Branch retinal artery occlusion with unruptured retinal arterial macroaneurysm post-SARS-CoV-2 vaccination: A case report

INTRODUCTION

Many adverse occurrences in the eye have been reported after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. This is the first report of a patient with an unruptured retinal arterial macroaneurysm (RAM) who developed branch retinal artery occlusion (BRAO) one day after SARS-CoV-2 vaccination (BNT162b2 by Pfizer-BioNTech).

PATIENT REPORT

A 75-year-old man with a pertinent history of type-2 diabetes mellitus visited the hospital complaining of sudden visual loss in his right eye 1 day after receiving the fourth dose of the SARS-CoV-2 mRNA vaccine; his best-corrected visual acuity (BCVA) decreased from 1.0 to 0.7 (Snellen decimal). The patient had previously been diagnosed with an unruptured RAM and superior paracentral acute middle maculopathy in the same eye. Fundus examination showed increased sheathing of blood vessels. Indocyanine green showed a hyperfluorescent area suggestive of RAM on the right eye disc. Fluorescein angiography and optical coherence tomography angiography revealed arterial obstruction findings in the upper retinal area.

DIAGNOSIS AND INTERVENTION

The patient was diagnosed with BRAO with RAM and was followed up without any additional treatment. Follow-up examination after 4 months did not show any improvement in BCVA value.

CONCLUSION

This case suggested that BRAO could develop after SARS-CoV-2 vaccination in patients with unruptured RAM; however, more research is required to investigate the causes.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Successful Management of Familial Exudative Vitreoretinopathy with a Large Macular Hole Using Inverted Internal Limiting Membrane Flap Technique

Introduction

This case report aims to shed light on a rare presentation of familial exudative vitreoretinopathy (FEVR) co-existing with a large full-thickness macular hole (FTMH) in a 16-year-old male and discuss its successful surgical management, thereby adding to the limited existing knowledge on this topic.

Case Presentation

Over an 8-month period, the patient had experienced progressively worsening visual blurring and distortion in his left eye. Following a comprehensive examination, diagnosis confirmed FEVR and an accompanying large FTMH. It was hypothesized that this unusual manifestation resulted from the tractional forces exerted by a thick posterior vitreous membrane and a thin epiretinal membrane - a distinctive attribute of FEVR. The patient underwent surgical intervention, which included pars plana vitrectomy (PPV), internal limiting membrane (ILM) peeling, gas tamponade, and the inverted ILM flap technique. Postoperative outcomes were favorable, with the FTMH successfully closed and substantial improvement observed in the patient's visual acuity at the 3-month follow-up visit.

Conclusion

This case report highlights a rare association of FEVR with FTMH, thereby broadening our understanding of potential complications in patients with FEVR. The successful surgical intervention reinforces the utility of the PPV and the inverted ILM flap technique in managing such complications. It underscores the need for clinicians to maintain vigilance for such atypical manifestations in FEVR patients.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Revolutionizing Patient Monitoring in Age-Related Macular Degeneration: A Comparative Study on the Necessity and Efficiency of the AMD VIEWER

(1) Background: Age-related Macular Degeneration (AMD) is a critical condition leading to blindness, necessitating lifelong clinic visits for management, albeit with existing challenges in monitoring its long-term progression. This study introduced and assessed an innovative tool, the AMD long-term Information Viewer (AMD VIEWER), designed to offer a comprehensive display of crucial medical data-including visual acuity, central retinal thickness, macular volume, vitreous injection treatment history, and Optical Coherent Tomography (OCT) images-across an individual eye's entire treatment course. (2) Methods: By analyzing visit frequencies of patients with a history of invasive AMD treatment, a comparative examination between a Dropout group and an Active group underscored the clinical importance of regular visits, particularly highlighting better treatment outcomes and maintained visual acuity in the Active group. (3) Results: The efficiency of AMD VIEWER was proven by comparing it to manual data input by optometrists, showing significantly faster data display with no errors, unlike the time-consuming and error-prone manual entries. Furthermore, an elicited Net Promoter Score (NPS) of 70 from 10 ophthalmologists strongly endorsed AMD VIEWER's practical utility. (4) Conclusions: This study underscores the importance of regular clinic visits for AMD patients. It suggests the AMD VIEWER as an effective tool for improving treatment data management and display.

POS1349 IMMUNOGLOBULIN G4-RELATED KIDNEY DISEASE’S PREDISPOSITION TO CHRONIC RENAL DYSFUNCTION, COMPLICATIONS OF MALIGNANCY, AND MORTALITY: A LONG-TERM NATIONWIDE MULTICENTER STUDY IN JAPAN

Background

In immunoglobulin G4-related kidney disease (IgG4-RKD), persistent renal insufficiency may be observed despite the good initial response to glucocorticoids[1, 2]. However, its long-term prognosis in relation to renal function as well as malignancy and mortality has not been well clarified.

Objectives

To clarify the long-term renal prognosis, complications of malignancy, mortality, and factors related to those outcomes in IgG4-RKD.

Methods

We retrospectively reviewed the medical records of patients with IgG4-RKD diagnosed by the expert members of the IgG4-RKD working group in the Japanese Society of Nephrology. We investigated clinical, radiological, and histopathological features at baseline and course of renal function, complications of malignancy, and mortality during the long-term observation periods (median 71 months) in 75 patients. Using collected data, we calculated the crude incidence rates (IR) of chronic kidney disease (CKD) status, malignancy, and death. Cox regression analyses were performed to assess CKD-related factors. Additionally, we calculated the standardized incidence ratio (SIR) of malignancy and standardized mortality ratio (SMR) using national Japan statistics.

