Continuous Corneal Endothelial Damage by Chlorhexidine Alcohol Used for Disinfection in Nonophthalmic Surgery

PURPOSE

To report a case of corneal endothelial damage caused by alcohol-containing chlorhexidine gluconate (CG-A) and its progression over time.

METHODS

This was a case report.

RESULTS

A 22-year-old man underwent neurosurgery under general anesthesia. CG-A (1%) was used for disinfection after the application of corneal protection tape. Postoperatively, the patient presented with hyperemia and swelling of the left conjunctiva and was referred to our department. Initial examination revealed left corneal epithelial erosion and corneal edema, which improved on postoperative day 14. The corneal endothelial cell density (ECD) was 3,345 cells/mm 2 on day 14, decreased rapidly to 2,090 cells/mm 2 on day 42, and slowly reduced to 1,122 cells/mm 2 on day 168. Thereafter, no decrease in ECD was observed.

CONCLUSIONS

CG formulations can lead to a persistent decrease in ECD over several months, even after improvement of acute corneal edema.

Comparison of Scheimpflug and Anterior Segment Optical Coherence Tomography Imaging Parameters for Japanese Patients With Fuchs Endothelial Corneal Dystrophy With and Without TCF4 Repeat Expansions

PURPOSE

The aim of this study was to investigate the association between cytosine-thymine-guanine trinucleotide repeat (TNR) expansion in TCF4 and the clinical phenotypes of corneal densitometry or anterior segment morphology in Fuchs endothelial corneal dystrophy.

METHODS

This retrospective cross-sectional study included 150 eyes from 75 Japanese consecutive patients with Fuchs endothelial corneal dystrophy. Cytosine-thymine-guanine repeat expansion of leukocyte-derived genomic DNA was analyzed through fragment analysis using polymerase chain reaction and triplet repeat primed polymerase chain reaction. Scheimpflug-based densitometry and anterior segment optical coherence tomography were applied. Corneal densitometry, and corneal and anterior segment morphology parameters were compared between patients with and without TNR expansion of 50 or more (expansion and nonexpansion groups, respectively) using a mixed model.

RESULTS

The average age of the patients was 66.8 ± 13.0 years, and the modified Krachmer grading scale was 1, 2, 3, 4, 5, and 6 for 7, 32, 28, 51, 6, and 18 eyes, respectively. Sixteen patients (21%) exhibited ≥50 TNR expansion. No significant differences in sex, age, history of keratoplasty, modified Krachmer grade, and corneal densitometry in either diameter or depth were observed between the 2 groups. No significant differences in anterior segment morphology, including the anterior chamber depth and anterior chamber angle width parameters, were observed using a univariate mixed model, except for central corneal thickness (P = 0.047). However, according to the multivariate mixed model, repeat expansion was not significantly associated with central corneal thickness (P = 0.27).

CONCLUSIONS

No significant differences in clinical phenotypes were found between Japanese patients having Fuchs endothelial corneal dystrophy with and without TNR expansion.

Systematic Review of the Diagnostic Criteria and Severity Classification for Fuchs Endothelial Corneal Dystrophy

PURPOSE

There are no defined diagnostic criteria and severity classification for Fuchs endothelial corneal dystrophy (FECD), which are required for objective standardized assessments. Therefore, we performed a systematic literature review of the current diagnosis and severity classification of FECD.

METHODS

We searched the Ovid MEDLINE and Web of Science databases for studies published until January 13, 2021. We excluded review articles, conference abstracts, editorials, case reports with <5 patients, and letters.

RESULTS

Among 468 articles identified, we excluded 173 and 165 articles in the first and second screenings, respectively. Among the 130 included articles, 61 (47%) and 99 (76%) mentioned the diagnostic criteria for FECD and described its severity classification, respectively. Regarding diagnosis, slitlamp microscope alone was the most frequently used device in 31 (51%) of 61 articles. Regarding diagnostic findings, corneal guttae alone was the most common parameter [adopted in 23 articles (38%)]. Regarding severity classification, slitlamp microscopes were used in 88 articles (89%). The original or modified Krachmer grading scale was used in 77 articles (78%), followed by Adami's classification in six (6%). Specular microscopes or Scheimpflug tomography were used in four articles (4%) and anterior segment optical coherence tomography in one (1%).

CONCLUSIONS

FECD is globally diagnosed by the corneal guttae using slitlamp examination, and its severity is predominantly determined by the original or modified Krachmer grading scale. Objective severity grading using Scheimpflug or anterior segment optical coherence tomography can be applied in the future innovative therapies such as cell injection therapy or novel small molecules.

Long-Term Corneal Refractive Power Changes Two Decades After Radial Keratotomy With Microperforations

ABSTRACT

We retrospectively examined corneal refractive power in three patients who had been followed up for more than 20 years after radial keratotomy (RK) with microperforations (MPs). All patients underwent RK in both eyes and were referred to our clinic because of postoperative decreased vision. MP was observed in five of the six eyes at the initial visit. The corneal refractive power of the anterior and posterior surfaces of the 6-mm-diameter cornea was examined using Fourier analysis based on corneal shape analysis using anterior segment optical coherence tomography. The spherical components decreased in all three cases. The asymmetry and higher-order irregularity components and fluctuations in corneal refractive power were markedly greater in the two cases with MP in both eyes. Fluctuations in corneal refractive power were observed at more than 20 years after RK with MP. Therefore, careful observation is necessary, even after a long-term postoperative follow-up period.

