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1.  Using ImageJ to Evaluate Optic Disc Pallor in Traumatic Optic Neuropathy 
To evaluate optic disc pallor using ImageJ in traumatic optic neuropathy (TON).
This study examined unilateral TON patients. The optic disc was divided into 4 quadrants (temporal, superior, nasal, and inferior), consistent with the quadrants on optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) thickness maps. Optic disc photography was performed and disc pallor was quantified using gray scale photographic images imported into ImageJ software. The correlation between optic disc pallor and RNFL thickness was examined in each quadrant.
A total of 35 patients (31 male, 4 female) were enrolled in the study. The mean participant age was 34.8 ± 15.0 years (range, 5 to 63 years). Overall RNFL thickness decreased in 6 patients, with thinning most often occurring in the inferior quadrant (28 of 35 eyes). There was a significant correlation between optic disc pallor and RNFL thickness (superior, rho = -0.358, p = 0.04; inferior, rho = -0.345, p = 0.04; nasal, rho = -0.417, p = 0.01; temporal, rho = -0.390, p = 0.02). The highest level of correspondence between disc pallor and RNFL thickness values outside of the normative 95th percentiles was 39.3% and occurred in the inferior quadrant.
Optic disc pallor in TON was quantified with ImageJ and was significantly correlated with RNFL thickness abnormalities. Thus, ImageJ evaluations of disc pallor may be useful for evaluating RNFL thinning, as verified by OCT RNFL analyses.
PMCID: PMC3958633
Fundus photography; Optic disc; Optic nerve injuries; Optical coherence tomography
2.  A Case of Ocular Myasthenia Gravis Presenting as Double Depressor Palsy 
A 65-year-old man who had been experiencing diplopia in front and down gaze for 15 days visited our hospital. Hypertropia was noted in the patient's left eye, and limitation of depression was found in the adduction, primary gaze, and abduction. Brain magnetic resonance imaging showed no remarkable findings. Two weeks after the first visit, the patient complained of ptosis in the left eye. An ice test was performed and the ptosis was resolved after the test. Then, anti-acetylcholine receptor binding antibody levels were checked and found to be slightly elevated. We prescribed methylprednisolone per os 24 mg for 2 weeks, and his symptoms improved after the 2-week treatment. Five weeks after his first visit, the patient showed an ortho result in the alternate prism cover test and normal ocular movements. This may be the first case in which ocular myasthenia gravis presented as double depressor palsy, and in such cases, the possibility of ocular myasthenia gravis should be considered to rule out double depressor palsy.
PMCID: PMC3958640
Double depressor palsy; Myasthenia gravis; Strabismus
3.  The Correlation between Angle Kappa and Ocular Biometry in Koreans 
To investigate normative angle kappa data and to examine whether correlations exist between angle kappa and ocular biometric measurements (e.g., refractive error, axial length) and demographic features in Koreans.
Data from 436 eyes (213 males and 223 females) were analyzed in this study. The angle kappa was measured using Orbscan II. We used ocular biometric measurements, including refractive spherical equivalent, interpupillary distance and axial length, to investigate the correlations between angle kappa and ocular biometry. The IOL Master ver. 5.02 was used to obtain axial length.
The mean patient age was 57.5 ± 12.0 years in males and 59.4 ± 12.4 years in females (p = 0.11). Angle kappa averaged 4.70 ± 2.70 degrees in men and 4.89 ± 2.14 degrees in women (p = 0.48). Axial length and spherical equivalent were correlated with angle kappa (r = -0.342 and r = 0.197, respectively). The correlation between axial length and spherical equivalent had a negative correlation (r = -0.540, p < 0.001).
Angle kappa increased with spherical equivalent and age. Thus, careful manipulation should be considered in older and hyperopic patients when planning refractive or strabismus surgery.
PMCID: PMC3849305  PMID: 24311927
Axial length; Corneal topography; Refractive errors
4.  Isolated complete bitemporal hemianopia in traumatic chiasmal syndrome 
Indian Journal of Ophthalmology  2013;61(12):759-760.
