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X-linked juvenile retinoschisis (XLRS) is an inherited retinal disease caused by mutations in the RS1 gene, resulting in splitting of the retinal layers and visual disturbances. To provide insights on this disease in our cohort, genetic examination, clinical presentation, and functional analysis were performed. We observed three main RS1 mutations in our cohort of six unrelated patients: RS1-D126G, RS1-R209H, and RS1-R213W. The RS1-D126G mutation, exclusively reported in Thai patients so far, showed the highest prevalence. Phenotypically, the D126G mutation manifested early (0.3-4 years old), presenting as asymmetrical visual acuity and schisis. Functional analysis revealed that the molecular pathomechanism of D126G was the failure of protein secretion attributable to endoplasmic reticulum retention. The understanding of the genotype-phenotype relationship and the pathomechanisms of specific mutations in a particular population could immensely benefit the pipeline of personalised treatment design for XLRS., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Alzheimer's disease is a type of neurodegenerative disorder that is characterized by the progressive degeneration of brain cells, leading to cognitive decline and memory loss. It is the most common cause of dementia and affects millions of people worldwide. While there is currently no cure for Alzheimer's disease, early detection and treatment can help to slow the progression of symptoms and improve quality of life. This research presents a diagnostic tool for classifying mild cognitive impairment and Alzheimer's diseases using feature-based machine learning applied to optical coherence tomographic angiography images (OCT-A). Several features are extracted from the OCT-A image, including vessel density in five sectors, the area of the foveal avascular zone, retinal thickness, and novel features based on the histogram of the range-filtered OCT-A image. To ensure effectiveness for a diverse population, a large local database for our study was collected. The promising results of our study, with the best accuracy of 92.17,% will provide an efficient diagnostic tool for early detection of Alzheimer's disease.

Mutations in the eyes shut homolog (EYS) gene are one of the common causes of autosomal recessive retinitis pigmentosa (RP). The lack of suitable animal models hampers progress understanding of the disease mechanism and drug development. This study reported the reprogramming of CD34+ hematopoietic stem/progenitor cells from a patient with compound heterozygous EYS mutations (c.6416 G > A and c.7228 + 1 G > A) into the induced pluripotent stem cell line, MUi038-A, using non-integrating vectors. The MUi038-A demonstrates pluripotency, tri-lineage differentiation potential, and a normal karyotype, offering a valuable model for studying the mechanism of EYS-related RP and new therapeutic development., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: La-Ongsri Atchaneeyasakul reports financial support was provided by the Faculty of Medicine, Siriraj Hospital, Mahidol University (Grant RO16534006). La-Ongsri Atchaneeyasakul reports financial support was provided by Siriraj Foundation (D1671). La-Ongsri Atchaneeyasakul reports financial support was provided by Chuan Ratanarak Foundation. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: We present a patient with retinopathy of prematurity (ROP) who developed worsening plus disease after complete regression of stage 3 ROP. The use of fundus fluorescein angiography (FFA) aided the visualization of occult neovascularization that caused the disease progression., Case Presentation: The patient was at high risk for ROP due to low birth weight of 690 g and gestational age of 25 weeks. After the diagnosis of stage 3 ROP in zone I without plus disease, she was treated initially with bilateral intravitreal bevacizumab (IVB) and followed by laser photocoagulation 5 weeks later. Despite the resolution of ROP stage, the plus disease worsened. Neither systemic risk factors nor skip laser areas were observed. Hence, FFA was performed and subsequently identified occult neovascularization with active leakage. Additional IVB and laser treatment in the capillary dropout area inside vascularized retina were added. The plus disease improved but mild arteriolar tortuosity persisted., Conclusions: Worsening of plus disease after completion of laser ablation and IVB with complete regression of stage 3 ROP is rare. Systemic risk factors such as continuous oxygen therapy and cardiovascular disease should be ruled out. FFA aided in identifying occult neovascularization and prompted further treatment., (© 2024. The Author(s).)

Purpose: To develop prediction models for severe retinopathy of prematurity (ROP) based on risk factors in preterm Thai infants to reduce unnecessary eye examinations in low-risk infants., Methods: This retrospective cohort study included preterm infants screened for ROP in a tertiary hospital in Bangkok, Thailand, between September 2009 and December 2020. A predictive score model and a risk factor-based algorithm were developed based on the risk factors identified by a multivariate logistic regression analysis. Validity scores, and corresponding 95% confidence intervals (CIs), were reported., Results: The mean gestational age and birth weight (standard deviation) of 845 enrolled infants were 30.3 (2.6) weeks and 1264.9 (398.1) g, respectively. The prevalence of ROP was 26.2%. Independent risk factors across models included gestational age, birth weight, no antenatal steroid use, postnatal steroid use, duration of oxygen supplementation, and weight gain during the first 4 weeks of life. The predictive score had a sensitivity (95% CI) of 92.2% (83.0, 96.6), negative predictive value (NPV) of 99.2% (98.1, 99.6), and negative likelihood ratio (NLR) of 0.1. The risk factor-based algorithm revealed a sensitivity of 100% (94, 100), NPV of 100% (99, 100), and NLR of 0. Similar validity was observed when "any oxygen supplementation" replaced "duration of oxygen supplementation." Predictive score, unmodified, and modified algorithms reduced eye examinations by 71%, 43%, and 16%, respectively., Conclusions: Our risk factor-based algorithm offered an efficient approach to reducing unnecessary eye examinations while maintaining the safety of infants at risk of severe ROP. Prospective validation of the model is required., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: To validate Postnatal Growth and Retinopathy of Prematurity (G-ROP) criteria for Thai infants., Study Design: A retrospective review of infants receiving ROP screening during 2009-2020., Methods: Baseline characteristics, clinical progression and final ROP outcomes were collected. G-ROP was applied to infants who met at least one of the following 6 criteria: birth weight (BW) below 1051 g, gestational age (GA) under 28 weeks, weight gain (WG) less than 120 g during postnatal day 10-19, WG less than 180 g during day 20-29, WG less than 170 g during day 30-39 and hydrocephalus., Results: A total of 684 infants (boys, 53.4%) were included. Median (IQR) BW was 1200 (960-1470) grams and median GA was 30 (28-32) weeks. Prevalence of ROP was 26.6%, with 28 (4.1%) having type 1, 19 (2.8%) type 2 and, 135 (19.7%) having other ROP. Treatment was performed in 26 infants (3.8%). Sensitivity of G-ROP to include type 1, 2 or treatment-requiring ROP cases was 100% with 36.9% specificity, excluding 235 (34.4%) cases of unnecessary screening. To adjust for our setting of initial eye examination at 4 weeks' postnatal date, the last 2 criteria of G-ROP were replaced by the occurrence of grade 3 or 4 intraventricular hemorrhage (IVH). This modified G-ROP criteria yielded 100% sensitivity, 42.5% specificity and excluded 271 (39.6%) cases of unnecessary screening., Conclusion: G-ROP criteria can be applied to our hospital setting. Occurrence of IVH grade 3 or 4 was proposed as an alternative in modified G-ROP criteria., (© 2023. Japanese Ophthalmological Society.)