Results

Fifty-nine patients were male, and 16 were female (median age 70 years). At diagnosis, their median eGFR was 45.1 mL/min/1.73m2 (interquartile range [IQR] 28.6-69.9). Seventy-two patients (96%) were treated with prednisolone at a median initial dose of 30 (IQR 30-39) mg/day, leading to a reasonable initial improvement of renal function. The IR of CKD was 30.2/100 person-years, and 66.7% (50/75) of the patients showed CKD at the last visit. Age- and sex-adjusted Cox regression analyses indicated that lower eGFR (per 10 mL/min/1.73m2, hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.61-0.80), pre-existing hypertension (HR 2.39, 95% CI 1.32-4.34), and wider areas with inflammation (>50% vs. <10%, HR 2.55, 95% CI 1.07-6.08) or fibrosis (>50% vs. <5%, HR 2.84, 95% CI 1.18-6.85) in the biopsied renal specimens at treatment initiation had a significant impact on the time to CKD. Eight patients (10.7%) died during follow-up due to malignancy, severe infection, cerebral hemorrhage, or myocardial infarction. The crude mortality rate was 1.76/100 person-years, and a SMR calculated according to national Japan statistics was 0.97 (95% CI 0.42-1.90). On the other hand, 15 patients were diagnosed as having malignancies during follow-up. The IR of malignancy was 3.71/100 person-years, and the SIR of malignancy was 1.80 (95% CI 1.03-2.93).

Conclusion

This study suggests that pre-treated renal insufficiency and extensive renal inflammatory and fibrotic lesions are related to CKD under glucocorticoid therapy in IgG4-RKD. Similarly with the whole IgG4-related disease, IgG4-RKD may have an increased incidence of malignancy but a mortality rate equivalent to the age- and sex-matched Japanese population.

References

[1]Saeki T et al. The clinical course of patients with IgG4-related kidney disease. Kidney Int. 2013 Oct;84(4):826-33.

[2]Mizushima I et al. Factors related to renal cortical atrophy development after glucocorticoid therapy in IgG4-related kidney disease: a retrospective multicenter study. Arthritis Res Ther. 2016 Nov 25;18(1):273.

Disclosure of Interests

None declared

A Case of Birdshot Chorioretinopathy following Varicella Zoster Virus-Induced Progressive Retinal Necrosis in the Contralateral Eye

Birdshot chorioretinopathy is an immune-mediated ocular inflammatory disease of the retina. We report a case of birdshot chorioretinopathy in one eye following progressive retinal necrosis caused by varicella zoster virus (VZV) in the contralateral eye. A 79-year-old female patient complained of decreased vision due to anterior chamber inflammation and vitreous opacity in the left eye starting 10 days earlier. Acute retinal necrosis was suspected and polymerase chain reaction analysis was performed using the anterior chamber aqueous. VZV DNA was detected, and antiviral drugs and steroids were systemically administered together with local therapy. As retinal necrotic changes and retinal detachment gradually developed, vitrectomy and silicone oil tamponade were performed. Despite these procedures, retinal necrosis gradually progressed. Eventually, extensive retinochoroidal atrophy resembling progressive outer retinal necrosis was observed. Two years and 4 months after onset, anterior chamber inflammation and white spots of the retina started to appear in the right eye. The number of white spots gradually increased all around the retina, regardless of systemic treatment with acyclovir and prednisolone. The fundus findings seemed consistent with birdshot chorioretinopathy. Diseases exhibiting white dots in the retina, such as sarcoidosis, were excluded. Ss-OCT examination revealed destruction of the layer structure mainly in the outer layers of the retina and a section of a white dot revealed that the retina appeared to be pulled into the RPE. To the best of our knowledge, this is the first report of birdshot chorioretinopathy in one eye after the onset of VZV-induced retinal necrosis in the contralateral eye.

Exacerbation of branch retinal vein occlusion post SARS-CoV2 vaccination: Case reports

RATIONALE

In this paper, we report on 2 patients who developed branch retinal vein occlusion (BRVO) exacerbation 1 day after administration of the BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine.

PATIENT CONCERNS

Case 1: A 71 year-old female developed vision loss in her left eye 1 day after receiving a second dose of the SARS-CoV-2 mRNA vaccine. This patient was diagnosed with temporal inferior BRVO and secondary macular edema (ME) in her left eye. ME resolved after 3 doses of intravitreal aflibercept (IVA). After treatment, no recurrence of ME was observed.Case 2: A 72 year-old man developed vision loss in his right eye 1 day after receiving the first dose of the SARS-CoV-2 mRNA vaccine. This patient was diagnosed with temporal superior BRVO in the right eye without ME. The patient was followed up and did not undergo any additional treatment.

DIAGNOSES

Case1: Temporal superior BRVO and secondary ME were observed in the left eye. Her best-corrected visual acuity (BCVA) was 20/30.Case2: Temporal superior BRVO recurrence and secondary ME were observed in the right eye. BCVA was 20/25.

INTERVENTIONS

Case1: Additional dose of IVA was administered. Case2: Two times of Intravitreal ranibizumab was administered twice.

