Comparison of Schlemm's Canal Morphology Parameters Between Propensity Score-Matched Primary Open-Angle Glaucoma and Exfoliation Glaucoma

Purpose

This study aimed to histologically compare the status of Schlemm's canal (SC) and Schlemm's canal endothelial (SCE) cells between trabeculectomy specimens from patients with primary open-angle glaucoma (POAG) and exfoliation glaucoma (EXG).

Methods

A total of 182 eyes from 152 patients with POAG and 138 eyes from 116 patients with EXG underwent immunohistochemical staining for thrombomodulin. Equal numbers of cases were selected from both groups using propensity score matching. The following parameters were evaluated: total SC length, staining positive and negative SC length (PSC and NSC, respectively), opened and closed SC length, staining positive and opened SC length, staining positive and closed SC length, staining negative and opened SC length (NOSC), and staining negative and closed SC length.

Results

After matching for age and gender, 87 cases were selected in each group. The EXG group had significantly higher preoperative IOP and medication scores. PSC was significantly longer in the POAG group, while NSC and NOSC were longer in the EXG group. Multiple regression analysis of these 174 cases revealed that PSC was significantly shorter in the EXG group. After matching for age, gender, preoperative IOP, and medication score, 64 cases were selected in each group, and NOSC was significantly longer in the EXG group.

Conclusions

These findings suggest that in EXG, SCE loss occurs independently of background factors such as aging and medication use. The loss of SCE may have a more critical impact on IOP elevation in EXG compared to POAG.

The effects of the first versus second glaucoma drainage implant surgery in patients with primary open-angle glaucoma

BACKGROUND

To investigate the outcome of non-valved glaucoma drainage implant surgery (GDIS) in primary open-angle glaucoma (POAG) patients divided in the first GDI group (patients who underwent the first GDIS) and the second GDI group (patients who underwent the second GDIS because of the failed first GDIS).

METHODS

Intraocular pressure (IOP), visual acuity (VA), visual field defect (VFD), medication score (MS), survival rate of GDIS, complications, and patient background was retrospectively analyzed. Two success criteria were set: Criteria (1) IOP reduction ≥ 20% and 5 < IOP ≤ 21, Criteria (2) IOP reduction ≥ 20% and 5 < IOP ≤ 14.

RESULTS

There were 136 eyes of 109 patients in the first GDI group and 32 eyes of 27 patients in the second GDI group. In the first GDI group and II, mean preoperative IOP was 26.7 ± 6.7 mmHg and 23.7 ± 3.5 mmHg, respectively (P = 0.09). No statistically significant difference in postoperative IOP reduction was found between the two groups (P = 0.39). At 5-years postoperative, the Criteria 1 (Criteria 2) survival rate in the first GDI group and the second GDI group was 60.4% (31.7%) and 61.2% (25.6%), respectively (Criteria 1: hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.30-1.35 [P = 0.24]; Criteria 2: HR: 0.81, 95% CI: 0.46-1.44, P = 0.48). No significant difference in VA, VFD change, MS, or complications was observed. Young patient age was the only significant factor for failure in the first GDI group (odds ratio: 0.95, 95% confidence interval: 0.91-1.00, P = 0.03).

CONCLUSION

The second GDIS may be as effective as the first GDIS for IOP reduction in POAG patients, however, there is a high risk of failure in young-age patients and the surgery may be ineffective in eyes requiring Criteria 2.

Different patterns in the corneal endothelial cell loss after pars plana and pars limbal insertion of the Baerveldt glaucoma implant

PURPOSE

To assess corneal endothelial cell (CE) loss after pars plana (PP) and pars limbal (PL) insertion of a Baerveldt glaucoma implant (BGI).

DESIGN

Retrospective multicenter interventional comparative study.

METHODS

We studied central CE loss for 5 years after BGI surgery in 192 eyes.

RESULTS

The prevalence of bullous keratopathy (BK) was greater in the PL cohort than in the PP cohort (P = .003). The CE loss after simultaneous PP vitrectomy and tube insertion into the vitreous cavity was 11.9% in the first year, which was greater than that of 2.9% in eyes where the tube was inserted simply into the vitreous cavity after a prior vitrectomy (P = .046). The annual percentage CE loss after the first year decreased unidirectionally in both of those groups and was 1.3% and 1.0% in the fifth year, respectively (P < .001). For limbal insertion, the CE loss in the simple PL cohort was biphasic, decreasing from 10.5% in the first year to 7.0% in the fifth year. Simultaneous cataract and BGI surgery enhanced the CE loss slightly in the first year in the PP and PL cohorts to 13.0% and 14.0%, respectively. However, these increases were not significant (P = .816 and .358, respectively). Low preoperative CE density (P < .001) and insertion site (P = .020) were significant risk factors for the development of BK.

CONCLUSIONS

CE loss in the PL and PP cohorts was biphasic and unidirectional, respectively. The difference in annual CE loss became evident over time. PP tube implantation may be advantageous when the preoperative CE density is low.

Barium-induced toxic anterior segment syndrome

Toxic anterior segment syndrome (TASS) is a rapid-onset inflammation of the eye following uneventful ocular surgery. We report a case of TASS following Baerveldt glaucoma implant (BGI) surgery. Inductively coupled plasma-mass spectrometry (ICP-MS) identified barium in the eye and in the eluate from the bleb of the BGI. We attribute TASS in our patient to the dissolution of barium from the BGI and its entry into the eye, where it causes severe inflammation.