Clinical Trial of Autologous Cultivated Limbal Epithelial Cell Sheet Transplantation for Patients with Limbal Stem Cell Deficiency

OBJECTIVE OR PURPOSE

To confirm the efficacy and safety of Good Manufacturing Practice (GMP)-compliant autologous cultivated limbal epithelial cell sheets in government-controlled clinical trials that adhered to Good Clinical Practice stipulations for patients with unilateral limbal stem cell deficiency (LSCD).

DESIGN

A prospective, multi-center, open-label, uncontrolled, single-arm clinical trial.

SUBJECTS, PARTICIPANTS OR CONTROLS

Ten consecutive eyes of 10 patients with unilateral LSCD were followed for two years after surgery. Preoperative LSCD stage was IIB in four eyes and III in six eyes.

METHODS

A limbal tissue biopsy was obtained from the healthy eye, after which limbal stem cells were dissociated and cultivated on temperature-responsive culture surfaces. All cell sheets were fabricated in a GMP-grade facility under established standard operating procedures. Cell sheets were evaluated using defined shipment criteria before transplantation, and only those that met the criteria were used. The cell sheet was transplanted onto each of the patients' diseased eye after removing the conjunctival scar tissue that covered the corneal surface. The severity of LSCD was determined according to a staging method agreed upon by global consensus, with eyes evaluated as being in stages IA-C representing successful corneal epithelial reconstruction. LSCD diagnosis and staging were determined by the trial's Eligibility Judgment Committee and Effect Assessment Committee using slit-lamp photographs including fluorescein staining. Both committees comprised two or three third-party cornea specialists, who were provided with information anonymously and randomly.

MAIN OUTCOME MEASURE

Corneal epithelial reconstruction rate was the primary endpoint.

RESULTS

Corneal epithelial reconstruction was successful in six of 10 eyes (60%) one year postoperatively and was significantly higher than the 15% clinically significant efficacy rate achieved by allogeneic limbal transplantation. The reconstruction rate was 70% of eyes two years postoperatively. Additionally, improvements in visual acuity were noted in 50% and 60% of eyes at one and two years, respectively. No clinically significant transplantation-related adverse events were observed.

CONCLUSION

The efficacy and safety of cultivated limbal epithelial cell sheet transplantation were thus confirmed, and the cell sheet, named Nepic, is now approved as a Cellular and Tissue-Based Product in Japan.

Novel corneal morphological alterations in Vogt-Koyanagi-Harada disease

PURPOSE

To determine whether visual function, especially when dependent on the anterior segment of ocular tissue, is altered during high-dose steroid treatment for Vogt-Koyanagi-Harada disease (VKH).

STUDY DESIGN

Retrospective case series METHODS: This case series included 18 eyes of 18 patients with VKH who received high-dose steroid therapy as initial treatment. All patients underwent anterior swept-source optical coherent tomography (CASIA-2) examinations during their clinical course to measure the central corneal thickness (CCT), average central corneal power (ACCP), maximum curvature (Kmax) and anterior chamber depth (ACD).

RESULTS

The treatment duration was classified into the initial phase (earliest initial phase eIP; 0-1 month, initial phase: IP; 1-3months), middle phase (MP; 3-6 months), and late phase (LP; 6-9 months). The CCT decreased significantly after treatment (eIP vs. IP, p<0.01, eIP vs. MP, p<0.01; eIP vs. LP, p<0.01). The CCT at eIP was correlated with the flare value at 0M (R²=0.22). The change in Kmax at MP and LP was correlated with the flare value at 0M. Moreover, CCT at MP was correlated with rate of change in nasal angle open distance (AOD) at IP and rate of change in temporal AOD at IP.

CONCLUSIONS

This study was the first to reveal morphological changes in the anterior segment of the eye in VKH using CASIA-2, which may affect visual acuity and the astigmatic axis. It is vital to assess corneal morphology to determine the cause of visual function deterioration in patients with VKH.

Corneal tomographic changes during corneal rigid gas-permeable contact lens wear in keratoconic eyes

Background/Aims

We aimed to investigate the refractive changes in the posterior corneal surface in keratoconus (KC) associated with wearing spherical corneal rigid gas-permeable contact lenses (corneal GPs) with apical touch or three-point touch fitting and the effect of spherical corneal GPs on corneal biomechanics.

Methods

Patients with KC wearing corneal GPs every day without facing complications were enrolled as a single group. Corneal tomographic data were obtained using a three-dimensional anterior segment optical coherence tomography from the same eye with and without corneal GPs. Dioptric data from the central 3-mm zone of the posterior corneal surface were decomposed into spherical, regular astigmatism, asymmetry and higher-order irregularity components using Fourier harmonic analysis. The corneal biomechanical indices were deformation amplitude ratio within 2 mm, integrated radius, stiffness parameter at first applanation and linear Corvis Biomechanical Index. Correlations between the difference in Fourier indices with and without corneal GPs and the corneal biomechanical parameters were analysed.