Retinitis pigmentosa (RP) affects 1:5000 individuals worldwide. Interestingly, variations in 271 RP-related genes are indicated to vary among populations. We aimed to evaluate the genetic prevalence and phenotypic profiles of Thai patients with RP. The clinical and whole exome sequencing data of 125 patients suggestive of inherited retinal diseases (IRD), particularly non-syndromic RP, were assessed. We found a total of 258 variants (63% of which remained unavailable in the ClinVar database) in 91 IRD-associated genes. Among the detected genes, the eyes shut homolog (EYS) gene showed the highest prevalence. We also provide insights into the genotypic, baseline, and follow-up clinical presentations of seven patients with disease-causing EYS variations. This study could provide comprehension of the prevalence of RP-related genes involved in the Asian population. It might also provide information to establish advanced and personalised therapy for RP in the Thai population., (© 2022. The Author(s).)

Choroideremia (CHM) is a monogenic, X-linked inherited retinal disease caused by mutations in the CHM gene. CHM patients develop progressive loss of vision due to degeneration of cell layers in the retina. In this report, the human-induced pluripotent stem cell, MUi032-A, was generated from CD34+ hematopoietic stem/progenitor cells of a male CHM patient by co-electroporation of non-integration episomal vectors containing OCT4/shp53, Sox-2/KLF4, and L-MYC/LIN-28. The MUi032-A showed normal karyotype and a hemizygous c.715C > T mutation. They expressed pluripotency markers and differentiated into cells derived from three germ layers. This cell line may be useful for disease mechanisms and gene therapy studies., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To study the effect of additional training with ophthalmic surgical simulation on the intraoperative complication rates of phacoemulsification performed by residents., Methods and Materials: This was a retrospective study of phacoemulsification surgeries performed by third-year residents at Siriraj Hospital. The operations were classified into two groups according to the experience of the surgeon in simulation training, that is, trained vs untrained. The main outcome was the total rate of complications. Other outcomes, including posterior capsule rupture, anterior capsulorhexis tearing, zonular dehiscence, retaining of lens material and intraocular lens (IOL) implantation methods, were also analysed., Results: In total, 2971 operations were performed, comprising 1656 operations by 21 residents in the trained group, and 1315 by 20 residents in the untrained group. The total rate of complications in the simulator-trained group was lower than in the untrained group (13.6% vs 17.3%, p=0.005). Only the rate of retaining lens material showed a statistically significantly reduction (p<0.001); however, the rates of posterior capsule rupture, anterior capsulorhexis tearing and zonular dehiscence were not significantly different (p=0.08, 0.17, 0.23, respectively). The IOL implantation methods and surgical aphakia rate between the two groups were similar (p=0.44). In the subgroup analysis, the posterior capsule rupture rate in the first half of all cases performed by the residents was lower in the trained group (8.8% vs 12.4%, p=0.02)., Conclusion: Ophthalmic simulation training reduces the total rate of complications of resident-performed phacoemulsification. It also shortens the learning curve for cataract surgery training, as indicated by the decreased posterior capsule rupture rate in the initial cases of cataract surgery., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate the clinical performance of an automated diabetic retinopathy (DR) screening model to detect referable cases at Siriraj Hospital, Bangkok, Thailand., Methods: A retrospective review of two sets of fundus photographs (Eidon and Nidek) was undertaken. The images were classified by DR staging prior to the development of a DR screening model. In a prospective cross-sectional enrollment of patients with diabetes, automated detection of referable DR was compared with the results of the gold standard, a dilated fundus examination., Results: The study analyzed 2533 Nidek fundus images and 1989 Eidon images. The sensitivities calculated for the Nidek and Eidon images were 0.93 and 0.88 and the specificities were 0.91 and 0.85, respectively. In a clinical verification phase using 982 Nidek and 674 Eidon photographs, the calculated sensitivities and specificities were 0.86 and 0.92 for Nidek along with 0.92 and 0.84 for Eidon, respectively. The 60°-field images from the Eidon yielded a more desirable performance in differentiating referable DR than did the corresponding images from the Nidek., Conclusions: A conventional fundus examination requires intense healthcare resources. It is time consuming and possibly leads to unavoidable human errors. The deep learning algorithm for the detection of referable DR exhibited a favorable performance and is a promising alternative for DR screening. However, variations in the color and pixels of photographs can cause differences in sensitivity and specificity. The image angle and poor quality of fundus photographs were the main limitations of the automated method., Translational Relevance: The deep learning algorithm, developed from basic research of image processing, was applied to detect referable DR in a real-word clinical care setting.

