We report a case of a ruptured triple hormone-secreting adrenal mass with hyperaldosteronism, hypercortisolism, and elevated normetanephrine levels, diagnosed as adrenal cortical carcinoma (ACC) by histology. A 53-year-old male patient who initially presented with abdominal pain was referred to our hospital for angiocoagulation of an adrenal mass rupture. Abdominal computed tomography revealed a heterogeneous 19×11×15 cm right adrenal mass with invasion into the right lobe of the liver, inferior vena cava, retrocaval lymph nodes, and aortocaval lymph nodes. Angiocoagulation was performed. Laboratory evaluation revealed excess cortisol via a positive 1-mg overnight dexamethasone suppression test, primary hyperaldosteronism via a positive saline infusion test, and plasma normetanephrine levels three times higher than normal. An adrenal mass biopsy was performed for pathological confirmation to commence palliative chemotherapy because surgical management was not deemed appropriate considering the extent of the tumor. Pathological examination revealed stage T4N1M1 ACC. The patient started the first cycle of adjuvant mitotane therapy along with adjuvant treatment with doxorubicin, cisplatin, and etoposide, and was discharged. Clinical cases of dual cortisol- and aldosterone-secreting ACCs or ACCs presenting as pheochromocytomas have occasionally been reported; however, both are rare. Moreover, to the best of our knowledge, a triple hormone-secreting ACC has not yet been reported. Here, we report a rare case and its management. This case report underscores the necessity of performing comprehensive clinical and biochemical hormone evaluations in patients with adrenal masses because ACC can present with multiple hormone elevations.

Purpose: We introduce a “cold steel” hammer-chisel technique for endoscopic dacryocystorhinostomy, then compare postoperative outcomes between this technique and a drill technique. Methods: This study included 191 patients (297 eyes) with nasolacrimal duct stenoses or obstructions who underwent endoscopic dacryocystorhinostomy using the hammer-chisel or drill technique. Surgical outcomes were compared via follow-up screening for epiphora and anatomical complications such as granuloma and fibrous membrane formation, canalicular obstruction, and synechiae. Results: Postoperative anatomical complications occurred in 29 eyes (18.6%) in the hammer-chisel group and 51 eyes (36.2%) in the drill group (p = 0.001). The anatomical failure rate was higher in the drill group [28 eyes (19.9%)] than in the hammer-chisel group [18 eyes (11.5%); p = 0.038]. Functional failure was observed in 13 eyes (8.3%) in the hammer-chisel group and 13 eyes (9.2%) in the drill group (p = 0.787). The mean operation time was significantly longer in the drill group (35.5 ± 10.4 minutes vs. 25.4 ± 9.1 minutes) (p < 0.001). Conclusions During endoscopic dacryocystorhinostomy, osteotomy with a hammer-chisel is more successful and leads to fewer complications than osteotomy with a drill.

Purpose: To compare the level of agreement between the Goldmann applanation tonometer (GAT), iCare IC200 rebound tonometer (IRT), and noncontact tonometer (NCT) in patients who underwent Descemet membrane stripping endothelial keratoplasty (DSEK), and to identify factors contributing to variations in intraocular pressure (IOP) measurements among the three tonometers. Methods: We retrospectively analyzed the medical records of 41 patients who underwent DSEK. IOP was measured using NCT, IRT, and GAT, in this order. We evaluated the level of agreement among IOP measurements using the three tonometers, and analyzed whether clinical factors affected the results. Results: We analyzed 49 eyes of 41 patients (average age: 62.0 years). The IOP values measured by IRT and NCT were lower than those measured by GAT, although the difference was not significant (p = 0.098 and p = 0.320, respectively). A Bland-Altman plot showed greater agreement between IOP measurements obtained by IRT and GAT than those obtained by NCT and GAT. In multivariate regression analysis, the IOP measured by GAT (β = 0.215, p = 0.022), corneal curvature (β = -1.692, p = 0.037), and postoperative duration (β = 0.042, p = 0.018) affected the difference in IOPs measured by GAT and IRT. The IOP measured by GAT (β = 0.301, p = 0.013) and corneal curvature (β = -2.670, p = 0.010) affected the difference in IOP measurements obtained by GAT and NCT. Conclusions In DSEK eyes, IRT showed good agreement and high correlation with GAT, suggesting that it is useful for IOP measurement. However, the IOP measured by GAT, corneal curvature, and postoperative duration should be considered when measuring IOP with an IRT.

