Publications by authors named "Hung-Chi Chen"

443 Publications

Technical details for inset of flaps in transfer of double-level gastroepiploic lymph node flaps for lower extremity lymphedema.

Asian J Surg 2022 Jul 15. Epub 2022 Jul 15.

China Medical University and China Medical University Hospital, Taichung, Taiwan. Electronic address:

Background: In this study, the method that can be followed to ensure rapid and uncomplicated recovery of lymph node flap (LNF) applied in the medial of the ankle for lymphedema treatment was investigated.

Methods: Thirty-seven patients with class II of lower limb lymphedema underwent transfer of gastroepiploic LNF to the medial ankle and popliteal fossa areas. At the popliteal fossa region, the wound could always be closed primarily by the advancement of neighboring skin. The wound closure could be classified into three types at the medial ankle area (A) The partially exposed LNF was covered with a split-thickness skin graft (STSG) (n = 9). (B) A larger local flap was elevated, and the donor site of the local flap was covered with STSG (n = 18). (C) The skin flap's donor site was treated with pre-tie sutures (n = 10).

Results: In the popliteal region, there was no complication of wound healing. In the ankle region, the wound was coated by a thin layer of hematoma over the exposed LNF in 5 patients of group A. It healed secondarily except for one patient who needed a secondary skin graft. The healing was perfect in group B. In group C the healing was good, but there was a hypertrophic scar in 7 patients and required steroid injection later.

Conclusion: To avoid complications of the gastroepiploic LNF at the medial ankle, it should be entirely covered by an anteriorly-based local flap, and the donor site defect of the local flap can be treated with either pre-tie sutures or a skin graft.
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http://dx.doi.org/10.1016/j.asjsur.2022.07.034DOI Listing
July 2022

Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes.

Arch Plast Surg 2022 May 27;49(3):378-396. Epub 2022 May 27.

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York.

Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.
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http://dx.doi.org/10.1055/s-0042-1748652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9142245PMC
May 2022

Oxidation-mediated scaffold engineering of hyaluronic acid-based microcarriers enhances corneal stromal regeneration.

Carbohydr Polym 2022 Sep 27;292:119668. Epub 2022 May 27.

Graduate Institute of Biomedical Engineering, Chang Gung University, Taoyuan 33302, Taiwan; Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; Department of Materials Engineering, Ming Chi University of Technology, New Taipei City 24301, Taiwan; Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 33303, Taiwan. Electronic address:

The functional design of scaffolding biomaterials with potent capabilities of promoting cell adhesion and proliferation is critically important for tissue repair and regeneration. Here, we exploit the effects of oxidation level of aldehyde hyaluronic acid (oHA) on gelatin microcarriers for repairing corneal injuries. Specifically, high oxidation levels can endow the microcarrier surface with large oHA grafting amount, smooth topography, and strong stiffness, consequently formulating biocompatible scaffolding materials with superior affinities for keratocyte attachment and growth. In a rabbit model of corneal alkali burn injury, single intracorneal injection of keratocytes/functionalized microcarriers with an appropriate oxidation level could effectively reduce corneal swelling (~62-fold improvement), recover ~94% collagen production and ~89% keratocan expression, and repair disordered collagenous stromal architecture after 4 weeks. These findings on the oxidation level effects of the aldehyde polysaccharide show a great potential use in the development of advanced scaffolds for efficient tissue engineering.
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http://dx.doi.org/10.1016/j.carbpol.2022.119668DOI Listing
September 2022

Carotid artery and soft tissue reconstruction with superficial femoral artery-sartorius muscle-anteromedial thigh chimeric free flap: A case report and review of the literature.

Microsurgery 2022 Jul 14;42(5):504-511. Epub 2022 Jun 14.

Division of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

Tumoral involvement of the carotid artery may require en-bloc resection in order to achieve a better regional control. Among the carotid reconstruction methods at disposal, autologous tissues appear to be more reliable in cases with high risk of infection and poor tissue healing like in radiated necks. We describe a case of a 55 year old man, who suffered from recurrent squamous cell carcinoma in the neck region, invading the common carotid artery. After en-bloc resection of the tumor together with skin, internal jugular vein, vagus nerve and common carotid artery, carotid reconstruction was performed with a flow-through chimeric flap based on superficial femoral vessels (15 cm). After resection of the tumor, the flap was used to replace the soft tissue defect (23 × 12 cm). Anteromedial thigh skin paddle (8 × 5 cm) and sartorius muscle (12 × 3 cm) were included in the flap. The superficial femoral vessels were reconstructed with 8-mm ringed polytetrafluoroethylene graft interposition. Thanks to an accurate surgical planning and a 2-team approach, the ischemia time of the leg was 42 min and there were no limb ischemia nor pathologic neurological signs after surgery. During the 12-month follow up, no other complication was registered. In our experience, microsurgical carotid reconstruction represents a reliable option with important advantages such as resistance to infection, optimal size matching, and good tissue healing between the irradiated carotid stump and the vascular graft.
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http://dx.doi.org/10.1002/micr.30925DOI Listing
July 2022

Amniotic membrane transplantation in a patient with impending perforated corneal ulcer caused by : A case report and review of literature.

World J Clin Cases 2022 Apr;10(12):3923-3929

Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333423, Taiwan.