Results

Thirty-two eyes of 32 patients with KC were enrolled. Spherical, regular astigmatism and asymmetry components were significantly smaller with corneal GP wear than without the wear (all p<0.001). All biomechanical indices were significantly correlated with the difference in the spherical components with and without corneal GPs.

Conclusion

Corneal biomechanical properties of KC were correlated with posterior corneal surface flattening induced by wearing corneal GPs on the spherical components. This effect is greater in biomechanically weaker corneas.

Severe Ocular Complications Associated With Wearing of Contact Lens in Japan

OBJECTIVES

To examine the severe ocular complications associated with contact lens wearing in Japan.

METHOD

A questionnaire was sent to 964 ophthalmologist training facilities inquiring for cases of contact lens-associated complications from April 2016 to March 2018. The inclusion criteria were as follows: (1) corrected distance visual acuity ≤0.1 decimal after treatment for 3 months, (2) corneal perforation observed during follow-up, and (3) requiring surgery. A secondary analysis was conducted, inquiring for further information on the type of contact lens, clinical manifestations, and course of treatment.

RESULTS

Forty-two patients with infectious keratitis met the inclusion criteria. Eight patients were users of rigid gas-permeable contact lens, and 34 were users of soft contact lens. Microbiological tests were positive in 73.0%. The organisms isolated in microbiological culture were bacteria in 11 patients (Pseudomonas aeruginosa in 9 patients), fungi in 2 patients, and Acanthamoeba in 14 patients. Ten patients were treated with local antibiotics, 11 with a combination of systemic antibiotics, and 21 with a combination of surgical approaches, including 13 with corneal transplantation.

CONCLUSIONS

The major cause of serious contact lens-associated ocular complications was microbial keratitis, and P. aeruginosa and Acanthamoeba were the major pathogens in Japan.

New severity grading system for Fuchs endothelial corneal dystrophy using anterior segment optical coherence tomography

PURPOSE

To report a new severity grading system for Fuchs endothelial corneal dystrophy (FECD) using anterior segment optical coherence tomography (AS-OCT).

METHODS

This observational case series included 75 eyes of 43 patients with FECD and 33 eyes of 33 healthy subjects. Pachymetry and posterior elevation maps were used to determine the AS-OCT-based grading scores. FECD severity was graded from 0-3 as follows: 0, normal; 1, guttae only; 2, stromal oedema; and 3, epithelial and stromal oedema. We further investigated the central corneal thickness (CCT), thinnest corneal thickness (TCT), anterior and posterior best-fit spheres (BFS), and the distance between the central cornea and the thinnest point.

RESULTS

Thirty-three eyes were graded as 0, four as 1, thirteen as 2, fourteen as 3, twenty-nine as 4, eleven as 5 and four as 6 by the modified Krachmer grade. Thirty-three, 41, 30 and 4 eyes were graded as 0, 1, 2 and 3, respectively, by the AS-OCT-based grading system. The inter-observer agreement was 100% for the AS-OCT-based grading system. The CCT, TCT, posterior BFS, and distance between the central cornea and thinnest point were significantly different between AS-OCT-based grades (p = 0.0001, 0.0001, 0.0036 and 0.0001, respectively). Anterior BFS was not significantly different with the AS-OCT-based grades (p = 0.1184).

CONCLUSION

We devised a new severity grading using only objective evaluation and quantitatively demonstrated corneal thickening, predominant flattening of the posterior corneal surface compared with the anterior surface, and displacement of the thinnest point away from the central cornea with FECD progression.

Fourier Analysis on Regular and Irregular Astigmatism of Anterior and Posterior Corneal Surfaces in Fuchs Endothelial Corneal Dystrophy

PURPOSE

To conduct Fourier analysis on regular and irregular astigmatism of the anterior and posterior corneal surfaces using anterior segment optical coherence tomography in patients with Fuchs endothelial corneal dystrophy (FECD) DESIGN: Observational case series.

METHODS

This study included 75 eyes of 43 FECD patients and 34 eyes of 34 healthy subjects in Osaka University Hospital. Corneal dioptric data from the central 6-mm zone of the anterior and posterior corneal surface were expanded into spherical, regular astigmatism, asymmetry, and higher-order irregularity components using Fourier analysis. We analyzed the association between each component and modified Krachmer grade.

RESULTS

There were significant differences in regular astigmatism, asymmetry, and higher-order irregularity components of the anterior corneal surface, and spherical, regular astigmatism, asymmetry, and higher-order irregularity components of the posterior corneal surface among modified Krachmer grades (P = .036, <.001, <.001, <.001, <.001, <.001, and <.001, respectively). Asymmetry component of the anterior and posterior corneal surfaces gradually increased with FECD progression. Higher-order irregularity components of the anterior and posterior corneal surfaces drastically increased in Grade 6. Many eyes had an axis of 0°-180° for the asymmetry component of the anterior surface and 180°-360° for that of the posterior surface.

CONCLUSION

Patients with severe FECD had a larger amount of asymmetry and higher-order irregularity components of the anterior and posterior corneal surfaces. Patients with FECD up to Grade 5 were characterized by anterior and posterior flattening in the inferior cornea, and those with Grade 6 showed irregularity in the anterior and posterior corneal surfaces.