X-linked retinitis pigmentosa (XLRP), a rare form of retinitis pigmentosa (RP), is predominantly caused by mutations in the retinitis pigmentosa GTPase regulator ( RPGR ) gene. Affected males often present with severe phenotypes and early disease onset. In contrast, female carriers are usually asymptomatic or show stationary phenotypes. Herein, we reported an 8-year-old female carrier, a daughter of a confirmed RP father with RPGR mutation, with an early onset of progressive cone-rod pattern retinal dystrophy. Additionally, the carrier experienced visual snow-like symptom as long as she recalled. Ophthalmological examination showed the reduction of visual acuity and attenuation of photoreceptor functions since the age of 5 years. Further analysis revealed a heterozygous pathogenic variant of the RPGR gene and a random X-inactivation pattern. Although she harboured an identical RPGR variant as the father, there were phenotypic intrafamilial variations. The information on the variety of genotypic and phenotypic presentations in XLRP carriers is essential for further diagnosis, management, and monitoring of these cases, including the design of future gene therapy trials., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Tuekprakhon, Pawestri, Suvannaboon, Thongyou, Trinavarat and Atchaneeyasakul.)

Autoimmune retinopathy (AIR) is a rare immune-mediated inflammation of the retina. The autoantibodies against retinal proteins and glycolytic enzymes were reported to be involved in the pathogenesis. This retrospective cohort study assessed the antiretinal autoantibody profiles and their association with clinical outcomes of AIR patients in Thailand. We included 44 patients, 75% were females, with the overall median age of onset of 48 (17-74, IQR 40-55.5) years. Common clinical presentations were nyctalopia (65.9%), blurred vision (52.3%), constricted visual field (43.2%), and nonrecordable electroretinography (65.9%). Underlying malignancy and autoimmune diseases were found in 2 and 12 female patients, respectively. We found 41 autoantibodies, with anti-α-enolase (65.9%) showing the highest prevalence, followed by anti-CAII (43.2%), anti-aldolase (40.9%), and anti-GAPDH (36.4%). Anti-aldolase was associated with male gender (P = 0.012, OR 7.11, 95% CI 1.54-32.91). Anti-CAII showed significant association with age of onset (P = 0.025, 95% CI - 17.28 to - 1.24), while anti-α-enolase (P = 0.002, OR 4.37, 95% CI 1.83-10.37) and anti-GAPDH (P = 0.001, OR 1.87, 95% CI 1.32-2.64) were significantly associated with nonrecordable electroretinography. Association between the antibody profiles and clinical outcomes may be used to direct and adjust the treatment plans and provide insights in the pathogenesis of AIR., (© 2021. The Author(s).)

Background: Retinitis pigmentosa (RP) is a progressive inherited retinal disease with great interest for finding effective treatment modalities. Stem cell-based therapy is one of the promising candidates. We aimed to investigate the safety, feasibility, and short-term efficacy of intravitreal injection of bone marrow-derived mesenchymal stem cells (BM-MSCs) in participants with advanced stage RP., Methods: This non-randomized phase I clinical trial enrolled 14 participants, categorized into three groups based on a single dose intravitreal BM-MSC injection of 1 × 10 6 , 5 × 10 6 , or 1 × 10 7 cells. We evaluated signs of inflammation and other adverse events (AEs). We also assessed the best corrected visual acuity (BCVA), visual field (VF), central subfield thickness (CST), and subjective experiences., Results: During the 12-month period, we noticed several mild and transient AEs. Interestingly, we found statistically significant improvements in the BCVA compared to baseline, although they returned to the baseline at 12 months. The VF and CST were stable, indicating no remarkable disease progression. We followed 12 participants beyond the study period, ranging from 1.5 to 7 years, and observed one severe but manageable AE at year 3., Conclusion: Intravitreal injection of BM-MSCs appears to be safe and potentially effective. All adverse events during the 12-month period required observation without any intervention. For the long-term follow-up, only one participant needed surgical treatment for a serious adverse event and the vision was restored. An enrollment of larger number of participants with less advanced RP and long-term follow-up is required to evaluate the safety and efficacy of this intervention., Trial Registration: ClinicalTrials.gov, NCT01531348 . Registered on February 10, 2012.

Purpose: Achromatopsia (ACHM) is an autosomal recessive cone disorder characterized by pendular nystagmus, photophobia, reduced visual acuity, and partial or total absence of color vision. Mutations in six genes (CNGA3, CNGB3, GNAT2, PDE6C, PDE6H, and ATF6) have been reported in ACHM. There is no information on these disease-associated genes in Thai population. This study aimed to investigate the molecular and clinical characteristics in Thai patients with ACHM., Methods: Seven unrelated Thai patients with ACHM were recruited. Detailed ophthalmologic examination was performed. Polymerase chain reaction (PCR)-coupled single-strand conformation polymorphism (SSCP) screening followed by Sanger sequencing was used to identify sequence variants in all exons and splice junctions of three genes (CNGA3, CNGB3, and GNAT2). The pathogenicity of the detected variants was interpreted. Segregation analysis was performed to determine variant sharing in available family members., Results: Four patients displayed different SSCP migration patterns. Sequence analysis revealed a reported pathogenic and a novel disease-associated variant in the CNGA3 gene. For the CNGB3 gene, we found two novel disease-associated variants and a reported variant of uncertain significance (VUS). Segregation analysis confirmed that the variants identified in each patient were present in the heterozygous state in their corresponding family members, which was consistent with an autosomal recessive mode of inheritance., Conclusions: This study demonstrated the first molecular and clinical characterization of ACHM in Thai patients. The identification of disease-associated genes in a specific population leads to a personalized gene therapy benefiting those affected patients.