OUTCOMES

Case1: Subsequently, ME resolved BCVA was 20/20. Case2: Subsequently, ME resolved BCVA was 20/25.

LESSONS

Both cases showed a possible association between SARS-CoV-2 vaccination and the exacerbation of BRVO.

Accuracy of Diabetic Retinopathy Staging with a Deep Convolutional Neural Network Using Ultra-Wide-Field Fundus Ophthalmoscopy and Optical Coherence Tomography Angiography

PURPOSE

The present study aimed to compare the accuracy of diabetic retinopathy (DR) staging with a deep convolutional neural network (DCNN) using two different types of fundus cameras and composite images.

METHOD

The study included 491 ultra-wide-field fundus ophthalmoscopy and optical coherence tomography angiography (OCTA) images that passed an image-quality review and were graded as no apparent DR (NDR; 169 images), mild nonproliferative DR (NPDR; 76 images), moderate NPDR (54 images), severe NPDR (90 images), and proliferative DR (PDR; 102 images) by three retinal experts by the International Clinical Diabetic Retinopathy Severity Scale. The findings of tests 1 and 2 to identify no apparent diabetic retinopathy (NDR) and PDR, respectively, were then assessed. For each verification, Optos, OCTA, and Optos OCTA imaging scans with DCNN were performed.

RESULT

The Optos, OCTA, and Optos OCTA imaging test results for comparison between NDR and DR showed mean areas under the curve (AUC) of 0.79, 0.883, and 0.847; sensitivity rates of 80.9%, 83.9%, and 78.6%; and specificity rates of 55%, 71.6%, and 69.8%, respectively. Meanwhile, the Optos, OCTA, and Optos OCTA imaging test results for comparison between NDR and PDR showed mean AUC of 0.981, 0.928, and 0.964; sensitivity rates of 90.2%, 74.5%, and 80.4%; and specificity rates of 97%, 97%, and 96.4%, respectively.

CONCLUSION

The combination of Optos and OCTA imaging with DCNN could detect DR at desirable levels of accuracy and may be useful in clinical practice and retinal screening. Although the combination of multiple imaging techniques might overcome their individual weaknesses and provide comprehensive imaging, artificial intelligence in classifying multimodal images has not always produced accurate results.

Changes in Choroidal Component Ratio and Circulation After Coffee Intake in Healthy Subjects

Purpose

The effects of coffee intake on the ratio of stromal and luminal components in the choroid and the underlying mechanism remain unclear. This prospective cross-sectional study aimed to explore how coffee intake affects the choroidal component ratio and circulation.

Methods

Forty-nine right eyes of healthy adult volunteers were evaluated as the coffee intake group. Thirty-two right eyes of healthy volunteers served as the control group. The participants consumed 185 mL of coffee or water, respectively, and the systemic hemodynamics, enhanced-depth imaging optical coherence tomographic (EDI-OCT) images, and foveal mean blur rate (MBR), an indicator of blood flow velocity, were recorded at baseline and after coffee or water intake. The EDI-OCT images were binarized using ImageJ software, and subfoveal choroidal thickness (SCT) and whole, luminal, and stromal choroidal areas were calculated.

Results

In the coffee intake group, significant decreases in SCT and luminal area peaked at 60 minutes after intake (both P < 0.001), whereas a significant increase in MBR peaked at 30 minutes (P < 0.001). No significant stromal area fluctuations were observed. SCT and luminal area fluctuations exhibited a significant positive correlation (r = 0.978, P < 0.001). Significant negative correlations of luminal area fluctuations with MBR fluctuations were observed by stepwise regression analysis (r = -0.220, P < 0.001). The control group exhibited no significant fluctuations.

Conclusions

Coffee-induced choroidal thinning may result mainly from a reduction in the choroidal vessel lumen, and this vessel lumen reduction correlated with an increased choroidal blood flow velocity after coffee intake. These coffee-induced changes in choroidal component ratio and circulation should be considered when evaluating choroids.

FRI0503 VALIDATION OF THE 2019 ACR/EULAR CLASSIFICATION CRITERIA FOR IGG4-RELATED DISEASE IN A JAPANESE KIDNEY DISEASE COHORT: A MULTI-CENTER RETROSPECTIVE STUDY BY THE IGG4-RELATED KIDNEY DISEASE (IGG4-RKD) WORKING GROUP OF THE JAPANESE SOCIETY OF NEPHROLOGY

Background:

The 2019 ACR/EULAR classification criteria for IgG4-RD have recently been published1). In the criteria, patients with an inclusion criteria score of >20 without exclusion criteria are classified as having IgG4-RD.

Objectives:

To validate the 2019 ACR/EULAR classification criteria for IgG4-RD in a Japanese kidney disease cohort.

Methods:

The study involved Japanese patients diagnosed as having kidney disease between April 2012 and May 2019, for whom sufficient clinical information and data on serum IgG4 values and/or immunohistological staining for IgG4 in renal biopsy samples were known. These patients were classified as having IgG4-RKD or non-IgG4-RKD (mimickers) based on the 2019 ACR/EULAR classification criteria for IgG4-RD, and the results were evaluated by expert opinion.

Results:

Among 105 included patients, the expert panel diagnosed 55 as having true IgG4-RKD and 50 as mimickers. The final diagnoses among the mimickers were vasculitis (n=11), idiopathic tubulointerstitial nephritis (TIN) (n=5), drug-induced TIN (n=5), Sjögren’s syndrome (n=4) and others. Among the 55 true IgG4-RKD patients, 4 had exclusion criteria, and 50 of the remaining 51 had an inclusion criteria score of ≥20 points (sensitivity 90.9%). On the other hand, 49 of the 50 mimickers were classified as having non-IgG4-RKD (specificity 98.0%) (Table 1).