Comparisons of Schlemm's canal and trabecular meshwork morphologies between juvenile and primary open angle glaucoma

The histologic differences in Schlemm's canal (SC) and trabecular meshwork (TM), obtained from the trabeculectomy specimens of different age-group glaucoma patients, were compared. This study involved 44 trabeculectomy specimens of 37 juvenile-onset open-angle glaucoma (JOAG) patients (Group A) and 24 trabeculectomy specimens of 24 elderly-onset primary OAG (POAG) patients (age range: 70-79 years, Group B) with no familial history of POAG. Clinical parameters of gender, maximum intraocular pressure (IOP), and the number of glaucoma medications used prior to trabeculectomy were investigated and compared between the two groups. From light microscopy photographs of hematoxylin-eosin, and immunohistochemical staining of markers for SC endothelium (SCE), the total SC length (TSC), comprised of the opened-SC length (OSC) and the closed-SC length (CSC), the percentage of CSC in TSC (%CSC), the percentage of positive SCE marker in CSC (%PinCSC), and the percentage of negative SCE marker in OSC (%NinOSC) were analyzed. Moreover, podoplanin staining patterns in the TM were investigated and compared between the two groups. Among the clinical parameters, the mean maximum IOP in Group A (33.41 ± 9.24 mmHg) was the only significant parameter when compared to that in Group B (22.96 ± 7.17 mmHg, P = 0.000003). TSC in Group A was significantly shorter than that in Group B (P = 0.00092), and %CSC (P = 0.00004) and %PinCSC (P = 0.00342) in Group B were significantly higher than those in Group A. No statistically significant difference in %NinOSC was found between Group A and Group B (P = 0.76060). Juxtacanalicular tissue (JCT) in Group A showed compact and weak staining with podoplanin, while the JCT and closed-SC area in Group B showed intense staining. In the Group A subjects, TSC (P = 0.04819) and OSC (P = 0.02867) were significantly shorter in the non-familial cases than in the familial cases. Platelet coagulations 10-37 μm in size at the defect of the SCE in the inner wall of the SC were observed in 8 eyes (18%) and 4 eyes (17%) in Group A and Group B, respectively. The platelets appeared to repair the SCE damage for maintaining the blood aqueous barrier in both groups of POAG eyes. Smaller SC diameters and accompanying TM abnormality were features observed in the young-onset JOAG patients, thus suggesting developmental abnormalities in the outflow routes. The collapse of SC lumen, presumably due to aging, was the feature observed in the elderly-onset POAG patients. In Group A, the significantly higher IOP, despite of no significant number of topical medications used prior to trabeculectomy, also suggested that JOAG eyes can be categorized as a distinct type of POAG from the eyes of elder-aged POAG patients. The SCE drop out observed in the glaucomatous eyes of the different age groups suggested that worsening of IOP control may possibly occur equally in both groups.

A case series of endoscopic cyclophotocoagulation with 532-nm laser in Japanese patients with refractory glaucoma

PURPOSE

To report an initial case series of Japanese patients with refractory glaucoma treated with endoscopic cyclophotocoagulation (ECP) using an ECP device that was equipped with a 532-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser.

METHODS

This observational case series included 10 consecutive glaucomatous eyes (7 with primary open-angle glaucoma; 3 with secondary glaucoma after cataract surgery) of 10 Japanese subjects (7 men, 3 women; mean age ± standard deviation, 65.7 ± 15.0 years) who underwent ECP to control intraocular pressure (IOP), and preserve visual function. Age, sex, glaucoma type, ocular surgical history, preoperative and postoperative logarithm of the minimum angle of resolution visual acuity (VA), IOP, number of antiglaucoma medications, perioperative complications, and treatments for complications were collected from the medical and surgical records. The IOP and numbers of antiglaucoma medications were compared between preoperative and postoperative values.

RESULTS

The mean preoperative IOP (27.3 ± 5.4 mm Hg; range, 19-36) and number of antiglaucoma medications (4.4 ± 0.8; range, 3-6) decreased significantly by 53% and 39% ( p = 0.0005 and p = 0.0043, respectively) to 12.9 ± 5.2 mm Hg (range, 8-20) and 2.7 ± 1.4 (range, 0-4), respectively, at the final visit. Compared with preoperative values, a mixed-effect regression model showed significant decreases in the IOP and numbers of medications at every time point up to 24 months postoperatively. No phthisis bulbi or persistent hypotony was recorded. At the final visit, compared with preoperative values, the VA decreased in three eyes by >0.2 unit because of glaucoma progression.

CONCLUSIONS

ECP with Nd:YAG laser is a reasonable option in eyes with refractory glaucoma.

A Histologic Categorization of Aqueous Outflow Routes in Familial Open-Angle Glaucoma and Associations With Mutations in the MYOC Gene in Japanese Patients

Purpose

This study evaluated specific relationships between pathogenic mechanisms and genetic polymorphisms in primary open-angle glaucoma (POAG). We analyzed the morphologies of trabeculectomy specimens obtained from patients with familial POAG.

Methods

We used light microscopy and transmission electron microscopy to examine specimens obtained from 17 eyes of 14 patients with familial POAG. We also conducted exome analyses of two families and used targeted Sanger sequencing to analyze samples obtained from the remaining patients.

Results

The POAG cases examined in this study were divided into two groups based on morphologic characteristics. Group A eyes (7 eyes from 5 patients) had an abnormally thick trabecular meshwork (TM), whereas group B eyes (10 eyes from 9 patients) had a TM of normal thickness. The characteristics of the outflow routes in group A eyes were remarkable and included apoptotic TM cells, abnormally thickened TM basement membranes, fused TM beams, and occluded Schlemm's canals. All group A patients harbored mutations (F369L, P370L, T377M, and T448P) in the myocilin (MYOC) gene that were not found in group B patients.

Conclusions

Although age matching of morphologic changes in the outflow routes was impossible due to the small sample size, this study suggests that abnormal TM cells may cause sequential damage in abnormally thickened TM basement membranes, TM cell apoptosis, TM beam fusion, and the occlusion of Schlemm's canals. The four detected MYOC mutations appeared to be associated with morphologic changes in the TM and the underlying pathogenesis of a subtype of familial POAG.