Purpose: Our goal was to describe the clinical and molecular genetic findings in Thai patients with Leber congenital amaurosis (LCA)., Methods: Whole exome sequencing (WES) was performed in eight unrelated patients. All genes responsible for inherited retinal diseases (IRDs) based on RetNet were selected for analysis. Potentially causative variants were filtered through a bioinformatics pipeline and validated using Sanger sequencing. Segregation analysis of the causative genes was performed in family members when available., Results: Eleven deleterious variants, six nonsense and five missense, were identified in seven genes: four LCA-associated genes (CEP290, IQCB1, NMNAT1, and RPGRIP1), one gene responsible for syndromic LCA (ALMS1), and two IRDs-related genes (CTNNA1 and CYP4V2). Clinical reassessment supported the diagnosis of syndromic LCA in those patients harboring potentially pathogenic variants in the ALMS1. Interestingly, two causative genes, CTNNA1 and CYP4V2, previously reported to cause butterfly-shaped pigment dystrophy (BSPD) and Bietti's crystalline dystrophy (BCD), respectively, were detected in two other patients. These two patients developed rapid and severe visual loss in contrast to BSPD and BCD patients in previous studies. The results of this study demonstrate that causative variants identified in the CTNNA1 and CYP4V2 genes are also associated with LCA., Conclusions: This is the first report describing the molecular genetics and clinical manifestations of Thai patients with LCA. The present study expands the spectrum of LCA-associated genes, which is a benefit for molecular diagnosis. The identification of mutations in the CTNNA1 and CYP4V2 genes requires further elucidation in larger cohorts with LCA.

Objective: To examine subfoveal choroidal thickness (SFCT) in Thai population using enhanced depth imaging spectral- domain optical coherence tomography (EDI-OCT) and to study its correlation with foveal retinal pigment epithelium thickness (FRPE), central neurosensory retinal thickness (CNRT), age, and refraction., Material and Method: Four hundred eighty eyes from 240 subjects without glaucoma, retinal, or choroidal diseases underwent scanning of the retina and choroid using EDI-OCT SFCT FRPE, and CNRT measurements were based on the 1:1 micron images and wereperformed by two independent observers. The reliability ofmeasurements between the observers was evaluated by intraclass correlation coefficient (ICC). The correlations of SFCT with FRPE, CNRT, age, and refractive error were analyzed, Results: The mean age of the subjects was 36.22 years (range 20-81years). The means (95% reference intervals) of SFCT, CNRT andFRPE were 294.02 μm (137.14-450.90 μm), 174.22 μm (141.82-206.62 μm), and 41.94 μm (34.65-49.23 μm), respectively. SFCT and CNRThad excellent reliability between the two observers [ICC = 0.947 (95% CI, 0.918-0.963) and 0.929 (95% CI, 0.906-0.945), respectively], while FRPE showed good reliability [ICC = 0. 729 (95% CI, 0.637-0.793)]. SFCT had a low positive correlation with FRPE (r = 0.179, p<0. 0001) but not with CNRT (p = 0.317). SFCT showed a positive correlation with refraction (r = 0.338, p<0.0001) and a negative correlation with age (r = -0.166, p<0.0001). Regression analysis suggested that the SFCT decreased by 12.23 pm per one decade oflife and by 11.42 pm per one diopter of myopia., Conclusion: Normal values of SFCT in Thai population were obtained SFCT significantly decreased with older age and higher myopia. SFCT was associated with FRPE, reflecting the same vascular supply of the choroid and retinal pigment epithelium. When measured with our technique based on the 1:1 micron images, the reliability ofSFCT measurement was very high despite highly morphologic inter-individual variations.

Purpose: To identify disease-causing mutations and describe genotype-phenotype correlations in Thai patients with nonsyndromic retinitis pigmentosa (RP)., Methods: Whole exome sequencing was performed in 20 unrelated patients. Eighty-six genes associated with RP, Leber congenital amaurosis, and cone-rod dystrophy were analyzed for variant detection., Results: Seventeen variants (13 novel and 4 known) in 13 genes were identified in 11 patients. These variants include 10 missense substitutions, 2 nonsense mutations, 3 deletions, 1 insertion, and 1 splice site change. Nine patients with identified inheritance patterns carried a total of 10 potentially pathogenic mutations located in genes CRB1, C8orf37, EYS, PROM1, RP2, and USH2A. Three of the nine patients also demonstrated additional heterozygous variants in genes ABCA4, GUCY2D, RD3, ROM1, and TULP1. In addition, two patients carried variants of uncertain significance in genes FSCN2 and NR2E3. The RP phenotypes of our patients were consistent with previous reports., Conclusions: This is the first report of mutations in Thai RP patients. These findings are useful for genotype-phenotype comparisons among different ethnic groups.

Objective: To study the prevalence of optic atrophy in patients with proliferative diabetic retinopathy (PDR) who underwent intravitreal bevacizumab injection and risk factors associated with optic atrophy., Material and Method: A retrospective case control study enrolled 269 cases (394 eyes) of patients with PDR, in which 166 cases (219 eyes) received intravitreal bevacizumab injection. Associated factors such as type of DM, hemoglobin A1c level, hypertension, hypercholesterolemia, chronic kidney disease, previous intravitreal surgery retinal detachment, and vitreous hemorrhage were recorded. Criteria for diagnosis of optic atrophy were decreased visual acuity, pale optic disc and decreased nerve fiber layer thickness, which was measured by Stratus optical coherence tomography (OCT). The association between intravitreal bevacizumab injection and optic atrophy was analyzed by multiple logistic regression., Results: Two hundred sixty nine patients with PDR, consisting of 166 patients with intravitreal bevacizumab injection and 103 cases without bevacizumab injection. Optic atrophy was found in 11.4% (25/219 eyes) and 8% (14/175 eyes) respectively. There was no evidence that intravitreal bevacizumab injection and associated systemic diseases were related to optic atrophy. The risk factor that was related to optic atrophy was previous intravitreal surgery (adjusted odds ratio (OR), 2.57 [95% CI, 1.13, 5.84], p = 0.024)., Conclusion: Anti-VEGF (bevacizumab) does not increase the risk of optic atrophy. The ophthalmologists should be aware of subsequent optic atrophy development in patients with PDR who undergo surgical intervention.