Table 1.

General characteristics and prevalence of individual items of true IgG4-RKD and non-IgG4-RKD (mimicker)

IgG4-RKD(true IgG4-RKD)(n=55)Non-IgG4-RKD(mimicker)(n=50)PAge at diagnosis,mean ±SD (years)69.9 ± 9.456.7 ± 17.4<0.001Male (%)76.4440.001Elevated serum IgG454/55 (98.2%)18/50 (36.0%)<0.001Serum IgG4 (mg/dl), mean±SD1028 ± 796226 ± 261<0.001Dense IgG4+Plasma cells (>10/hpf) in the kidney biopsy48/51 (94.1%)13/40 (32.5%)<0.001Storiform fibrosis in the kidney biopsy28/51 (54.9%)3/50 (6%)<0.001Hypocomplementemia39/55 (70.1%)7/42 (16.7%)<0.001Renal pelvis thickening/soft tissue5/55 (9%)1/50 (2%)0.20Bilateral renal cortex low-density areas29/55 (52.7%)7/50 (14.0%)<0.001Exclusion criteria present4/55 (7.3%)22/50 (44%)<0.001Total inclusion criteria points >20 without exclusion criteria50/55 (90.9%)1/50 (2%)<0.001

Conclusion:

The 2019 ACR/EULAR classification criteria for IgG4-RD showed good agreement with expert classification in this Japanese kidney disease cohort.

References:

[1] Wallace ZS, et al. The 2019 American College of Rheumatology/European League Against Rheumatism classification criteria for IgG4-related disease. Ann Rheum Dis. 79:77-87, 2020

Disclosure of Interests:

None declared

Accuracy of deep learning, a machine learning technology, using ultra-wide-field fundus ophthalmoscopy for detecting idiopathic macular holes

We aimed to investigate the detection of idiopathic macular holes (MHs) using ultra-wide-field fundus images (Optos) with deep learning, which is a machine learning technology. The study included 910 Optos color images (715 normal images, 195 MH images). Of these 910 images, 637 were learning images (501 normal images, 136 MH images) and 273 were test images (214 normal images and 59 MH images). We conducted training with a deep convolutional neural network (CNN) using the images and constructed a deep-learning model. The CNN exhibited high sensitivity of 100% (95% confidence interval CI [93.5-100%]) and high specificity of 99.5% (95% CI [97.1-99.9%]). The area under the curve was 0.9993 (95% CI [0.9993-0.9994]). Our findings suggest that MHs could be diagnosed using an approach involving wide angle camera images and deep learning.

Changes in choroidal thickness in healthy pediatric individuals: a longitudinal study

AIM

To investigate the changes in the choroidal thickness in healthy pediatric children in a longitudinal study, and to determine the ocular and systemic parameters that were significantly correlated with the changes in the choroidal thickness.

METHODS

This study included 64 eyes of 34 healthy Japanese children with a mean age (±SD) of 4.4 (±0.4)y (range, 3.6-5.8y) at baseline. Swept-source optical coherence tomography (SS-OCT) was used to record images of the retina and choroid at the baseline and after a mean follow-up period of about 1.5y. The 3D raster scan protocol was used to construct the choroidal thickness map. Mean choroidal thickness was calculated for each of the nine sectors of the Early Treatment Diabetic Retinopathy Study grid. Best-corrected visual acuity, axial length, body height, and weight were also measured. Changes in measurements were defined as the baseline values subtracted from the values at the final visit. A generalized estimating equation was used to eliminate the effect of within-subject intereye correlations.

RESULTS

The mean central choroidal thickness was significantly reduced during the follow-up period (baseline, 301.8±8.6 µm; final visit, 286.6±8.0 µm, P<0.001). The decrease in the choroidal thickness was greatest in the central sector, followed by the sectors of the inner and outer rings. The inner and outer rings had diameters of 1 to 3 mm and 3 to 6 mm, respectively. The changes in the choroidal thickness in the central, inner ring, and outer ring sectors were significantly and negatively correlated with the age, baseline body height, baseline body weight, and elongation of the axial length.

CONCLUSION

These results indicate that the choroidal thickness among preschool-aged Japanese children decreased significantly during the follow-up period. The choroidal thinning is significantly associated with the elongation of axial length. These characteristics should be considered in the evaluation of choroidal thickness in younger children with retinochoroidal disorders.

Observation of self-polarization in BSA protected Au20 clusters

Bovine serum albumin (BSA)-protected gold clusters (atomicity ∼ 20), prepared using a wet chemical route, show strong dipolar radiative transition with a gap energy of 1.93 eV due to the high oscillator strength, as confirmed by the emission studies. Self-arrangement of the clusters with fixed atomicity yields a low dispersive dielectric and electric self-polarization nature. The electrical hysteresis loop measurements returned a remanent polarization of 0.05 μC cm^-2, which can be correlated with the dipolar orientation (activation energy ∼ 45.32 meV), originating from the structure-dependent deformation of the charge density.