Histological Findings in the Trabecular Meshwork of a Patient with Atopic Glaucoma

Purpose:

The aim of this study was to report a case of atopic dermatitis showing elevated intraocular pressure (IOP) beyond the baseline levels followed by a modified 360-degree suture trabeculotomy, and to analyze the histological findings in the trabecular meshwork.

Methods:

A 40-year-old male suffered from blurred vision in the right eye (OD). He had a medical history of severe atopic dermatitis and intraocular lens implantation OU due to atopic cataract. At the initial presentation, the visual acuity was 0.03, and IOP was 35 mmHg OD. Slit-lamp examination demonstrated corneal epithelial edema OD. Increased IOP was refractory to several topical medications. The patient underwent a modified 360-degree suture trabeculotomy. The visual field defect, however, deteriorated with persistently high IOP. The patient underwent trabeculectomy together with drainage implant surgery. In the outflow routes, although there seemed to be an opening of Schlemm’s canal into the anterior chamber, there was no endothelium of the canal in the region of its opening. The fibrotic changes were conspicuous around Schlemm’s canal.

Conclusion:

The histological results indicated that trabeculotomy might not be an appropriate treatment for patients with atopic glaucoma, possibly because of excessive repair to the newly created uveoscleral outflow in addition to the increased postoperative fibrosis in the trabecular meshwork and Schlemm’s canal.

Long-term results of non-valved glaucoma drainage implant surgery and glaucoma drainage implant combined with trabeculectomy

Purpose:

The purpose was to investigate the efficacy and complications of nonvalved glaucoma drainage implant (GDI) surgery and GDI combined with trabeculectomy.

Subjects and Methods:

Serial Japanese patients who received GDI were retrospectively investigated. The survival rate of eyes was analyzed using the Kaplan-Meier method, defining death as: (1) Intraocular pressure (IOP) <6 mmHg, or ≥22 mmHg, and <20% reduction of preoperative IOP, (2) additional glaucoma surgery, (3) loss of light perception. Prognostic factors of age, sex, previous surgery, type of glaucoma, synechial closure, preoperative IOP, type of GDI (single-, double-plate Molteno, Baerveldt 350) and GDI combined with trabeculectomy were investigated employing proportional hazards analysis.

Results:

One hundred and twenty-four eyes of 109 patients aged 53.3 ± 7.8 years old were analyzed. Types of GDI were single-plate (15.3%), double-plate Molteno (71.8%), and Baerveldt 350 (12.9%). The results of survival rate analysis were 86.1, 71.1, 71.1, and 64.6% for 1, 3, 5, and 10 years respectively. Thirty-four eyes (27.4%) died because of uncontrolled IOP (19.4%), loss of light perception (5.6%), and additional glaucoma surgery (2.4%). Single-plate Molteno was the only risk factor for failure. Persistent unphysiological hypotony (0.8%) and bullous keratopathy (5.6%) were observed.

Conclusion:

Nonvalved GDI surgery and GDI combined with trabeculectomy using nonabsorbable tube ligature proved to be an excellent device for any type of glaucoma in Japanese patients. Hypotony and corneal endothelial loss are the most serious complication in the long-term results of our patients.

The Early Postoperative Complications of Two Different Tube Ligation Methods in Baerveldt Implant Surgery

Objective: To investigate the early postoperative complications in two different tube ligation methods during the first 3 months in Baerveldt implant surgery.

Participants: This study involved 157 eyes from 144 patients who underwent Baerveldt Implant Surgery at the Japanese Red Cross Medical Center, Tokyo, Japan.

Methods: Pre- and postoperative intraocular pressure (IOP), combined surgery, postoperative time-point of tube ligation release, and postoperative complications in two different tube ligation methods [absorbable ligation method using 8-0 polyglactin suture (group A) and nonabsorbable ligation method using 7-0 nylon suture (group B)] were retrospectively reviewed.

Results: After excluding eyes that had undergone combined trabeculectomy (26 eyes) and vitrectomy (2 eyes), eyes with previous tube surgery (22 eyes), and eyes that had undergone the stent method (1 eye), 30 of 28 patients in group A and 71 eyes of 71 patients in group B were found to fit the criteria of this study. The rate of successful surgical outcome was 80% in group A and 74.6% in group B (p = 0.705). During the 3 months postoperative, high IOP tended to occur more often in group B (67.6%) than in group A (46.7%) (p = 0.073), and ciliochoroidal detachment tended to occur more often in group A (10.0%) than group B (2.8%) (p = 0.154).

Conclusion: The results of this study show that both ligation methods are effective, however, the selection of tube ligation method should be done in accordance with the different method-specific risks to which may occur.

How to cite this article: Kawamorita S, Hamanaka T, Sakurai T. The Early Postoperative Complications of Two Different Tube Ligation Methods in Baerveldt Implant Surgery. J Curr Glaucoma Pract 2014;8(3):96-100.

Histopathology of the trabecular meshwork and Schlemm's canal in primary angle-closure glaucoma

PURPOSE

To investigate the detailed histopathology of trabecular meshwork changes associated with primary angle closure glaucoma (PACG).

METHODS

Thirty trabecular blocks obtained from trabeculectomy (TLE) of 25 PACG patients were embedded in paraffin for immunohistochemical staining of thrombomodulin, CD68, D2-40, and epon for transmission electron microscopy. Eleven TLE blocks obtained from normal-tension glaucoma patients were used as a control. Histologic changes of outflow routes were analyzed by comparing the existence of iridotomy, gonioscopy-evaluated angle closure, intraocular pressure (IOP), episodes of acute attack, visual field defect classified by Aulhorn-Greve, anterior chamber depth, lens thickness, and axial length.

