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양하측 수평시야결손으로 나타난 양측 후두엽 뇌경색
No full textPURPOSE: Horizontal visual field defects are generally caused by lesions before the optic chiasm, but we report a case with bilateral inferior altitudinal defects secondary to bilateral occipital lobe infarction.
CASE SUMMARY: A 57-year-old male with a history of diabetes and hypertension presented with a month of blurring in the inferior visual field. His corrected visual acuity was 1.0 in the right eye and 0.63 in the left eye, and the intraocular pressure was normal in each eye. Pupillary response, ocular movement, and color vision tests were normal in both eyes. There was no specific finding of the optic disc and macula on fundus examination. Visual field examination revealed an inferior congruous homonymous hemianopia with horizontal meridian sparing and a left incongruous homonymous quadrantanopia. Optical coherence tomography for peripapillary retinal nerve fiber layer thickness revealed a mild decrease in the inferior disc of both eyes. Brain magnetic resonance imaging confirmed the presence of an acute infarction confined with upper medial calcarine fissures of bilateral occipital lobe and the right splenium of the corpus callosum, which were consistent with inferior altitudinal hemianopia and left superior incongruous quadrantanopia, respectively. Brain magnetic resonance angiography showed multiple stenosis of bilateral posterior cerebral arteries.
CONCLUSIONS: The altitudinal visual field defects could be caused by the occipital lesion medial to the calcarine fissure, and unusual visual defects could be due to a combination of multiple lesions.목적: 수평시야결손은 일반적으로 시신경교차 이전 병변에 의해서 발생하지만, 양하측 수평시야결손으로 나타난 양측 후두엽 뇌경색을 경험하여 이를 보고하고자 한다.
증례요약: 57세 남자가 1달 전부터 아래시야 흐림을 주소로 내원하였다. 당뇨와 고혈압으로 약 복용 중이었다. 교정시력은 우안 1.0, 좌안 0.63, 안압은 정상이었다. 동공반응, 안구운동, 색각검사 결과는 양안 모두 정상이었다. 안저검사에서 시신경과 황반부에 특이소견은 관찰되지 않았다. 시야검사에서 수평경선을 침범하지 않은 양하측 반맹과 불일치성의 좌측 상사분맹이 확인되었다. 빛간섭단층촬영에서는 양안 하측 시신경유두주변 망막신경섬유층의 두께가 약간 감소되어 있었다. 뇌자기공명영상에서 급성 뇌경색이 확인된 양측 후두엽 새발톱틈새(calcarine fissure) 상내측 병변으로 양하측 반맹을, 우측 측두엽 뇌량팽대 병변으로 불일치성의 좌측 상사분맹을 설명할 수 있었다. 뇌자기공영혈관조영술에서 양측 뒤대뇌동맥에 다발성 협착이 있었다.
결론: 후두엽 뇌병변도 새발톱틈새 내측에 국한되면 수평시야결손을 보일 수 있고, 다발성 병변일 경우 시야결손이 합쳐져 비전형적인 모습으로 나타날 수 있었다
Anomalous extraocular muscles in Crouzon syndrome with V-pattern exotropia
Full text linkStrabismus associated with Crouzon syndrome is common and often complex. V-pattern strabismus is most commonly reported in this condition and is mainly thought to be due to an excyclorotation of the orbits and rectus muscle pulleys. We report two cases of children with Crouzon syndrome and V-pattern exotropia who had rectus muscle heterotopy on orbital imaging and were also found intraoperatively to have anomalous extraocular muscles. At the time of surgery, bifid insertion, misdirection, and fibrosis of extraocular muscles were noted. This highlights the various causes of V-pattern strabismus associated with Crouzon syndrome, including dysmorphic orbits and extraocular muscle anomalies
한쪽 관상봉합 두개골조기유합증 환아에서 두개골성형술 5년 후의안과적특징
No full textPurpose: To investigate ocular asymmetry status 5 years after cranioplasty in children with unilateral coronal craniosynostosis. Methods: The medical records of 41 children who underwent cranioplasty at a mean age of 11.7 months were retrospectively reviewed. The cranial vault asymmetry index (CVAI) and the amount of head tilt were measured on images obtained before cranioplasty. Presence of anisometropia, aniso-astigmatism, amblyopia, and strabismus was evaluated at a mean age of 6.8 years. Correlations among the CVAI, direction of synostotic suture and ocular asymmetries were analyzed. Results: Before cranioplasty, the CVAI was 4.5%; 31 of 41 patients (75.6%) exhibited head tilting, which was contralateral to the synostotic suture site in 29 of these patients. At a mean of 5.6 years after cranioplasty, anisometropia of ≥ 1.00 diopters on the spherical equivalent was present in 9 patients (22.0%) and aniso-astigmatism of ≥ 1.00 diopters in 10 patients (24.4%). Amblyopia was in 15 patients (36.6%); the eye contralateral to the synostotic suture was more frequently affected, and anisometropic amblyopia was the most common subtype. Strabismus was present in 28 patients (68.3%); exodeviation and vertical deviation were the most common subtypes. The non-dominant eye was the eye ipsilateral to the synostotic suture in 12 of 13 patients (92.3%) with simulated superior oblique palsy and in 7 of 10 patients (70.0%) with dissociated vertical deviation. In children with CVAI of ≥ 5%, anisometropia was significantly more common than in other children (p = 0.04), but we found no relationship between any other type of ocular asymmetry and a high CVAI. Conclusions: Ocular asymmetries including anisometropia, aniso-astigmatism, amblyopia, and strabismus were observed even 5 years after successful cranioplasty treatment for unilateral coronal craniosynostosis, emphasizing the need for continuous ophthalmic follow-up.목적: 한쪽 관상봉합 두개골조기유합증 환아에서 두개골성형술 5년 후 관찰되는 두 눈 비대칭성을 포함한 안과적 특징을 알아보고자 하였다.
대상과 방법: 평균 11.7개월에 두개골성형술을 시행받은 41명의 의무기록을 후향적으로 조사하였다. 두개골성형술 전 영상에서 두개골 비대칭률과 머리기울기를 측정하였고, 평균 6.8세에 굴절부등, 부등난시, 약시, 사시를 평가하였다. 두개골비대칭률, 유합된 관상봉합 방향과 안과적 비대칭성과의 관련성을 분석하였다.
결과: 두개골성형술 전 두개골비대칭률은 4.5%였고, 머리기울임이 31명(75.6%)에서 있었는데 29명은 유합된 관상봉합의 반대쪽으로 머리를 기울였다. 두개골성형술 5.6년 후 구면렌즈대응치 1.00디옵터 이상의 굴절부등이 9명(22.0%), 1.00디옵터 이상의 부등난시는 10명(24.4%)에서 있었다. 약시는 15명(36.6%)에서 있었고 굴절부등약시가 가장 흔하였다. 약시안은 유합된 관상봉합의 반대쪽 눈에서 더 흔하였다. 사시는 28명(68.3%)에서 있었고, 외편위와 수직편위가 가장 흔하였다. 유사상사근마비인 13명 중 12명(92.3%), 해리수직편위인 10명 중 7명(70.0%)은 유합된 관상봉합쪽 눈이 사시안이었다. 두개골비대칭률이 5% 이상인 경우 굴절부등의 빈도가 의미 있게 높았지만(p=0.04), 다른 안과적 비대칭성과는 상관관계가 없었다.
결론: 성공적인 한쪽 관상봉합 두개골조기유합증 수술 후 5년이 경과하여도 굴절부등, 부등난시, 약시, 사시와 같은 두 눈 비대칭이 흔히 관찰될 수 있으므로 지속적인 안과 경과 관찰이 반드시 필요하다
국내 학대뇌손상 환아의 안과 소견: 2011-2022년 단일권역외상센터 자료
Full text linkPurpose: To investigate the ophthalmic findings associated with abusive head trauma (AHT) at a major trauma center in Korea. Methods: We retrospectively reviewed the medical records of 14 children with AHT referred for an ophthalmologic examination at a large regional trauma center from January 2011 to December 2022. We analyzed pertinent findings for AHT and its sequelae on brain computed tomography, skeletal surveys obtained using X-ray, external photographs, and fundus photographs taken with a portable fundus camera. Results: Among 14 patients (mean age, 7.4 months) with subdural hematoma from AHT, nine (64.3%) had retinal hemorrhages. Eight of these patients (88.9%) required neurosurgery, while only one child (20.0%) among the five without retinal hemorrhages needed drainage for brain hemorrhages. All patients with retinal hemorrhages (mean age, 6.0 months) presented with numerous multilayered hemorrhages across the entire retina including dome-shaped hemorrhages (six patients), perimacular ridges (one patient), and retinal hemorrhages at different stages of healing (one patient). The retinal hemorrhages resolved within an average of 2.4 months without necessitating retinal surgery. In five patients followed for an average of 28.2 months, there were instances of optic disc pallor in three, cortical visual impairment in one, and fovea scarring in one. Conclusions: More than half of the Korean children with AHT had extensive retinal hemorrhages leading to ophthalmic sequelae in the majority. These findings support the need for long-term active ophthalmic follow-up in AHT cases.목적: 국내 단일권역외상센터에서 학대뇌손상으로 확인된 환아의 안과 소견을 알아보고자 하였다.