Introduced in 1988 by Kaneko and colleagues, selective ophthalmic arterial infusion of chemotherapeutic drug has recently gained more interest among retinoblastoma experts worldwide. The report showed that the procedure could be repeated up to 12 treatments without serious side effects. We report a 4-year-old girl with bilateral retinoblastoma. The left eye was enucleated for the group E disease. The right eye started with 3 retinal tumors (group C) was treated with systemic chemotherapy plus local therapy. Seven months after the last cycle of chemotherapy, the tumor recurred close to the fovea. Systemic chemotherapy was reinitiated without success. To avoid aggressive cryotherapy and external-beam radiotherapy, selective ophthalmic arterial infusion of chemotherapeutic drugs was performed for 15 sessions. The tumor responded partially without evidence of drug-induced retinal toxicity by the electroretinogram. Minor irregularities of the inner wall of supraclinoid portion of the internal carotid artery were observed only at the sixth session. Narrowing of the vascular lumen occurred on the last 2 sessions. We demonstrate that this technique when performed repeatedly could result in the anatomic changes of the small blood vessel. Careful follow-up is necessary for early detection of any serious consequences.

Background: Posterior capsule rupture is one of the most common intra-operative complications of cataract surgery and may lead to other sequelae that affect visual outcome., Objective: To determine the visual outcome and sequelae at 1 year after cataract surgery complicated by posterior capsule rupture and factors related to poor visual outcome., Material and Method: Retrospective chart reviews of the patients who underwent cataract surgery complicated by posterior capsule rupture in Siriraj Hospital between January 2006 and December 2009 were performed. Data collected included demographic data, underlying systemic diseases, pre-existing ophthalmic diseases, type of cataract, type of operation, vitrectomy methods, type of intraocular lens (IOL) implantation, pre-operative and post-operative visual acuity, subsequent complications and management., Results: There were 525 cases that received cataract surgery complicated by posterior capsule rupture. After excluding 280 cases with the follow-up period of shorter than 1 year 245 eyes of 242 patients were studied. These comprised 111 males and 131 females. The mean age was 69.3 years, ranged from 40 to 92 years. The mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) at 1 year was 0.43 (median 0.24). The proportion of patients who had BCVA of 0.3 logMAR or better was 64.5%. After excluding eyes with pre-existing diseases, 72.9% got this level of BCVA. Vitrectomy was required in 75.5%; which consisted of anterior vitrectomy (68.6%) and posterior vitrectomy (6.9%). Primary intra-ocular lens insertion was performed in 87.4%, mostly in the ciliary sulcus (75.5%). Subsequent complications occurred in 13.9%, which included secondary glaucoma (4.9%), cystoid macular edema (2.4o), endophthalmitis (1.6%), rhegmatogenous retinal detachment (1.2%o), IOL displacement (1.2%), uveitis (1.2%), corneal decompensation (0.8%) and fibrous ingrowth (0.4%). The factors associated with the poor visual outcome worse than 0.3 logMAR were pre-existing ocular diseases, incision requiring more than 2 stitches, posterior vitrectomy and subsequent complications (p < 0.05)., Conclusion: Most of the patients had favorable visual outcome after cataract surgery complicated by posterior capsule rupture. Meticulous vitrectomy to prevent subsequent complications and foldable IOL insertion to minimize the wound size are recommended.

Objective: To identify the prognostic factors that predict visual outcome in eyes with penetrating ocular injuries with retained intraocular foreign bodies (IOFBs)., Design: Retrospective cases series, Material and Method: The authors reviewed the records of 228 patients who had penetrating eye injuries with retained posterior segment IOFBs managed at Siriraj Hospital between June 1995 and February 2008. One hundred and forty-one patients (61.8%) were included in the present study. Associations between final visual outcome and various pre-operative and post operative variables were statistically analyzed., Results: After a mean follow-up of 10.4 +/- 7.7 months, 68 eyes (48.2%) achieved visual acuity of 6/18 or better The final visual acuity ranged between 6/24 and 6/60 in 22 eyes (15.6%) and 51 eyes (36.2%) had visual acuity less than 6/60. Final visual acuity significantly depended on initial visual acuity (p = 0.002), size of entry wound (p = 0.020), size of foreign body (p = 0.018), presence of vitreous hemorrhage (p = 0.014), retinal detachment (p = 0.026) and endophthalmitis (p < 0.0001)., Conclusion: Visual outcome in penetrating ocular injuries with retained IOFBs was affected by initial visual acuity, size of entry wound, size of foreign body, vitreous hemorrhage, retinal detachment and endophthalmitis. These factors may be helpful for pre-operative counseling and predicting the final visual outcome.

Purpose: The purpose of this study was to analyze the outcome of treating epidemic keratoconjunctivitis (EKC) with 2% povidone-iodine (PVP-I) solution., Methods: A prospective, interventional, uncontrolled study was performed in participants diagnosed with EKC. PVP-I was applied to the affected eyes 4 times a day for a week. Participants were informed about transient eye stinging and discoloration after application. Drug discontinuation was allowed for early recovery or encountering any adverse effects. Data collection included history, symptoms, and signs at the initial presentation and at 1 week. Main outcomes were the recovery rate within a week of treatment and drug tolerability., Results: Of 172 enrolled, 61 participants completed the study. EKC occurred bilaterally in 40 participants (66%). Single eye from each participant was included for analysis. The mean (standard deviation) time elapsed before treatment was 2.1 (1.46) days. The recovery rate within a week of treatment was 77% (95% confidence interval, 65.1-85.8). Twenty-eight participants (45.9%) recovered within a week after the onset. Application of PVP-I was sustained until recovery or completing a 7-day trial in 78.7%. No severe ocular or systemic adverse effects have been reported related to this treatment., Conclusions: Ocular application of 2% PVP-I was tolerable. This measure successfully relieved ocular discomfort from EKC in 3 quarters of the study group within a week. A randomized, controlled trial is required to verify the benefit of this measure.

