Interobserver concordance for endoscopic ultrasonography-guided fine-needle aspiration on-site cytopathology

INTRODUCTION

Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is an accurate method of diagnosing and staging gastrointestinal and thoracic malignancy. A key issue in maximizing FNA accuracy is to ensure that an adequate specimen is obtained. On-site cytopathology increases the diagnostic yield of EUS-FNA. However, this increases the time and costs. Physicians trained in EUS and in pathology are capable of interpreting cytologic adequacy from EUS-FNA specimens. Furthermore, on-site interpretation by the endoscopist could reduce cost and procedure duration. The learning curve of endossonographers in on-site cytopathology and how they could contribute in EUS-FNA accuracy increase is unknown.

OBJECTIVE

To determine the interobserver concordance of on-site cytopathology interpretation of EUS-FNA specimens by comparing endosonographers trained in cytology with a physician cytopathologist.

METHODS

A prospective blinded study comparing one endossonographer with one physician cytopathologist. The study was developed in the Santa Casa Medical School, Brazil from February to November 2012. Fifteen different cases of EUS-FNA were analysed, in a total of 50 slides. Each observer described the slides for the adequate or not of tissue sampling, and classified as benign, suspicious, malign or undefined. The analyses were then matched.

RESULTS

We analyzed the concordance of 50 slides description made by the endossonographer and physician cytopathologist, according to enough material, cellular group identification and final diagnosis. Kappa (κ) indexes were: Presence of material κ = 0.480 (P < 0.001); presence of malignance κ = 0.808 (P < 0.001); in subepithelial lesions κ = 0.615 (P = 0.06); in pancreatic lesions κ = 0.675 (P < 0.001); in mediastinal lesions κ = 0.243 (P = 0.128).

CONCLUSION

Our study showed that endosonographers and cytopathologists had good concordance in EUS-FNA specimens on-site cytopathology interpretation, except in mediastinal/pulmonary cases.

Influence of layer, size and organ of subepithelial lesions of upper gastrointestinal tract in outcomes of endoscopic ultrasound-guided fine-needle aspiration

INTRODUCTION

The endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as a minimally invasive and safe method for material procurement in the differential diagnosis of subepithelial lesions (SEL) of upper gastrointestinal tract (UGT), especially in suspicious lesions of gastrointestinal stromal tumors (GIST). There are few studies discussing the factors that influence the EUS-FNA in the diagnosis of SEL.

AIM

To establish possible associations between lesion size, layer and organ of origin with the outcome of EUS-FNA in patients with SELs of UGT.

METHODS

A retrospective analysis using data of patients referred to French-Brazilian Center of EUS of endoscopy Department of Santa Casa de São Paulo Hospital, with previous endoscopic diagnosis of SEL, which underwent EUS-FNA from May 2006 to August 2011.

RESULTS

A total of 222 patients were submitted to EUS. 15 with extrinsic compressions and 207 with SEL. Of these, 89 underwent to EUS-FNA. Ninety-two SEL were diagnosed on EUS and punctured. The EUS-FNA was positive in 58.7%. In lesions measuring 2-3 cm and >3 cm, the EUS-FNA was positive in 80% and 72%, respectively (P < 0.001).

CONCLUSION

The size of SELs was the only variable that influenced the outcome of EUS-FNA. Best results are achieved in lesions larger than 2 cm.

Relevance of endoscopic ultrasound in the management of esophagus cancer therapy

INTRODUCTION

The objective of this case series study by retrospective analysis was to determine the relevance of endoscopic ultrasound (EUS) in therapeutic decision esophageal cancer.

MATERIAL AND METHODS

Using medical records of the Department of Endoscopy of Santa Casa de São Paulo, we have collected data from 16 patients, in 4 years, diagnosed of esophageal cancer, and presented in the form of clinical cases to a specialist surgeon in esophageal cancer and a clinical oncologist, for therapeutic evaluation before and after the outcome of EUS.

RESULTS

Both of them choose non-resective and not curative methods (68.8% by surgeon vs. 87.5% oncologist) before EUS. The best treatment by the surgeon was chemotherapy and palliative radiotherapy associated (25%) and palliative endoscopic prostheses (25%), and by the oncologist, neoadjuvant chemotherapy and radiotherapy associated (56.2%). After EUS, the resective surgical treatment was the both choice in only 6.2% of cases, and the rest of 93.8%, non-resective. The surgeon choice was chemotherapy and palliative radiotherapy associated (44%), and oncologist choice was neoadjuvant chemotherapy and radiotherapy associated (44%). Analysis by the Chi-square method, comparing respective versus non-resective treatment, surgeon versus oncologist, with and without the EUS, obtained values of P = 0.39 and P = 0.46, respectively. The comparison between healing and non-healing treatment had the same P value. Regarding the change in behavior (resective vs. non-resective), there was a change of approach by the surgeon in 25% of cases (P = 0.17) and the oncologist moved conduct in 6.25% of cases. Comparing the changing of behavior among experts, the P value was 0.33. Despite evidence of behavior change after the EUS, the statistical point of view, the P value had no significant relevance. The main factor involved is probably due to a reduced number of sample cases. However, this is a pilot study, and is needed other with a larger number of cases.

CONCLUSION

The data obtained allow us to conclude that EUS proved to be an important test for the change in staging and therapeutic management of esophageal cancer.

Comparative study of bipolar eletrocoagulation versus argon plasma coagulation for rectal bleeding due to chronic radiation coloproctopathy

BACKGROUND AND STUDY AIM

Chronic radiation coloproctopathy (CRCP) is a well-recognized complication of radiotherapy, with rectal bleeding the most common presentation. It is frequently refractory to conservative management, but the optimal endoscopic treatment of bleeding secondary to CRCP is still controversial. The efficacy and safety of bipolar eletrocoagulation (BEC) and argon plasma coagulation (APC) in the management of bleeding from CRCP were evaluated and compared.

PATIENTS AND METHODS

30 patients (mean age 67.4 years) with active and chronic bleeding from telangiectasias, were randomly allocated to BEC or APC and stratified by severity of CRCP according to clinical severity and endoscopic findings (Saunders score). Success was defined as eradication of all telangiectasias, and therapeutic failure as need for more than seven sessions or for other treatment. Complications were categorized as minor (e.g. fever, anal or abdominal pain) or major (hemorrhagic).

RESULTS

Both treatments were equally effective for the treatment of CRCP rectal bleeding. Only one failure was observed in each group (P = 1.000). There was no significant difference between the two groups regarding number of sessions, minor or major complications, or relapse. However, overall complication rate was significantly higher in the BEC group (P = 0.003).

CONCLUSIONS

BEC and APC are both effective for the therapy of bleeding telangiectasias from CRCP. There are probably no major differences between them. Although APC seemed safer than BEC in this investigation, further studies, involving a much larger population, are needed to assess the complication rates and determine the best management option.

The incidence of bacteraemia after argon plasma coagulation in patients with chronic radiation proctocolitis

AIM

Argon plasma coagulation (APC) is considered a safe treatment for haemorrhagic chronic radiation proctocolitis (CRPC), but bacteraemia is a rare complication. The study aimed to evaluate the frequency of bacteraemia after APC.

METHOD

A prospective study of 21 patients who underwent APC (30 procedures) for CRPC was carried out. Blood cultures (Bactec(®) ) were obtained before and 30 min after the procedure (60 samples total). Patients were monitored for 48 h after the procedure to detect signs of infection.

RESULTS

None of the 21 patients had fever or any sign suggestive of infection after any of the 30 sessions. All baseline blood cultures were negative and two (7%) of the 30-min blood cultures were positive (Staphylococcus hominis n = 1; Streptococcus bovis and Rhodotorula sp n = 1). The first was likely to be a contaminant and the second patient had no evidence of any other colonic disease (neoplasia or polyps) beside CRPC.

CONCLUSION

APC is a low-risk procedure regarding bacteraemia and does not warrant prophylactic antibiotic administration.