Background: () is an opportunistic pathogen that can lead to severe ocular infections. In previous reports, penetrating keratoplasty (PK) was usually adopted for the treatment of persistent corneal ulcers. This report describes an unusual case of nonhealing descemetocele caused by treated by antibiotics plus amniotic membrane transplantation (AMT).

Case Summary: A 63-year-old woman presented with a right persistent corneal ulcer that she had suffered from for the past 9 mo. The culture of a corneal scraping yielded . The right eye descemetocele decreased in diameter from 3 to 0.8 mm after the continuous administration of topical vancomycin and ceftriaxone for 2 wk. Due to the slow healing, AMT was performed. Her corneal erosion healed and gradually became clear. Her visual acuity recovered from initially counting fingers to 100/200 at the last follow-up, 67 mo after AMT.

Conclusion: Antibiotics plus AMT may be an effective alternative treatment other than PK to promote epithelialization and to reduce inflammation in the corneas complicated by keratitis.
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http://dx.doi.org/10.12998/wjcc.v10.i12.3923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9100738PMC
April 2022

Keratitis in Taiwan: Molecular Identification, Antifungal Susceptibilities, and Clinical Features.

J Fungi (Basel) 2022 May 3;8(5). Epub 2022 May 3.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan.

We performed molecular identification and antifungal susceptibilities of pathogens and investigated clinical features of 43 culture-proven keratitis cases from 2015-2020 in Taiwan. The pathogens were identified by sequencing of their internal transcribed spacer regions of ribosomal DNA and translation elongation factor 1α gene; their antifungal susceptibilities (to seven agents) were determined by broth microdilution method. We also collected clinical data to compare the drug susceptibilities and clinical features of species complex (FSSC) isolates with those of other species complexes (non-FSSC). The FSSC accounted for 76.7% pathogens, among which (32.6%) and (27.9%) were the most common species. Among clinically used antifungal agents, amphotericin B registered the lowest minimal inhibitory concentration (MIC), and the new azoles efinaconazole, lanoconazole and luliconazole, demonstrated even lower MICs against species. The MICs of natamycin, voriconazole, chlorhexidine, lanoconazole, and luliconazole were higher for the FSSC than the non-FSSC, but no significant differences were noted in clinical outcomes, including corneal perforation and final visual acuity. In Taiwan, the FSSC was the most common complex in keratitis; its MICs for five tested antifungal agents were higher than those of non-FSSC, but the clinical outcomes did not differ significantly.
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http://dx.doi.org/10.3390/jof8050476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9144221PMC
May 2022

Reducing complications in reconstruction of the cervical esophagus with anterolateral thigh flap: The five points protocol.

J Plast Reconstr Aesthet Surg 2022 Apr 28. Epub 2022 Apr 28.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 91, Xueshi Road, North District, Taichung City 404, Taiwan. Electronic address:

Patients suffering from hypopharyngeal cancer commonly present in the advanced stage and undergo a circumferential pharyngolaryngectomy. The possibility to reconstruct the esophagus and achieve an oral alimentation can significantly reduce the additional burden of a jejunostomy. The cervical esophagus is usually reconstructed with jejunal free flap (JFF) or fasciocutaneous free flap such as the anterolateral thigh (ALT) free flap. The latter has proved its donor-site safety and fast recovery. However, it is burdened by a high fistula rate. We present our five points protocol for reducing fistula rate and improving outcome. Twenty-eight patients underwent total pharyngolaryngectomy and required esophageal reconstruction with ALT flap from 2015 to 2020. In each patient, we performed five adjustments: a thicker dermal layer, a two-layer closure, a barrier from the tracheostomy, a nonabsorbable monofilament suture, and two NG tubes to enhance neoesophageal drainage. Twenty-five (89%) patients returned to solid or soft food diet after the reconstruction. Three patients had liquid diet. Contrast media leakage was observed in only 2 (7%) patients during esophagography at three weeks, with only one needing surgical revision. Our five points protocol for ALT reconstruction of cervical esophagus proved to be effective in achieving an incredibly low rate of complications, without the burden of significant donor-site complications.
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http://dx.doi.org/10.1016/j.bjps.2022.04.043DOI Listing
April 2022

Free Colon Tissue Transfer for the Management of Xerostomia in Head and Neck Cancer Patients: A Bacteriological Study and Clinical Case Series.

J Plast Reconstr Aesthet Surg 2022 Apr 22. Epub 2022 Apr 22.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taiwan. Electronic address:

Introduction: Patients with head and neck cancer may suffer from xerostomia after repetitive surgery or radiation therapy. Free colon tissue transfer was used to restore the lubrication of the oral cavity, and a bacteriological study in mice was conducted to evaluate how the intestine transfer from the intra-abdominal to extra-abdominal locations may affect bacterial colonization.

Patients And Methods: Twelve patients received free colon transfer for the reconstruction of their intraoral mucosal defect following trismus release. Thirty-five patients received ileocolon flap transfer to fill the pharyngeal defects. In an animal study with mice, a pedicled ileum segment was transferred to the subcutaneous space of the abdominal wall. The transferred ileum segments were biopsied for bacterial genome analysis after 3 months.

Results: All but one transferred flap survived. Colon secretion was suitable for oral lubrication without the unpleasant smell 1 month postoperatively. In an animal study, genome analysis showed that the same bacterial species still existed in the transferred intestinal tissue.