Correlation between optic nerve head circulation and visual function before and after anti-VEGF therapy for central retinal vein occlusion: prospective, interventional case series

BACKGROUND

To determine the correlation between the optic nerve head (ONH) circulation determined by laser speckle flowgraphy and the best-corrected visual acuity or retinal sensitivity before and after intravitreal bevacizumab or ranibizumab for central retinal vein occlusion.

METHODS

Thirty-one eyes of 31 patients were treated with intravitreal bevacizumab or ranibizumab for macular edema due to a central retinal vein occlusion. The blood flow in the large vessels on the ONH, the best-corrected visual acuity, and retinal sensitivity were measured at the baseline, and at 1, 3, and 6 months after treatment. The arteriovenous passage time on fluorescein angiography was determined. The venous tortuosity index was calculated on color fundus photograph by dividing the length of the tortuous retinal vein by the chord length of the same segment. The blood flow was represented by the mean blur rate (MBR) determined by laser speckle flowgraphy. To exclude the influence of systemic circulation and blood flow in the ONH tissue, the corrected MBR was calculated as MBR of ONH vessel area - MBR of ONH tissue area in the affected eye divided by the vascular MBR - tissue MBR in the unaffected eye. Pearson's correlation tests were used to determine the significance of correlations between the MBR and the best-corrected visual acuity, retinal sensitivity, arteriovenous passage time, or venous tortuosity index.

RESULTS

At the baseline, the corrected MBR was significantly correlated with the arteriovenous passage time and venous tortuosity index (r = -0.807, P < 0.001; r = -0.716, P < 0.001; respectively). The corrected MBR was significantly correlated with the best-corrected visual acuity and retinal sensitivity at the baseline, and at 1, 3, and 6 months (all P < 0.050). The corrected MBR at the baseline was significantly correlated with the best-corrected visual acuity at 6 months (r = -0.651, P < 0.001) and retinal sensitivity at 6 months (r = 0.485, P = 0.005).

CONCLUSIONS

The pre-treatment blood flow velocity of ONH can be used as a predictive factor for the best-corrected visual acuity and retinal sensitivity after anti-VEGF therapy for central retinal vein occlusion.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

UMIN000009072. Date of registration: 10/15/2012.

A Genome-wide Association Study of Periodontitis in a Japanese Population

Periodontitis is a multifactorial disease in which bacterial, lifestyle, and genetic factors are involved. Although previous genetic association studies identified several susceptibility genes for periodontitis in European populations, there is little information for Asian populations. Here, we conducted a genome-wide association study and a replication study consisting of 2,760 Japanese periodontitis patients and 15,158 Japanese controls. Although single-nucleotide polymorphisms that surpassed a stringent genome-wide significance threshold ( P < 5 × 10−8) were not identified, we found 2 suggestive loci for periodontitis: KCNQ5 on chromosome 6q13 (rs9446777, P = 4.83 × 10−6, odds ratio = 0.82) and GPR141-NME8 at chromosome 7p14.1 (rs2392510, P = 4.17 × 10−6, odds ratio = 0.87). A stratified analysis indicated that the GPR141-NME8 locus had a strong genetic effect on the susceptibility to generalized periodontitis in Japanese individuals with a history of smoking. In conclusion, this study identified 2 suggestive loci for periodontitis in a Japanese population. This study should contribute to a further understanding of genetic factors for enhanced susceptibility to periodontitis.

Swept-source optical coherence tomographic findings of choroidal osteoma

Purpose

To report the morphologic features of a choroidal osteoma using swept-source optical coherence tomography (SS-OCT) and fundus autofluorescence (FAF).

Methods

Two eyes of two cases with a choroidal osteoma were studied using SS-OCT and FAF.

Results

The location of the tumor was circumpapillary without macular involvement in case 1 and juxtapapillary with macular involvement in case 2. Both cases had a mixture of calcified and decalcified areas, and a concomitant choroidal neovascularization was found in case 2. The FAF images showed decreased autofluorescence in the central decalcified regions and relatively preserved fluorescence in marginal calcified regions in both cases. SS-OCT revealed a normal inner retina and an abnormal outer retina in both cases, and subretinal fluid in case 2. The calcified regions appeared sponge-like and were multilayered in case 2. A lamellar reflective pattern was observed in the decalcified regions in case 1, and hyperreflective mound-like areas were observed in both cases. SS-OCT demonstrated hyperreflective areas above Bruch's membrane accompanied by disruption of Bruch's membrane in case 1. The chorioscleral border was visible in both cases.

Conclusions

The FAF pattern in the calcified and decalcified areas of the choroidal osteoma may correspond to the different stage of tumor evolution. The SS-OCT findings indicate that choroidal osteomas can have characteristic reflective patterns and alterations of the overlying retina.

Inhibitory effects of sword bean extract on alveolar bone resorption induced in rats by Porphyromonas gingivalis infection

BACKGROUND

The domesticated legume, Canavalia gladiata (commonly called the sword bean), is known to contain canavanine. The fruit is used in Chinese and Japanese herbal medicine for treating the discharge of pus, but its pharmacological mechanisms are still unclear.

OBJECTIVES

This study examined the effect of sword bean extract (SBE) on (i) oral bacteria and human oral epithelial cells in vitro, and (ii) the initiation and progression of experimental Porphyromonas gingivalis-induced alveolar bone resorption in rats.