Influence of size of neodymium:yttrium-aluminium-garnet laser posterior capsulotomy on visual function

PURPOSE

The aim of this study was to examine the influence that the size of a neodymium:yttrium-aluminium-garnet (Nd:YAG) laser capsulotomy performed for posterior capsule opacification (PCO) has on visual acuity (VA), and on contrast VA and that in the presence of glare (glare VA).

METHODS

A total of 41 consecutive eyes with PCO first underwent Nd:YAG laser capsulotomy of smaller than pupillary size, after which the capsulotomy was secondarily enlarged, 2 weeks later, to greater than pupillary size. Best-corrected VA, and contrast VA and glare VA under photopic and mesopic conditions were measured after the small and large capsulotomies were made.

RESULTS

After enlargement, the mean capsulotomy area increased significantly from 4.8 to 15.3 mm(2) (P<0.0001). Best-corrected VA did not improve significantly after enlargement (P=0.1282). However, photopic contrast VA and glare VA at moderate to low contrast visual target before enlargement were significantly worse than those after enlargement (P<or=0.0242); furthermore, mesopic contrast VA and glare VA improved significantly after enlargement (P<or=0.0431).

CONCLUSION

Contrast VA and glare VA with a small capsulotomy were significantly worse than those with a large capsulotomy, which suggests that a capsulotomy larger than the pupillary size is necessary to restore contrast sensitivity and glare disability.

Anterior capsule contraction and intraocular lens decentration and tilt after hydrogel lens implantation

AIM

To prospectively investigate changes in the area of the anterior capsule opening, and intraocular lens (IOL) decentration and tilt after implantation of a hydrogel IOL.

METHODS

100 patients underwent implantation of a hydrogel IOL in one eye and an acrylic IOL implantation in the opposite eye. The area of the anterior capsule opening, and the degree of IOL decentration and tilt were measured using the Scheimpflug videophotography system at 3 days, and at 1, 3, and 6 months postoperatively.

RESULTS

The mean anterior capsule opening area decreased significantly in both groups. At 6 months postoperatively, the area in the hydrogel group was significantly smaller than that in the acrylic group. The mean percentage of the area reduction in the hydrogel group was also significantly greater than that in the acrylic group, being 16.9% in the hydrogel group and 8.8% in the acrylic group. In contrast, IOL decentration and tilt did not progress in either group. No significant differences were found in the degree of IOL decentration and tilt throughout the follow up period.

CONCLUSIONS

Contraction of the anterior capsule opening was more extensive with the hydrogel IOL than with the acrylic IOL, but the degree of IOL decentration and tilt were similar for the two types of lenses studied.

Correlation between pupillary size and intraocular lens decentration and visual acuity of a zonal-progressive multifocal lens and a monofocal lens

OBJECTIVE

To see whether there is a correlation between pupillary area or intraocular lens (IOL) decentration and tilt and the visual acuity (VA) at all distances for eyes with a zonal-progressive multifocal IOL or a monofocal IOL.

DESIGN

Comparative, nonrandomized, interventional study.

PARTICIPANTS

Fifty-five eyes of 55 patients undergoing five-zone refractive multifocal IOL implantation and 55 eyes of 55 age-matched patients undergoing monofocal IOL implantation.

INTERVENTION

All eyes underwent phacoemulsification and IOL implantation.

MAIN OUTCOME MEASURES

The VAs from far to near distances were examined using an all-distance vision tester at 1 month after surgery. The pupillary area was also measured using an infrared pupillometer, and the degrees of IOL decentration and tilt were measured using a Scheimpflug videophotography system. Univariate associations between VA and the pupillary area and IOL decentration or tilt were evaluated statistically.

RESULTS

The mean intermediate VAs and contrast sensitivities at all spatial frequencies in the multifocal IOL group were worse than those in the monofocal IOL group, whereas near VA was better in the multifocal group. In the multifocal group, smaller pupillary area was associated significantly with worse near logarithm of the minimum angle of resolution (LogMAR) VA (r = 0.636), but not with far or intermediate VAs. When pupil diameter was 4.5 mm or greater, near mean VA reached 20/63. A greater degree of IOL decentration was associated significantly with worse far and intermediate LogMAR VAs (r = 0.460 at 5.0 m and 0.527 at 1.0 m) but not with near VA. When decentration was 0.9 mm or greater, distance mean VA did not reach 20/32. However, the correlation between tilt and VA was not statistically significant. In the monofocal group, no significant correlation was found between pupillary area, IOL decentration, or tilt and the VA.

CONCLUSIONS

Smaller pupil size is correlated significantly with worse near VA, whereas greater decentration is correlated with worse distance and intermediate VA in eyes with refractive multifocal IOLs. Specifically, a pupil diameter of less than 4.5 mm cannot provide useful near VA, and decentration of 0.9 mm is the maximum allowable limit for adequate distance VA. However, pupil size and IOL decentration do not influence VA in eyes with monofocal IOLs.

Evaluation of left atrial function by the functional volume change curve derived from Doppler flow spectra

The objective of this study was to clarify the left atrial (LA) reservoir and booster pump function in patients with left ventricular (LV) diastolic dysfunction. To determine LA reservoir and booster pump function, a new algorithm to determine LA functional volume change curve (FVC) was developed from Doppler flow spectra of pulmonary venous flow and LV inflow by transthoracic echocardiography in 110 patients. Patients were classified into normal (N), and abnormal (AB) and pseudonormal (PN) groups on the basis of their Doppler flow patterns. From the indices of FVC, atrial reservoir volume (ARV), passive emptying volume (PEV) and active emptying volume (AEV) were obtained. ARV/stroke volume (SV) was increased in the AB group, but decreased in the PN group compared with N (N, 0.61+/-0.09; AB, 0.73+/-0.10; PN, 0.52+/-0.13, p<0.05). PEV/SV was significantly decreased in AB, but increased in PN compared with N (N, 0.27+/-0.07; AB, 0.19+/-0.07; PN, 0.31+/-0.18, p<0.05). AEV/SV was significantly increased in AB, but decreased in PN compared with N (N, 0.41+/-0.08; AB, 0.56+/-0.10; PN, 0.26+/-0.19, p<0.05). Thus, in patients with an abnormal relaxation pattern, the LA reservoir and booster pump function are augmented, but in patients with a pseudonormal pattern, both LA reservoir and booster pump function are deteriorated, suggesting a vulnerability to pulmonary congestion.

Effect of cataract surgery on intraocular pressure control in glaucoma patients

PURPOSE

To examine the effect of cataract surgery on intraocular pressure (IOP) control in eyes with angle-closure glaucoma (ACG) and open-angle glaucoma (OAG).

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

METHODS

This study included 74 eyes with ACG and 68 eyes with OAG having cataract surgery. The IOP was measured and the number of glaucoma medications recorded preoperatively, 1 month postoperatively, and then every 3 months. The IOP control in the 2 groups was compared using survival analysis, with failure criteria being an IOP greater than 21 mm Hg, addition of medications, or the need for additional glaucoma surgery.

RESULTS

The mean IOP and number of medications decreased significantly after surgery in both groups (P <.0001). However, the mean decrease in IOP and percentage of IOP reduction in the ACG group were greater than in the OAG group, and fewer medications were required in the ACG group. The cumulative survival probability of IOP control at 24 months was 91.9% in the ACG group and 72.1% in the OAG group. The survival curve in the ACG group was significantly better than in the OAG group (P =.0012). The IOP was controlled without medication in 30 eyes (40.5%) in the ACG group and 13 (19.1%) in the OAG group; the difference between groups was significant (P =.0055).

CONCLUSIONS

Cataract surgery substantially reduced IOP and the number of medications required for IOP control in glaucomatous eyes. Specifically, cataract extraction normalized the IOP in most eyes with ACG.