Correlation Between Angle Parameters and Central Corneal Thickness in Fuchs Endothelial Corneal Dystrophy

PURPOSE

To evaluate the correlation between anterior chamber parameters and central corneal thickness (CCT) or peripheral corneal thickness (PCT) in patients with Fuchs endothelial corneal dystrophy (FECD) using anterior segment optical coherence tomography.

METHODS

This case-control study included 20 eyes from 20 patients with FECD and 31 eyes from 31 patients with healthy corneas. CCT was measured as an indicator of FECD severity. Anterior chamber angle parameters, including trabecular-iris angle (TIA500) and angle opening distance (AOD500), were measured as an indicator of peripheral anterior chamber morphology. We also analyzed PCT and lens vault (LV). The relationships between CCT or PCT and anterior chamber parameters were also analyzed in patients with FECD.

RESULTS

Patients with FECD had a larger CCT (593.9 ± 54.6 μm vs. 533.0 ± 25.4 μm, P < 0.001), smaller TIA500 (21.8 ± 9.9 vs. 32.5 ± 11.2 degrees, P = 0.002), smaller AOD500 (0.21 ± 0.11 vs. 0.34 ± 0.18 mm, P = 0.002), and greater LV (0.60 ± 0.27 vs. 0.40 ± 0.29 mm, P = 0.02) than control subjects. In patients with FECD, CCT was negatively correlated with the angle parameters TIA500 (R = 0.29, P = 0.009) and AOD500 (R = 0.19, P = 0.03). There were no significant correlations between PCT and TIA500 (R = 0.008, P = 0.29) or AOD500 (R = 0.007, P = 0.29). There were also no significant correlations between CCT and LV (R = 0.02, P = 0.55).

CONCLUSIONS

Larger CCT was significantly associated with narrower anterior chamber angle width, but not with LV. We showed that the severity of FECD is associated with angle chamber morphology.

Systematic review of clinical research on regenerative medicine for the cornea

PURPOSE

To conduct a systematic review of clinical research on the use of regenerative medicine for the cornea in human patients.

METHODS

A systematic literature search of MEDLINE and the Cochrane Library was performed in May 2020.

RESULTS

Forty-two articles were identified. Thirty-eight of those articles focused on the treatment for limbal stem cell deficiency (LSCD), of which 17 articles involved autologous cultured limbal epithelial cell sheet transplantation (CLET), 13 involved allogeneic CLET, and 14 involved autologous cultured oral mucosal epithelial cell sheet transplantation (COMET). For autologous CLET, the median ocular surface reconstruction rate, visual recovery rate, incidence of immunologic rejection, infectious keratitis, and ocular hypertension/glaucoma were 74.1%, 54.5%, 0%, 4.6%, and 6.3%, respectively. For allogeneic CLET, they were 71.4%, 71.4%, 7.1%, 12.0%, and 7.1%, respectively. For autologous COMET, they were 66.7%, 66.7%, 0%, 5.3%, and 8.1%, respectively. Systemic immunosuppressants and steroid medications were predominantly used following allogeneic CLET, whereas they were not routinely used after autologous CLET. Three studies focused on the treatment of keratoconus using autologous adipose-derived adult stem cells and reported no marked adverse events. One study reported on the treatment of bullous keratopathy using allogeneic cultured corneal endothelial cells. All patients achieved an endothelial cell density of >500 cells, and the corrected distance visual acuity improved in 82% of the treated eyes.

CONCLUSIONS

The results show that regenerative medicine for the cornea demonstrated a satisfactory efficacy and safety. Through translational research, we are expecting to establish a new treatment for waiting patients.

Optimizing correction of coma aberration in keratoconus with a novel soft contact lens

PURPOSE

To report on a second-generation prototype contact lens (modified lens) with enhanced optics to correct coma aberration and compare its performance with that of the prototype contact lens (conventional lens) used to optimise correction of coma aberration in keratoconus (KC).

METHODS

Both lenses were designed as a set of standardised soft contact lenses (SCLs) with asymmetric powers along the posterior surface. The modified lens differs from the conventional lens in that the optical zone is decentred superiorly by 0.7 mm. The on-eye performance was compared between the SCLs and no-lens wearing in terms of manifest refraction, corrected distance visual acuity (CDVA), ocular aberrations, subjective quality of vision, and on-eye lens position relative to the pupil.

RESULTS

Thirty-four KC eyes were included. SCLs significantly decreased coma aberration compared to no-lens wear (none, 0.68 ± 0.27 μm; conventional lens, 0.37 ± 0.28 μm; modified lens, 0.19 ± 0.15 μm; P < 0.001), with the reduction in coma aberration being significantly greater with the modified lens than with the conventional lens (P = 0.018). No significant difference in manifest refraction or CDVA was found among the three conditions. Quality of vision was significantly better with the modified lens than with no SCL wear (P < 0.05) but no differences were found between the SCLs. The on-eye optical center position relative to the pupil was closer to the pupil centre using the modified lens than the conventional lens (P < 0.001).

CONCLUSION

Optimisation of the location of the optical zone in a standardised asymmetric SCL improves correction of coma aberrations and on-eye optical centration.