RESULTS

Occlusion of the Schlemm's canal (SC) of <150 μm was observed in 11 eyes, which significantly correlated with gonioscopy-evaluated angle closure (T = 19.33 > χ² (f,α) = 9.488). Moderate correlation between SC occlusion and IOP before TLE was also observed (correlation coefficient: -0.540). Slightly negative or no correlations were found between SC occlusion and the other parameters. Thinned SC endothelium at the junction or degenerated SC endothelium and various degrees of SC occlusion and fusion of the trabecular beams where trabecular cells degenerated with damaged mitochondria were the general findings in the PACG eyes involved in this study.

CONCLUSIONS

Persistent trabecular-iris contact or peripheral anterior synechia may block aqueous outflow resulting in a progressive process of SC endothelial damage and subsequent SC occlusion, as well as trabecular cell damage possibly due to impairment of mitochondrial function and subsequent fusion of the trabecular beams. These changes may be the reason for residual glaucoma after laser iridotomy or cataract surgery.

Sarcoidosis with acute recurrent polyarthritis and hypercalcemia

A 45-year-old woman had bleary eyes and recurrent episodes of fever and arthritis in the knees and ankles. The patient had anterior uveitis, negative findings of the tuberculin test, and an increased serum lysozyme level, but bilateral hilar lymphadenopathy (BHL) was absent. During the course of her disease, the serum calcium and angiotensin-converting enzyme levels gradually increased to above the normal level, and the patient was clinically diagnosed as having sarcoidosis. The clinical features of arthritis were typical of those of Löfgrens syndrome although BHL and erythema nodosum were absent. The patient was successfully treated with 15 mg/day of prednisolone.

A case of Chandler's syndrome revealed by ultrastructural studies of the trabecular meshwork

PURPOSE

To investigate ultrastructural changes in the aqueous outflow route and discuss the mechanisms associated with intraocular pressure (IOP) elevation in a patient with presumably early stage Chandler's syndrome.

METHODS

A 47-year-old man underwent trabeculectomy because of elevated IOP. A specimen obtained during surgery was studied by transmission electron microscopy.

RESULTS

Electron microscopy showed the presence of a monolayer composed of corneal endothelium-like cells and thick basement membrane-like material. Neovascularization was also observed in the corneoscleral trabeculum.

CONCLUSIONS

Our results indicate that several mechanisms, including the formation of basement membrane-like tissue, infiltration of inflammatory cells and neovascularization, might contribute to the elevation of IOP in Chandler's syndrome. These may occur even when there is no history of conspicuous inflammatory reaction in the anterior ocular segments.

The efficacy and safety of dose escalation of dorzolamide used in combination with other topical antiglaucoma agents

We investigated the dose-escalation profile of dorzolamide used in combination with other antiglaucoma agents in patients with primary glaucoma and ocular hypertension. In a prospective, open-label study, 78 patients received dorzolamide 0.5% in addition to other topical antiglaucoma agents for > or =4 weeks. The concentration of dorzolamide was then escalated to 1.0% and intraocular pressure (IOP) measured every 4 weeks for 12 weeks. Dose escalation of dorzolamide from 0.5% to 1.0% resulted in a significant reduction in IOP throughout the 12 weeks of treatment at the higher dose. Mean baseline IOP was 19.7 mmHg. At 4, 8, and 12 weeks after dose escalation, mean IOP had decreased to 17.8 (-9.4%), 17.6 (-10.8%), and 17.5 (-10.7%) mmHg. No serious drug-related adverse effects were reported. These results indicate that dose escalation of dorzolamide from 0.5% to 1.0% is effective and well tolerated as adjunctive therapy for patients in whom IOP is insufficiently controlled by combination therapy.

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

PURPOSE

To investigate the cause of the secondary glaucoma in a case of Sturge-Weber syndrome by histopathology.

CASE

A 10-year-old boy with Sturge-Weber syndrome and glaucoma in the right eye was studied. 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 that the ciliary muscle was dislocated anteriorly, and the Schlemm canal was not present. The spaces in the juxtacanalicular connective tissue (JCT) were replaced by vascular structures and connective tissue. There were two kinds of vascular structures: in one, the endothelium was surrounded by pericytes; and in the other, the endothelium was not surrounded by pericytes.

CONCLUSIONS

Developmental abnormalities of the Schlemm canal and the JCT may have caused the glaucoma. These observations suggest that the developmental abnormalities of both the mesoderm and the neural crest might be involved in the pathogenesis of the glaucoma in cases of Sturge-Weber syndrome.

Monitoring of morphological development of the arachidonic-acid-producing filamentous microorganism Mortierella alpina

Morphological parameters, such as hyphal growth rate, tip formation rate, tip extension rate and branch formation rate, of Mortierella alpina have been measured using a flow-through chamber under 25 different combinations of carbon and nitrogen concentrations. Morphological parameters were influenced not by C/N ratio but by carbon concentration in the medium. Specific rates of hyphal growth and tip formation both remained constant at a low carbon concentration of 5 g/l. Tip extension rate from one tip was 60 microm tip(-1) h(-1) at a carbon concentration below 15 g/l, and the branching formation rate was independent of carbon concentration. Tip extension rate was a function of specific hyphal growth rate, which in turn was linearly proportional to the specific tip formation rate, demonstrating that tip extension rate was exponentially proportional to the specific tip formation rate. Branch formation rate per hyphal element remained unchanged even at tip extension rates lower than 60 microm tip(-1) h(-1) and at specific hyphal growth rates lower than 0.83 h(-1), but decreased drastically at higher rates of tip extension and hyphal growth.

Pathological study of cases with secondary open-angle glaucoma due to sarcoidosis

PURPOSE

To investigate the cause of secondary open-angle glaucoma due to sarcoidosis.

DESIGN

Observational case series studied by histological methods.

