Preliminary repair of eyelids for the treatment of opaque corneas caused by burns

The treatment of opaque cornea as a result of a burn is challenging, because the cornea often re-opacifies even after transplantation. One of the main risk factors is the deformity of the eyelids, and we have developed a new treatment for this. Preliminary repair of the lower eyelid is done by an auricular composite graft before transplantation, so that the grafted materials can be safely protected by the eyelids. The results of treatment since have greatly improved. Preliminary repair of the eyelid is an effective way to secure successful transplantation.

Efficacy of core vitrectomy preceding triple corneal procedure

AIMS

To evaluate the effectiveness of core vitrectomy preceding triple corneal procedure (penetrating keratoplasty, extracapsular cataract extraction, and intraocular lens (IOL) implantation).

METHODS

Thirty one consecutive eyes of 31 patients with indication for triple corneal procedure were randomly assigned to either triple procedure with core vitrectomy (vitrectomy group) or without vitrectomy (control group). The success rate of IOL implantation, IOL positioning, intraoperative and postoperative complications, endothelial cell loss, and best corrected visual acuity (BCVA) were compared. Follow up period was six months. Factors that may contribute to vitreous pressure elevation were also investigated in each case.

RESULTS

There was no statistically significant difference in each clinical parameter examined except a tendency of facilitating IOL implantation (p = 0.11). There were two cases of vitreous loss in the control group. Retinal detachment was not seen in any of the cases. The body mass index and age were related to higher vitreous pressure (p<0.05).

CONCLUSION

Core vitrectomy preceding triple corneal procedure is not necessary for all cases.

Retinal ischemia and angle neovascularization in proliferative diabetic retinopathy

PURPOSE

To analyze the relationship between the extent of retinal ischemia in proliferative diabetic retinopathy and angle neovascularization.

METHODS

Panoramic fundus fluorescein angiography and 360-degree fluorescein gonioangiography to detect the angle neovascularization were performed on 70 eyes of 46 patients with proliferative diabetic retinopathy. Statistical significance was evaluated by chi-squared test. Statistical significance was evaluated if the value (T) was greater than the level of significance, chi(0.05)(2)(2) = 5.99.

RESULTS

Retinal ischemia in fluorescein angiography was evaluated in four areas: capillary occlusion in (1) temporal raphe; (2) radial peripapillary capillaries; (3) the midperiphery (grade I, less than 25% of the area; grade II, 25% to 50%; grade III, 50% to 75%; grade IV, more than 75%); and (4) optic disk with neovascularization. The angle neovascularization was divided into two types: type I (14 eyes) and type II (12 eyes). Capillary occlusion in the temporal raphe and radial peripapillary capillaries, and papillary leakage significantly increased the risk of angle neovascularization (T = 8.28, 10.04, 6.44 respectively). Grade III and IV capillary occlusion in the midperiphery had a significant risk of angle neovascularization when compared with grade I (between grade III: T = 9.03, grade IV: T = 19.36) and II (between grade III: T = 6.31, grade IV: T = 16.09).

CONCLUSION

Risk factors for angle neovascularization were retinal nonperfusion in the midperiphery wider than grade III, capillary occlusion in the radial peripapillary capillaries and temporal raphe, and optic disk. Fluorescein gonio angiography was found to be a powerful tool for the early detection of angle neovascularization, especially in dark irides.

[Histopathological study of a case with glaucoma due to Sturge-Weber syndrome]

PURPOSE

To investigate by histopathology the cause of secondary glaucoma due to Sturge-Weber syndrome.

CASE

A 10-year-old boy with Sturge-Weber syndrome and glaucoma in the right eye is reported. Trabeculectomy was performed because of uncontrolled intraocular pressure and the trabeculectomy specimen was examined histologically by both light and electron microscopy.

RESULTS

Histological examination of the trabeculectomy specimen showed the ciliary muscle dislocated anteriorly and there was no Schlemm's canal. The spaces in juxtacanalicular connective tissue(JCT) were replaced by vascular structures and connective tissue. There were two kinds of vascular structures, one where the endothelium was surrounded by pericytes and the other where it was not surrounded by pericytes.