Conclusions: No unpleasant smell or infections were noted in this clinical series despite the animal study showing that the bacterial spectrum did not change in the transferred intestine. Therefore, free colon tissue transfer could safely provide lubrication in patients with xerostomia.
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http://dx.doi.org/10.1016/j.bjps.2022.04.019DOI Listing
April 2022

Soft palate reconstruction with free jejunum flap: Impact on the velopharyngeal insufficiency.

J Plast Reconstr Aesthet Surg 2022 04 28. Epub 2022 Apr 28.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 91, Xueshi Road, North District, Taichung City, 404, Taiwan.

If inadequately reconstructed, large resections of the soft palate inevitably cause velopharyngeal insufficiency, nasal regurgitation and reduce speech intelligibility. A series of 12 free Jejunal flaps are presented, with 28.5 months median follow up (IQR 10.5), with evidence that the flaps provided appropriate secretions and good functionality for speech and resumption of oral intake. A retrospective case series was performed, from 2004 to 2020, including patients diagnosed with palate locally advanced squamous cell carcinoma and reconstructed with free jejunum flap. Twelve patients were included, with mean age of 66 years. No flap loss, thrombosis or infection were recorded. Oral feeding was achieved in all patients, on an average after 36 days from the operation. Speech intelligibility improved by 4 points in a scale 0-10. The thin, pliable, and elastic properties of the free jejunal flap are optimally suited for a functional reconstruction of the three-dimensional palatal defects. With its serous and mucous secretion, the free jejunal flap can lead to early return to solid diet and minimize functional impairment of phonation and speech.
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http://dx.doi.org/10.1016/j.bjps.2022.04.044DOI Listing
April 2022

Application of a Deep Learning System in Pterygium Grading and Further Prediction of Recurrence with Slit Lamp Photographs.

Diagnostics (Basel) 2022 Apr 2;12(4). Epub 2022 Apr 2.

Institute of Clinical Medicine, National Yang Ming Chiao Tung University, No. 201, Sec.2, Shih-Pai Rd. Peitou, Taipei 11221, Taiwan.

Background: The aim of this study was to evaluate the efficacy of a deep learning system in pterygium grading and recurrence prediction.

Methods: This was a single center, retrospective study. Slit-lamp photographs, from patients with or without pterygium, were collected to develop an algorithm. Demographic data, including age, gender, laterality, grading, and pterygium area, recurrence, and surgical methods were recorded. Complex ocular surface diseases and pseudopterygium were excluded. Performance of the algorithm was evaluated by sensitivity, specificity, F1 score, accuracy, and area under the receiver operating characteristic curve. Confusion matrices and heatmaps were created to help explain the results.

Results: A total of 237 eyes were enrolled, of which 176 eyes had pterygium and 61 were non-pterygium eyes. The training set and testing set were comprised of 189 and 48 photographs, respectively. In pterygium grading, sensitivity, specificity, F1 score, and accuracy were 80% to 91.67%, 91.67% to 100%, 81.82% to 94.34%, and 86.67% to 91.67%, respectively. In the prediction model, our results showed sensitivity, specificity, positive predictive value, and negative predictive values were 66.67%, 81.82%, 33.33%, and 94.74%, respectively.

Conclusions: Deep learning systems can be useful in pterygium grading based on slit lamp photographs. When clinical parameters involved in the prediction of pterygium recurrence were included, the algorithm showed higher specificity and negative predictive value in prediction.
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http://dx.doi.org/10.3390/diagnostics12040888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9029774PMC
April 2022

Vascularized Lymph Node Transfer for the Treatment of Posttraumatic Lower Extremity Lymphedema: A Preliminary Report.

Indian J Plast Surg 2022 Feb 28;55(1):97-101. Epub 2022 Feb 28.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.

 Posttraumatic lymphedema develops more frequently than expected and reports on its management are scarce in the literature. We aimed to report the clinical outcomes of a case series of posttraumatic lymphedema patients treated with different vascularized lymph node transfers (VLNTs).  Five patients with secondary posttraumatic lower limb lymphedema treated with VLNT were included in this report. The groin-VLNT (  = 1), supraclavicular-VLNT (  = 2), and gastroepiploic-VLNT (  = 2) were implemented. The average flap area was 69.8 cm . Patients underwent postoperative complex decompressive therapy for an average of 10.0 months.  The average mean circumference reduction rate was 24.4% (range, 10.2-37.6%). Postsurgical reduction in the number of infection episodes per year was observed in all patients. The mean follow-up was 34.2 months.  VLNT is a promising surgical treatment for posttraumatic lymphedema patients. In our report, VLNT has demonstrated to reduce the volume and number of infections per year in posttraumatic lymphedema.
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http://dx.doi.org/10.1055/s-0041-1740520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9015821PMC
February 2022

Prospective outcome analysis of ulnar tunnel syndrome: Comparing traumatic versus non-traumatic etiologies.

Asian J Surg 2022 Mar 16. Epub 2022 Mar 16.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Taoyuan, Taiwan. Electronic address:

Background: Ulnar tunnel syndrome (UTS) is relatively uncommon compared to the carpal tunnel or cubital tunnel syndromes. Few reports dedicated to the functional outcomes after surgical intervention of the UTS exist. Herein we compare the outcomes of patients with UTS of different etiologies.