Quantitative Analysis of the Association Between Follow-Up Duration and Severity of Limbal Stem Cell Deficiency or Visual Acuity in Aniridia

Purpose

This study aimed to quantitatively analyze the association between follow-up duration and the severity of limbal stem cell deficiency (LSCD) or visual acuity in patients with aniridia.

Methods

A total of 52 eyes of 27 patients with aniridia were enrolled at Osaka University Hospital. Medical records were retrospectively reviewed to obtain information on the severity of LSCD and corrected distance visual acuity (CDVA). LSCD severity was based on a modified severity grading scale. We used an ordered logistic regression model to examine the association between follow-up duration and LSCD severity, and a linear regression model with a generalized linear mixed model for the association between follow-up duration and visual acuity.

Results

The mean follow-up duration was 5.2 ± 6.3 years. The mean age at the last follow-up visit was 40.5 ± 18.9 years. The mean CDVA was 1.52 ± 1.09 logMAR. At the last follow-up, 1 examined eye (1.9%) was categorized as stage 0, 7 (13.5%) as Ia, 9 (17.3%) as Ib, 5 (9.6%) as Ic, 2 (3.8%) as IIb, 12 (23.1%) as IIc, and 11 (21.2%) as III. Five eyes (9.6%) were unclassifiable. There was a significant association between follow-up duration and LSCD severity (odds ratio per +1 year, 1.41; P < 0.001). CDVA significantly decreased as follow-up duration increased. Each increase of 1 year in the follow-up duration was associated with a mean difference of +0.021 logMAR (95% confidence interval [CI] 0.01–0.03; P < 0.001).

Conclusions

We quantitatively demonstrate that LSCD severity and visual impairment significantly progress as follow-up duration increases.

Cell jamming, stratification and p63 expression in cultivated human corneal epithelial cell sheets

Corneal limbal epithelial stem cell transplantation using cultivated human corneal epithelial cell sheets has been used successfully to treat limbal stem cell deficiencies. Here we report an investigation into the quality of cultivated human corneal epithelial cell sheets using time-lapse imaging of the cell culture process every 20 minutes over 14 days to ascertain the level of cell jamming, a phenomenon in which cells become smaller, more rounded and less actively expansive. In parallel, we also assessed the expression of p63, an important corneal epithelial stem cell marker. The occurrence of cell jamming was variable and transient, but was invariably associated with a thickening and stratification of the cell sheet. p63 was present in all expanding cell sheets in the first 9 days of culture, but it's presence did not always correlate with stratification of the cell sheet. Nor did p63 expression necessarily persist in stratified cell sheets. An assessment of cell jamming, therefore, can shed significant light on the quality and regenerative potential of cultivated human corneal epithelial cell sheets.

Anterior segment optical coherence tomography and in vivo confocal microscopy in cases of mucopolysaccharidosis

Purpose

To report anterior segment evaluation in patients with mucopolysaccharidosis 1 using anterior segment optical coherence tomography and in vivo confocal microscopy.

Observations

Case 1 involved a 26-year-old man with mucopolysaccharidosis 1 Hurler-Scheie syndrome who presented with a corrected distance visual acuity of 20/67 in the right eye and 20/50 in the left eye because of bilateral corneal opacification. He had undergone bone marrow transplantation at the age of 7 years. Anterior segment optical coherence tomography revealed a very narrow anterior chamber angle; a flat, thickened cornea; and astigmatism with the rule. Confocal microscopy demonstrated hyper-refractive deposits in the corneal epithelial basal layer, decreased subepithelial nerves, and depletion of keratocytes in the anterior and posterior stroma. Endothelial cells were not visible.Case 2 involved an 18-year-old woman who presented with increased corneal opacity in both eyes. Her medical history included mucopolysaccharidosis 1 Hurler syndrome and bone marrow transplantation at the age of 2 years. Her corrected distance visual acuity could not be measured because of severe intellectual disability. Anterior segment optical coherence tomography demonstrated a flat and thick cornea.

Conclusions and importance

Anterior segment optical coherence tomography can provide detailed morphological information for the anterior segment in patients with severe corneal opacification associated with mucopolysaccharidosis 1. Moreover, in vivo confocal microscopy facilitates the detailed observation of corneal cellular changes. Thus, these tools can provide data that would contribute to an increased understanding of corneal changes in patients with mucopolysaccharidosis 1.

Transient extremely shallow anterior chamber caused by ciliochoroidal detachment in a patient with Mycobacterium chelonae keratitis

Purpose

To report a case of Mycobacterium chelonae keratitis that resulted in a transient reduction of anterior chamber depth.

Observations

A 46-year-old man with keratoconus and reduced visual acuity (20/286) in his left eye presented with ciliary injection 16 months after femtosecond laser-assisted penetrating keratoplasty (PK). A slit-lamp examination showed a corneal ulcer with infiltrates and edema in both the host and graft between the 3 o'clock and 6 o'clock positions. Microbiologic tests confirmed the presence of M. chelonae. Topical arbekacin and moxifloxacin, erythromycin/colistin ointment, and oral clarithromycin were prescribed. We monitored anterior chamber depth by anterior segment optical coherence tomography (AS-OCT) throughout the recovery period. The anterior chamber depth was normal before treatment, with an intraocular pressure (IOP) of 7 mmHg. Although ciliary injection and infiltrates were gradually resolved, slit-lamp examination and AS-OCT revealed an extreme reduction of anterior chamber depth without corneal perforation, 1 month after beginning treatment. The IOP was 5 mmHg, and ciliochoroidal detachment (CCD) was present. The anterior chamber increased with the resolution of CCD and keratitis. Although hypotony continued despite the resolution of CCD and keratitis, the IOP eventually recovered to ≥10 mmHg at 1 month after remission. Onset and resolution of transient reduction of anterior chamber depth presumably occurred by anterior rotation and recovery of the ciliary body, respectively. Subsequent PK triple surgery enabled visual recovery to 20/100.

