsforECE.Asystemicantifungalagentcombinedwithintravitrealinjectionor vitrectomy was our method for treating these cases and the complications. The outcomes were generally poor, with a final visual acuity (VA) of better than 0.1 in 10 cases, counting finger to 0.1 in six cases, light perception to hand motion in six cases, and no light perception in two cases. Conclusion: Unsatisfactory visual outcome in ECE is related to poor initial VA and complications. Early diagnosis and prompt treatment are necessary for these patients. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Long-term results of extraction of childhood cataracts and intraocular lens implantation

Pages 152-155 I-Ting Sun, Hsi-Kung Kuo, Yung-Jen Chen, Po-Chiung Fang, Sue-Ann Lin, Pei-Chang Wu, Min-Tse Kuo, Mei-Ching Teng

Purpose: To study the long-term changes in refraction and visual outcome after extraction of congenital/ developmental cataracts and intraocular lens (IOL) implantation in children. Methods: Cataract extraction and IOL implantation were performed in 33 eyes of 21 children aged 4e59 months. Refraction and best-corrected visual acuity (BCVA) were measured 4e5 years later. The cases were grouped by age at surgery: Group A: 1 year, Group B: 1e3 years, and Group C: >3 years. Results: The mean myopic change was significantly lower in bilateral (mean 3.88  2.47 D) than in unilateral (mean7.68 5.04 D) cases (p¼0.003). The latest BCVAvalues were logMAR 0.760.86 and logMAR 0.43  0.32 in unilateral and bilateral cases, respectively (p ¼ 0.055). The mean myopic change values were 5.17  4.49 D, 6.34  3.44 D, and 3.45  2.50 D in Groups A, B, and C, respectively (p ¼ 0.104). The latest BCVA values were logMAR 0.84  0.46, logMAR 0.55  0.64, and logMAR 0.14  0.17 in Groups A, B, and C, respectively (p ¼ 0.035). Conclusion: Best-corrected Snellen visual acuity 0.2 was achieved in most patients. We found less myopic shift in patients with bilateral cataracts and better visual outcomes in patients who underwent cataract surgery at older ages, probably because the cataracts in older patients were less dense initially and thus less likely to cause deprivation amblyopia. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Changes in corneal curvature after wearing the orthokeratology lens

Pages 156-159 Chien-Chih Chou, Yu-Chuen Huang, Yi-Yu Tsai, Jane-Ming Lin, Wen-Lu Chen, Hui-Ju Lin

Introduction: The orthokeratology lens (OK lens) is designed to reshape the cornea and correct refraction error. Owing to the convenience of ceasing the use of glasses during the day, the use of the OK lens is increasing in myopic children. In this study, changes in corneal curvature and astigmatism after wearing the OK lens were analyzed. Methods: This retrospective cohort study included 65 children (130 eyes) who underwent full and regular examinations. None of the participants had any ocular disease other than myopia and astigmatism. The OKlenses used in this study were four-zone, reverse-geometrylenses. The corneal curvature of each patient was checked annually after the patients discontinued daily wearing of the OK lens for 10 days. Student t test and repeated measures analysis of variance (ANOVA) analyses were performed to compare the results. Results: The radius of corneal curvature showed a progressive annual increase with significant differences, both in the steepest and flattest radius of the corneal curvature (p < 0.001 and p ¼ 0.001, respectively). The mean radius of the steepest and flattest corneal curvature increased significantly from baseline to the following years consecutively (all p < 0.001). Nevertheless, astigmatism did not change significantly in any of the tests. Conclusion: Corneal curvature changed as the patients grew older. There was a statistically significant increase in the radius of the corneal curvature in the myopic children studied. Forcorrect fit of OK lenses, the radius of the corneal curvature should be regularly checked prior to dispensing a new set of lenses. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Case Reports