Methods: Patients diagnosed with UTS between 2016 and 2020 were recruited. Ulnar tunnel release was performed in all patients, along with other necessary osteosynthesis or reconstructive procedures in the traumatic group. Patients were followed-up every six months post-operatively. Outcomes measured include: objective evaluations, subjective questionnaires, records of clinical signs, and grading of the British Medical Research Council scale for intrinsic muscle strength.

Results: 21 patients were recruited, and favorable results were noted in all of them after surgery. Traumatic UTS patients had a worse initial presentation than the non-traumatic cases, but had a greater improvement after surgery and yielded outcomes comparable with those of the patients without trauma. Patients with aberrant muscles in their wrists had better outcomes in some objective measurements than those without aberrant muscles.

Conclusions: Ulnar tunnel release improves the outcome of patients regardless of the etiology, especially in patients with trauma-induced UTS. Thus, a proper diagnosis of the UTS should be alerted in all patients encountering paresthesia in the ulnar digits, ulnar-sided pain, weakness of grip strength, or intrinsic weakness to ensure good outcomes.
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http://dx.doi.org/10.1016/j.asjsur.2022.03.006DOI Listing
March 2022

Comparison of total anastomosis time between four different combinations of suturing and knot tying techniques in microsurgical anastomosis.

J Plast Surg Hand Surg 2022 Mar 18:1-7. Epub 2022 Mar 18.

Department of Plastic Reconstructive and Aesthetic Surgery, China Medical University Hospital, Taichung, Taiwan.

Background: Various techniques have been described for performing microsurgical anastomosis with providing high patency rates. Although the total anastomotic time may not be an issue when dealing with a single set of anastomoses, using a faster technique may save significant amount of time in cases of transferring flaps with shorter critical ischemia time or where multiple anastomoses are required. This study compares the total anastomosis time between four different combinations of commonly used suturing and knot tying techniques.

Methods: Twenty-four rats were divided into 4 groups. Simple interrupted suture with conventional knot tying technique (SIS-CT) was used in group I, continuous suture technique with conventional knot tying (CST) was used in group II, simple interrupted suture with airborne knot tying technique(SIS-AT) was used in group III, and continuous-interrupted suture with airborne knot tying technique(CIS-AT) was used in group IV for microsurgical anastomosis. Total anastomosis time and patency rates with each technique and samples from anastomotic sites were analyzed.

Results: The mean time required for microvascular anastomosis of the femoral artery was 1075 s in group I, 799 s in group II, 844 s in group III, and 973 s in group IV. The difference between four groups was statistically significant. The anastomoses in group II and group III were completed in the shortest period of time. Intergroup comparison revealed that the difference between group II and group III was not statistically significant, however, total anastomosis time for completion of the anastomosis was significantly longer for group I, followed by group IV. Thrombosis rates and histological analysis revealed no significant differences among four groups.

Conclusion: CST and SIS-AT techniques can significantly reduce microsurgical anastomosis time and provide high patency rates. Also, the time needed to complete an anastomosis was significantly shorter for CIS-AT when compared to SIS-CT.
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http://dx.doi.org/10.1080/2000656X.2022.2052083DOI Listing
March 2022

Efficacy of Myopia Control and Distribution of Corneal Epithelial Thickness in Children Treated with Orthokeratology Assessed Using Optical Coherence Tomography.

J Pers Med 2022 Feb 14;12(2). Epub 2022 Feb 14.

Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung 20401, Taiwan.

The association between myopia control efficacy in children treated with orthokeratology and corneal epithelial thickness is still unknown. The aim of this study was to explore the corneal epithelial thickness and its association with axial length changes in children treated with orthokeratology. This retrospective cohort study enrolled children aged from 9 to 15 years who had received orthokeratology for myopia control and had been followed up for at least 1 year. Anterior segment optical coherence tomography was performed to generate wide epithelial thickness maps of the patients. Annual axial length changes were calculated from the axial length at 6 months after the initiation of orthokeratology lens wear and at final measurements. Corneal epithelial thickness data were obtained from 24 sectors and a central 2 mm zone of the wide epithelial thickness map. Associations between annual axial length changes and corneal epithelial thickness for each sector/zone of the wide epithelial thickness map, and orthokeratology treatment data were determined by generalized estimating equations. Finally, a total of 83 eyes of 43 patients (mean age 11.2 years) were included in the analysis. The mean annual axial length change was 0.169 mm; when regressing demographic and ortho-k parameters to mean annual axial length changes, age and target power were both negatively associated with them (β = -14.43, = 0.008; β = -0.26, = 0.008, respectively). After adjusting for age and target power, the annual axial length changes were positively associated with the corneal epithelium thickness of IT1, I1, SN2, and S2 sectors of the wide epithelial thickness map, and negatively with that of the I3 sector. In conclusion, we identified associations between annual axial length changes and the corneal epithelium thickness of certain sectors in children treated with orthokeratology. This may facilitate the design of orthokeratology lenses with enhanced efficacy for myopia control.
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http://dx.doi.org/10.3390/jpm12020278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8875657PMC
February 2022

Refractive Changes Following Premature Posterior Capsulotomy Using Neodymium:Yttrium-Aluminum-Garnet Laser.

J Pers Med 2022 Feb 13;12(2). Epub 2022 Feb 13.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan.