METHODS

Seven trabeculectomy specimens from six patients with secondary open-angle glaucoma due to ocular sarcoidosis (trabeculectomy group) and anterior parts of seven autopsy eyes from four patients (autopsy eye group) diagnosed as confirmed sarcoidosis were processed for light and transmission electron microscopy. Pathological changes of outflow routes were investigated.

RESULTS

Granulomata were found in three eyes of the trabeculectomy group and in three eyes of the autopsy eye group. Part of the Schlemm canal was occluded and replaced by fibrotic tissue and it became narrow in four eyes of the trabeculectomy group and three eyes of the autopsy eye group. The spaces of the trabecular meshwork appeared wide, even in the area close to granulomata and peripheral anterior synechia of the iris. Infiltration of lymphocytes, monocytes, and macrophages around the Schlemm canal was found in all eyes of the trabeculectomy group and in four eyes of the autopsy eye group. The infiltration of these cells was observed not only in the inner wall, but also in the posterior outer wall of the Schlemm canal and the collector channels.

CONCLUSION

"Schlemm canalitis" is proposed from the results of inflammatory cell infiltration around the wall of the canal. The occlusion of the Schlemm canal by granulomata or fibrotic tissue replacement of the canal may play an important role in secondary open-angle glaucoma due to sarcoidosis.

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.

Mycelial pellet intrastructure and visualization of mycelia and intracellular lipid in a culture of Mortierella alpina

The intrastructure of mycelial pellets of Mortierella alpina, which accumulate fatty acids in mycelia, was visualized following labeling with fluorescein isothiocyanate (FITC) and Nile red using fluorescence microscopy. The pellet was an ellipse shape, but its intrastructure was shaped as a doughnut with a cave inside. Using three-dimensional image analysis, it was shown that the lipid was produced on the edge of the pellet, which corresponded to the area where the mycelial density was high. The cavity ratio of the pellet section was determined on the basis of the FITC fluorescence intensity, and in the early culture stage remained at 0.2 in a 10-kl fermentor culture, but finally increased to 0.35. Mycelial pellet volume paralleled the cavity ratio. Application of the technique used here allows analysis of the intrastructure of fungal pellets and new types of fungal biological study.

Headspace solid-phase microextraction and gas chromatographic-mass spectrometric screening for volatile hydrocarbons in blood

Optimization for headspace solid-phase microextraction (SPME) was studied with a view to performing gas chromatographic-mass spectrometric (GC-MS) screening of volatile hydrocarbons (VHCs) in blood. Twenty hydrocarbons comprising aliphatic hydrocarbons ranging from n-hexane to n-tridecane, and aromatic hydrocarbons ranging from benzene to trimethylbenzenes were used in this study. This method can be used for examining a burned body to ascertain whether the victim had been alive or not when the burning incident took place. n-Hexane, n-heptane and benzene, the main indicators of gasoline components, were found as detectable peaks through the use of cryogenic oven trapping upon SPME injection into a GC-MS instrument. The optimal screening procedure was performed as follows. The analytes in the headspace of 0.2 g of blood mixed with 0.8 ml of water plus 0.2 microg of toluene-d8 at -5 degrees C were adsorbed to a 100-microm polydimethylsiloxane (PDMS) fiber for 30 min, and measured using the full-mass-scanning GC-MS method. The lower detection limits of all the compounds were 0.01 microg per 1 g of blood. Linearities (r2) within the range 0.01 to 4 microg per 1 g of blood were only obtained for the aromatic hydrocarbons at between 0.9638 (pseudocumene) and 0.9994 (toluene), but not for aliphatic hydrocarbons at between 0.9392 (n-tridecane) and 0.9935 (n-hexane). The coefficients of variation at 0.2 microg/g were less than 8.6% (n-undecane). In conclusion, this method is feasible for the screening of volatile hydrocarbons from blood in forensic medicine.

The quantitative analysis of three action modes of volatile anesthetics on purple membrane

We quantitatively assessed the spectroscopic changes of purple membrane in relation to the concentrations of a volatile anesthetic. As reported previously, volatile anesthetics show three modes of action on purple membrane. By using an anesthetic for which the concentration in solution could be determined spectroscopically and by applying modified analytical methods regarding the M-intermediate lifetime, we were able to clarify the quantitative relation between anesthetic concentration and each mode of action, a relation which in the past has only been described qualitatively. We also determined through the measurement of transient pH changes with pyranine that the proton pump efficiency per photochemical cycle in an action mode induced with low concentrations of anesthetic does not change from that of the native state. Moreover, we dynamically obtained the individual M-bacteriorhodopsin difference spectrum of each state at room temperature using our flash photolysis system equipped with a wavelength-tunable dye laser. These results demonstrated again that we should clearly distinguish different action modes of anesthetics according to their concentrations.

A Case Report of Neovascular Glaucoma Due to Carotid Artery Occlusive Disease. Diagnosis of Neovascular Glaucoma and Histological Characteristics

Purpose: The methods of diagnosing neovascular glaucoma were evaluated in a case with carotid artery occlusive disease. A trabeculectomy specimen taken from this patient was examined histologically to find the characteristic picture of this slowly progressive neovascular glaucoma.Materials and Methods: The left eye of a 48-year old man with neovascular glaucoma due to carotid artery occlusive disease had been previously diagnosed as uveitis with ocular hypertension. His left eye was examined by fluorescein fundus and gonioangiography. Trabeculectomy was performed because of uncontrolled intraocular pressure and the trabeculectomy specimen was examined histologically including immunohistochemistry with antibodies against von Willebrand factor antigen.Results: The characteristic picture of fluorescein fundus angiography was filling delay in the choroid and stained walls of the retinal arteries and veins. Fluorescein gonioangiography using a fundus camera clearly demonstrated new vessels in the pupil and angle with intense fluorescein leak in spite of faint neovascularization in those areas when observed by slit lamp with gonioscopy. Histological examination of the trabeculectomy specimen revealed proliferation of new vessels in the spaces of the trabecular meshwork and focal occlusion of Schlemm's canal.Conclusion: Fluorescein fundus angiography and gonioangiography by fundus camera is very useful for diagnosis of neovascular glaucoma due to carotid artery occlusive disease. Neovascular proliferation in the trabecular meshwork with slight of peripheral anterior synechia and focal occlusion of Schlemm's canal may be peculiar to such slowly progressive neovascular glaucoma.