Purpose: To report a case of orbital infarction syndrome in a patient with hemophagocytic lymphohistiocytosis (HLH).Case summary: A 70-year-old woman with diabetes mellitus and hypertension was referred to the Department of Ophthalmology for sudden-onset left upper eyelid ptosis after being diagnosed with HLH. After 3 days, the best corrected visual acuity in the right eye was 0.8, while there was no light perception in the left eye. In the left eye, the ocular motility examination showed limitations in all fields of gaze. On fundus examination, optic disc pallor, retinal hemorrhage, and narrowed retinal arteries were observed in the left eye. Fluorescein angiography showed no blood flow in the retinal arteries and veins in the left eye. On neck computed tomography angiography, the left distal internal carotid artery was narrowed. Orbit computed tomography showed exophthalmos and extraocular muscle hypertrophy in the left eye. Orbit magnetic resonance imaging confirmed optic nerve edema, enhancement of the optic nerve sheath, and high signal intensity of the intraocular fat in the left eye. Slit-lamp examination revealed ischemia of the anterior segment and ischemic necrosis of the eyelid in the left eye. The patient was diagnosed with orbital infarction syndrome. Conclusions Several factors may lead to ischemia of the orbital tissues in patients with HLH, including coagulopathy, an increased incidence of blood clots, and inflammation in the orbit. It is necessary to consider the possibility of orbital infarction syndrome when HLH patients present with visual loss, ocular movement limitations, and anterior segment ischemia.

Purpose: To investigate the relative risks (RRs) for dementia among individuals with glaucoma. Methods: We conducted a search of PubMed, Web of Science, Scopus, and Cochrane databases for observational cohort studies examining the association between glaucoma and dementia until March 2023. Two authors independently screened all titles and abstracts according to predefined inclusion and exclusion criteria. Pooled RR and 95% confidence intervals (CIs) were generated using random-effect models. Results: The meta-analysis included 18 cohort studies conducted in eight countries and involving 4,975,325 individuals. The pooled RR for the association between glaucoma and all-cause dementia was 1.314 (95% CI, 1.099–1.572; I2 = 95%). The pooled RRs for the associations of open-angle glaucoma with Alzheimer dementia and Parkinson disease were 1.287 (95% CI, 1.007–1.646; I2 = 96%) and 1.233 (95% CI, 0.677–2.243; I2 = 73%), respectively. The pooled RRs for the associations of angle-closure glaucoma with all-cause dementia and Alzheimer dementia were 0.978 (95% CI, 0.750–1.277; I2 = 17%) and 0.838 (95% CI, 0.421–1.669; I2 = 16%), respectively. No evidence of publication bias was detected in the Begg-Mazumdar adjusted rank correlation test (p = 0.47). Conclusions Based on current observational cohort studies, there is evidence supporting that glaucoma is a risk factor for dementia in the adult population.

Purpose: To report a rare case of severe ocular hypertension following intravenous methylprednisolone treatment in a child with bilateral optic neuritis.Case summary: A 6-year-old girl presented with bilateral severe visual loss and disc swelling. Magnetic resonance imaging revealed optic nerve enhancement, and she received high-dose intravenous methylprednisolone for 3 days and oral prednisolone 30 mg/day for 2 weeks. Two weeks after initiating treatment, ophthalmologic examination revealed an intraocular pressure (IOP) of 46 mmHg in the right eye and 42 mmHg in the left eye. The best-corrected visual acuity was 1.0 in the right eye and 0.6 in the left eye. Relative afferent pupillary defect was noted in the left eye. Fundus examination showed normal cup-to-disc ratio (0.4) in both eyes. The iridocorneal angle was open in all directions. The treatment plan included the cessation of oral prednisolone and initiation of latanoprost and dorzolamide-timolol fixed combination agent. After 12 hours, the IOP decreased to 18 mmHg in the right eye and 14 mmHg in the left eye. Six months later, her visual acuity was 1.0 in both eyes, and IOP was maintained at 11 and 13 mmHg in the right and left eye, respectively. Optic disc examination showed no sign of glaucomatous change with normal cup-to disc ratio in both eyes. Conclusions Since steroid medication may cause asymptomatic IOP elevation, regular intraocular pressure measurements are required during steroid treatment for pediatric optic neuritis. The administration of IOP-lowering eyedrops returned IOP to the normal range without damaging the optic nerve.