Association studies of CTLA-4, CD28, and ICOS gene polymorphisms with type 1 diabetes in the Japanese population

Co-stimulatory molecules of CD28, cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), and the newly identified inducible co-stimulator (ICOS) are expressed on cell surfaces and provide regulatory signals for T-cell activation. Their genes are candidate susceptibility genes for type 1 diabetes because they co-localize to Chromosome 2q33 with the IDDM12 locus. After determining the genomic structure and screening for polymorphisms of the ICOS gene, we performed association studies between newly identified polymorphisms of the ICOS gene, together with known polymorphisms of CD28 and CTLA-4 genes, and type 1 diabetes. The 49A/G dimorphism in exon 1 and the (AT)n in the 3' untranslated region of the CTLA-4 gene were significantly associated with type 1 diabetes. Evaluation of the CTLA-4 49A-3'(AT)n 86-bp haplotype frequency in patients and controls confirmed the results from the analysis of each polymorphic site. Dimorphism in intron 3 of the CD28 gene was associated with type 1 diabetes only in the early-onset group. In contrast, there was no association with the microsatellite polymorphisms in the ICOS gene or dimorphisms in the promotor region of CTLA-4. Of the three genes encoding co-stimulatory molecules, the CTLA-4 gene appears to confer risks for the development of type 1 diabetes.

Influence of cataract surgery on automated perimetry in patients with glaucoma

PURPOSE

To investigate the influence of cataract surgery on automated perimetry in patients with glaucoma.

DESIGN

Interventional case series.

METHODS

A total of 105 eyes of 105 consecutive patients with glaucoma who were scheduled for cataract surgery underwent Humphrey static threshold testing (30-2 program) before and at 1 month after surgery. These eyes were divided into two groups based on the presence of absolute or near absolute (dense) scotomata before surgery (minimum threshold value 5 decibels or less). Changes in numbers of the dense scotomata, mean deviation, pattern standard deviation, and corrected pattern standard deviation were analyzed.

RESULTS

No significant changes were found in the numbers of dense scotomata and central dense scotomata within five-degree visual fields between before and after surgery. In the group with dense scotomata, the mean pattern standard deviation and corrected pattern standard deviation worsened significantly after surgery, whereas the mean deviation improved significantly. However, in the group without dense scotomata, the pattern standard deviation and corrected pattern standard deviation showed a slight improvement, whereas the mean deviation improved significantly. When the central scotoma was present in two or fewer meridians before surgery, the mean visual acuity after surgery reached 20/25 and was better than that in patients with three or four central scotomata (P =.0014).

CONCLUSIONS

Cataract does not produce a dense scotoma on automated perimetry. However, because it does produce relative scotomata, actual glaucomatous visual field defects may be hidden to some extent. When a central dense scotoma is present before surgery in two or fewer meridians, the patient may well achieve substantial improvement in postoperative visual acuity.

Changes in posterior capsule opacification after poly(methyl methacrylate), silicone, and acrylic intraocular lens implantation

PURPOSE

To prospectively evaluate the progression of posterior capsule opacification (PCO) after poly(methyl methacrylate) (PMMA), silicone, and acrylic intraocular lens (IOL) implantation.

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

METHODS

Three hundred eyes of 300 patients scheduled to have IOL implantation were initially randomized into 3 groups based on IOL type: PMMA, silicone, or acrylic. Of the 300 eyes, 269 completed the follow-up. The PCO density in these eyes was measured 1 week and 3, 6, 12, 18, and 24 months postoperatively using special computer software developed for the Scheimpflug videophotography system. Visual acuity and the incidence of neodymium:YAG (Nd:YAG) laser capsulotomy were also examined.

RESULTS

Three months postoperatively and later, the mean PCO value in the PMMA group increased significantly (P <.0001); the increase in the silicone and acrylic groups was not significant. The PCO value in the PMMA group was significantly greater than in the silicone or acrylic group (P <.0001). The PCO value in the acrylic group was slightly less than in the silicone group at 18 and 24 months, but the difference was marginal. The survival rate not requiring Nd:YAG capsulotomy was least in the PMMA group, followed by the silicone and acrylic groups in that order (P <.0001). The mean logMAR visual acuity in the PMMA group increased postoperatively and was worse than in the silicone or acrylic group.

CONCLUSIONS

The degree of PCO after PMMA IOL implantation progressed significantly with time, while the progression after silicone and acrylic IOL implantation was slight. Therefore, PCO in eyes with a PMMA IOL was significantly more extensive than in those with a silicone or acrylic IOL and resulted in marked impairment of visual acuity.

Effect of low-intensity warfarin therapy on left atrial thrombus resolution in patients with nonvalvular atrial fibrillation: a transesophageal echocardiographic study

The presence of left atrial thrombus (LAT) is associated with an increased risk of embolic stroke. However, it has yet to be established definitively whether low-intensity warfarin therapy (INR: 1.5-2.0) can prevent LAT formation in patients with nonvalvular atrial fibrillation (NVAF). The present study analyzed the clinical and transesophageal echocardiography (TEE) features of 123 such patients to identify risk factors for LAT formation and the efficacy of prophylactic low-intensity warfarin therapy. Left atrial thrombi were found in 35 patients (28%) in whom systemic hypertension (49% vs 23%; p<0.01) and ischemic heart disease (17% vs 3%; p<0.01) were more frequent. Left ventricular ejection fraction (54+/-14% vs 60+/-11%; p<0.05), left ventricular end-diastolic dimension (51+/-7 mm vs 48+/-5 mm; p<0.05), spontaneous echo contrast (2.2+/-0.7 vs 1.4+/-0.9; p<0.01), left atrial diameter (50+/-6 mm vs 43+/-7 mm; p<0.01), left atrial appendage blood velocity (22.3+/-8.7 cm/s vs 37.2+/-21.5 cm/s; p<0.01) and the incidence of left ventricular hypertrophy (37% vs 15%; p<0.01) were also significantly different between the groups. Fourteen patients received continuous warfarin therapy (target INR: 1.5-2.0) and on the follow-up TEE study the left atrial thrombus resolved in 10 (71%). There were no thromboembolic events or major hemorrhagic complications in these patients, so it was concluded that low-intensity warfarin therapy is efficacious in treating LAT formation in patients with NVAF.

Association of IFN-gamma and IFN regulatory factor 1 polymorphisms with childhood atopic asthma

BACKGROUND

IFN-gamma and related molecules play important roles in the differentiation and function of TH2 cells.

OBJECTIVE

We sought to determine whether IFNG and related genes contribute to any susceptibility to atopic asthma, a representative TH2-dominant disorder.

METHODS

We investigated the association of IFNG (CA repeat polymorphism within the first intron), IRF1 (GT repeat polymorphism within the intron 7), IFNGR1 (Val 14 Met), and IFNGR2 (Gln 64 Arg) gene polymorphisms with atopic asthma in the Japanese child population.

RESULTS

A significant association (P =.0018) was observed between IFNG gene polymorphism and atopic asthma. The tendency was more prominent in patients with age of onset of 3 years or younger (P =.0004) or patients with a family history of allergic diseases (P =.0038). Furthermore, there was a significant association between IRF1 gene whole-allele distribution and atopic asthma (P =.044). The tendency was more prominent in patients with onset at 3 years of age or less (P =.0058). On the other hand, IFNGR1 and IFNGR2 gene polymorphisms showed no association with atopic asthma.

CONCLUSION

These results suggested that among IFNG and related genes, IFNG and IRF1 genes confer genetic susceptibility to atopic asthma in Japanese children.

Lack of association between CD28/CTLA-4 gene polymorphisms and atopic asthma in the Japanese population

Atopic asthma occurs in genetically susceptible individuals in the presence of environmental factors. Recently, the costimulation signal from CD80-CD86 to CD28/CTLA-4 has been suggested to play an important role in the development of atopic asthma. In the present study, we analyzed three polymorphic regions within the CTLA-4 gene, an A/G substitution in exon 1 position 49, a C/T base exchange in the promoter position -318 and an (AT)n repeat polymorphism in the 3'-untranslated region of exon 4, and a CD28 gene polymorphism with a T/C substitution in intron 3 position +17 in 120 patients with atopic asthma and 200 normal controls. The polymorphism frequencies of CTLA-4/CD28 genes in patients did not differ from those in normal controls. Thus, the present study was unable to reveal any association between CTLA-4/CD28 gene polymorphisms and atopic asthma in the Japanese population.