Validity of brief intelligence tests for patients with Alzheimer's disease

The validity of two kinds of brief intelligence tests for patients with Alzheimer's disease (AD) was investigated. In study 1, five short forms of the Japanese Wechsler Adult Intelligence Scale-Revised (JWAIS-R) were administered to 102 AD patients. The results showed that the intra-class correlation coefficients (ICC) between IQ estimated with the short forms and those obtained by administration of the full JWAIS-R were satisfactory, ranging from 0.82 to 0.98, and that the abbreviated forms took a shorter time to execute. In study 2, the Raven's Coloured Progressive Matrices (RCPM) and the Mini-Mental State Examination (MMSE) were administered to 67 AD patients. The ICC between the IQ estimated with these tests and the full-scale IQ of the JWAIS-R were both acceptable at 0.57, and each test could be carried out in a very short time. It was concluded that these brief tests, particularly the WAIS-R short forms, are highly practical for quick measurement of intelligence in AD patients, although they have their respective limitations.

Semantic priming in patients with Alzheimer and semantic dementia

Semantic priming for pairs of words having semantic relation (members of the same category) but not associative relation was tested in four patients with mild Alzheimer-type dementia (AD), three patients with semantic dementia (SD) and three normal controls. Priming effects were exhibited by all the AD patients and normal controls but by none of the SD patients. The facilitation did not differ depending on whether words were written in kanji or kana. The nature of semantic deficits in AD and SD is discussed.

[A case report of neovascular glaucoma due to carotid artery occlusive disease--diagnosis of neovascular glaucoma and histological characteristics]

PURPOSE

The methods of diagnosing neovascular glaucoma were evaluated in a case with carotid artery occlusive disease. A trabeculectomy specimen taken from this patient was examined histologically to find the characteristic picture of this slowly progressive neovascular glaucoma.

MATERIALS AND METHODS

The left eye of a 48-year old man with neovascular glaucoma due to carotid artery occlusive disease had been previously diagnosed as uveitis with ocular hypertension. His left eye was examined by fluorescein fundus and gonioangiography. Trabeculectomy was performed because of uncontrolled intraocular pressure and the trabeculectomy specimen was examined histologically including immunohistochemistry with antibodies against von Willebrand factor antigen.

RESULTS

The characteristic picture of fluorescein fundus angiography was filling delay in the choroid and stained walls of the retinal arteries and veins. Fluorescein gonioangiography using a fundus camera clearly demonstrated new vessels in the pupil and angle with intense fluorescein leak in spite of faint neovascularization in those areas when observed by slit lamp with gonioscopy. Histological examination of the trabeculectomy specimen revealed proliferation of new vessels in the spaces of the trabecular meshwork and focal occlusion of Schlemm's canal.

CONCLUSION

Fluorescein fundus angiography and gonioangiography by fundus camera is very useful for diagnosis of neovascular glaucoma due to carotid artery occlusive disease. Neovascular proliferation in the trabecular meshwork with slight of peripheral anterior synechia and focal occlusion of Schlemm's canal may be peculiar to such slowly progressive neovascular glaucoma.

Gas chromatographic-mass spectrometric analysis of dichlorobenzene isomers in human blood with headspace solid-phase microextraction

Headspace solid-phase microextraction (HS-SPME) was utilized for the determination of three dichlorobenzene isomers (DCBs) in human blood. In the headspace at 30 degrees C, DCBs were absorbed for 15 min by a 100-micron polydimethylsiloxane (PDMS) fiber. They were then analyzed by capillary column gas chromatography-mass spectrometry (GC-MS). By setting the initial column oven temperature at 20 degrees C, the three isomers were resolved at the baseline level. p-Xylene-d10 was used as the internal standard (I.S.). For quantitation, the molecular ion at m/z 146 for each isomer and the molecular ion at m/z 116 for I.S. were selected. For day-to-day precision, relative standard deviations in the range 3.2-10.7% were found at blood concentrations of 1.0 and 10 micrograms/ml. Each compound was detectable at a level of at least 0.02 microgram per 1 g of whole blood (by full mass scanning). HS-SPME-GC-MS, when performed at relatively low temperatures, was found to be feasible in toxicological laboratories. Using this method, the plasma levels of one patient who had drunk a pesticide-like material were measured.

Flow-through thin latissimus dorsi perforator flap for repair of soft-tissue defects in the legs

Flow-through thin latissimus dorsi perforator flaps were used in six cases with complicated defects of the legs. This flap has a small amount of latissimus dorsi muscle with a considerable amount of fatty tissue removed to make a thin flap. In addition, the flap has several branches of the subscapular vessel, which are interposed to the recipient vessels of the legs. The advantages of this thin flap are: (1) flow-through vascular reconstruction can preserve the main vessels of the damaged legs; (2) the double arterial inflows and venous drainage systems of the flap ensure safe vascularization of the flap; (3) a flow-through venous drainage system from the distal extremities can also be established to prevent congestion of the affected legs; (4) this flap is versatile (it can be either thin or large); and (5) even in emergent ischemic legs, simultaneous elevation of the flap is possible with preparation of the legs. This flow-through flap is indicated for: (1) cases with a large skin defect and obstruction of the main vessels in the leg; (2) cases with a possibility of tumor recurrence in the legs; and (3) young women or girls with a large defect in the legs, rather than the rectus abdominis musculocutaneous flap.