A 29-year-old man presented with a chief complaint of lateral blindness in the left eye at 4 months after an accidental fall. His best corrected visual acuity was 0.7 in the left eye and 1.0 in the right eye. Visual field test showed a complete bitemporal hemianopic defect without any neurologic symptoms. An orbital computed tomography scan with non-enhancement conducted at the time of the visit showed multiple frontal skull fractures and cerebromalacia a small fracture in the sphenoidal boneboth frontal lobes. No radiological abnormalities of the visual pathway were detected. Optical coherence showed reduced thickness in the retinal nerve fiber layer, primarily in the superior and inferior part of the left eye. To our knowledge, a complete bitemporal hemianopia without neurological deficits is extremely rare in traumatic chiasmal syndrome.
PMCID: PMC3917398  PMID: 24212216
Bitemporal hemianopia; Traumatic chiasmal syndrome; visual field
5.  Characteristics of pupillo-accommodative functions according to time of onset, gender and age in tonic pupil 
To evaluate the characteristics of pupillo-accommodative functions in patients with idiopathic tonic pupil according to the time of onset, gender, and age.
Totally, 15 males and 19 females were divided into 2 groups depending on the time of disease onset: group I (onset <2 months, n=20) and group II (onset >2 months, n=14). A supersensivity test was conducted by applying diluted pilocarpine 0.125% to the eye and accommodative functions were evaluated using the near-point of accommodation (NPA) as the cutoff point, at which the patient experienced blurred vision. Pupil size and the ratio of decrease in the affected pupil after instillation of 0.125% pilocarpine were investigated.
There was no significant difference between the 2 groups regarding the various pupillary reflex results, including data on the affected pupil size before and after 0.125% pilocarpine, anisocoria, and ratio of pupil decrease. No significant difference in NPA was found between the 2 groups. However, female patients were noted to have greater anisocoria and a faster constriction ratio than those of the male patients (P=0.02 and P=0.04). On subgroup analysis, female patients from group II had larger affected-pupil sizes before 0.125% pilocarpine instillation and longer NPAs than those of the male patients.
No relationship was found between time of onset and dysfunction of pupillo-accommodative functions. Pupillo-accommodative functions and age were not related, except for the NPA.
PMCID: PMC3808916  PMID: 24195044
tonic pupil; accommodation; cholinergic supersensitivity
6.  Long-term Follow-up of Acute Isolated Accommodation Insufficiency 
To define the long-term results of accommodation insufficiency and to investigate the correlation between accommodation insufficiency and other factors including near point of convergence (NPC), age, and refractive errors.
From January 2008 to December 2009, 11 patients with acute near vision disturbance and remote near point of accommodation (NPA) were evaluated. Full ophthalmologic examinations, including best corrected visual acuity, manifest refraction and prism cover tests were performed. Accommodation ability was measured by NPA using the push-up method. We compared accommodation insufficiency and factors including age, refractive errors and NPC. We also investigated the recovery from loss of accommodation in patients.
Mean age of patients was 20 years (range, 9 to 34 years). Five of the 11 patients were female. Mean refractive error was -0.6 diopters (range, -3.5 to +0.25 diopters) and 8 of 11 patients (73%) had emmetropia (+0.50 to -0.50 diopters). No abnormalities were found in brain imaging tests. Refractive errors were not correlated with NPA or NPC (rho = 0.148, p = 0.511; rho = 0.319, p = 0.339; respectively). The correlation between age and NPA was not significant (rho = -395, p = 0.069). However, the correlation between age and NPC was negative (rho = -0.508, p = 0.016). Three of 11 patients were lost to follow-up, and 6 of 8 patients had permanent insufficiency of accommodation.
Accommodation insufficiency is most common in emmetropia, however, refractive errors and age are not correlated with accommodation insufficiency. Dysfunction of accommodation can be permanent in the isolated accommodation insufficiency.
PMCID: PMC3596614  PMID: 23543051
Accommodation; Convergence; Diplopia
7.  Relationship of Hypertropia and Excyclotorsion in Superior Oblique Palsy 
To evaluate the correlation between hypertropia and excyclotorsion in acquired superior oblique palsy (SOP).
Thirty-one patients with acquired unilateral SOP were recruited for this study. The torsional angle of each patient was assessed via one objective method (fundus photography) and two subjective methods (double Maddox rod test and major amblyoscope). The patient population was divided into two groups (concordance group, n = 19 and discordance group, n = 12) according to the correspondence between the hypertropic eye (paralytic eye) and the more extorted eye (non-fixating eye), which was evaluated by fundus photography.