MATERIAL AND METHODS

A high-performance liquid chromatography/ultraviolet method was applied to quantitate canavanine in SBE. By assessing oral bacterial growth, we estimated the minimum inhibitory concentration and minimum bactericidal concentration of SBE, canavanine, chlorhexidine gluconate (CHX) solution. The cytotoxicity of SBE, canavanine, CHX, leupeptin and cystatin for KB cells was determined using a trypan blue assay. The effects of SBE, canavanine, leupeptin and cystatin on Arg-gingipain (Rgp) and Lys-gingipain (Kgp) were evaluated by colorimetric assay using synthetic substrates. To examine its effects on P. gingivalis-associated periodontal tissue breakdown, SBE was orally administered to P. gingivalis-infected rats.

RESULT

Sword bean extract contained 6.4% canavanine. SBE and canavanine inhibited the growth of P. gingivalis and Fusobacterium nucleatum. The cytotoxicity of SBE, canavanine and cystatin on KB cells was significantly lower than that of CHX. Inhibition of Rgp with SBE was comparable to that with leupeptin, a known Rgp inhibitor, and inhibition of Kgp with SBE was significantly higher than that with leupeptin at 500 μg/mL ( p < 0.05). P. gingivalis-induced alveolar bone resorption was significantly suppressed by administration of SBE, with bone levels remaining comparable to non-infected animals ( p < 0.05).

CONCLUSION

The present study suggests that SBE might be effective against P. gingivalis-associated alveolar bone resorption.

Assessment of the Plasma/Serum IgG Test to Screen for Periodontitis

Chronic periodontitis is a silent infectious disease prevalent worldwide and affects lifestyle-related diseases. Therefore, efficient screening of patients is essential for general health. This study was performed to evaluate prospectively the diagnostic utility of a blood IgG antibody titer test against periodontal pathogens. Oral examination was performed, and IgG titers against periodontal pathogens were measured by ELISA in 1,387 individuals. The cut-off value of the IgG titer was determined in receiver operating characteristic curve analysis, and changes in periodontal clinical parameters and IgG titers by periodontal treatment were evaluated. The relationships between IgG titers and severity of periodontitis were analyzed. The best cut-off value of IgG titer against Porphyromonas gingivalis for screening periodontitis was 1.682. Both clinical parameters and IgG titers decreased significantly under periodontal treatment. IgG titers of periodontitis patients were significantly higher than those of healthy controls, especially in those with sites of probing pocket depth over 4 mm. Multiplied cut-off values were useful to select patients with severe periodontitis. A blood IgG antibody titer test for Porphyromonas gingivalis is useful to screen hitherto chronic periodontitis patients (ClinicalTrials.gov number NCT01658475).

Efficacy of the Quickert procedure for involutional entropion: the first case series in Asia

PURPOSE

To report the efficacy of the Quickert procedure in the first case series of involutional entropion in an elderly Asian population, and to introduce the technique to Asian ophthalmologists including general ophthalmologisits and ophthalmic trainees.

METHODS

We conducted a retrospective review of 13 consecutive patients underwent the Quickert procedure for involutional entropion by occasional eyelid surgeons at Tokushima University Hospital or Mino Tanaka Hospital from September 2003 to April 2010. Demographic data, including gender, age, history of previous eyelid surgery, systemic disease, recurrence of entropion, postoperative complications, and symptoms were analyzed.

RESULTS

There were 5 male (38.5%) and 8 female (61.5%) subjects with a mean age of 77.8 years. Three patients underwent previous surgery for entropion were included. Entropion was rectified in all patients by a single Quickert procedure, and no recurrence was observed for a maximum of 89 months after the surgery. Although notching of the eyelid margin and mild symblepharon were observed in one patient, no symptoms associated with these complications were reported.

CONCLUSION

The Quickert procedure can be one of the surgical procedures of choice for involutional entropion and should be common surgical approach for occasional eyelid surgeons in Asia as well as in western countries.

Inhibitory effect of 5,8,11-eicosatrienoic acid on angiogenesis

INTRODUCTION

Cartilage contains high levels of n-9 eicosatrienoic acid (20:3n-9) but no blood vessels. 20:3n-9 might inhibit angiogenesis.

MATERIALS AND METHODS

Angiogenesis was measured in human umbilical vein endothelial cells and diploid fibroblasts. Co-culture was performed with vascular endothelial growth factor-A (VEGF-A, 10 ng/mL) and fatty acids (0.1-10 μmol/L). After 10 days of incubation and immunostaining for endothelial cells, vessel areas were calculated with image analyser software.

RESULTS

Addition of 20:3n-9 and n-3 eicosatrienoic acid (20:3n-3) dose dependently inhibited VEGF-A-stimulated angiogenesis (more than the positive control suramin). Arachidonic, eicosapentaenoic, dihomo-γ-linolenic (20:3n-6) and oleic acids did not affect VEGF-A-stimulated angiogenesis even at 10 μmol/L. Arachidonic and dihomo-γ-linolenic acids enhanced angiogenesis without VEGF-A.

DISCUSSION AND CONCLUSIONS

We suggest that the presence of 20:3n-9 in cartilage may be related to its vessel-free status and that 20:3n-9 may be useful for the treatment of disorders with excessive vasculature.

ACKNOWLEDGEMENTS

This work was partly supported by Polyene Project, Inc.