Therapeutic dilemma in serpiginous choroiditis

Pages 160-162 Chieh-Yin Cheng, San-Ni Chen, Jiunn-Feng Hwang, Chun-Ju Lin

A 43-year-old woman had blurred vision in the left eye for 4 years. Her best-corrected visual acuity was 20/20 in the right eye and 20/200 in the left eye. The fundus showed grayish-yellow, jigsaw-puzzleshaped lesions at the level of the retinal pigment epithelium and choriocapillaries emanating from the optic nerve head in both eyes. Fluorescein angiography showed late leakage in active lesions and hypofluorescence in hyperpigmented areas. Oral prednisolone and cyclosporine were given first. However, after posterior subtenon triamcinolone injections in both eyes and one intravitreal triamcinolone injection in the left eye, macular edema worsened. Steroid-induced central serous chorioretinopathy was suspected, so we tapered prednisolone rapidly and changed to azathioprine. Subsequent optical coherence tomography demonstrated retinal pigment epithelial detachment in the right eye subsided gradually. Fundus autofluorescence imaging showed progressively quiescent lesions. Unfortunately, acute myocardial infarction, atrial fibrillation, and ischemic stroke developed after 6 weeks azathioprine. In the acute phase of serpiginous choroiditis, corticosteroids are most commonly used. However, steroid therapy may be complicated with steroid-induced central serous chorioretinopathy. When we shift to other systemic immunosuppressive regimens, such as azathioprine, the possibility of acute myocardial infarction should be kept in mind. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Intravitreal dexamethasone implant for a vitrectomized eye with diabetic macular edema

Pages 163-167 Tsu-Hua Chen, Jia-Kang Wang, Shu-Wen Chang

A 71-year-old man suffered from diabetic vitreous hemorrhage in his left pseudophakic eye. He received 20-gauge pars plana vitrectomy and removal of taut posterior hyaloid traction in June 2011. Spectraldomain optical coherence tomography demonstrated cystoid macular edema 1 month after the operation. The macular edema did not respond to macular grid laser. Intravitreal bevacizumab (1.25 mg) was injected, which was effective for managing diabetic macular edema initially. The edema recurred 3 months following the bevacizumab injection. Subsequent intravitreal triamcinolone 1 mg also failed to treat the macular edema. Ozurdex, a dexamethasone implant, was injected intravitreally in January 2012. The central foveal thickness decreased, and visual acuity improved. The effect persisted for 6 months. There was no systemic or ocular adverse event during the follow-up period. This intravitreal dexamethasone implant could be helpful for diabetic macular edema in vitrectomized eyes. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Central retinal vein occlusion after gamma knife radiosurgery for cavernous sinus dural arteriovenous fistula

Pages 168-172 Yen-Chun Lin, Chang-Hsien Ou, Cheng-Loong Liang, Huan-Chen Hsu, Shih-Hao Tsai, Yan-Ming Chen

A 70-year-old man presented to our clinic complaining of binocular diplopia and persistent redness in the left eye for 5 months. Conjunctival vessels were dilated and tortuous in both eyes. Intraocular pressure was 16 mmHg in the right eye and 23 mmHg in the left eye. Complete bilateral sixth cranial nerve and partial left third cranial nerve palsies were noted. Brain computed tomography and cerebral angiography revealed a Barrow Type C dural arteriovenous fistula. The patient underwent gamma knife radiosurgery (GKRS) at a dose of 18 Gy and a target volume of 3.3 mL. Within 1 month of GKRS, the patient reported an improvement in diplopia, but 4 months following the procedure, he experienced micropsia, metamorphopsia, and darkness in his left eye. Prominent flame-shaped hemorrhages and retinal edema, the typical picture of central retinal vein occlusion (CRVO), developed in his left eye. Intraocular pressure in this eye was controlled with antiglaucoma topical medication. 5 months later, the left retina had appeared normal. Antiglaucoma drops were gradually tapered and eventually discontinued. The GKRS, used in recent decades, is noninvasive and effective in the treatment of dural arteriovenous fistula. However,CRVO can occurafterGKRS. Here,wepresent,in detail, aclinicalcourseof CRVO that developed after GKRS. Our findings may be useful for further understanding of this rare complication. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.

Ocular manifestations as the initial presentations of Wilson disease

Pages 173-175 Jinn-Liang Lin, Ming-Shan He, Rong-Kung Tsai

A 19-year-old woman presented with Kayser-Fleischer ring in her corneas and sunflower cataracts in both eyes. There were no coexisting neurologic or hepatic symptoms, both brain magnetic resonance imaging (MRI) and abdominal echo showed minimal changes. Serum copper concentration (Cu) and ceruloplasmin were abnormal, and 24-hour urine collection showed abnormally high levels of copper (348.0 mg/day). A diagnosis of Wilson disease was made. We report the interesting case of rare manifestations of Wilson disease; initially with ocular presentations without neurologic symptoms. Early detection and treatment of Wilson disease is possible in patients with only ocular manifestations, and can prevent a catastrophic sequel. Copyright  2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.