The mean value of objective torsion was 5.09° ± 3.84°. The subjective excyclotorsion degrees were 5.18° ± 4.11° and 3.65° ± 1.93° as measured by double Maddox rod test and major amblyoscope, respectively. Hypertropia and the excyclotorsional angle did not differ significantly between the groups (p = 0.257). Although no correlation was found in the discordance group, the concordance group showed a significant and positive correlation between hypertropia and excyclotorsion (p = 0.011).
Torsional deviation was not related to hypertropia. However, in the concordance patients in whom the hypertropic eye showed excyclotorsion, a significant positive correlation was found between hypertropia and excyclotorsion.
PMCID: PMC3550310  PMID: 23372378
Major amblyoscope; Strabismus; Noncomitantsuperior oblique palsy; Torsion
9.  Recurrent abducens nerve palsy with optic perineuritis 
PMCID: PMC3359049  PMID: 22762061
10.  Attempts to Reduce the Progression of Myopia and Spectacle Prescriptions during Childhood: A Survey of Eye Specialists 
To determine methods tried in clinical trials to reduce the progression of myopia in children, and spectacle prescribing patterns of hospital ophthalmologists.
A multi-sectioned survey composed of Likert items relating to the methods of reducing myopia progression (orthokeratology lenses [O-K lenses], undercorrected glasses, and topical atropine) and the patterns of prescribing spectacles for children (including two cases involving a 5-year-old girl and an 8-year-old boy) were distributed to members of the Korean Ophthalmological Society, and the collected data was statistically analyzed.
A total of 78 out of 130 ophthalmologists returned the survey. On a scale of 1 to 5, the mean rates of whether the ophthalmologists think O-K lenses arrest myopia progression, and whether they recommend their patients to wear O-K lenses if indicative, were 3.06 and 2.75, respectively. Moreover, the mean rates of whether they consider that wearing glasses which are undercorrected would slow down the progression of the myopia, or if they think topical atropine helps in arresting myopia progression in children, were 2.34 and 1.27, respectively. In response to the case studies, the majority of practitioners preferred to prescribe the full amount found in cycloplegic refraction to pediatric patients with myopia.
Ophthalmologists in clinical practice encouraged children to wear O-K lenses more than undercorrected glasses as a way to retard myopia progression. However, the application of atropine is rarely tried in clinical trials. In managing pediatric patients with myopia (case specific), the majority of the practitioners chose to prescribe glasses with full cycloplegic correction.
PMCID: PMC3223709  PMID: 22131779
Atropine; Eyeglasses; Myopia; Orthokeratology lenses
11.  A case of branch retinal artery obstruction complicated after anterior ischemic optic neuropathy 
To report a case of branch retinal artery obstruction (BRAO) complicated after anterior ischemic optic neuropathy (AION).
A 42 year-old woman who complained of visual disturbance was performed ophthalmological examinations such as fundus photography, fluorescent angiography (FAG) and visual field test.
At first visit, disc swelling was noted and arterial circulation was intact, however, 1 week after onset, the inferior branch retinal artery began to shrink and the flame hemorrhage intensified. Sixteen months later, the optic disc evidenced an atrophic change; additionally, a ghost vessel in the inferior branch retinal artery was found.
We report a case of complications of BRAO arising after AION which caused the mechanical compression on the arterial circulation.
PMCID: PMC3340872  PMID: 22553698
anterior ischemic optic neuropathy; branch retinal artery obstruction; complication; fluorescent angiography
12.  A case of oculomotor nerve palsy associated with antimitotic spindle apparatus 
In this case report, we describe a case of isolated oculomotor nerve palsy associated with antibodies to mitotic spindle apparatus (anti-MSA). A 28-year-old female patient had acute, painful vertical diplopia. She had limited depression and adduction in the right eye. There was no relative afferent pupillary defect. Brain magnetic resonance imaging showed no abnormal findings. Laboratory tests were all negative, with the exception of positive anti-MSA, She had an excellent and rapid response to treatment with corticosteroids, and completely recovered after two weeks of steroid pulse therapy.
PMCID: PMC3096615  PMID: 21607022
antibodies; mitotic spindle apparatus; autoimmune disease; third nerve palsy
13.  Analysis of the Causes of Optic Disc Swelling 
To investigate the clinical manifestations and diagnoses of optic disc swelling.
The medical records of 49 patients who experienced optic disc swelling between March 2008 and June 2009 were retrospectively reviewed. The characteristics of non-arteritic anterior ischemic optic neuropathy (NA-AION) and optic neuritis (ON), which showed optic disc swelling most commonly, were compared.