Purpose: Increased level of cyclooxygenase-2 (COX-2) plays a significant role in the pathogenesis of cancers. High expression of COX-2 has been demonstrated in several cancer types including retinoblastoma. However, the in vivo study did not confirm the anti-proliferative effect of COX-2 inhibitor, celecoxib, on a murine transgenic retinoblastoma model. We, therefore, aim to investigate COX-2 expression in paraffin-embedded retinoblastoma specimens in a larger study group., Methods: We reviewed 55 retinoblastoma specimens obtained during 1995 to 2005. Clinical and histopathological data were recorded. Immunohistochemical evaluation of COX-2 expression was performed using a rabbit monoclonal antibody to human cyclooxygenase-2., Results: Forty-four of 55 specimens (80%) showed negative immunoreactivity for COX-2 expression. For the 11 specimens (20%, 95% CI = 11.6-32.4%) with positive COX-2, all immunostainings were less than 50% of tumor area. Demographic data and treatment details were available in 53 specimens. Enucleation was performed as a primary treatment in 43 specimens (81%). Other treatments, mainly systemic chemotherapy, were given prior to enucleation in 10 specimens (19%). There was no statistical difference in COX-2 expression between the specimens identified as primary and secondary enucleation (p = 0.66). Regarding the histopathological findings, there were no significant differences between COX-2 negative and COX-2 positive groups., Conclusions: It appears that COX-2 is not overexpressed in our retinoblastoma specimens, which is different from previous studies. This conflicting data reduces the possibility of introducing Cox-2 inhibitors in the treatment of retinoblastoma.

Purpose: To identify genetic mutations of the XLRS1 gene and to describe the ocular phenotypes in two unrelated Thai patients with X-linked juvenile retinoschisis., Methods: Ophthalmic examination, including best-corrected visual acuity and fundus examination and photography, was performed in all participants. Electroretinography (ERG) and optical coherence tomography were performed when possible. All six exons of the XLRS1 gene were amplified, and mutation screening was determined by denaturing high-performance liquid chromatography and DNA sequencing., Results: Two point mutations were identified, a novel missense mutation c.378A > G (p.D126G) in exon 5 and a reported mutation c.637C > T (p.R213W) in exon 6. The first proband with the p.D126G mutation developed vitreous hemorrhage in both eyes at age 7 months. Foveal and peripheral schisis with several inner layer holes were detected in both eyes. The second proband with the p.R213W mutation developed slightly blurred vision at age 10 years. Fundus examination showed numerous fine white dots at the macula without foveal or peripheral schisis. Electronegative ERG results were documented in both probands., Conclusions: A novel p.D126G mutation appeared to be associated with a severe phenotype with vitreous hemorrhage developing in infancy. Both intra- and interfamilial clinical variabilities were recognized in our patients.

Purpose: To compare the efficacy in pupil dilatation between a mixture containing 0.75% tropicamide and 2.5% phenylephrine and the alternate application of 1% tropicamide and 10% phenylephrine eye drops., Material and Methods: Patients requiring pupil dilatation were randomized to receive one drop of the mixture every 10 min for four times or our standard application of one drop of 1% tropicamide alternating with one drop of 10% phenylephrine every 10 min for two cycles. Pupil size was measured under bright light with the pupil gauge before, and every 5 min after initial application for 40 min. Application of the drops was discontinued once the pupil diameter reached 7 mm. Blood pressure and pulse rate were monitored every 15 min., Results: Of 40 patients (age 57.3+/-10.9 years, range 35-70 years), 22 were randomized into the mixture group and 18 into the alternate drug group. Baseline pupil sizes were 1.7+/-0.5 mm in the mixture group and 1.8+/-0.4 mm in the alternate drug group. The pupils were successfully dilated to 7 mm within 40 min in 17 patients of the mixture group compared to seven patients in the alternate drug group ( P =0.004, Log Rank test). The mean pupil sizes at 40 min were 6.6+/-0.8 and 6.0+/-0.9 mm in the mixture and alternate drug groups respectively ( P =0.050, t-test). Blood pressure and pulse rate were stable and similar in both groups., Conclusions: The mixture of 0.75% tropicamide and 2.5% phenylephrine is superior to our standard application of 1% tropicamide alternating with 10% phenylephrine. It provides faster and more successful pupil dilatation within 40 min.

Purpose: Since 1997, our institute has used neoadjuvant chemotherapy for intraocular retinoblastoma. However, some of the patients showed signs of recurrence months to years later. We therefore attempted to determine the prognostic factors of treatment outcomes and survival in our patients., Methods: We reviewed 90 patients treated from 1997 to 2006. The following information was recorded: demographic and ophthalmological data, clinical classification, histopathological data, and treatment methods and outcomes., Results: Enucleation was avoided in two of 57 eyes in the unilateral group. Sixteen of 54 eyes in the bilateral group were salvaged by systemic chemotherapy with local treatment. There was no difference in histopathological findings between the two groups. Nine of 57 patients in the unilateral group demonstrated poor outcomes, compared with four of 27 in the bilateral group. Significant poor prognostic factors for survival were optic nerve head invasion, orbital involvement, abnormal results on bone marrow aspiration, lumbar puncture, bone scan, and group E or F classification., Conclusions: The 15% mortality rate in our patients is slightly higher than that reported in developed countries. Delayed diagnosis and treatment is the main cause of avoidable deaths. Improving education of both clinicians and parents would increase survival rates in this potentially fatal disease.