Influence of astigmatism on multifocal and monofocal intraocular lenses

PURPOSE

To examine the influence of astigmatism on the visual acuity of patients with multifocal and monofocal intraocular lenses.

METHODS

Thirty eyes of 30 patients who underwent five-zone refractive multifocal intraocular lens implantation and 30 eyes of 30 age-matched patients who had monofocal intraocular lens implantation were included. The visual acuities of these patients at 5.0, 3.0, 2.0, 1.0, 0.7, 0.5, and 0.3 m were measured by means of an all-distance vision tester after addition of a cylindrical lens of 0, 0.5, 1.0, 1.5, 2.0, and 2.5 diopters.

RESULTS

Mean visual acuity at all distances decreased in proportion to the diopters of astigmatism in both the multifocal and monofocal intraocular lens groups. When astigmatism was 0.5, 1.0, or 1.5 diopters, distance visual acuity in the multifocal group was significantly worse than that in the monofocal group; with astigmatism of 2.0 diopters or more, intermediate visual acuity was also worse in the multifocal group. In contrast, near visual acuity in the multifocal group was significantly better than that in the monofocal group at all astigmatic diopters. When astigmatism was within 1.0 diopter, visual acuity in the multifocal group reached 20/29 at distance and 20/50 at near. Mean contrast sensitivity was also worse in the multifocal group than in the monofocal group.

CONCLUSIONS

Both distance and intermediate visual acuity deterioration caused by astigmatism was greater with a multifocal intraocular lens than with a monofocal intraocular lens, whereas near visual acuity was better with the multifocal intraocular lens. When astigmatism was within 1.0 diopter, eyes with a multifocal intraocular lens achieved good visual acuity at both distance and near.

Echoendoscopic evaluation of botulinum toxin intrasphincteric injections in Chagas' disease achalasia

Botulinum toxin (BT) has recently been indicated as an alternative treatment of idiopathic achalasia with a success rate of 60-70%. One-third of BT-treated cases either fail to respond or fail to sustain the response beyond 6 months. An explanation for BT therapeutic failure would be that the lower esophageal sphincter muscular layer (LES) may be missed as injection is delivered 'blindly'. We aimed to evaluate the percentage of exact endoscopically 'blind' LES punctures using echoendoscopy after the injection of BT for the treatment of Chagas' achalasia (CA). Five patients with CA (mean age 53 years) were randomized to receive 1.2 ml of BT or the same amount of saline injected endoscopically. Echoendoscopy was performed immediately after puncture. Patients were evaluated by the clinical score of dysphagia, radiological examination, upper endoscopy and esophageal manometry and followed up for 6 months. All puncture sites were identified: 17 out of 20 (85%) in the muscle layer and 3 out of 20 (15%) in the submucosa. The three patients in the treatment group showed clinical improvement (average clinical score fell from 14 to 2 after 7 days, and remained at 4 after 6 months of follow-up). The mean pressure of the LES dropped by 29%. Neither patient in the placebo group showed clinical improvement, and the mean pressure of the LES increased by 35%. Endoscopic 'blind' injection of BT into the LES through endoscopy for the management of achalasia is a safe and reproducible technique and has a high percentage of exactness.

Novel polymorphism in the coding region of the IL-13 receptor alpha' gene: association study with atopic asthma in the Japanese population

Interleukin (IL)-4 and IL-13 play key roles in the development of atopic asthma. The IL-13 receptor (R) alpha' chain is a component of both IL-4R and IL-13R complexes. By screening the whole coding region of the IL-13Ralpha' gene for polymorphisms, we identified a new polymorphism at nucleotide position 1050 from the ATG start codon. The allelic frequency of the C/T polymorphism in the Japanese population was found to be 0.97:0.03. Because of the low frequency of the T allele, the association study failed to indicate any significant association between this polymorphism and atopic asthma in the Japanese population. Further studies are required in other racial groups with higher frequencies of this polymorphism to elucidate the association.

Changes in anterior chamber angle width and depth after intraocular lens implantation in eyes with glaucoma

OBJECTIVE

To examine the changes in anterior chamber angle width and depth induced by intraocular lens (IOL) implantation in eyes with angle-closure glaucoma (ACG), in eyes with open-angle glaucoma (OAG), and in eyes with no evidence of glaucoma or ocular hypertension.

DESIGN

A comparative, nonrandomized, interventional study.

PARTICIPANTS

Seventy-seven eyes with ACG, 73 eyes with OAG, and 74 control eyes undergoing cataract extraction and IOL implantation.

INTERVENTION

All eyes underwent phacoemulsification and soft acrylic IOL implantation.

MAIN OUTCOME MEASURES

The angle width and depth of the anterior chamber were measured using a Scheimpflug videophotography system before surgery, and at 1 week and at 1, 3, 6, 9, and 12 months after surgery.

RESULTS

Before surgery, the mean anterior chamber angle width and depth in the ACG group was less than that in either the OAG or control groups by approximately 10 degrees in angle width and 1.0 mm in depth (P < 0.0001). After cataract extraction and IOL implantation, the angle width and depth increased significantly in all three groups (P < 0.0001). Although the width and depth in the ACG group were still smaller than that in the other groups, the differences decreased to 2 degrees for angle width and 0.3 mm for depth. In addition, no significant differences were found in these values between the OAG and control groups before or after surgery. Furthermore, no significant changes were observed in the angle width or depth in any of the three groups throughout the postoperative observation period. As expected, the mean preoperative intraocular pressure (IOP) in the ACG and OAG groups was higher than that in the control group. After cataract surgery, however, the mean IOP decreased significantly and was almost the same in all three groups at 1, 6, and 12 months after surgery.

CONCLUSIONS

The width and depth of the anterior chamber angle in eyes with ACG increased significantly after cataract extraction and IOL implantation and became similar to that in eyes with OAG and that in normal eyes, which may lead to the decrease in IOP seen in the postoperative period. No significant changes were observed in angle width and depth in any of the three groups after surgery.

Analysis of measles virus binding sites of the CD46 gene in patients with subacute sclerosing panencephalitis

Measles virus (MV) binding sites of the CD46 gene were sequenced in patients with subacute sclerosing panencephalitis (SSPE) and in controls. There were 3 novel polymorphisms, including C/T at nucleotide position 38 (C/T38), G/A at position 176 (G/A176), and C/T at position 453 (C/T453), at allele frequencies of.97:.03, .99:.01, and.97:.03, respectively. The G/A176 polymorphism causes an Arg/Gln amino acid change within the essential binding sites of MV, whereas the C/A38 polymorphism causes a Ser/Phe change outside the MV binding sites. The C/T453 polymorphism does not produce an amino acid change. Two of the 40 SSPE patients and 2 of the 32 controls had both C/T38 and C/T453 polymorphisms in heterozygous patterns. One control subject, but no SSPE patients, had the G/A176 polymorphism in a heterozygous pattern. Thus, it is not likely that CD46 gene alteration has a role as a host susceptibility factor in the development of SSPE.

Intraocular lens tilt and decentration after implantation in eyes with glaucoma

PURPOSE

To evaluate the extent of intraocular lens (IOL) tilt and decentration after implantation in eyes with glaucoma.

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

METHODS

Fifty-two eyes of 52 patients with glaucoma and 52 control eyes from 52 age-matched patients had phacoemulsification with IOL implantation. Twenty-nine eyes had closed-angle glaucoma (CAG), and the other 23 eyes had open-angle glaucoma (OAG). The extent of IOL tilt and decentration was measured using Scheimpflug videophotography 1 week and 1, 3, 6, 9, and 12 months postoperatively.