NA-AION was the most common disorder (34.7%) that presented with optic disc swelling. ON was identified in 15 patients (30.6%). Seven out of 49 patients (14.3%) had intracranially associated diseases, such as papilledema and compressive optic neuropathy. Pseudopapilledema was noted in four patients (8.2%). Other diseases (e.g., papillophlebitis, neuroretinitis, and diabetic papillopathy) were seen in six patients (12.2%). Ocular pain was observed more commonly in patients with ON (p = 0.001). Patients with ON expected a better visual prognosis than patients with NA-AION (0.12 ± 0.32 vs. 0.49 ± 0.35, p = 0.001).
NA-AION and ON should be considered in the differential diagnosis when patients with optic disc swelling present to the neuro-ophthalmology clinic. Detailed history taking and supportive examinations, such as visual field, color-vision and imaging tests, should also be performed as indicated. Regular follow-up of such exams is necessary for the differential diagnosis of these diseases.
PMCID: PMC3039192  PMID: 21350692
Ischemic optic neuropathy; Korea; Optic disc swelling; Optic neuritis
14.  Maculopathy Associated with Tacrolimus (FK 506) 
A 63-year-old man with a history of liver transplantation presented to our clinic complaining of visual disturbance. He had been receiving tacrolimus (FK 506) for 30 months (6 mg/day for 2 years and 3 mg/day for 6 months); he reported that the visual disturbance began while taking tacrolimus. A full ophthalmologic examination and electrophysiologic and imaging studies were performed. The best corrected visual acuity was 0.1 in both eyes. There were no abnormal finding in the anterior segment, pupillary reflexes were normal and, there was no swelling in either optic disc. Although the foveal reflex was slightly decreased, fluorescein angiography revealed non-specific signs, with the exception of a window defect. A multifocal electro-retinogram revealed decreased amplitude of the central ring. A Swedish interactive threshold algorithm-standard 10-2 visual field test revealed a central scotoma. These findings suggest that tacrolimus may result in maculopathy. Therefore, careful ophthalmologic examination is necessary in the patients taking tacrolimus.
PMCID: PMC3039201  PMID: 21350701
Maculopathy; Optic neuropathy; Tacrolimus; Transplantation; Visual field
15.  Effect of Amiloride to Retinal Toxicity Induced by Tissue Plasminogen Activator 
The effects of amiloride on cellular toxicity caused by tissue plasminogen activator (tPA) in mouse primary retinal cells were investigated.
Primary retinal cell cultures were maintained using glial conditioned medium. Commercial tPA and L-arginine were added, and the level of cyclic guanosine monophosphate (cyclic-GMP) in the culture supernatant was assessed using an ELISA assay. We measured the cell viability of cultured retinal cells pretreated with three different concentrations of amiloride (1, 10, and 100 µm) in addition to commercial tPA or L-arginine treatment.
After exposing the cultured mouse retinal cells to tPA plus L-arginine or L-arginine alone, cyclic-GMP concentrations were 61.9 ± 5.1 pmole/mL and 63.1 ± 6.1 pmole/mL, respectively. However, the control group had a significantly lower concentration of cyclic-GMP (37.2 ± 3.4 pmole/mL, p < 0.01). The cyclic GMP-dissolved solution did not cause retinal cell death. In the control group and the group treated with 1 µm amiloride and tPA containing L-arginine, the cell viability was 43.7% and 44.5%, respectively. However, cell viability increased to 70.6% with 10 µm amiloride and 78.4% with 100 µm amiloride (p = 0.015).
L-arginine increases intracellular cyclic-GMP and may give rise to retinal cells through this mechanism. In addition, amiloride in concentrations greater than 10 µm protects against L-arginine-induced retinal cell death.
PMCID: PMC3464322  PMID: 23060725
Amiloride; Arginine; Retinal toxicity; Tissue plasminogen activator
16.  Effect of fibrin glue as an adjuvant to hang-back surgery 
BMC Ophthalmology  2012;12:14.
The hang-back surgery is a useful technique in the field of strabismus surgery. The aim of this study is to determine the stabilizing effects of fibrin glue as an adjuvant to hang-back surgery.
Materials and methods
Four (4)-mm hang-back recessions of the superior rectus muscle was performed in 32 eyes of 16 rabbits. Only in the left eye of the 16 rabbits, fibrin glue was applied between the recessed muscle bed and the sclera at the end of hang-back surgery (fibrin glue group). After 6 weeks, we compared the stability of the recessed rectus muscle between the fibrin glue group and the control group by evaluating the displacement of the muscle.