We aimed to determine the timing of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy on corrected-distance visual acuity (CDVA), intraocular pressure (IOP), and spherical equivalent (SE) in patients with posterior capsular opacification (PCO). There were 59 patients with unilateral PCO and a history of Nd:YAG laser capsulotomy enrolled and further divided into the early Nd:YAG group (timing < 12 months, = 25) and late Nd:YAG group (timing > 12 months, = 34) depending on the elapsed months from phacoemulsification to Nd:YAG laser capsulotomy. The primary outcomes were CDVA, IOP, and SE before (immediately before Nd:YAG laser capsulotomy) and after (weeks one and four after the laser treatment). The independent t test was applied to analyze the difference in CDVA, IOP, and SE between the two groups, while the generalized estimating equation with Bonferroni adjustment was conducted to evaluate the effect of all the parameters on the change in SE with adjusted odds ratio (aOR) and 95% confidence interval (CI). The CDVA showed significant improvement in both the early Nd:YAG group ( = 0.005) and the late Nd:YAG group ( = 0.001), and hyperopic change occurred in both the early Nd:YAG group ( = 0.003) and the late Nd:YAG group ( = 0.017). The early Nd:YAG group revealed more significant hyperopic change compared with the late Nd:YAG group four weeks after Nd:YAG treatment ( < 0.001), which was still significant after multivariable analysis (aOR: 0.899, 95% CI: 0.868-0.930, = 0.011). In addition, a deeper ACD (aOR: 0.764, 95% CI: 0.671-0.869, = 0.019) was significantly correlated with hyperopic change. In conclusion, Nd:YAG laser capsulotomy performed within one year after cataract surgery may lead to significant hyperopic change, in which the ACD alteration affects the hyperopic shift significantly.
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http://dx.doi.org/10.3390/jpm12020272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8874370PMC
February 2022

An Assessment of Cataract Severity Based on Antioxidant Status and Ascorbic Acid Levels in Aqueous Humor.

Antioxidants (Basel) 2022 Feb 16;11(2). Epub 2022 Feb 16.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou 333423, Taiwan.

Cataract is the leading cause of blindness throughout the world. Currently, the cataract severity evaluation is based on the subjective LOCS III guideline. To ameliorate the evaluation system and develop an objective and quantitative analysis, we investigated the relationships among aqueous humor total antioxidant capacity (AqTAC), ascorbic acid (AqAA) concentration, and cataract severity. In this study, we enrolled 130 cataract patients who underwent phacoemulsification between April 2019 and March 2020. The AqTAC and AqAA were measured by our own developed TAC assay and commercially available kit. Cataract severity was recorded by nuclear opalescence (NO) and cortical cataract (CC) degree according to LOCS III. Cumulative dissipated energy (CDE) during phacoemulsification was recorded to verify the severity of the cataract. As a result, we found a moderate correlation between AqTAC and CDE ( < 0.001). In addition, we found AqTAC independently associated with the CDE when analyzed by multivariate linear regression ( < 0.001). AqTAC also negatively correlated to cataract severity when measured by NO and CC ( = 0.012 in NO grade 3 vs. grade 1; = 0.012 in CC grade 2 vs. grade 1; < 0.001 in CC grade 3 vs. grade 1). We further found AqAA provided 71.9 ± 13.5% of AqTAC, and showed a high correlation (rho = 0.79, < 0.001). In conclusion, we found a significant correlation between AqTAC/AqAA and cataract severity measured by CDE. The correlation was superior to the correlation between LOCS III and CDE. Aqueous humor TAC owns the potential to assess cataracts in an objective and quantitative way.
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http://dx.doi.org/10.3390/antiox11020397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8869206PMC
February 2022

The Pathomechanism, Antioxidant Biomarkers, and Treatment of Oxidative Stress-Related Eye Diseases.

Int J Mol Sci 2022 Jan 23;23(3). Epub 2022 Jan 23.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan.

Oxidative stress is an important pathomechanism found in numerous ocular degenerative diseases. To provide a better understanding of the mechanism and treatment of oxidant/antioxidant imbalance-induced ocular diseases, this article summarizes and provides updates on the relevant research. We review the oxidative damage (e.g., lipid peroxidation, DNA lesions, autophagy, and apoptosis) that occurs in different areas of the eye (e.g., cornea, anterior chamber, lens, retina, and optic nerve). We then introduce the antioxidant mechanisms present in the eye, as well as the ocular diseases that occur as a result of antioxidant imbalances (e.g., keratoconus, cataracts, age-related macular degeneration, and glaucoma), the relevant antioxidant biomarkers, and the potential of predictive diagnostics. Finally, we discuss natural antioxidant therapies for oxidative stress-related ocular diseases.
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http://dx.doi.org/10.3390/ijms23031255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8835903PMC
January 2022

The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up.

J Clin Med 2022 Jan 24;11(3). Epub 2022 Jan 24.

Department of Plastic Surgery, China Medical University, Taichung 404, Taiwan.

Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods.

Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed.

Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed ( < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, = 0.006 and = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 ( < 0.05).

Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.
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http://dx.doi.org/10.3390/jcm11030570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8836833PMC
January 2022

Restoring blood flow to the lateral plantar artery after elevation of an instep flap or medialis pedis flap.