RESULTS

The mean tilt angle in the glaucoma group was significantly greater than in the control group throughout the follow-up. Mean decentration length was also greater in the glaucoma than in the control group, but the difference was not significant. The incidence of eyes showing a marked tilt (greater than 5 degrees) or decentration (greater than 0.5 mm) was higher in the glaucoma than in the control group. The mean tilt angle and the incidence of eyes showing a marked tilt or decentration in the CAG group were significantly greater than in the control group.

CONCLUSION

Intraocular lens tilt was more extensive in the eyes with glaucoma, especially in those with CAG, than in normal eyes. Decentration was also greater in the glaucoma groups than in the control group, although the differences were not significant.

Repetitive coxsackievirus infection induces cardiac dilatation in post-myocarditic mice

The relation between mycarditis and dilated cardiomyopathy (DCM) is controversial. To clarify the pathogenic mechanism of these diseases, the present study examined the effect of repetitive inoculation with coxsackievirus B3 (CVB3) in post-myocarditic mice. Inbred 3-week-old A/J mice were inoculated intraperitoneally with CVB3 (Nancy strain; 2x10(4) plaque-forming units) and reinfected in the same manner with CVB3 at 40 weeks (3W+/40W+). All mice were killed at 42 weeks old. The weight of the hearts of the 3W+/40W+ group were significantly increased compared with those of the 3W-/40W+ group, and both the heart weight/body weight and lung weight/body weight ratios of the 3W+/40W+ group were also significantly increased over those of the 3W-/40W- group, although the levels of serum neutralizing antibody titers were significantly increased in the 3W+/40W+ group over the level of the other groups. No increase in inflammatory cell infiltration or fibrosis progression was observed in the 3W+/40W+ group relative to the 3W+/40W- group, but the second inoculation resulted in a significant left ventricular dilatation and in left and right ventricular free wall thinning (3.31+/-0.20 mm vs 2.61+/-0.19 mm, p<0.05; 0.54+/-0.09 mm vs 0.72+/-0.16 mm, p<0.05, respectively). The sarcomere length was also significantly increased in the 3W+/40W+ group compared with that of the other groups, as determined by electron microscopy. Degenerative or necrotic areas in the infected hearts were not stained with anti-mouse IgG antibody, but were stained, only in 3W+/40W+ mice, with anti-mouse IgM antibody. The concentrations of TNF-alpha in the hearts of the 3W+/40W+ group were increased significantly over those of the 3W+/40W- group. Repetitive CVB3 infection produced cardiac dilatation without inflammatory cell infiltration in post- myocarditic mice. Autoimmunity mediated by the circulation of certain antibodies (eg, antibodies against the CVB3 genome or a CVB3-related protein) may be part of the pathogenic mechanism for this phenomenon. Thus, repetitive virus infection might contribute to the pathogenesis of cardiac dilatation.

[Anesthetic management for carotid and coronary artery surgery--concomitant versus two stage operation]

We reviewed the anesthetic management of 16 patients with concomitant severe coronary and carotid artery diseases. Eight patients underwent concomitant operations of coronary artery bypass graft and carotid endarterectomy, while the other 8 patients underwent two stage operation. Candidates for concomitant operations had unstable angina or serious coronary disease such as three vessel disease or severe stenosis of LMT. In comparison, most of patients undergoing two stage operation had symptomatic or occlusive carotid disease. In all cases, anesthesia was maintained with fentanyl and midazolam and the perfusion pressure during cardiopulmonary bypass was maintained above 70 mmHg. Some patients received thiopental or propofol for brain protection. The concomitant operations required much more transfusion and longer operation time than two stage operation. In addition, several cases of the concomitant operation needed intra-aortic balloon pumping or high dose of catecholamines. Indications for concomitant operation or two stage operation have to be determined through discussion among anesthesiologist, neurovascular as well as cardiovascular surgeons.

Intraocular lens tilt and decentration, anterior chamber depth, and refractive error after trans-scleral suture fixation surgery

OBJECTIVES

To compare the extent of intraocular lens (IOL) tilt and decentration, as well as the anterior chamber depth after trans-scleral suture IOL fixation after either secondary out-of-the-bag or primary in-the-bag IOL implantation.

DESIGN

Retrospective, comparative, nonrandomized, interventional study.

PARTICIPANTS

Fifty-two eyes that underwent scleral suture fixation were compared with 51 eyes that underwent secondary out-of-the-bag implantation and 50 eyes that underwent in-the-bag implantation.

INTERVENTION

One-piece polymethyl methacrylate IOL implantation by three different techniques.

MAIN OUTCOME MEASURES

The tilt angle and decentration length of the IOL, as well as the anterior chamber depth, were measured by the Scheimpflug videophotography system. The spherical equivalent error from the predicted value was also examined.

RESULTS

The mean tilt angle in the scleral suture fixation group was significantly greater than that in either the out-of-the-bag or the in-the-bag implantation group (P<0.0001). The mean decentration length was also largest in the suture group, followed by the out-of-the-bag group and the in-the-bag group (P<0.0001). The anterior chamber depth in the suture group and the out-of-the-bag group was significantly smaller than that in the in-the-bag group (P<0.0001). The spherical equivalent error in the suture group and the out-of-the-bag group was also greater than that in the in-the-bag group (P<0.0001).

CONCLUSIONS

The extent of both tilt and decentration after scleral suture fixation was greater than that observed after either out-of-the-bag or in-the-bag implantation. The anterior chamber depth with the sutured or out-of-the-bag fixated IOL was shallower than that with the in-the-bag fixated IOL, which resulted in a significant myopic shift.

Reproducibility of posterior capsule opacification measurement using Scheimpflug videophotography

PURPOSE

To examine the intraobserver and interobserver reproducibility in measuring posterior capsule opacification (PCO) using a Scheimpflug videophotography system.

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

METHOD

Twenty eyes with PCO and 10 without PCO had 5 independent measurements 15 minutes apart performed by 3 observers. The eyes without PCO were selected within 1 week after surgery. Intraobserver and interobserver reproducibility were evaluated using the coefficient of variation and intraclass correlation coefficient.

RESULTS

The median coefficients of variation of the 3 observers were 11.6%, 11.3%, and 9.8%, respectively, which indicates an acceptably low observer variability. The intraobserver correlation coefficients of the 3 observers were all more than 0.95, and the interobserver correlation coefficient was 0.976, which indicates excellent reproducibility.

CONCLUSION

The results of intraobserver and interobserver reproducibility of PCO measurement using the Scheimpflug videophotography system indicate it would be effective for use in research and clinical management of PCO.

Anterior capsule contraction and intraocular lens dislocation in eyes with pseudoexfoliation syndrome

AIMS

To examine the extent of anterior capsule contraction as well as intraocular lens (IOL) decentration and tilt following implant surgery in eyes with pseudoexfoliation syndrome (PE).

METHODS

53 eyes from 53 patients with PE and 53 control eyes from 53 age matched patients, undergoing phacoemulsification and implant surgery, were recruited. The anterior capsule opening area and the amounts of IOL decentration and tilt after undergoing continuous curvilinear capsulorhexis were measured using the Scheimpflug videophotography system at 1 week and 1, 3, 6, 9, and 12 months postoperatively.

RESULTS

The mean area of the anterior capsule opening in the PE group was significantly smaller than that in the control group at 1 month postoperatively and later. The percentage reductions in the PE group were approximately 25%, while they were less than 10% in the control group. The degree of IOL tilt was also larger in the PE group than in the control group. Five eyes (9.4%) in the PE group underwent a neodymium: YAG laser anterior capsulotomy, but none in the control group underwent a capsulotomy.

CONCLUSIONS

The contraction of the anterior capsule opening was more extensive in the PE eyes than in the control eyes, thus resulting in a high Nd:YAG laser anterior capsulotomy rate. The IOL tilt was also greater in the PE eyes than in the control eyes.