The frequency of stable insertion of the recessed muscle at the intended site was greater in the fibrin glue group (9 eyes) compared to the control group (3 eyes) (p = 0.028). In the control group, 5 eyes showed anterior displacement and 8 eyes showed posterior displacement and in the fibrin glue group, 1 eye showed anterior displacement, and 6 eyes showed posterior displacement. Anterior displacement was more common in the control group (6.3% Vs 31.3%). The control group and the fibrin glue group showed similar histological findings on microscopic examination.
Fibrin glue is effective in stabilizing the new rectus muscle insertion and decreasing the displacement in the hang-back surgery.
PMCID: PMC3473302  PMID: 22677044
Fibrin glue; Hang-back surgery; Rabbit
17.  Quantitative Analysis of Optic Disc Color 
To evaluate the reproducibility of ImageJ software in analyzing the color of the optic disc.
One hundred twelve normal participants (56 males and 56 females) were enrolled in this study. The image of the optic disc was taken using Kowa digital disc photo-graphy, and the gray scales of the nasal rim (NR), brightest cupping center (BCC) and largest inferior retinal vein (IRV) were calculated using histogram in ImageJ. Three different observers calculated the gray scales three separate times. Reproducibility was assessed using the interclass correlation coefficient (ICC).
The mean age of the participants was 50.6 years old (range, 11 to 82 years). The mean gray scales of the nasal rim were 91.81, 94.91, and 93.24; those of the brightest cupping center were 174.84, 179.94, and 177.76; and those of the largest inferior retinal vein were 61.85, 53.48, and 56.73 for observers 1, 2, and 3, respectively. Inter-observer reproducibility for NR, BCC and IRV was considered good based upon ICC values of 0.944, 0.860, and 0.789 for observers 1, 2, and 3, respectively. Significant age-related differences between the values of the brightest cupping center were noted, and the gray scale score was decreased in the older participants (p < 0.001).
The gray scale of the brightest cupping center diminished with age. ImageJ can be a useful objective tool with high reproducibility in the analysis of optic disc color.
PMCID: PMC3102820  PMID: 21655042
Gray scale; ImageJ; Optic disc; Reproducibility
18.  Complete Visual Recovery after Mycotic Aneurysm Embolization Complicated by Cavernous Sinus Thrombophlebitis 
A 62-year-old woman has been suffered from cavernous sinus thrombophlebitis which was confirmed by four-vessel angiography, orbit magnetic resonance imaging, and blood culture. Three weeks after recovery of cavernous sinus thrombophlebitis, right eye proptosis and complete third, fourth, and sixth cranial nerve palsies developed. Best-corrected visual acuity decreased to 20/70 in the right eye. Repeat magnetic resonance imaging demonstrated a 1.5-cm-sized mass in the right cavernous sinus, suspicious for mycotic aneurysm. Amphotericin B supplementation was begun and was followed by successful transarterial Guglielmi detachable coil embolization. Four months later, extraocular movement was normalized, and visual acuity improved to 20/25 in the right eye.
PMCID: PMC2955279  PMID: 21052516
Cavernous sinus thrombosis; Guglielmi detachable coils embolization; Mycotic aneurysm
19.  A Case of Myotonic Dystrophy With Pigmentary Retinal Changes 
A 46-year-old man presented with visual disturbances in both eyes. His best corrected visual acuity was 0.7 (both eyes). Ptosis and limitation of ocular movement in every direction were observed. Slit lamp examination showed a bilateral iridescent cataract. Fundus examination showed peripheral depigmentation of the retinal pigment epithelium and pigmentary clumping in both eyes that agreed with blocked fluorescence and widow defects on fluorescein angiography. The amplitude of b-wave was decreased on electroretinography. Fourteen months later, the patient's best corrected visual acuity decreased to 0.3 due to increased lens opacity. Phacoemulsification and intraocular lens implantation were performed on both eyes. At the patient's final visit, retinal findings were stable with a best corrected visual acuity of 0.7 in both eyes. In conclusion, the visual disturbance could have been caused by both cataracts and retinal degeneration, meaning the fundus should be examined carefully in patients with myotonic dystrophy.
PMCID: PMC2694290  PMID: 19568364
Cataract; Myotonic dystrophy; Pigmentary retinal changes

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