Purpose: To investigate changes in intraocular pressure (IOP) and iridocorneal angle (ICA) configuration during smartphone use under room light. Methods: We included healthy adults aged 19-35 years with no ophthalmological abnormalities. All read text on a smartphone for 6 minutes under room light. IOP was measured via rebound tonometry at baseline and at 2, 4, and 6 minutes. ICA images were obtained via anterior segment optical coherence tomography after each IOP measurement. After 6 minutes, participants stopped reading text and rested for 2 minutes. IOP was then measured again. Results: The IOP significantly increased at 2, 4, and 6 minutes of reading compared to baseline (p < 0.001) but recovered to baseline after 2 minutes of rest (p = 1.000). The anterior chamber depth decreased significantly, and the anterior chamber angle width increased after 6 minutes of smartphone reading (both p < 0.05). Conclusions IOP increased when reading smartphone text under room light but the ICA did not change. Prolonged smartphone reading is inappropriate for a patient at risk of glaucoma or glaucoma progression. Such patients should be cautioned.

Objective: This study examined the mediating effect of mindfulness and consciousness among five factors on the effect of stress on Internet game addiction tendency. Methods: An online survey was conducted on 400 men and women between their 20s and 40s across Korea. The scales used in the study were the Internet game addiction scale based on the DSM-5, Perceived Stress Scale, Mindfulness Scale, and Five-Factor Personality Scale. For data analysis, structural equation modeling was conducted, and Sobel verification was carried out to verify the significance of the mediating effects. Results: The results of the study are as follows: Stress showed a positive correlation with Internet game addiction tendency, mindfulness mediated the effect of stress on Internet game addiction tendency. Conclusion Of the five personality factors, conscientiousness also mediated the effect of stress on Internet game addiction tendency. This study highlights the need for further research for individuals with game addiction tendency.

Purpose: To investigate changes in intraocular pressure (IOP) and iridocorneal angle (ICA) configuration during smartphone use under room light. Methods: We included healthy adults aged 19-35 years with no ophthalmological abnormalities. All read text on a smartphone for 6 minutes under room light. IOP was measured via rebound tonometry at baseline and at 2, 4, and 6 minutes. ICA images were obtained via anterior segment optical coherence tomography after each IOP measurement. After 6 minutes, participants stopped reading text and rested for 2 minutes. IOP was then measured again. Results: The IOP significantly increased at 2, 4, and 6 minutes of reading compared to baseline (p < 0.001) but recovered to baseline after 2 minutes of rest (p = 1.000). The anterior chamber depth decreased significantly, and the anterior chamber angle width increased after 6 minutes of smartphone reading (both p < 0.05). Conclusions IOP increased when reading smartphone text under room light but the ICA did not change. Prolonged smartphone reading is inappropriate for a patient at risk of glaucoma or glaucoma progression. Such patients should be cautioned.

Objective: This study examined the mediating effect of mindfulness and consciousness among five factors on the effect of stress on Internet game addiction tendency. Methods: An online survey was conducted on 400 men and women between their 20s and 40s across Korea. The scales used in the study were the Internet game addiction scale based on the DSM-5, Perceived Stress Scale, Mindfulness Scale, and Five-Factor Personality Scale. For data analysis, structural equation modeling was conducted, and Sobel verification was carried out to verify the significance of the mediating effects. Results: The results of the study are as follows: Stress showed a positive correlation with Internet game addiction tendency, mindfulness mediated the effect of stress on Internet game addiction tendency. Conclusion Of the five personality factors, conscientiousness also mediated the effect of stress on Internet game addiction tendency. This study highlights the need for further research for individuals with game addiction tendency.