대상과 방법: 2011년 1월부터 2022년 12월까지 본원 권역외상센터에서 학대뇌손상으로 확인되어 안과로 의뢰된 환아 14명의 의무기록을 후향적으로 조사하였다. 뇌 전산화단층촬영, X선 골격촬영, 정면사진, 휴대용 안저카메라를 이용한 안저촬영에서 학대뇌손상과 관련된 소견과 그 후유증을 조사하였다.
결과: 평균 7.4개월에 학대뇌손상으로 인한 경막하출혈이 있었던 14명 가운데 망막출혈은 9명(64.3%)에서 관찰되었다. 이 가운데 8명(88.9%)이 신경외과수술을 하였으나, 망막출혈이 없었던 5명 가운데 1명(20.0%)만 뇌출혈 배액술을 받았다. 망막출혈이 있었던 환아는 평균 6.0개월이었고, 모두 두 눈에서 광범위하게 망막의 여러 층에서 다량의 출혈이 있었으며 돔모양 망막출혈(6명), 황반부 주변 융기된 망막주름(1명), 발생 시기가 다른 망막출혈이 동시에 관찰되는 경우(1명)가 있었다. 망막출혈은 평균 2.4개월 후 모두 흡수되어 망막수술이 필요하지 않았다. 평균 28.2개월 경과 관찰한 5명에서 시신경유두창백 3명, 피질시각장애 1명, 황반부 망막흉터 1명이 관찰되었다.
결론: 국내 학대뇌손상 환아에서도 광범위한 망막출혈이 절반 이상에서 관찰되었고, 대부분 안과적 후유증이 남았다. 학대뇌손상에서 장기적이고 적극적인 안과 경과 관찰이 필요하겠다
스마트폰을 이용한 정량적 견인회선검사
No full textPurpose: To evaluate the utility of a quantitative forced cyclorotation test using a smartphone in patients with unilateral superior oblique palsy. Methods: Twenty-nine patients who underwent muscle surgery for superior oblique palsy were included. With patients under anesthesia prior to surgery, the 12 and 6 o’clock positions of the limbus were marked, the globe was maximally excyclorotated and incyclorotated, and photographs of the globe were taken in each position. The maximum angle of rotation was read by two masked observers using two different smartphone applications. Maximum excyclorotation and incyclorotation were compared between patients with superior oblique palsy alone and patients with both superior oblique palsy and intermittent exotropia; associations were evaluated regarding age at surgery, angle of hypertropia, and cyclotorsion on fundus photographs. Results: The intraclass correlation coefficient between the two readers was 0.989. The maximum excyclorotation of affected eyes was significantly greater than that of the fellow eyes (46.1 ± 9.9° vs. 41.7 ± 7.6°; p = 0.040). Maximum incyclorotation did not differ between the two eyes. The maximum excyclorotation of affected eyes of 18 patients with unilateral superior oblique palsy alone was significantly greater than that of the fellow eyes (47.0 ± 9.5° vs. 39.4 ± 6.3°; p = 0.010). The maximum excyclorotation of affected eyes of 11 patients with both superior oblique palsy and intermittent exotropia was similar to that of the fellow eyes (44.5 ± 10.9° vs. 45.5 ± 8.3°). Maximum incyclorotation did not differ according to group or eye. Maximum excyclorotation did not differ according to age at surgery, angle of hypertropia, or cyclotorsion on fundus photographs. Conclusions: New forced cyclorotation tests using a smartphone quantitatively assess the passive range of cyclorotation, and detect bilateral differences, particularly in patients with unilateral superior oblique palsy alone. © 2020 Korean Ophthalmological Society (KOS). All rights reserved
간헐외사시 수술력이 있는 환아에서 저농도 아트로핀의 근시진행 억제 효과