Arch Plast Surg 2022 Jan 15;49(1):80-85. Epub 2022 Jan 15.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

The instep flap and medialis pedis flap are both originate based on the medial plantar artery. The medialis pedis flap is based from the deep branch and the instep flap is based from the superficial branch. To increase the axial rotation, it is acceptable to ligate the lateral plantar artery. However, this can partially affect the blood supply of the plantar metatarsal arch. We restored the blood flow with a vein graft between the posterior tibial artery and the ligated stump. From 2012 to 2020, 12 cases of heel reconstruction, including seven instep flaps and five medialis pedis flaps, were performed with ligation of the lateral plantar artery. The stump of the lateral plantar artery was restored with a vein graft and between the posterior tibial artery and the ligated stump. Patients were followed for 18 months. Long-term results showed the vascular restoration of the lateral plantar artery remained patent demonstrated by doppler ultrasonography. Restoring blood flow to the lateral plantar artery maintains good blood supply to the toes. If the patient in the future develops a chronic degenerative disease, with microvascular complications, bypass surgery can still be performed because of the patency of both branches.
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http://dx.doi.org/10.5999/aps.2021.00472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8795643PMC
January 2022

Corneal Endothelial Changes Following Early Capsulotomy Using Neodymium:Yttrium-Aluminum-Garnet Laser.

Diagnostics (Basel) 2022 Jan 8;12(1). Epub 2022 Jan 8.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou 333423, Taiwan.

We aimed to survey whether the timing of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy would alter the corneal endothelial morphology and density. A retrospective cohort study was conducted, and 48 patients with unilateral posterior capsular opacity (PCO) and Nd:YAG laser capsulotomy performance were enrolled. The participants were divided into the early Nd:YAG group (timing ≤ 12 months, = 20) and late Nd:YAG group (timing > 12 months, = 28) depending on elapsed months between phacoemulsification and Nd:YAG laser capsulotomy. Endothelial cell density (ECD), coefficient of variant (CV), hexagonality (HEX), and central corneal thickness (CCT) between the two groups were collected. A generalized estimate equation was conducted to evaluate the corneal endothelial parameters between the two groups with an adjusted odds ratio (aOR) and 95% confidence interval (CI). The CDVA was improved after treatment in both groups (both < 0.001). Chronically, ECD in the early group was significantly decreased one week after treatment (2221.50 ± 327.73/mm vs. 2441.55 ± 321.80/mm, < 0.001), which recovered to 2369.95 ± 76.37/mm four weeks after the treatment but was still lower than the preoperative status ( < 0.001). In addition, the HEX percentage showed a significant reduction at four weeks after treatment ( = 0.028). The ECD in the early group was significantly lower than that in the late group (aOR: 0.167, 95% CI: 0.079-0.356, = 0.003) in both week 1 ( < 0.001) and week 4 ( = 0.004) after laser treatment. In conclusion, the early application of Nd:YAG laser capsulotomy within one year after cataract surgery may be the reason for postoperative ECD decrement without known etiology.
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http://dx.doi.org/10.3390/diagnostics12010150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8775002PMC
January 2022

Elevated Risk of Mood Disorders after the Occurrence of Recurrent Retinal Detachment: A Population-Based Cohort Study.

Ophthalmologica 2022 13;245(3):249-257. Epub 2022 Jan 13.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan.

Introduction: The aim of this study was to investigate the risk of mood disorders in patients who experienced retinal detachment (RD) by using the National Health Insurance Research Database in Taiwan.

Methods: Participants with a diagnosis of RD were regarded as the study group, and an age- and sex-matched group without a diagnosis of RD served as the control group. The outcomes related to mood disorders after RD included: (1) psychiatric outpatient department visits; (2) behavioural therapy; (3) sleep or anxiety-related disorders; and (4) major depressive disorder (MDD).

Results: A total of 4,129 participants diagnosed with RD and 16,516 non-RD individuals were enrolled in the study. There were no significant differences in the four mood disorder-related outcomes between the study and control groups. However, the patients with recurrent RD who received more than two treatments and female patients with RD who needed surgical treatment showed a higher probability of developing MDD than did the non-RD subjects (incidence rate: 0.96 vs. 0.36; adjusted hazard ratio [aHR]: 2.382, 95% confidence interval [CI]: 1.032-5.496, log-rank p = 0.0325; and aHR: 6.895, 95% CI: 1.659-28.656, log-rank p = 0.0060, respectively).

Conclusion: Patients with recurrent RD and multiple surgeries and females with RD who needed surgical treatment were at greater risk for developing MDD.
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http://dx.doi.org/10.1159/000521290DOI Listing
June 2022

Dysphagia in a Patient with Esophageal and Hypopharyngeal Cancers After Esophageal Reconstruction: A Pharyngeal Clearance Facilitating Maneuver.

Dysphagia 2022 Jan 9. Epub 2022 Jan 9.

Department of Physical Medicine and Rehabilitation, China Medical University Hospital, 2 Yude Road, Taichung, 404, Taiwan.

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http://dx.doi.org/10.1007/s00455-021-10394-1DOI Listing
January 2022

Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study.

Microsurgery 2022 Jul 7;42(5):433-440. Epub 2022 Jan 7.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

Background: Recent studies have analyzed the combination of suction-assisted lipectomy (SAL) and vascularized lymph node transfer (VLNT) in lymphedema treatment, reporting positive outcomes. However, it is difficult to draw conclusions due to the heterogeneity of the studies. Aim of this prospective study is to evaluate the effectiveness of the combination of VLNT and SAL in lymphedema treatment.