Binding of volatile anesthetics to purple membranes studied by X-ray diffraction

Volatile anesthetics, diiodomethane and trifluoroethyl iodide, acted on the purple membrane of Halobacterium halobium in two different modes depending on the concentration. At low concentration, the absorption maximum of bacteriorhodopsin shifted from 561 to 558 nm (BR558) and the M-intermediate of the photocycle decayed faster than the native one. Higher concentration induced a species absorbing maximally at 480 nm (BR480) and the long-lived M-intermediates. The X-ray study suggested that anesthetics bound specifically to the protein-lipid interfacial region within a trimer near the surface of membrane in BR558 and entered into the hydrophobic domain of the membrane in BR480.

Corneal marginal ulcer in relapsing polychondritis: treatment with keratoepithelioplasty

This article describes a case of corneal marginal ulcer caused by relapsing polychondritis (RPC) that was treated with keratoepithelioplasty. The patient underwent keratoepithelioplasty with lamellar keratoplasty in the left eye. No relapse occurred in the nasal side in which corneal lenticules were grafted, whereas vascular invasion developed in the temporal side in which no lenticules were grafted. Keratoepithelioplasty was an effective surgical procedure to prevent a recurrence of corneal marginal ulcer in a patient with RPC.

Typus melancholicus in light of the five-factor model of personality

The present paper examines Typus melancholicus (TM), which is widely accepted as premorbid personality of depression in Germany and Japan, from the view-point of the five-factor model of personality, which has recently been gaining international popularity as the comprehensive model of personality traits. Two measures of TM, von Zerssen's F-list and Kasahara's scale, as well as the personality questionnaire for the five-factor model, NEO Five Factor Inventory, were completed for 140 consecutive psychiatric outpatients by their close relatives. It was found that (a) the two measures of TM had good internal consistency reliability, (b) they had reasonable concurrent validity, and (c) TM was characterized by high Conscientiousness, high Agreeableness and, to a lesser degree, high Extraversion. The results were largely in agreement with theoretical prediction and provide further support to the construct validity of the TM measures. Whether combining the three personality traits into one type is meaningful in depicting a particular premorbid personality constellation awaits further empirical examination.

Premorbid personality traits of patients with organic (ICD-10 F0), schizophrenic (F2), mood (F3), and neurotic (F4) disorders according to the five-factor model of personality

The present article aims to examine premorbid personality traits of psychiatric patients with various diagnoses by asking their close relatives to retrospectively rate the patients' usual self with a questionnaire designed for the five-factor model of personality, a rapidly emerging comprehensive theory of personality structure. Data for 140 patients and 84 controls were analyzed. Although psychiatric patients as a group were characterized by high neuroticism and low conscientiousness when compared with the healthy controls, there were only a few traits that distinguished a particular diagnostic group from either the normal control or from the rest of the patients: neurotic disorder patients had higher neuroticism scores than the normal controls; unipolar depressives had a higher conscientiousness score than the rest of the patient group. No salient premorbid trait was noted for patients with organic mental disorders, schizophrenic disorders or bipolar disorders.

Effortful echolalia

We report three cases of effortful echolalia in patients with cerebral infarction. The clinical picture of speech disturbance is associated with Type 1 Transcortical Motor Aphasia (TCMA, Goldstein, 1915). The patients always spoke nonfluently with loss of speech initiative, dysarthria, dysprosody, agrammatism, and increased effort and were unable to repeat sentences longer than those containing four or six words. In conversation, they first repeated a few words spoken to them, and then produced self initiated speech. The initial repetition as well as the subsequent self initiated speech, which were realized equally laboriously, can be regarded as mitigated echolalia (Pick, 1924). They were always aware of their own echolalia and tried to control it without effect. These cases demonstrate that neither the ability to repeat nor fluent speech are always necessary for echolalia. The possibility that a lesion in the left medial frontal lobe, including the supplementary motor area, plays an important role in effortful echolalia is discussed.

Dissociations between reading responses and semantic priming effects in a dyslexic patient

We report a patient (Y.Y.) with senile dementia of the Alzheimer's type. The patient read aloud some words composed of two or three kanji characters with errors applying typical pronunciations of each character and defined them in keeping with the mispronunciation if the pronunciation represented another real word. The results of single-word semantic priming in a lexical decision task, however, suggested normal recognition processes for these kanji-words, despite the patient's reading errors. We consider her reading to represent surface dyslexia in Japanese. We discuss these dissociations between reading responses and priming effects in the context of dual-route models of human reading, and conclude that the "visual route" (direct access from orthography to semantics and phonology) was not completely disrupted, but partially preserved and functioning in automatic access.

Typus melancholicus is not the premorbid personality trait of unipolar (endogenous) depression

The present paper aims to examine whether Typus melancholicus is a distinguishing premorbid personality of unipolar (endogenous) depressive patients vis-à-vis psychiatric patients with different diagnoses and healthy control subjects. Two observer-rated scales for Typus melancholicus were administered to a consecutive series of psychiatric patients (n = 140) and a group of control subjects (n = 84). To the authors' own surprise, the only statistically significant finding was the low Typus melancholicus score among unipolar (endogenous) depressives in comparison with normal controls but not with other psychiatric patients. In addition, this finding held only for one of the two rating scales and among women only. According to the other rating scale for Typus melancholicus, there was no difference between unipolar (endogenous) depressives and the normal control or other psychiatric patients. These findings are discussed with particular emphasis on the methodological aspects of studies of premorbid personality of psychiatric disorders, a favored subject in the psychiatric science for decades.

