Age-related macular degeneration is the leading cause of irreversible visual loss in elderly patients. After photodynamic therapy, therapy targeting vascular endothelial growth factor (VEGF) therapy has become the gold standard for treating neovascular age-related macular degeneration. Although monthly intravitreal injections of anti-VEGF agents are the most promising treatment to improve and sustain vision, as-needed treatments were administered based on the monthly examinations mainly because of costeffectiveness. However, as-needed treatments are considered reactive treatments that burden patients and doctors with required monthly examinations and potentially decrease the improved vision. To address this, the treat-and-extend regimen, a proactive treatment, has been advocated as individualized medicine. This article reviews the characteristics of currently available anti-VEGF agents and treatment strategies.

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Anterior ischemic optic neuropathy (AION) is due to optic nerve head ischemia, and there is currently no effective treatment. Age is a significant risk factor for both arteritic and nonarteritic AION (NAION), although we do not fully understand the changes that occur in aging that lead to selective vulnerability of the optic nerve head. Arteritic AION, which is most often seen in the setting of giant cell arteritis, is caused by vasculitis and thromboembolism of the ophthalmic circulation leading to impaired perfusion of the short posterior ciliary artery and infarction of the optic nerve head. More commonly, AION is nonarteritic, and vision loss is typically altitudinal and noted most commonly upon awakening. NAION has been associated with a variety of risk factors, including disc-at-risk, vascular risk factors including diabetes, vasospasm and impaired autoregulation, nocturnal hypotension, and sleep apnea. This review summarizes the clinical presentation of non-arteritic AION and arteritic AION associated with giant cell arteritis and the current and future treatment approaches for human NAION based on lessons from photochemical thrombosis models of NAION.

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A 33-year-old male patient with ipsilateral intermittent oscillopsia and blurry vision for 18 months was found to have intorsional nystagmus of the right eye, especially when gazing at the nasal lower field. The oscillations improved with exercise and were aggravated by rest. An abnormal head posture, with a tilt towards the left, and mild right superior oblique muscle paresis were noted by the prism cover test and motility examination. Neurovascular compression was not confirmed by 0.9-mm thick, high-resolution magnetic resonance imaging with fast imaging employing steady state acquisition sequence. After treatment with oxcarbazepine (600 mg/day), the oscillations resolved and there have been no complications during the 1-year follow-up period. Superior oblique myokymia is a rare form of nystagmus that may cause oscillopsia and blurry vision. Oxcarbazepine, a structural derivative of carbamazepine, can be used to successfully eliminate oscillopsia without serious adverse reaction.

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Objective: To compare the visual outcomes and central retinal thickness (CRT) 1 week, 2 weeks, and 4 weeks after surgery in diabetic patients without retinopathy and nondiabetic patients. The relationships between glycated hemoglobin (HbA1c) and visual outcomes and changes in CRT were also evaluated. Methods: Patients who underwent uncomplicated phacoemulsification cataract surgery were enrollec from May 2009 to December 2010, excluding those with preoperative retinal diseases. CRT and bestcorrected visual acuity were obtained preoperatively and at 1 week, 2 weeks, and 4 weeks. Results: There were 101 eyes in the nondiabetic group and 58 eyes in the diabetic without retinopathy group. There was no difference in preoperative CRT between the two groups. A significant increase in thickness was observed at postoperative Week 4 (p < 0.001) in both groups. However, there were no significant differences in CRT and best-corrected visual acuity before surgery and in all postoperative periods between the groups. In the diabetic without retinopathy group, CRT and visual outcomes were not statistically related to HbA1c level at any time point. Conclusion: There were no significant differences in improvements in postphacoemulsification CRT and visual outcomes between the groups. In the diabetic without retinopathy group, the visual outcomes and CRT were not related to the level of HbA1c. Therefore, as long as there is no diabetic retinopathy, the early postoperative visual recovery and central retinal thickness may not be different from patients withou diabetes mellitus.

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A 41-year-old female with a history of migraine had no previous ocular problems except myopia with spherical refraction of −2.25 D OD and −1.75 D OS. She experienced sudden onset of bilateral blurred vision, ocular fullness sensation, and headache after undergoing topiramate therapy for 7 days (50 mg/ day). Her visual acuities with the presenting glasses were 20/200 OD and 20/50 OS. Intraocular pressures (IOPs) were 44 mmHg OD and 49 mmHg OS, respectively. Autorefraction measurement showed spherical refraction of −5.25 D OD and −4.75 D OS. Best-corrected visual acuities were 20/20 for both oculus dexter (OD) and oculus sinister (OS). Slit-lamp examination revealed bilateral conjunctival chemosis, very shallow anterior chambers, forward displacement of lens–iris diaphragm, round and sluggishly reacting pupils, and closed angles on gonioscopy. A B-scan ultrasound displayed choroidal thickening in both eyes. An ultrasound biomicroscopy demonstrated bilateral 360° ciliochoroidal effusions with forward rotation of ciliary body but no pupillary block. Impression of topiramate-induced bilateral angleclosure glaucoma and acute myopic shift was recorded. She was advised to discontinue topiramate immediately and was administered antiglaucoma medication and mydriatics. Two days later, IOP returned to normal limits and myopic shift resolved after 1 week. Her visual acuity with previous glasses improved to 20/20 OU. In addition, choroidal effusions also subsided gradually. The presented case highlights the possible side effects of topiramate, offers management and suggestion for such a condition, and brings awareness to sulfa drug complications.