CONCLUSIONS

Developmental abnormalities of Schlemm's canal and JCT may have caused glaucoma in this case. These observations suggested that development of both mesoderm and neural crest might be involved in the pathogenesis of glaucoma due to Sturge-Weber syndrome.

Vitrectomy for diabetic macular edema: the role of posterior vitreous detachment and epimacular membrane

PURPOSE

To evaluate the surgical efficacy of pars plana vitrectomy on eyes with diabetic macular edema in the presence or absence of a complete posterior vitreous detachment and with or without an epimacular membrane.

METHODS

Pars plana vitrectomy was performed on 30 eyes of 29 cases with diabetic macular edema. Visual acuity was measured, and retinal thickness was determined by optical coherence tomography before and after vitrectomy. To evaluate the relationship between the effects of vitrectomy and the presence or absence of posterior vitreous detachment and/or epimacular membrane, all eyes were placed into one of four groups: group A, eyes with posterior vitreous detachment and epimacular membrane; B, eyes with posterior vitreous detachment and without epimacular membrane; C, eyes without posterior vitreous detachment and with epimacular membrane; and D, eyes without posterior vitreous detachment and without epimacular membrane. The expression of vascular endothelial growth factor and interleukin-6 was investigated immunohistochemically in epimacular membrane specimens obtained from seven eyes with diffuse diabetic macular edema.

RESULTS

The postoperative mean visual acuity (0.653 +/- 0.350: mean +/- SD logarithm of minimal angle of resolution [logMAR]) was significantly better than the mean preoperative visual acuity (0.891 +/- 0.319 logMAR; Wilcoxon signed-rank test, P =.0007). The postoperative foveal thickness (264.5 +/- 118.6 microm) was significantly thinner than the preoperative foveal thickness (477.8 +/- 147.7 microm; Wilcoxon signed-rank test, P <.0001). There were no significant differences in the improvement of visual acuity and decrease of foveal thickness between the four groups (Kruskal-Wallis test, P =.13, P =.65, respectively). All of the epimacular membranes obtained at surgery expressed vascular endothelial growth factor and interleukin-6.

CONCLUSIONS

These results demonstrated that vitrectomy with removal of epimacular membrane is generally an effective procedure in reducing diabetic macular edema, and the outcome does not depend on the presence absence of posterior vitreous detachment and epimacular membrane.

Surgical outcomes in juvenile retinal detachment

PURPOSE

To evaluate retrospectively clinical features and surgical outcomes of rhegmatogenous retinal detachment in juvenile patients.

METHODS

Between 1991 and 1996, 28 patients younger than 15 years of age with rhegmatogenous retinal detachment (32 eyes) underwent the first surgical procedure, scleral buckling and/or pars plana vitrectomy, at our hospital.

RESULTS

The major types of juvenile detachment, in order of frequency, were idiopathic, familial exudative vitreoretinopathy, trauma, and high myopia. Proliferative vitreoretinopathy (PVR) of grade C or D was involved in 12 cases (37.5%). Among the 12 eyes with PVR, 7 attained retinal reattachment after the first surgery with scleral buckling. The overall reattachment rate was 28/32 (87.5%) after the first operation and 30/32 (93.8%) after the second operation.

CONCLUSION

These findings indicate that the reattachment rate and visual prognosis can be as good in juvenile retinal detachment as in adult cases, when appropriate surgical procedures are used.

[Anesthesia for severely burned patients--23 operations in 8 burned patients]

Severely burned patients require repeated debridement or skin grafting soon after the burn injury until the closure of the injury. We retrospectively examined 23 operations in 8 severely burned patients who had undergone debridement or skin grafting more than twice within 30 days. We classified 23 operations into 1st to 4th categories according to days after the burn injury and compared each group regarding intraoperative fluid balance, hypovolemia and perioperative complications. In the 3rd or 4th operation, mean blood loss and fluid administration were more than those of the 1st or 2nd operation. Respiratory dysfunctions or circulatory complications such as hypotension, oliguria occurred more frequently during or after the 3rd or 4th operation. Since patients are in hyperdynamic and hypercatabolic state at the time of the 3rd or 4th operation patients, they will be easily damaged in the peri-operative period. This study suggests that we should bear in mind, in the anesthetic management of burned patients, that they can be in hyperdynamic state as well as in shock state.