Background: To identify genetic mutations of the VMD2 gene in two Thai families with Best macular dystrophy., Materials and Methods: Ophthalmic examination including best-corrected visual acuity (BCVA), dilated fundus examination and fundus photography, and electro-oculography (EOG) was performed in two probands and their family members. Mutation screening of the VMD2 gene was performed by single-strand conformation polymorphism (SSCP) analysis followed by direct DNA sequencing of the abnormal exons., Results: The 58-year-old male proband demonstrated typical egg yolk-like macular lesion in both eyes. Mutational screening of VMD2 identified a band shift in exon 7, which was confirmed by direct DNA sequencing to be a G to A transition at position 724 bp. This novel missense mutation resulted in the change of an amino acid valine to methionine and was responsible for the abnormal Arden ratio in the proband's daughter. The second male proband age 25 had a characteristic egg yolk-like macular lesion in the left eye and a scrambled egg appearance in the right. Mutation analysis identified a C to T transition at position 652 bp in exon 6. This reported missense mutation led to an amino acid substitution of cysteine for arginine. The mutation was documented in the maternal grandmother, the mother, as well as the elder sister of the proband., Conclusions: The Val-242-Met mutation is associated with a late-onset visual disturbance and the Arg-218-Cys mutation was associated with marked intra-familial clinical variability of expression. Presymptomatic testing will be available to the family members at risk with high accuracy.

Objective: To evaluate the efficacy of nonmydriatic digital retinal images for determining diabetic retinopathy., Material and Method: Single field 45-degree digital retinal images of 225 eyes from 142 diabetic patients were obtained with a nonmydriatic camera. The images were diagnosed and graded by a general ophthalmologist. These results were compared with clinical diagnosis obtained by retinal specialists, after examination by using biomicroscope with plus lens and indirect ophthalmoscope of the patients. International clinical diabetic retinopathy disease severity scale was used for grading diabetic retinopathy in all cases., Results: Presence of diabetic retinopathy was detected in 70 eyes (31.1%). The sensitivity and specificity for determining diabetic retinopathy was 68.57% (95%CI 57.00-78.20) and 92.25% (95%CI 87.00-95.50), respectively. The positive predictive value and negative predictive value was 80.00% (95%CI 68.20-88.20) and 86.67% (95%CI 80.60-91.00). Overall accuracy was 84.89%., Conclusion: Single field 45-degree nonmydriatic digital retinal images were limited by fair sensitivity for determining diabetic retinopathy although overall accuracy from the present study was relatively high. Upcountry, this tool might facilitate increased access of diabetic patients for eye evaluation but cannot replace standard eye examination.

Purpose: To describe a large Thai family with lattice corneal dystrophy (LCD) type I and to determine whether this LCD is associated with mutations within the transforming growth factor-beta-induced (TGFBI) gene., Methods: A six-generation family with LCD type I was identified and diagnosed on the basis of clinical and/or histopathologic evaluation. Visual acuity testing and slit-lamp biomicroscopic evaluation were carried out and corneal photography was documented. All 17 exons and flanking intron sequences of the TGFBI gene were sequenced., Results: Thirty-three participants demonstrated LCD in both eyes, most of which was symmetrical. Age at onset of decreased vision was the mid- to late twenties. Visual acuity varied from 6/6 to no light perception. Two patients, 74 and 42 years of age, demonstrated a thick yellowish plaque covering the corneal surfaces. DNA sequencing revealed a heterozygous mutation in exon 13 (A1762G), changing histidine to arginine at codon 572 (H572R). Ten of 42 clinically unaffected family members, all under 25 years of age, exhibited the same mutation., Conclusions: This is the first report of a molecular analysis of LCD type I in Thai patients. The novel mutation identified is associated with distinct phenotypes and later onset of the disease compared with the more common R124C mutation., (Copyright Japanese Ophthalmological Society 2006.)

Purpose: To describe the ophthalmic findings and mutation analyses of the PAX6 gene in Thai aniridia patients., Methods: Ten patients from six unrelated families underwent a comprehensive ophthalmic examination. Mutations in the PAX6 gene were screened by single-strand conformational polymorphism (SSCP) and direct DNA sequencing of the SSCP variants., Results: Seven patients developed cataracts and six developed glaucoma. Mutation analysis demonstrated four different truncating mutations, two of which were de novo. These included one novel insertion/deletion mutation (c.474del12insGA in exon 5) and three nonsense mutations. R203X and R240X are common recurrent mutations, while Q277X in exon 10 is novel. All mutations resulted in loss of function of the PAX6 protein., Conclusion: Our data confirm inter- and intrafamilial variable phenotypic manifestations of which the underlying mechanisms may be haploinsufficiency or dominant-negative mutation.

Objective: Postoperative endophthalmitis reflects in part quality and safety aspects of cataract surgery. Preoperative 5% povidone-iodine was introduced as a quality improvement effort. This study evaluated the effect of this additional measure on the occurrence of endophthalmitis after cataract surgery., Method: Topical 5% povidone-iodine solution was applied onto the ocular surface just prior to transferring the patient into the operative theater for cataract surgery. Other prophylactic measures were allowed to continue as before. Patients developing postoperative intraocular inflammation and undergoing intravitreal antibiotic injection were included as occurrences of endophthalmitis. Alteration in endophthalmitis rate was analyzed using a 'p control chart' of a statistical process control method. The incidence in the povidone-iodine-receiving group was compared to those before implementation and concurrent nonreceiving groups., Result: The postoperative endophthalmitis rate showed a significant reduction after introduction of povidone-iodine. A year before, 9 of 3,052 eyes developed endophthalmitis (0.294%). After introduction, this occurred in 4 of 4,089 eyes receiving povidone-iodine (0.097%) and 1 of 502 nonreceiving eyes (0.199%) in the following 16 months. Despite the apparent lower rate, comparison between groups was not statistically significant. Moderate to severe but tolerable eye irritation after application was reported in 6.6%. No other adverse events were detected., Conclusion: Topical preoperative 5% povidone-iodine contributed an additional effect to the reduction of the postoperative endophthalmitis rate after cataract surgery. This measure was rather safe to apply as a prophylaxis against endophthalmitis in cataract surgery.