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This article reports a rapid response of intravitreal aflibercept for the treatment of a case of neovascular age-related macular degeneration that developed tachyphylaxis to bevacizumab and ranibizumab. An 80-year-old man with neovascular age-related macular degeneration became unresponsive to monthly treatment with bevacizumab or ranibizumab after initial responsiveness, to as-needed treatment with these antivascular endothelial growth factor drugs for 49 months. Subretinal fluid and pigment epithelial detachment had sustained in spite of 14 bevacizumab and seven ranibizumab injections prior to intravitreal aflibercept treatment. After only one injection of intravitreal aflibercept, a marked improvement was seen within 1 week. Complete drying of subretinal fluid and marked subsidence of pigment epithelial detachment were noted 4 weeks after the first aflibercept injection and sustained for three consecutive monthly injections. This case reveals that shifting to aflibercept may be an effective alternative treatment for neovascular age-related macular degeneration that becomes tachyphylactic to bevacizumab or ranibizumab.

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Purpose: To evaluate the findings of optical coherence tomography (OCT) in the acute and convalescent stages in patients with white dot syndrome. Patients were followed up at our clinic for at least 6 months. Materials and methods: A consecutive case series of patients with white dot syndrome were enrolled in this study. Only patients with disease onset less than 1 week were included in this study. Slit-lamp biomicroscopy, indirect ophthalmoscopy, fluorescein angiography, indocyanine green angiography (ICGA), OCT, visual field test, and corrected decimal visual acuity test were performed on all patients. Results: A total of eight eyes from eight patients were analyzed in this study, including cases with acute zonal occult outer retinopathy (AZOOR), punctate inner choroidopathy and AZOOR, multiple evanescent white dot syndrome, and multifocal choroiditis. In the acute stage, OCT demonstrated diffuse or segmental attenuation/loss of inner segment/outer segment (IS/OS) signal. Choroidal thickening with increased choroidal vascular porosity as compared with the fellow eyes was noted in all eyes. The ICGA showed hypofluorescence patches in the late phase. In the convalescent stage, complete or partial restoration of photoreceptor IS/OS was noted along with a partial or complete resolution of choroidal thickening and choroidal vascular porosity in OCT. The ICGA also demonstrated resolved choroidal hypofluorescence in the convalescent stage. Conclusion: Choroidal thickening and increased choroidal vascular porosity in addition to disruption of photoreceptor IS/OS were characteristic OCT features of white dot syndrome. Recovery of vision was accompanied with restoration of OCT findings in both retina and choroid.

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Background/Purpose: The goal of strabismus surgery is to align the eyes, help eliminate diplopia, and restore and/or expand binocular visual function. Adults with strabismus are subjected to psychosocial prejudices, and many patients seek strabismus correction for these reasons. Methods: A surgical audit was performed on 91 adult patients, by a singular surgeon. The type of strabismus, preoperative measurements, and indications for surgery were obtained from the patient notes, as were all final outcomes. Final measurements, on average, were taken at 16 weeks postoperatively, and patients were asked to comment subjectively on their outcome. Results: The majority of patients were seeking surgery for combined psychosocial and cosmetic reasons (78.4%), or combined psychosocial and functional indications (9.6%), whereas the remainder were seeking surgery for functional indications only. Eighty-three percent of patients reached the desired surgical outcome of <10 prism dioptres; 97.6% were satisfied or very satisfied with their surgery, with the remaining patients having a neutral standpoint, and none were dissatisfied. Conclusion: Adult strabismus surgery is highly successful and provides patients with a good level of satisfaction. Many patients seek surgical correction for cosmesis and psychosocial benefits.

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Two elderly patients with histories of myelodysplastic syndrome and idiopathic thrombocytopenic purpura both suffered from blurred vision for a long time and asked for cataract surgery. Due to their extremely low platelet counts, 5000/μL and 6000/μL, respectively, we administrated 12-unit platelet transfusions each, 2 hours to the surgery. The operations were carried out smoothly, and there were no bleeding-associated complications during these operative procedures. Both patients were satisfied with their visual improvement at postoperative 1-week follow up with visual acuity of 0.8 and 1.0, respectively, and there was no adverse event reported. From these two cases, we suggested that in patients with thrombocytopenia, phacoemulsification cataract surgery can be performed with preoperative platelet transfusion, producing favorable results without any bleeding-associated complications.

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Purpose: To investigate the long-term effects of multiple intravitreal injections on intraocular pressure (IOP) in patients with exudative age-related macular degeneration, and to determine whether this is related to a pre-existing diagnosis of glaucoma. Methods: A retrospective study was carried out on 209 eyes in 173 patients with neovascular age-related macular degeneration who received at least three intravitreal injections of bevacizumab or ranibizumab, or both, from January 2006 to December 2012 at Shin Kong Wu Ho-Su Memorial Hospital. Sequential changes in IOP following the intravitreal injections were documented and the incidence and characteristics of the patients diagnosed with glaucoma were recorded and analyzed. Results: Two hundred and nine eyes in 173 patients were included in this study. The mean number of injections was 10.1 (range 3–23). No significant change was found in IOP (p = 0.41, paired t test) and none of the patients experienced delayed ocular hypertension during the treatment course. No correlation was found between differences in IOP and the number of injections (correlation coefficient -0.086) and no significant change in IOP was found in patients with or without glaucoma (p = 0.42 and 0.37, respectively, paired t test). In addition, the use of drugs to lower IOP did not increase with repeated intravitreal injections in patients with glaucoma [single drug, 24 (63.2%) patients; two drugs 14 (36.8%) patients]. Conclusion: Repeated intravitreal antivascular endothelial growth factor injections of bevacizumab or ranibizumab, or both, did not increase the risk of increasing IOP in patients with exudative age-related macular degeneration, with or without glaucoma.

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