Patients And Methods: Between January 2016 and May 2019, 94 patients with upper or lower limb stage IIb-III lymphedema were enrolled and treated with the gastroepiploic VLNT followed by SAL. Patients were prospectively evaluated through circumference measurement and clinical examination, including number of episodes of cellulitis.

Results: Among patients enrolled in the study 83 were affected by lower limb lymphedema (LLL) and 11 were affected by upper limb lymphedema (ULL). Average follow-up was 3 ± 0.8 years. In the LLL group, the mean circumference reduction rates (CRR) were 60.4, 56.9, 29.6, and 55.4% above and below the knee, above the ankle, and at the foot level, respectively. A statistically significant difference was noted at all the levels (p < .05), but above the ankle (p = .059). Regarding the ULL group, the mean CRR were 80.7, 60.7, 65.0 and 49.6% above and below the elbow, at wrist and at mid-hand, respectively. CRR were reported at all the levels but no statistical difference was noted. The number of episodes of cellulitis dropped significantly (p < .05).

Conclusion: This study supports the use of VLNT+SAL in lymphedema grades IIb-III, with important implications for the clinical practice.
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http://dx.doi.org/10.1002/micr.30855DOI Listing
July 2022

Novel Wireless Bioimpedance Device for Segmental Lymphedema Analysis Post Dual-Site Free Vascularized Lymph Node Transfer: A Prospective Cohort Study.

Sensors (Basel) 2021 Dec 8;21(24). Epub 2021 Dec 8.

Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan.

An innovative wireless device for bioimpedance analysis was developed for post-dual-site free vascularized lymph node transfer (VLNT) evaluation. Seven patients received dual-site free VLNT for unilateral upper or lower limb lymphedema. A total of 10 healthy college students were enrolled in the healthy control group. The device was applied to the affected and unaffected limbs to assess segmental alterations in bioimpedance. The affected proximal limb showed a significant increase in bioimpedance at postoperative sixth month (3.3 [2.8, 3.6], = 0.001) with 10 kHz currents for better penetration, although the difference was not significant (3.3 [3.3, 3.8]) at 1 kHz. The bioimpedance of the affected distal limb significantly increased after dual-site free VLNT surgery, whether passing with the 1 kHz (1.6 [0.7, 3.4], = 0.030, postoperative first month; 2.8 [1.0, 4.2], = 0.027, postoperative third month; and 1.3 [1.3, 3.4], = 0.009, postoperative sixth month) or 10 kHz current ((1.4 [0.5, 2.7], = 0.049, postoperative first month; 3.2 [0.9, 6.3], = 0.003, postoperative third month; and 3.6 [2.5, 4.1], < 0.001, postoperative sixth month). Bioimpedance alterations on the affected distal limb were significantly correlated with follow-up time ( = 0.456, = 0.029 detected at 10 kHz). This bioimpedance wireless device could quantitatively monitor the interstitial fluid alterations, which is suitable for postoperative real-time surveillance.
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http://dx.doi.org/10.3390/s21248187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8707995PMC
December 2021

The use of free colon flap transfer for management of xerostomia in a patient.

Microsurgery 2022 Feb 23;42(2):199-200. Epub 2021 Dec 23.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

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http://dx.doi.org/10.1002/micr.30852DOI Listing
February 2022

Higher Order Aberrations following Scleral Buckling Surgery in Patients with Rhegmatogenous Retinal Detachment.

Healthcare (Basel) 2021 Nov 27;9(12). Epub 2021 Nov 27.

Department of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.

We aim to evaluate magnitudes of higher order aberrations (HOAs) from 3rd-6th order after scleral buckling (SB) for rhegmatogenous retinal detachment (RRD). A retrospective cross-sectional study of 19 patients with RRD who received SB (six receiving encircling SB, thirteen receiving segmental SB) was conducted. A wavefront analysis for surveying HOAs and other ophthalmic parameters were collected. Data between operated and fellow eyes, and a subgroup analysis of operated eyes, were analyzed by the Mann-Whitney U test, while a generalized linear model was applied to evaluate the correlation of HOAs to best-corrected visual acuity (BCVA) and optical symptoms. BCVA in the operated eyes was significantly worse (LogMAR: 0.18 ± 0.23 versus 0.05 ± 0.07, = 0.001). Tilt (0.32 ± 0.14 versus 0.13 ± 0.08, = 0.004), defocus (1.78 ± 0.47 versus 1.05 ± 0.17, = 0.019) and coma (0.43 ± 0.11 versus 0.27 ± 0.09, = 0.016) were significantly increased after SB. All root mean square (RMS), including RMS-3, RMS-4 and total RMS, were higher in operated eyes (all < 0.05). Regarding Zernike terms, a significant elevation of vertical coma in the operated eyes was found ( = 0.038). In addition, tilt (0.41 ± 0.10 versus 0.17 ± 0.12, = 0.007), defocus (2.27 ± 0.58 versus 0.82 ± 0.39, = 0.001) and coma (0.59 ± 0.17 versus 0.11 ± 0.10, = 0.015) were higher in the segmental subgroup, whereas spherical aberration (SA) was higher in the encircling subgroup (0.22 ± 0.04 versus 0.40 ± 0.15, = 0.024) and RMS-4 and total RMS were increased in the segmental subgroup (both < 0.05). Besides, tilt was correlated to worse BCVA ( = 0.036), whereas all four HOAs were correlated to the presence of optical symptoms (all < 0.05). In conclusion, SB may increase HOAs, which could be associated with unfavorable postoperative visual outcomes and subject symptoms.
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http://dx.doi.org/10.3390/healthcare9121643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8701237PMC
November 2021

Capturing Pluripotency and Beyond.