Anti-glomerular basement membrane (anti-GBM) disease accompanied by vasculitis that was not positive for antineutrophil cytoplasmic antibodies to myeloperoxidase and proteinase 3: a report of two cases and the incidence of anti-GBM disease at one institution

BACKGROUND

Anti-glomerular basement membrane (anti-GBM) disease is thought to be distinct from vasculitis. In contrast, there have been several papers suggesting the presence of angiitis in cases that were positive for anti-GBM antibody (Ab), as well as for either myeloperoxidase (MPO)- or proteinase 3 (PR3)-anti-neutrophil cytoplasmic antibody (ANCA) (Group I). We experienced four patients who had anti-GBM Abs, but not MPO- and PR3-ANCA (Group II), and two of these patients were found to have vasculitis. Therefore, we performed an in-depth study on these two patients.

METHODS

The patients with anti-GBM disease were isolated from 578 cases whose renal tissues were examined, and they were categorized into two groups. We have already published the data about Group I. We then proceeded to study two vasculitic patients in Group II clinically, pathologically, and serologically. The anti-GBM Ab and ANCA levels were detected by enzyme-linked immunosorbent assays. Renal specimens were studied by routine staining as well as immunohistochemical investigations of CD31 and type IV collagen.

RESULTS

The total number of patients with anti-GBM disease was 7 (7/578 = 1.2%), with 3 patients belonging to Group I and 4 patients belonging to Group II. Two patients in Group II were diagnosed to have vasculitis, but the remaining 2 patients did not. One vasculitic patient was complicated by pulmonary hemorrhage, while the other vasculitic patient displayed peripheral neuropathy as well as a small cavity lesion in the lung. The latter patient was found to be positive for perinuclear (p)-ANCA, but not for any other ANCA subsets. The renal pathology in the two vasculitic patients showed crescentic glomerulonephritis (CSGN) and immunoglobulin (Ig) G linear deposits along the glomerular capillary loops. The former patient showed fibrinoid angiitis in an afferent arteriole as well as peritubular capillaritis. The latter patient demonstrated peritubular capillaritis. These peritubular capillaritides were diagnosed by the loss of CD31 and type IV collagen staining, the blurred appearance of peritubular capillary walls by periodic acid-Schiff staining, and the pericapillary infiltration of inflammatory cells.

CONCLUSION

The incidence of anti-GBM disease was very low, and our patients were categorized into two groups (Groups I and II) based on whether or not they were positive for MPO- or PR3-ANCA. Two patients in Group II were found to have vasculitis. According to our results, we concluded that the anti-GBM disease of Group II could also be associated with vasculitis.

Dual myeloperoxidase-antineutrophil cytoplasmic antibody- and antiglomerular basement membrane antibody-positive cases associated with prior pulmonary fibrosis: a report of four cases

BACKGROUND

Both myeloperoxidase-associated antineutrophil cytoplasmic antibody (MPO-ANCA) and antiglomerular basement membrane antibody (anti-GBM Ab) positivity have been demonstrated in patients with rapidly progressive glomerulonephritis (RPGN), either with or without pulmonary hemorrhage; however, the implications of these antibodies in such patients have not yet been elucidated. The cases with dual positive antibodies were studied clinically, serologically, and pathologically, and the implications of antibodies are discussed here.

PATIENTS AND METHODS

Four patients with prior pulmonary fibrosis, who subsequently developed RPGN and pulmonary hemorrhage, were studied clinically, serologically, and pathologically. The clinical data were reviewed extensively and the dual positive antibodies were detected by enzyme-linked immunosorbent assays. Pathological studies were performed with a renal biopsy in one patient, a gastric biopsy in another patient, and autopsy materials in the remaining 2 patients.

RESULTS

All 4 patients had prior pulmonary fibrosis before the symptoms of RPGN when the dual positivity of MPO-ANCA and anti-GBM Ab was detected. Three cases were accompanied by pulmonary hemorrhage around the time of RPGN whereas the remaining case demonstrated pulmonary hemorrhage a few years later. Renal tissue specimens in 3 cases showed circumferential crescents and linear immunoglobulin G deposits along the glomerular capillary loops in glomeruli. Two autopsy specimens revealed vasculitis of the small arteries and arterioles of the kidney, and one of them showed similar vasculitic findings in both the gastrointestinal tract walls and the adipose tissues of the adrenal glands. Additionally, a case with pulmonary hemorrhage occurring after remission was associated with re-elevated MPO-ANCA levels but without anti-GBM Ab positivity. A gastric biopsy was unremarkable and non-contributory for the diagnosis, but this case showed vasculitic symptoms of peripheral neuritis and retinal hemorrhage. Taken together, all 4 cases demonstrated prior pulmonary fibrosis and dual positivity of MPO-ANCA as well as anti-GBM Abs at the time of RPGN, and were associated with either pulmonary hemorrhage or its occurrence thereafter.

CONCLUSION

Four cases that showed prior pulmonary fibrosis as well as subsequent RPGN and pulmonary hemorrhage were both MPO-ANCA- and anti-GBM Ab-positive at the time of RPGN. The glomeruli disclosed features compatible with anti-GBM Ab disease, but the clinical and pathological vasculitic manifestations, including prior pulmonary fibrosis that might be an early manifestation of ANCA disease, suggested the occurrence of MPO-ANCA-associated vasculitis. Furthermore, 1 case subsequently showed repetitive pulmonary hemorrhage with re-elevated MPO-ANCA positivity but without anti-GBM Ab positivity, and this event was possibly due to MPO-ANCA-associated alveolar capillaritis. As anti-GBM Ab disease is generally thought not to manifest the clinical and pathological features of vasculitis excluding the kidney, MPO-ANCA might be a key factor regarding the occurrence of this dual positive disease.