Quantitative comparison of posterior capsule opacification after polymethylmethacrylate, silicone, and soft acrylic intraocular lens implantation

OBJECTIVE

To quantitatively compare the extent of posterior capsule opacification (PCO) after polymethylmethacrylate (PMMA), silicone, and soft acrylic intraocular lens implantation.

PATIENTS AND METHODS

A total of 240 eyes from 240 patients undergoing implant surgery were randomized into 3 groups based on the type of lens implanted: PMMA, silicone, and soft acrylic. The density value of PCO in 185 eyes was quantitated approximately 2 years after surgery by a new measurement method using the Scheimpflug videophotography system.

RESULTS

Twenty-one eyes (30.4%) in the PMMA group, 4 (5.7%) in the silicone group, and 2 (2.7%) in the acrylic group had already undergone Nd:YAG laser posterior capsulotomy. The mean +/- SD PCO values were 26.3 +/- 12.2 computer-compatible tape steps (CCT) in the PMMA group, 12.0 +/- 8.3 CCT in the silicone group, and 16.0 +/- 10.3 CCT in the acrylic group. The PCO value in the PMMA group was significantly greater than that in the silicone or acrylic group (P < .001). The visual acuity loss in the PMMA group was also greater than that in the silicone or acrylic group (P < .001).

CONCLUSION

Based on the PCO value and capsulotomy rate, the PCO was more extensive with the PMMA lens than with either the silicone or soft acrylic lens, which led to visual acuity loss.

Area reduction in the anterior capsule opening in eyes of diabetes mellitus patients

PURPOSE

To compare the extent of area reduction in the anterior capsule opening after continuous curvilinear capsulorhexis in the eyes of diabetes mellitus (DM) patients with that in the eyes of patients without DM.

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

METHODS

Ninety-one eyes of 91 DM patients and 91 age-matched eyes of patients without DM (control group) having intraocular lens (IOL) implantation were recruited for this prospective study. The DM group comprised 36 eyes with diabetic retinopathy (DR) and 55 without retinopathy (NDR). The anterior capsule opening area was quantitated using Scheimpflug photography 1 week and 1, 3, and 6 months postoperatively.

RESULTS

There was no statistically significant difference in mean anterior capsule opening area between the DM and control groups at 1 week or 1 month postoperatively. The area was significantly smaller in the DM group at 3 (P = .0221) and 6 (P = .0075) months. The percentage area reduction was also greater in the DM group than in the control group. The area in the DR group was significantly smaller than in the control group at 3 (P = .0392) and 6 (P = .0080) months. The percentage reduction in the DR group was larger than in the NDR or control group.

CONCLUSIONS

After IOL implantation, contraction of the anterior capsule opening area was more extensive in eyes of DM patients than in those of patients without DM, especially in the case of DR.

Interferon-alpha therapy for chronic active Epstein-Barr virus infection: potential effect on the development of T-lymphoproliferative disease

PURPOSE

A patient with aggressive chronic active Epstein-Barr virus (CAEBV) infection is described whose disease activity subsided after interferon (IFN)-alpha therapy.

PATIENT AND METHODS

The patient had intermittent fever, cytopenia, liver dysfunction, hepatosplenomegaly, abnormal titers of EBV-associated antibodies, and positive EBV genomes.

RESULTS

Despite repeated trials of the antiviral agents prednisolone and gamma-globulin, his condition deteriorated. The administration of IFN-alpha (1 x 10(5) U/kg subcutaneously 3 times per week) led to a dramatic clinical improvement. During the IFN-alpha therapy, the rearrangement bands of T-cell antigen receptor genes disappeared assessed by Southern blotting with a decrease in the number of activated T cells, although the EBV-genome remained evident.

CONCLUSIONS

These observations suggest that IFN-alpha is useful in managing CAEBV, possibly restraining the clonal development of T-lymphoproliferative disease (LPD) and EBV-associated B-LPD, although it does not eradicate the proliferation of EBV.

Anterior capsule contraction and intraocular lens dislocation after implant surgery in eyes with retinitis pigmentosa

OBJECTIVE

The purpose of the study was to investigate the extent of anterior capsule contraction, intraocular lens (IOL) decentration, and tilt after implant surgery in eyes with retinitis pigmentosa (RP).

DESIGN

A case-control study.

PARTICIPANTS

Forty-seven eyes from 47 patients with typical RP and 47 control eyes from 47 age-matched healthy patients were studied.

INTERVENTION

Phacoemulsification surgery with polymethylmethacrylate IOL implantation with continuous curvilinear capsulorrhexis was performed.

MAIN OUTCOME MEASURES

The area of the anterior capsule opening obtained with capsulorrhexis and the amount of the decentration and tilt of the IOL were measured using a Scheimpflug photography system at 1 week and 1, 3, 6, 9, and 12 months after surgery.

RESULTS

The mean area in the RP group was found to be significantly smaller than that in the control group at 1 month after surgery and later (P < 0.0001). The percent area reduction in the RP group at 6 months was 45.2 +/- 25.8% and 4.6 +/- 13.5% in the control group. Both the decentration length and tilt angle were also greater in the RP group than in the control group. Fourteen (29.8%) of the 47 RP eyes had undergone a neodymium:YAG (Nd:YAG) laser anterior capsulotomy at 12 months after surgery, whereas none of the control eyes had undergone an Nd:YAG.

CONCLUSIONS

Anterior capsule contraction in the RP eyes was more extensive than in the control eyes, leading to a high Nd:YAG laser anterior capsulotomy rate. Both lens decentration and tilt also were greater in the RP eyes than in the control eyes.

In vivo quantitative measurement of posterior capsule opacification after extracapsular cataract surgery

PURPOSE

To introduce a new in vivo quantitative measurement of posterior capsule opacification (PCO) after extracapsular cataract surgery and also to analyze the correlation between opacification density and the patient's visual acuity.

METHODS

Prospectively, the opacification density value in the central 3-mm portion of the posterior capsule was quantitated by means of an area densitometry with the Scheimpflug photography system (EAS-1000). The EAS-1000 examination was performed on 40 eyes with clinically significant PCO both before and after undergoing Nd:YAG laser posterior capsulotomy, and on 10 eyes without PCO. The correlation between the opacification density value and the visual acuity was analyzed with a linear regression analysis.

RESULTS

The mean opacification density values +/- SD were 48.8 +/- 29.5 computer-compatible tapes (CCT) steps in the PCO group before capsulotomy, 15.5 +/- 7.8 CCT steps in the PCO group after capsulotomy, and 12.9 +/- 4.9 CCT steps in the non-PCO group. The mean opacification density value in the PCO group before capsulotomy was significantly greater than that in the PCO group after capsulotomy or than that of the non-PCO group. A linear regression analysis determined that the opacification density value also correlated well with the visual acuity (R2 = .808).

CONCLUSIONS

We have established a new in vivo quantitative measurement of PCO. Because the opacification density value obtained by this measurement correlated well with the patient's visual acuity, we consider this measurement to be useful in both the research and clinical management of PCO.

Comparison of decentration and tilt between one piece and three piece polymethyl methacrylate intraocular lenses

BACKGROUND

The extent of the decentration and tilt was prospectively compared between one piece polymethyl methacrylate (PMMA) and three piece PMMA intraocular lenses (IOLs) which were implanted in the capsular bag after performing continuous curvilinear capsulorhexis.

METHODS

91 patients underwent a one piece PMMA IOL implantation in one eye as well as the implantation of the three piece PMMA IOL with polyvinylidene fluoride loops in the opposite eye. The length of the lens decentration and the angle of the tilt were quantitated using the anterior eye segment analysis system (EAS-1000) at 1 week as well as 1, 3, and 6 months postoperatively.

RESULTS

The mean length of the decentration in the one piece IOL was smaller than that in the three piece IOL at 1 week (p = 0.0092), 1 month (p = 0.0044), 3 months (p = 0.0069), and 6 months (p = 0.0010) postoperatively. However, no significant difference was found in the degree of the tilt between the two types of IOLs throughout the observation periods.