Full text linkРurроsе: To evaluate the effect of low-dose atropine on myopia control in children with a history of surgery for intermittent exotropia (IХT). Меthоds: We retrospectively reviewed the medical records of children who used 0.05% atropine for ≥ 1 year to control myopia progression. This group included 45 patients with a history of IХT surgery and 57 patients with no such history. The annual changes in spherical equivalent and axial length were compared 6 months before, 6 months after, and 1 year after atropine instillation between the IХT surgery group and myopia controls. In this comparison, the dominant eye was paired with the right eye and the non-dominant eye with the left eye. We also analyzed the difference between IХT surgery cases corrected within versus not within 10 prism diopters (PD) at the start of low-dose atropine treatment. Rеsults: A total of 102 patients had an average of -3.81 ± 1.53 diopters (D) and used low-dose atropine for an average of 16.8 months from a mean age of 8.2 years. On average, the IХT surgery group underwent muscle surgery for 28.1 PD of IХT at 7.8 years. A year after instillation, the myopia progression rate was -0.52 ± 0.89 D/year and 0.27 ± 0.40 mm/year in the IХT surgery group compared to -0.47 ± 0.83 D/year and 0.31 ± 0.24 mm/year in the myopia control group with no significant differences. However, after 6 months of instillation, the dominant eye in the IХT surgery group exhibited a significantly faster myopia progression rate than the right eye in the myopia control group (-0.84 ± 1.61 D/year vs. -0.56 ± 0.80 D/year, p = 0.04; 0.27 ± 0.33 mm/year vs. 0.22 ± 0.21 mm/year, p = 0.02). No difference was found in the myopia control effect between corrected and uncorrected cases in the IХT surgery group. Cоnсlusіоns: The effect of low-dose atropine on myopia control in children after IХT surgery was similar to that in myopia controls. However, it was less effective in the dominant eye during the early treatment period.목적: 간헐외사시 수술력이 있는 근시 환아에서 저농도 아트로핀의 근시진행 억제 효과에 대해 알아보고자 하였다.
대상과 방법: 아트로핀 0.05%를 1년 이상 점안한 근시 환아 중 간헐외사시 수술력이 있는 45명과 없는 57명의 의무기록을 후향적으로 조사하였다. 점안 전후 6개월, 1년에 측정한 구면렌즈대응치와 안구 길이의 연간 변화량을 간헐외사시 수술군의 우세안과 근시대조군의 우안, 비우세안과 좌안을 짝지어 비교하였다. 간헐외사시 수술군에서는 점안 시작 무렵 10프리즘디옵터(prism diopters, PD) 이내로 교정된 군과 안된 군의 차이도 분석하였다.
결과: 평균 -3.81 ± 1.53디옵터(diopters, D)인 102명은 평균 8.2세부터 16.8개월 동안 저농도 아트로핀을 점안하였다. 간헐외사시 수술군은 평균 7.8세에 28.1 PD의 외편위로 수술받았다. 간헐외사시 수술군은 점안 1년 후 -0.52 ± 0.89 D/year, 0.27 ± 0.40 mm/year, 근시대조군은 -0.47 ± 0.83 D/year, 0.31 ± 0.24 mm/year의 근시진행률을 보여 의미 있는 차이는 없었다. 다만, 점안 6개월 후 간헐외사시 수술군의 우세안은 -0.84 ± 1.61 D/year, 0.27 ± 0.33 mm/year, 근시대조군의 우안은 -0.56 ± 0.80 D/year, 0.22 ± 0.21 mm/year의 근시진행률을 보여 간헐외사시 수술군이 의미 있게 근시진행이 빨랐다(각각 p=0.04, p=0.02). 간헐외사시 교정군과 비교정군 간 억제 효과 차이는 없었다.
결론: 간헐외사시 수술력이 있어도 저농도 아트로핀의 근시진행 억제 효과는 유사하였지만, 점안 초기 우세안에서는 억제 효과가 적었다
Binocular discrepancy in lateral rectus muscle attachment in intermittent exotropia with eye dominance
No full textPURPOSE: To determine whether there is asymmetry in the lateral rectus (LR) muscle attachment between both eyes in patients with intermittent exotropia (IXT) with a non-dominant eye, but without amblyopia or anisometropia.