Pure amnesia caused by bilateral temporal lobe astrocytoma--case report

A 32-year-old male presented with progressive pure amnesia caused by astrocytoma invading the bilateral medial temporal lobes. Methionine positron emission tomography demonstrated the extent of tumor invasion well. His memory impairment was partially improved by treatment for the astrocytoma. Lesion of the bilateral hippocampus causes memory impairment, but pure memory loss without other associated neurological sign or deterioration of consciousness is rare in a case of cerebral neoplasm.

Cytoskeleton and tissue origin in the anterior cynomolgus monkey eye

We studied cytoskeletal proteins and other markers for embryologic origin in the outflow pathways of the aqueous humor, cornea, sclera, and ciliary muscle of the cynomolgus monkey. The corneal endothelium and trabecular cells stained with markers for vimentin, smooth muscle cell alpha-actin, F-actin, spectrin, vinculin, and talin. The endothelium of Schlemm's canal stained with markers for vimentin, spectrin, and F-actin. These results suggest that trabecular cells are a kind of myofibroblast and support the belief that the endothelial cells of Schlemm's canal are vascular in origin. Fibrillary staining with antibodies to vimentin, spectrin, neurofilament protein, and glial acid fibrillary protein was observed along and between the ciliary muscle cells. Cells in the deep sclera adjacent to the supraciliary space stained with antibodies to smooth muscle alpha-actin, alpha-vinculin, talin, and desmin. These cells may anchor ciliary muscle cells into the sclera or may be developmental remnants of ciliary muscle cells. Leu 19 immunoreactivity was found in the corneal endothelium, in all trabecular cells, in ciliary muscle cells, and in keratocytes and fibroblasts in the superficial part of the cornea and sclera. All of these cells are therefore likely to express neural cell adhesion molecules indicating neuroectodermal origin.

One-stage reconstruction of established facial paralysis using a rectus abdominis muscle transfer

A free vascularized rectus abdominis muscle graft with a long motor nerve was used for reconstruction of unilateral established facial paralysis in one stage. Regarding the procedure, the pedicle vessels were anastomosed to the recipient vessels in the ipsilateral face, and the motor nerve of the muscle was sutured to the contralateral facial nerve. The advantages of using the rectus abdominis muscle are as follows: (1) the muscle is very thin, not bulky, (2) the muscle can be split easily to reduce the volume, (3) the intercostal nerve is long enough (more than 20 cm) to reach the contralateral facial nerve for suturing, (4) the pedicle vessels are large and long, (5) it is possible to carry out simultaneous operations with two teams, and (6) the donor-site morbidity is minimal. The disadvantages of this method are that complicated surgical dissection is required to obtain a motor nerve and that a postoperative abdominal hernia may occur.

[A study of utilization and imitation behavior in cases with striatocapsular infarction]

Utilization behavior (UB) and imitation behavior (IB) were first described by Lhermitte (1983; 1986) for neurobehavioral disorders due to the frontal lobe damage. Recently, the similar symptoms were also observed in several reports of subcortical lesion cases without any lesion of the frontal lobe. We studied 16 consecutive patients with unilateral striatocapsular infarction (SCI), and found 7 patients (44%) presenting UB and/or IB. Characteristics of patients with UB and/or IB revealed the following factors: older age, higher frequency of right-sided lesion, absence of severe aphasia or apraxia, higher frequency of unilateral spatial neglect and/ or psychic change, and no evidence of significant large cerebral artery lesion on angiography. In most of SCI cases, whether IB and/or UB was present or not, the single-photon emission CT demonstrated decreased perfusion in the ipsilateral frontotemporal areas, and the result of neuropsychological assessment was compatible with frontal lobe dysfunction. UB and IB observed in our patients are not only considered to have resulted from secondary impairment of frontal lobe, but also regarded as one of the right hemispheric syndromes associated with such background factors as aging, neglect and general inattention.

[Application of oculokinetic perimetry in examination of the eye]

Oculokinetic perimetry was performed using the same protocol at four health screening facilities to determine its usefulness for identifying visual field abnormalities including glaucoma during complete physical screenings in Japan. Ophthalmoscopy of the optic disc, 26-point oculokinetic perimetry (OKP), and applanation tonometry were performed in 2,768 eyes. If any one of the tests yielded an abnormal result, the eye was then examined with a Humphrey visual field analyzer (HVFA, program 30-2). After the tests were completed, the results were evaluated by ophthalmologists for evidence of primary open-angle glaucoma and normal tension glaucoma and were classified into one of 3 groups: confirmed glaucoma, suspected glaucoma, and no glaucoma. OKP detected abnormalities in the visual field in 96 eyes (3.5%). Of these 96 eyes, 29 eyes had confirmed glaucoma, 52 eyes were suspected of having glaucoma and 15 eyes had no glaucoma. The remaining 15 eyes had no glaucoma, but in 7 of them other ophthalmological disease was diagnosed. The sensitivity, specificity, positive predictive value, and negative predictive value of OKP for detecting glaucomatous visual field defect were 0.46, 0.99, 0.84 and 0.96, respectively. The high specificity and negative predictive value show that OKP is unlikely to produce false positive results, but its low sensitivity suggests that it is not suitable for the early detection of glaucoma. However, OKP identified advanced glaucoma and other ophthalmological diseases associated with visual field abnormalities, suggesting that it is a useful screening test.

X-ray diffraction pattern from internal structure of bovine rhodopsin

Pure bovine rhodopsin pellets were prepared by removal of cholic acid from rhodopsin-cholic acid complex, and X-ray diffraction patterns from the internal structure of rhodopsin were obtained for the first time using wet and dry pellet samples. The peaks at around 10 and 4.3 A spacings observed for both samples can be attributed to alpha-helices in rhodopsin molecule, providing direct evidence of the helical structure of rhodopsin. A shoulder peak at around 34 A spacing was also observed for the dry pellet, which can be explained by the first-neighbor distance between rhodopsin molecules in the sample.