Conclusions and importance

severe anterior segment inflammation due to infectious keratitis may cause CCD and subsequent reduction of anterior chamber depth due to anterior rotation. AS-OCT is a non-invasive and efficient tool for the evaluation of iridociliary structure and the anterior chamber in patients with infectious keratitis.

Efficacy of therapeutic soft contact lens in the management of gelatinous drop-like corneal dystrophy

Background/Aims

To investigate the efficacy of therapeutic soft contact lenses (SCLs) in gelatinous drop-like corneal dystrophy (GDLD) management.

Methods

This was a retrospective, consecutive, observational case series, including 20 patients (40 eyes) with GDLD treated in Osaka University Hospital within the last 15 years. We tested the effects of therapeutic SCL on clinical features, visual acuity and surgical interventions. Examinations for clinical features and visual acuity were done on patients who had no surgical intervention for 3 years. Scoring and evaluation of changes in three main clinical GDLD features and visual acuity (logMAR units) were performed using Fisher’s exact test and Mann-Whitney U test. Surgery-free survival time was compared by Kaplan-Meier analyses in all patients.

Results

We found a significantly lower rate of progression in GDLD nodular lesions in patients wearing SCLs compared with those who did not (p=0.0179). No suppressant effects were observed regarding opacity and neovascularisation, and no significant improvements were found in visual acuity (in logMAR values, SCL-on: mean=− 0.036, median=0; SCL-off: mean=0.149, median=+ 0.088; p=0.14). The surgery-free survival time for all 16 SCL-on eyes was 2770 ± 1918 days, significantly longer than that for 22 SCL-off eyes, 1342 ± 1323 days (Kaplan-Meier analysis, p=0.0007), suggesting that therapeutic SCL extends the period until surgical intervention and reduces their necessity in patients with GDLD.

Conclusion

Wearing therapeutic SCLs in GDLD slows the progression of nodular lesions and decreases the need for surgical interventions.

Clinical evaluation of a newly developed graft inserter (NS Endo-Inserter) for Descemet stripping automated endothelial keratoplasty

Purpose

The aim of this study was to describe the postoperative outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) performed using our newly developed graft inserter (NS Endo-Inserter) and compare the findings with those for DSAEK performed using the Busin glide.

Patients and methods

In this retrospective, case-control, institutional study, we studied the clinical outcomes of DSAEK performed using the NS Endo-Inserter (NS group, n=13) or the Busin glide (Busin group, n=10) for patients with corneal endothelial dysfunction. Clinical parameters, including the distance-corrected visual acuity (DCVA), endothelial cell (EC) loss, and intraoperative/postoperative complications, were assessed over a 6-month follow-up period.

Results

At 6 months after surgery, the mean DCVA showed no significant difference between the two groups. EC loss at 3 and 6 months after DSAEK was 9.1%±20.7% and 18.2%±22.6%, respectively, in the NS group and 44.0%±25.5% and 46.5%±23.3%, respectively, in the Busin group; differences between groups were statistically significant at both 3 and 6 months (P=0.024 and P=0.016, respectively). Anterior chamber hemorrhage was observed in one patient in the Busin group. Rebubbling after surgery was required for one eye in the Busin group. No complications were observed in the NS group.

Conclusion

Our newly developed graft inserter for DSAEK may cause significantly less EC damage than the conventional pull-through technique using the Busin glide. Our inserter permits safe endothelial graft delivery without anterior chamber collapse and can result in successful graft attachment without complications at 6 months after surgery.

Acute hydrops with a 180-degree massive edematous cavern demonstrated by three dimensional view of anterior segment optical coherence tomography in a patient with pellucid marginal corneal degeneration, a case report

Background

Pellucid marginal corneal degeneration is a non-inflammatory disorder complicated by severe inferior corneal thinning. The central portion of the cornea, consequently, appears to protrude outwards, decreasing vision by means of an irregular stigmatism. Additionally, acute hydrops can occur in case of Descemet’s membrane rupture.

Case presentation

A 41-year-old Japanese woman presenting with severe visual loss in the left eye was examined and observed to have had full thickness corneal perforation as well as a Descemet membrane rupture with massive edema in the corneal stroma. Anterior segment optical coherence tomography-based corneal topography revealed a distorted crab claw sign indicating pellucid marginal corneal degeneration. The Descemet membrane rupture allowed acute hydrops to occur which was especially noteworthy given the scale of edema present within the stroma, rotating 180 degrees along the limbus, causing a smiley-face like lesion. We visualized it via a gonioscopic three-dimensional optical coherence tomography to build a three-dimensional video. Patient history revealed a previous acute hydrops in the right eye as well, which was ultimately treated with anterior lamellar keratoplasty, suggesting the pellucid marginal corneal degeneration had a classic bilateral involvement, which was also characterized with bilateral acute hydrops.