CONCLUSION

These results clarified that the one piece PMMA IOL with rigid PMMA haptics implanted in the capsular bag provides a better centration than the three piece PMMA IOL with flexible haptics, whereas the tilt was the same between the two types of IOLs.

Hypogammaglobulinaemia in a patient with ring chromosome 21

An 8 year old boy with ring chromosome 21 who was susceptible to sinorespiratory infections due to hypogammaglobulinaemia is reported. He presented with the characteristic features of monosomy 21 syndrome, such as psychomotor retardation, hypertonia, large saccular ears, prominent nasal bridge, micrognathia, thrombocytopenia, and patent ductus arteriosus. His serum IgG concentration was less than 1.5 g/l at 3 years and 6 months of age after repeated hospitalisations with pneumonia, otitis media, and convulsions. Regular replacement of intravenous gammaglobulin effectively reduced such infectious episodes. A predisposition to infection in patients with ring chromosome 21 may be explained by hypogammaglobulinaemia and merit treatment with gammaglobulin.

Decentration and tilt of polymethyl methacrylate, silicone, and acrylic soft intraocular lenses

PURPOSE

The purpose of the study is to investigate the periodic changes regarding the decentration and tilt of the intraocular lens (IOL) and to compare any differences in the decentration and tilt among polymethyl methacrylate (PMMA), silicone, and acrylic soft IOLs.

METHODS

A total of 225 cataractous eyes undergoing IOL implant surgery were randomized into 3 groups based on the type of IOL: group A, one-piece PMMA IOL; group B, three-piece silicone IOL; and group C, three-piece acrylic soft IOL. Both the length of the decentration and the degree of the tilt of the IOL were quantitated using the Anterior Eye Segment Analysis System (EAS-1000). All eyes underwent EAS-1000 examinations at 1 week as well as 1, 3, 6, 9, and 12 months after surgery.

RESULTS

All IOLs were confirmed to be implanted accurately in the capsular bag after continuous curvilinear capsulorhexis was accomplished. No statistically significant differences were observed regarding the IOL decentration or tilt between the various postoperative periods in any of the three IOL groups. Furthermore, the differences regarding both the IOL decentration and the tilt between the three IOLs were not determined to be statistically significant throughout the observation period.

CONCLUSIONS

As long as the IOL was placed properly in the capsular bag after the continuous capsulorhexis, neither the decentration nor the tilt of the IOL showed a significant progression up to 12 months after surgery. Furthermore, both the extent of the decentration and tilt almost were the same among the PMMA, silicone, and acrylic soft IOLs.

Corneal shape changes after scleral buckling surgery

PURPOSE

A prospective study was conducted to investigate the corneal shape changes due to scleral buckling surgery. These changes were analyzed based on the type of buckling procedures performed.

METHODS

A total of 89 eyes from 88 patients were stratified into four groups based on the type of buckling procedures used, including:group A, local buckling; group B, encircling; group C, encircling with vitrectomy; and group D, encircling with additional segmental buckling. These eyes underwent keratometry and videokeratography examinations before surgery as well as at 1, 3, and 6 months after surgery.

RESULTS

No statistical significance was observed in the amounts of the induced corneal astigmatism and the refractive cylinder among the four groups. After local or segmental buckling (groups A and D), corneal steepening, which corresponded to the buckle, occurred at a high incidence. After encircling (groups B and C), either peripheral corneal flattening with focal central steepening or flattening on one side with coupled steepening on the opposite side was observed. Such corneal changes persisted for up to 6 months in an irregular and asymmetric configuration.

CONCLUSIONS

All four types of circumferential scleral buckling surgery were found to produce prolonged irregular and asymmetric corneal shape changes, whereas the patterns of the changes differed depending on the buckling procedures used.

Reduction in the area of the anterior capsule opening after polymethylmethacrylate, silicone, and soft acrylic intraocular lens implantation

PURPOSE

To report reduction in the area of anterior capsule opening at various postoperative intervals after continuous capsulorrhexis and to compare any differences in the area reduction between polymethylmethacrylate, silicone, and soft acrylic intraocular lenses.

METHODS

Prospectively, 240 eyes of 240 patients undergoing phacoemulsification and intraocular lens implant surgery were randomized into three groups based on the type of intraocular lens used: polymethylmethacrylate, silicone, and soft acrylic. The area of the anterior capsule opening was quantitated, and examinations were performed at 1 week and 1, 3, and 6 months postoperatively.

RESULTS

After intraocular lens implantation, the mean anterior capsule opening area 3 months postoperatively was significantly smaller than that at 1 week in all groups (polymethylmethacrylate, P = .0090; silicone, P < .0001; soft acrylic, P = .0127). Mean percentages in area reduction at both 3 and 6 months postoperatively were significantly greater than those at 1 week and 1 month (P < .0001). In comparing the three intraocular lenses at 1 week postoperatively, no statistical significance was observed regarding the anterior capsule opening area between the three groups. However, the mean anterior capsule opening areas in the polymethylmethacrylate and soft acrylic intraocular lens groups were significantly larger than those in the silicone intraocular lens group at 1 month (P = .0024), and 3 months (P = .0032), and 6 months (P = .0022) postoperatively.

CONCLUSIONS

After continuous capsulorrhexis and intraocular lens implant surgery, the area of the anterior capsule opening gradually decreased for up to 3 months postoperatively. The contraction of the anterior capsule opening was greater in the silicone group than in either the polymethylmethacrylate or the soft acrylic groups.

Risk factors for corneal endothelial injury during phacoemulsification

PURPOSE

To determine the principal risk factors for corneal endothelial injury during phacoemulsification.

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

METHODS

We prospectively investigated 859 consecutive eyes of 800 patients who had had phacoemulsification surgery. The percentage of corneal endothelial cell loss at 3 months after surgery was quantitated using specular microscopy. The firmness of the nucleus was graded by Emery's classification prior to surgery. We selected nine variables that could be associated with endothelial injury. The univariate associations between the endothelial cell loss and these variables were evaluated using simple correlation coefficients. A multiple linear regression analysis was performed to identify independent predictors of endothelial cell loss.

RESULTS

In the simple regression analysis, older age, small pupil diameter, high nucleus grade, large nucleus, greater infusion volume, type of IOL implanted, and a greater amount of total emitted ultrasound energy were univariately associated with endothelial cell loss. In the multiple linear regression analysis, the best final model (R2 = 0.42) identified high nucleus grade, greater infusion volume, type of IOL implanted, and large nucleus as independent predictors of endothelial cell loss.

CONCLUSION

Both univariate and multivariate analyses identified the firmness of the nucleus as the most significant risk factor for endothelial cell loss. Therefore, mechanical contact with nuclear fragments is considered the principal cause of endothelial injury.

Corneal endothelial cell loss in phacoemulsification surgery with silicone intraocular lens implantation

PURPOSE

To clarify the extent of corneal endothelial injury from silicone intraocular lens (IOL) implantation in small incision cataract surgery.

METHODS

Two hundred forty eyes that had phacoemulsification surgery were divided into four groups: Group A comprised 70 eyes that received a conventional silicone IOL; Group B, 63 eyes that received a higher refractive index silicone IOL; Group C, 71 eyes that received a poly(methyl methacrylate) (PMMA) IOL; Group D, 36 eyes that had phacoemulsification without an IOL. Cell density of the corneal endothelium in all eyes was examined by specular microscopy preoperatively and 3 months postoperatively, and the percentage of endothelial cell loss was determined. The differences in endothelial cell loss between the four groups were statistically compared using the Kruskal-Wallis test.

RESULTS

Percentages of endothelial cell loss were 4.5 +/- 5.1% in Group A, 4.3 +/- 5.3% in Group B, 6.3 +/- 5.4% in Group C, and 4.3 +/- 4.9% in Group D. No statistically significant difference was observed among these four groups, although the percentage of cell loss in Group C was slightly larger than that in the other groups.