Nitrilase-Catalyzed Production of Nicotinic Acid from 3-Cyanopyridine in Rhodococcus rhodochrous J1

The nitrilase which occurs abundantly in cells of Rhodococcus rhodochrous J1 catalyzes the direct hydrolysis of 3-cyanopyridine to nicotinic acid without forming nicotinamide. By using resting cells, the reaction conditions for nicotinic acid production were optimized. Under the optimum conditions, 100% of the added 3-cyanopyridine could be converted to nicotinic acid, the highest yield achieved being 172 mg of nicotinic acid per 1.0 ml of reaction mixture containing 2.89 mg (dry weight) of cells in 26 h.

A Novel Therapeutic and Prophylactic Vaccine (HVJ-Envelope / Hsp65 DNA + IL-12 DNA) against Tuberculosis Using the Cynomolgus Monkey Model

We have developed a novel tuberculosis (TB) vaccine; a combination of the DNA vaccines expressing mycobacterial heat shock protein 65 (HSP65) and interleukin 12 (IL-12) delivered by the hemagglutinating virus of Japan (HVJ)-envelope and -liposome (HSP65 + IL-12/HVJ). An IL-12 expression vector (IL-12DNA) encoding single-chain IL-12 proteins comprised of p40 and p35 subunits were constructed. This vaccine provided remarkable protective efficacy in mouse and guinea pig models compared to the BCG vaccine on the basis of C.F.U of number of TB, survival, an induction of the CD8 positive CTL activity and improvement of the histopathological tuberculosis lesions. This vaccine also provided therapeutic efficacy against multi-drug resistant TB (MDR-TB) and extremely drug resistant TB (XDR-TB) (prolongation of survival time and the decrease in the number of TB in the lung) in murine models. Furthermore, we extended our studies to a cynomolgus monkey model, which is currently the best animal model of human tuberculosis. This novel vaccine provided a higher level of the protective efficacy than BCG based upon the assessment of mortality, the ESR, body weight, chest X-ray findings and immune responses. All monkeys in the control group (saline) died within 8 months, while 50% of monkeys in the HSP65+hIL-12/HVJ group survived more than 14 months post-infection (the termination period of the experiment). Furthermore, the BCG priming and HSP65 + IL-12/HVJ vaccine (booster) by the priming-booster method showed a synergistic effect in the TB-infected cynomolgus monkey (100% survival). In contrast, 33% of monkeys from BCG Tokyo alone group were alive (33% survival). Furthermore, this vaccine exerted therapeutic efficacy (100% survival) and augmentation of immune responses in the TB-infected monkeys. These data indicate that our novel DNA vaccine might be useful against Mycobacterium tuberculosis including XDR-TB and MDR-TB for human therapeutic clinical trials.

Efficacy of intravitreal bevacizumab (Avastin) for short-term treatment of diabetic macular edema

PURPOSE

To report the efficacy of intravitreal injections of bevacizumab for diabetic macular edema (DME) in the short-term.

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

Medical records of 20 eyes of 19 patients who underwent intravitreal injections of bevacizumab for persistent diabetic macular edema were reviewed retrospectively. All eyes received intravitreal injections of bevacizumab (1.25 mg/0.05 ml). The clinical course of best-corrected visual acuity (BCVA) using a logarithm of the minimum angle of resolution chart, and averaged foveal retinal thickness using an optical coherence tomography (OCT) were monitored for up to four weeks after the injection.

RESULTS

BCVA at one week improved by two lines or more in six eyes (30%) and in nine eyes (45%) at four weeks. However, no significant improvement in the mean BCVA from baseline was observed at one week (P>0.05) and four weeks (P>0.05). Mean retinal thicknesses (RT) were 411+/-170 mum at baseline, 349+/-102 microm at one week after the injection (P<0.05), and 380+/-159 microm at four weeks (P>0.05). One week after the injection, significant regression of macular edema was seen. However, recurrence occurred at four weeks. No complications such as severe vision loss, endophthalmitis, or systemic events developed.

CONCLUSION

No changes in BCVA and RT were observed in the short-term observation after the intravitreal injection of bevacizumab for DME.

Extracorporeal membrane oxygenation in a patient with propionic acidaemia: a therapeutic option for cardiac failure

We report a Japanese girl affected with a neonatal-onset form of propionic acidaemia (PA). She developed severe metabolic crisis after dehydration at 2 years of age. Bradycardia with complete atrioventricular block responded to haemodiafiltration, but severe cardiac failure was refractory to inotropic treatment. She was diagnosed with acute cardiac dysfunction caused by PA-induced metabolic crisis. Extracorporeal membrane oxygenation (ECMO), a technique for providing mechanical circulatory support, was required. This is the first case report of a PA patient who recovered from a life-threatening metabolic crisis with cardiac failure by ECMO. Cardiac failure may be a cause of death, but it is occasionally an under-recognized complication. Mitochondrial dysfunction in the myocardium due to propionyl-CoA could contribute to the pathomechanism of cardiac complications of PA. We believe that ECMO should be attempted in PA patients with cardiac failure, in addition to haemodiafiltration and other therapeutic measures, because doing so may lead to the recovery of cardiac dysfunction, as was evident in our patient. In conclusion, prompt investigations and management of cardiac complications should be performed immediately during PA-induced metabolic crises.