Conclusion

This appears to be a very rare and interesting presentation of bilateral pellucid marginal degeneration, wherein not only acute hydrops formed bilaterally, but the cavity within the cornea stroma was exceptionally large with an unusual shape. Using the gonioscopic three-dimensional optical coherence tomography imaging, we were able to easily visualize the massive intrastromal cavern, and appropriately planned the crescent-shaped anterior lamellar keratoplasty. The 3d video constructed using this data is particularly elucidative compared to 2d images. As such, we recommend utilizing 3d imaging in cases where more conventional topography is not as explanatory with respect to precise nature of deformation.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0757-7) contains supplementary material, which is available to authorized users.

Corneal regenerative medicine

Recently, regenerative medicine has become a highlighted field because it has great potential to induce a paradigm shift of supportive conventional therapy into definitive treatment. The cornea is the avascular, transparent, dome-shaped outermost layer of the eyeball, and it consists of three layers: epithelium, stroma, and endothelium. Conventional corneal transplantation, known as keratoplasty, has two main problems, a donor shortage and immunological rejection. Therefore, regenerative medicine has been applied to overcome these challenges. Regenerative medicine involving the corneal epithelium has been clinically applied, along with an understanding of corneal epithelial stem cell biology, earlier than that of the corneal stroma or endothelium. Thus, the effectiveness and safety of cultivated corneal or oral mucosal epithelial cell sheet transplantation have been reported by many researchers. Clinical studies on regenerative medicine for corneal stroma or endothelium have begun after basic and nonclinical study. Translational research has been performed to make corneal regenerative medicine a universal therapy. This article reviews corneal regenerative medicine.

A Novel Method Using Quantum Dots for Testing the Barrier Function of Cultured Epithelial Cell Sheets

PURPOSE

The corneal epithelium provides a barrier to protect the deeper structures of the eye from any particles or pathogens. Cultured epithelial cell sheets are used in transplantation surgery for corneal repair or regeneration. The purpose of this study was to develop a novel method using fluorescent quantum dot nanoparticles for validating the quality and barrier function of cultured epithelial cell sheets.

METHODS

Human function epithelial cell sheets, cultured from oral mucosal or corneal limbal cells, were incubated in either normal calcium-containing medium or medium containing no calcium with a calcium chelator. Also contained in the media were suspensions of two different sizes of quantum dots. Following incubation, analysis of quantum dot penetration was carried out using confocal microscopy.

RESULTS

In contrast to the cell sheets incubated in calcium-containing medium, removal of extracellular calcium resulted in the disruption of tight junctions, compromising the cell sheet's barrier function. This caused a reduction in transepithelial electrical resistance and deeper, more ubiquitous penetration of the quantum dots into the paracellular space and interior of the cell sheet.

CONCLUSIONS

This method provides easy to interpret qualitative and quantitative data on the functionality of a cell sheet's tight junctions, as well as nanoscale and microscale structural information on its surface and interior morphology, and any localized areas of damage or abnormality. This novel technique could be used as part of the validation system for cultured epithelial cell sheets for use in transplantation.

Relationship between Corneal Guttae and Quality of Vision in Patients with Mild Fuchs' Endothelial Corneal Dystrophy

PURPOSE

To investigate the effect of the severity of corneal guttae on quality of vision (QOV) in patients with mild Fuchs' endothelial corneal dystrophy (FECD).

DESIGN

Cross-sectional study.

PARTICIPANTS

Twenty-three eyes of 14 patients with mild FECD without corneal edema on slit-lamp examination (5 pseudophakic eyes and 18 phakic eyes with mild lens opacity; grade 1.0-2.0 nuclear opalescence, grade 1.0-2.0 nuclear color, grade 1.0 cortical cataract, and grade 1.0 posterior subcapsular cataract on the Lens Opacities Classification System, version III).

METHODS

The area ratio of the corneal guttae (ARCG) in the endothelial cells was measured by multifocal specular microscopy. The QOV parameters, that is, corrected distance visual acuity (CDVA), letter contrast sensitivity (LCS), and intraocular straylight, also were measured. The correlations were assessed between the ARCG and QOV parameters and between the straylight and CDVA and LCS.

MAIN OUTCOME MEASURES

The ARCG, logarithm of the minimum angle of resolution CDVA, LCS, and straylight.

RESULTS

Univariate analysis showed that the ARCG was correlated significantly with the CDVA, LCS, and straylight (R(2) = 0.41, P = 0.001; R(2) = 0.55, P = 0.001; and R(2) = 0.39, P = 0.002, respectively). Univariate analysis also showed that straylight was correlated significantly with the CDVA and LCS (R(2) = 0.47, P = 0.001 and R(2) = 0.41, P = 0.001, respectively).

CONCLUSIONS

Corneal guttae without edema caused the QOV to deteriorate in eyes with FECD. Patients with higher straylight had worse CDVA or LCS. Intraocular forward light scatter caused by corneal guttae may result in visual disturbances. Quantification of corneal guttae can be useful to evaluate the effect of guttae on the QOV and determine the surgical indications of endothelial keratoplasty for eyes with mild FECD.