METHODS: In total, 109 patients who underwent bilateral lateral rectus recession for IXT were included, 81 with and 28 without eye dominance. The limbus-insertion distance and tendon width of the LR muscle were measured intraoperatively using callipers. The insertion-equator distance (presumed arc of contact), area of contact (arc of contact × tendon width), and torque value (radius of globe × arc of contact) of the LR muscle were calculated based on intraoperative measurements and axial length measured using a partial interferometer. Parameters regarding LR muscle attachment were compared between fellow eyes and between groups.
RESULTS: Mean measurements in all parameters related to LR muscle attachments other than tendon width were not different between the two eyes or between groups. The mean tendon width of the non-dominant eye was 9.2 ± 0.7 mm, narrower than the 9.4 ± 0.5 mm width in either eye of patients without dominance (p = 0.020). However, there was no difference in all parameters in 21 pairs of patients after matching. The proportion of patients who showed binocular discrepancies in attachment measurements beyond that attributable to potential measuring errors did not differ between the two groups.
CONCLUSIONS: Structural parameters related to LR muscle attachments did not differ based on eye dominance, suggesting that the anatomic structure of LR muscle attachments is not responsible for eye dominance in IXT
Range of forced cyclorotation in superior oblique palsy and V-pattern strabismus
No full textPURPOSE: To quantify a passive range of cyclorotation using a smartphone application and evaluate its associations with fundus torsion and rectus muscle cyclorotation in superior oblique palsy (SOP) and V-pattern strabismus.
METHODS: Fifty-two patients showing overelevation in adduction (30 with congenital SOP and 22 with V-pattern strabismus) underwent forced cyclorotation on the photographs. A photograph of the globe was taken in maximally excyclorotated and incyclorotated positions after marking at the 6 and 12 o'clock limbus under general anaesthesia, and the rotational alignment of these markings was read using the toriCAM application. The degrees of forced cyclorotation were compared between the two groups. Disc-fovea angle on fundus photographs and rectus muscle cyclorotation in the coronal view on orbital computed tomography were correlated with the range of forced excyclorotation.
RESULTS: The range of forced excyclorotation was greater in V-pattern strabismus than that in SOP (58.5° vs. 46.8°, p < 0.001), whereas the ranges of incyclorotation were similar between the two groups (39.0° vs. 39.0°, p = 0.543). Regression analysis revealed a significant increase in the range of excyclorotation with the degree of rectus muscle excyclorotation, after accounting for age and angle of hypertropia (r2 = 0.475, p = 0.001). The range of excyclorotation did not correlate with the amount of fundus extorsion and grade of overelevation in adduction.
CONCLUSIONS: The range of excyclorotation was correlated with the rectus muscle excyclorotation in these populations, suggesting that the results from this forced cyclorotation test may reflect orbital alignment and oblique muscle status
반복적인 시신경 침범으로 재발한 급성백혈병
No full textPurpose: To report two cases with recurrent involvement of the optic nerve as the initial sign of acute leukemic relapse. Case summary: An 8-year-old male with acute lymphoblastic leukemia on the maintenance chemotherapy was referred for a decrease in visual acuity in the right eye. The visual acuity and optic disc swelling were completely resolved with high-dose steroid therapy. Two months after the initial presentation, the symptoms recurred and brain/orbit magnetic resonance imaging (MRI) showed high intensity along the right optic nerve from the retrobulbar area to the optic chiasm. The visual acuity was restored after high-dose steroid therapy. One month after the second attack, the symptoms recurred and the cerebrospinal fluid cytology was positive for lymphoblasts. Three weeks after the intrathecal chemotherapy, the visual acuity improved fully, but optic disc atrophy developed. A 45-year-old male, who received allogenic peripheral blood stem cell transplantation for acute myeloid leukemia, presented with a decrease in visual acuity in the left eye. The left optic disc swelling improved with high-dose steroid therapy, but the medication was restarted due to the recurrence of symptoms 3 weeks later. Brain MRI showed a mass lesion compressing the left optic nerve, presumed to be a myeloid sarcoma. One month after local irradiation, the visual acuity was no light perception in the left eye. Conclusions: In patients with a prior history of acute leukemia, the recurrent involvement of the optic nerve should be considered as a central nerve system relapse, regardless of improvement with steroid treatment. © 2020 The Korean Ophthalmological Societ
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