Cells 2021 12 16;10(12). Epub 2021 Dec 16.

Limbal Stem Cell Laboratory, Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou 333, Taiwan.

During the development of a multicellular organism, the specification of different cell lineages originates in a small group of pluripotent cells, the epiblasts, formed in the preimplantation embryo. The pluripotent epiblast is protected from premature differentiation until exposure to inductive cues in strictly controlled spatially and temporally organized patterns guiding fetus formation. Epiblasts cultured in vitro are embryonic stem cells (ESCs), which recapitulate the self-renewal and lineage specification properties of their endogenous counterparts. The characteristics of totipotency, although less understood than pluripotency, are becoming clearer. Recent studies have shown that a minor ESC subpopulation exhibits expanded developmental potential beyond pluripotency, displaying a characteristic reminiscent of two-cell embryo blastomeres (2CLCs). In addition, reprogramming both mouse and human ESCs in defined media can produce expanded/extended pluripotent stem cells (EPSCs) similar to but different from 2CLCs. Further, the molecular roadmaps driving the transition of various potency states have been clarified. These recent key findings will allow us to understand eutherian mammalian development by comparing the underlying differences between potency network components during development. Using the mouse as a paradigm and recent progress in human PSCs, we review the epiblast's identity acquisition during embryogenesis and their ESC counterparts regarding their pluripotent fates and beyond.
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http://dx.doi.org/10.3390/cells10123558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700150PMC
December 2021

Clinical Features and Molecular Characteristics of Methicillin-Susceptible Ocular Infection in Taiwan.

Antibiotics (Basel) 2021 Nov 25;10(12). Epub 2021 Nov 25.

Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.

This study analyzed the clinical features and molecular characteristics of methicillin-susceptible (MSSA) ocular infections in Taiwan and compared them between community-associated (CA) and health-care-associated (HA) infections. We collected ocular isolates from patients at Chang Gung Memorial Hospital between 2010 and 2017. The infections were classified as CA or HA using epidemiological criteria, and the isolates were molecularly characterized using pulsed-field gel electrophoresis, multilocus sequence typing, and Panton-Valentine leukocidin (PVL) gene detection. Antibiotic susceptibility was evaluated using disk diffusion and an E test. A total of 104 MSSA ocular isolates were identified; 46 (44.2%) were CA-MSSA and 58 (55.8%) were HA-MSSA. Compared with HA-MSSA strains, CA-MSSA strains caused a significantly higher rate of keratitis, but a lower rate of conjunctivitis. We identified 14 pulsotypes. ST 7/pulsotype BA was frequently identified in both CA-MSSA (28.3%) and HA-MSSA (37.9%) cases. PVL genes were identified in seven isolates (6.7%). Both CA-MSSA and HA-MSSA isolates were highly susceptible to vancomycin, teicoplanin, tigecycline, sulfamethoxazole-trimethoprim, and fluoroquinolones. The most common ocular manifestations were keratitis and conjunctivitis for CA-MSSA and HA-MSSA, respectively. The MSSA ocular isolates had diverse molecular characteristics; no specific genotype differentiated CA-MSSA from HA-MSSA. Both strains exhibited similar antibiotic susceptibility.
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http://dx.doi.org/10.3390/antibiotics10121445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8698105PMC
November 2021

Different autologous tissue for stabilization of the pedicle in the presence of acute angulation, compression, crossing, and kinking.

J Plast Reconstr Aesthet Surg 2022 Feb 14;75(2):893-939. Epub 2021 Nov 14.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan; Profesor of Plastic Surgery and Microsurgery, China Medical University Hospital, Taichung, Taiwan. Electronic address:

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http://dx.doi.org/10.1016/j.bjps.2021.11.016DOI Listing
February 2022

Acute visual loss as the first ocular symptom in a Sjögren's syndrome patient with bilateral common carotid artery occlusion: a case report.

BMC Ophthalmol 2021 Nov 27;21(1):409. Epub 2021 Nov 27.

Department of Ophthalmology, Show Chwan Memorial Hospital, Changhua, Taiwan.

Background: Sjögren's syndrome may be a risk factor for carotid artery stenosis. Bilateral common carotid artery occlusion (BCCAO) in a patient with Sjögren's syndrome was not reported before. In this report, we describe a female with Sjögren's syndrome who had acute visual loss due to ocular ischemic syndrome (OIS) with BCCAO.

Case Presentation: A 50-year-old female with Sjögren's syndrome visited our clinic with acute visual loss in the left eye. The best corrected visual acuity (BCVA) was 2/100 in the left eye, and the intraocular pressure (IOP) was normal in both eyes. Ocular ischemic change was observed during the ophthalmic examination. Aortography and computed tomography angiography (CTA) showed nearly total occlusion of the bilateral CCA. Thus, OIS with BCCAO was diagnosed. The vision in the left eye improved to 30/100 after carotid artery stenting for the left common carotid artery.

Conclusions: BCCAO may be present in patients with Sjögren's syndrome. Large vessel abnormalities should be considered when acute visual loss is found in a patient with Sjögren's syndrome.
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http://dx.doi.org/10.1186/s12886-021-02177-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8626982PMC
November 2021
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