Objectives: To compare the incidence and characteristics of patients with endophthalmitis after extracapsular cataract extraction (ECCE) to those after phacoemulsification, Material and Method: Records of patients receiving intravitreal antibiotic injection to treat endophthalmitis after cataract surgery between Jan 2001 and Dec 2004 were reviewed. Demographic data and other characteristics including associated diseases, details of cataract surgical procedure and intraoperative complication, onset of endophthalmitis after cataract surgery, presenting symptoms and signs of endophthalmitis, how endophthalmitis was managed, causative organisms, duration of hospitalization and results of treatment were collected. This information was compared between those of endophthalmitis patients after ECCE and those after phacoemulsification., Results: There were 5 cases who developed endophthalmitis after ECCE and 31 cases after phacoemulsification. The incidence was 0.365% after ECCE and 0.279% after phacoemulsification (p = 0.589). Visual acuity (VA) before cataract surgery in ECCE group was worse than the phacoemulsification group (median VA: counting fingers vs 6/36, p = 0.001). Median onset of endophthalmitis was 8 days after ECCE and 6 days after phacoemulsification. Presenting symptoms and signs were similar. Causative agents were identified in 4 (80%) and 14 (45%) cases in the ECCE and phacoemulsification groups respectively. Gram-positive bacteria were the major cause of infection in both groups. Endophthalmitis caused by citrobacter sp. in ECCE group and enterococcus or streptococcus sps. the phacoemulsification in the group ended up with enucleation or no light perception., Conclusion: The present study has not demonstrated an apparent difference between endophthalmitis after ECCE and those after phacoemulsification. Endophthalmitis after either procedure can be managed as the same condition.

Purpose: To assess the role of serum anticardiolipin IgG antibody and fasting plasma homocysteine levels as risk factors for retinal vascular occlusive disease in Thai patients., Methods: This is a retrospective, case-control study. Forty-one consecutive patients with recent onset of retinal vascular occlusive diseases were enrolled. In conjunction with a routine laboratory work up, serum anticardiolipin IgG antibody and plasma homocysteine were evaluated. Ninety volunteers without a history of retinal vascular occlusive disease were chosen as controls., Results: In general, mean levels of anticardiolipin IgG antibody and homocysteine did not differ between the patients and controls. However, when the groups without a history of underlying systemic diseases were compared, there were statistically significant differences in the anticardiolipin IgG antibody level between patients and controls (mean 12.24 +/- 8.66 and 7.70 +/- 6.69 GPL units/ml, respectively) with a P value of 0.024., Conclusions: No association was found between plasma homocysteine level and retinal vascular occlusion in our patient population. A high level of anticardiolipin IgG antibody is shown to be a risk factor only in patients without a history of underlying systemic diseases. The effect of anticardiolipin IgG antibody on the development of retinal vascular occlusive disease appears to be limited and may not be a major cause.

Purpose: The aim of this study was to verify the applicability of standard guidelines for the screening of retinopathy of prematurity (ROP) and to determine the appropriate criteria for Thai neonates., Methods: Records of ROP screening of infants born in our hospital between 1995 and 2000 with a birth weight below 2000 g or a gestational age of less than 36 weeks were studied. Criteria to screen infants with a birth weight below 1500 g or a gestational age of less than 28 weeks in the American guidelines and similar birth weight but a gestational age of less than 31 weeks in the British recommended guidelines were applied and evaluated in terms of sensitivity and specificity. Criteria reaching 100% sensitivity with the maximum specificity were deemed appropriate., Results: Of the 514 screened infants, 33 had developed stage 2+ ROP and beyond. The mean +/- SD birth weight and gestational age were 1046 +/- 257 (710-1680 g) and 29.2 +/- 2.5 weeks (24-35 weeks), respectively. The age at intervention was 6-16 weeks. Sensitivity for both American and British guidelines was 93.9%. By screening infants with birth weights below 1500 g or gestational age less than 33 weeks, we could achieve 100% sensitivity with 18.3% specificity. We decided that the initial examination should be performed 4-6 weeks after birth. By applying these criteria to 62 referred cases we also were able to include in the screening all cases of concern in this group., Conclusions: Regional criteria for ROP screening is required and should be evaluated periodically and modified accordingly.

Aims: To compare the efficacy and ocular adverse effects of topical prednisolone acetate, ketorolac tromethamine, and fluorometholone acetate in reducing inflammation after phacoemulsification., Method: One hundred and twenty eyes were enrolled in a prospective, investigator-masked, randomized controlled trial. Each drug was prescribed 4 times a day for 28 days. The following data were recorded weekly: visual acuity, intraocular pressure, slit lamp biomicroscopy, grading of cells and flare in the anterior chamber, and ocular symptoms., Results: The number of eyes with a minimal amount of cells in the anterior chamber in the ketorolac group was less than the prednisolone group on day 7 (11:20, p = 0.008) and day 14 (23:31, p = 0.015), and than fluorometholone group on day 7 (11:21, p = 0.011). Intraocular pressure in the prednisolone group was higher than the ketorolac group on day 21 (14.6:12.2 mmHg, p = 0.016). One eye in the prednisolone group had intraocular pressure of 32 mmHg. Burning sensation was reported frequently in the ketorolac group., Conclusion: All 3 drugs were effective in reducing post-operative inflammation. The efficacy of prednisolone acetate and fluorometholone acetate was comparable. Ketorolac tromethamine showed less efficacy than corticosteroids, however, it did not induce ocular hypertension.