CONCLUSION

The implantation of silicone IOLs and PMMA IOLs causes minimal corneal endothelial cell loss in contemporary small incision surgery.

[Changes in axial length after scleral buckling surgery]

The eye lengthens after scleral buckling surgery for retinal detachment. We investigated the changes in axial length and refraction after scleral buckling. A total of 89 eyes from 88 patients which were all scheduled to undergo scleral buckling were included in this study. The eyes were classified into four groups based on the type of buckling procedures:1 local buckling, 2 encircling, 3 encircling with vitrectomy, and 4 encircling with local buckling. We examined the axial length of these eyes using ultrasonography, preoperatively and at 1, 3, and 6 months postoperatively. The refractive changes were also examined. Depending on the type of scleral buckling procedure employed, the eyes in Groups 2, 3, and 4 clearly lengthened, but those of Group 1 did not. The amount of axial lengthening in Groups 2, 3, and 4 was significantly greater than in Group 1 at 3 and 6 months after surgery. In the spherical equivalent, a myopic shift occurred in the eyes in Groups 2, 3, and 4, and this shift was significantly greater than in Group 1 In addition, the correlation between the extent of axial lengthening and myopic shift was significant. In conclusion, the axial length increases with a myopic shift due to encircling, whereas local buckling changed the axial length only slightly.

Capsular capture of silicone intraocular lenses

PURPOSE

To examine the incidence of capsular capture in silicone IOL implantation and determine its effect on visual acuity.

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

METHODS

This study comprised 144 eyes that had phacoemulsification with three-piece silicone intraocular lens (IOL) implantation that were evaluated about 3 months after surgery. The examination included the status of the haptic and optic placement, extent of posterior capsular opacification (PCO), and the best corrected visual acuity.

RESULTS

One hundred twenty-eight eyes had an in-in haptic placement, 15 had in-out placement, and 1 had out-out placement. Capsular capture occurred in 30 eyes (20.8%). The extent of PCO in eyes with capsular capture was greater than in those without capture. The best corrected visual acuity in eyes with capsular capture was worse than in those without capture. In addition, eyes with in-out and out-out haptic placement had significantly worse PCO and visual impairment than the eyes with in-in placement.

CONCLUSION

There was a high incidence of capsular capture after silicone IOL implantation. This complication, along with the undesirable placement of the haptics, led to PCO and thus visual impairment.

The correlation between incision size and corneal shape changes in sutureless cataract surgery

PURPOSE

To examine the correlation between incision size and corneal shape changes in sutureless surgery using corneal topography.

METHODS

Two hundred eyes undergoing sutureless cataract surgery were assigned randomly to three groups according to the incision size: group A, 3.2-mm incision; group B, 4.0-mm incision; and group C, 5.0-mm incision. All eyes were examined by corneal topography preoperatively as well as at 1 week and at 1, 3, and 6 months after surgery.

RESULTS

In the average of difference maps of eyes in the 3.2-mm incision group, a wound-related flattening in the peripheral cornea occurred 1 week after surgery, but decreased rapidly thereafter. Subsequently, no significant changes were observed in the cornea after 1 month. In the 4.0-mm incision group, with a reduction of the wound-related peripheral flattening, an irregular steepening appeared in the lower central cornea 6 months after surgery. In the 5.0-mm incision group, a similar steepening in the lower cornea occurred just after surgery. This steepening persisted and even extended to the upper central cornea in its later postoperative periods.

CONCLUSION

The 3.2-mm incision hardly produced any irreversible corneal shape changes, whereas both the 4.0- and 5.0-mm incisions caused a persistent irregular steepening in the central cornea.

Corneal endothelial cell loss following phacoemulsification using the Small-Port Phaco

We studied the extent of corneal endothelial injury after phacoemulsification using the Small-Port Phaco (SPP), a new phacoemulsification instrument that allows linear aspiration during phacoemulsification. Of 72 eyes undergoing phacoemulsification, the SPP was used in 33 (group 1) and a standard phacoemulsification instrument in 39 (group 2). Endothelial cell density was examined by specular microscopy preoperatively and at 1 and 3 months after surgery, and the percentage of endothelial cell loss was evaluated. Operative factors influencing endothelial injury such as the duration of ultrasound emission, the ultrasound power expended, and the amount of irrigating solution used also were measured. The percentages of endothelial cell loss at both 1 and 3 months were significantly less (P < .05) in group 1 than in group 2 (in group 1, 4.3 +/- 3.4% at 1 month, and 5.6 +/- 3.8% at 3 months; in group 2, 6.9 +/- 4.6%, and 8.3 +/- 5.4%, respectively). The duration of emission was shorter and the ultrasound power discharged was smaller in the SPP cases. Since the total ultrasound energy emitted in the SPP cases was less than that in the standard-instrument cases, we conclude that the reduced corneal endothelial damage observed in group 1 was directly related to the smaller total ultrasound power expended in these cases.

Corneal topographic analysis of superolateral incision cataract surgery

Using corneal topography, we compared the corneal shape changes following superolateral incision cataract surgery with those following conventional superior incision surgery. In our superolateral incision procedure, a 6.5 mm limbal incision was made from the 9 o'clock to 11 o'clock meridians to avoid incising the superior limbus. One hundred four patients were divided into two groups; Group 1 comprised 66 patients who had surgery using the superolateral approach; Group 2 comprised 38 patients who had surgery using the superior approach. The corneas were examined by keratometer and topographic modeling system preoperatively, and at one week and one, three, and six months postoperatively. Keratometric measurements showed that surgically induced astigmatism (SIA) in Group 1 was significantly less than that in Group 2 throughout the six-month observation. The standard SIA deviation in Group 1 was also smaller than that in Group 2, indicating a smaller degree of variability in the superolateral incision surgery. In the corneal topographic analysis, a color-coded map averaging all the Group 1 corneas at each interval showed a slight steepening in the central cornea in the 10 o'clock meridian one week after surgery. This surgically induced steepening disappeared by one month, and the corneal shape recovered its preoperative shape. In contrast, the Group 2 averaged map showed a marked steepening of the upper and lower corneas. The steepening gradually decreased but remained until three months after surgery. Superolateral incision surgery induced a smaller degree of change in the corneal shape, as well as in SIA, than superior incision surgery. The postoperative corneal shape changes disappeared rapidly after the superolateral incision, and the corneal shape soon stabilized and recovered its preoperative shape.

Corneal endothelial cell loss after phacoemulsification using nuclear cracking procedures

This study assessed corneal endothelial damage in endocapsular phacoemulsification surgery using a nuclear cracking procedure in which the nucleus was divided into four quadrants and emulsified. Forty-five eyes had phacoemulsification using this technique, and 33 eyes had phacoemulsification using undivided sculpting techniques (without cracking). We examined the extent of endothelial cell loss at one and three months after surgery using specular microscopy. We also measured ultrasound time, time spent for phacoemulsification, and infusion volume during surgery. Endothelial cell loss was significantly less in the nuclear cracking group than in the undivided sculpting group. Ultrasound time in surgery with cracking was significantly shorter than that in surgery without cracking. The time for the phacoemulsification maneuvers and the infusion volume were the same for both procedures. These findings indicate that the ultrasound time was shortened using the nuclear cracking technique and resulted in less corneal injury.

Cancer-associated retinopathy with retinal phlebitis

A 50-year-old man with cancer-associated retinopathy was investigated using light and electron microscopy, immunofluorescence studies, and western blotting. He had visual disturbance, ring-like scotoma, and night blindness bilaterally. There were narrowed retinal arterioles and dilated retinal venules. Oral corticosteroid therapy had positive effects. Immunostaining using the patient's serum revealed a positive reaction in the ganglion cell layer of normal retina. Western blotting showed that the patient's serum antibody reacted with normal retinal proteins of 24 and 48 kDa. Multiple metastases were evident at autopsy.