Effect of non-invasive tear stability assessment on tear meniscus height

PURPOSE

To investigate the effect of non-invasive tear stability assessment with forced eye opening on the lower tear meniscus.

METHODS

Twenty-three eyes of 23 patients with aqueous-deficient dry eye and 23 eyes of 23 normal subjects were enrolled. All subjects underwent imaging with a Keratograph 5M equipped with a modified tear film scanning function. Lower tear meniscus images were captured, and tear meniscus height (TMH) was measured with an integrated ruler before and after non-invasive Keratograph break-up time (NIKBUT) measurements in each subject. Subjects were instructed to keep their eyes open as long as possible during NIKBUT measurements, and the recording was discontinued at the next blink.

RESULTS

The TMH values of the normal and dry eye groups were 0.20±0.05 mm and 0.14±0.03 mm, respectively, at baseline. The TMH values of dry eyes were significantly smaller than those of normal eyes (p<0.001). Significant increases in TMH values were observed in both normal (0.10±0.12 mm) and dry eyes (0.04±0.09 mm) with the NIKBUT measurement (p<0.001, p=0.039). A moderate negative correlation was observed between increased TMH and baseline TMH in dry eyes (r=-0.44, p=0.03), whereas no correlation was observed in normal eyes (r=0.04, p=0.85).

CONCLUSIONS

Forced eye opening required for the non-invasive tear stability assessment influences the TMH measurement possibly due to reflex tear secretion, even in patients with aqueous-deficient dry eye. TMH should be assessed before tests that require forced eye opening.

Effect of diquafosol ophthalmic solution on the optical quality of the eyes in patients with aqueous-deficient dry eye

PURPOSE

To investigate the short- and long-term effects of diquafosol ophthalmic solution on the optical quality of the eyes in patients with aqueous-deficient dry eye.

METHODS

Sixteen eyes in 16 patients with mild or moderate aqueous-deficient dry eye were treated with 3% diquafosol ophthalmic solution. Ocular higher-order aberrations (HOAs) were measured with a wavefront sensor before and at 15 min after diquafosol instillation at the baseline visit and at 4 weeks after treatment initiation. Dry eye symptoms, tear break-up time (BUT), corneal/conjunctival fluorescein staining and Schirmer's test were also evaluated before and after treatment with diquafosol.

RESULTS

Treatment with diquafosol ophthalmic solution significantly improved dry eye symptoms, corneal staining and BUT. Compared with mean total HOAs at baseline (0.180 ± 0.06 μm), those at 4 weeks after treatment significantly decreased (0.148 ± 0.039 μm; p = 0.035), whereas those 15 min after diquafosol instillation at the baseline visit did not change significantly (0.170 ± 0.049 μm; p = 0.279).

CONCLUSIONS

Although no significant change in HOAs was observed as a short-term effect of a single-drop instillation of diquafosol, long-term use of diquafosol to treat aqueous-deficient dry eye reduced HOAs as well as improved corneal epithelial damage and tear film stability.

Maintenance and distribution of epithelial stem/progenitor cells after corneal reconstruction using oral mucosal epithelial cell sheets

We assessed the maintenance and distribution of epithelial stem/progenitor cells after corneal reconstruction using tissue-engineered oral mucosal cell sheets in a rat model. Oral mucosal biopsy specimens were excised from green fluorescent protein (GFP) rats and enzymatically treated with Dispase II. These cells were cultured on inserts with mitomycin C-treated NIH/3T3 cells, and the resulting cell sheets were harvested. These tissue-engineered cell sheets from GFP rats were transplanted onto the eyes of a nude rat limbal stem cell deficiency model. Eight weeks after surgery, ocular surfaces were completely covered by the epithelium with GFP-positive cells. Transplanted corneas expressed p63 in the basal layers and K14 in all epithelial layers. Epithelial cells harvested from the central and peripheral areas of reconstructed corneas were isolated for a colony-forming assay, which showed that the colony-forming efficiency of the peripheral epithelial cells was significantly higher than that of the central epithelial cells 8 weeks after corneal reconstruction. Thus, in this rat model, the peripheral cornea could maintain more stem/progenitor cells than the central cornea after corneal reconstruction using oral mucosal epithelial cell sheets.

Ocular forward light scattering and corneal backward light scattering in patients with dry eye

PURPOSE

To evaluate ocular forward light scattering and corneal backward light scattering in patients with dry eye.

METHODS

Thirty-five eyes in 35 patients with dry eye and 20 eyes of 20 healthy control subjects were enrolled. The 35 dry eyes were classified into two groups according to whether superficial punctate keratopathy in the central 6-mm corneal zone (cSPK) was present or not. Ocular forward light scattering was quantified with a straylight meter. Corneal backward light scattering from the anterior, middle, and posterior corneal parts was assessed with a corneal densitometry program using the Scheimpflug imaging system.

RESULTS

Both dry eye groups had significantly higher intraocular forward light scattering than the control group (both P<0.05). The dry eye group with cSPK had significantly higher values in anterior and total corneal backward light scattering than the other two groups. Moderate positive correlations were observed between the cSPK score and corneal backward light scattering from the anterior cornea (R=0.60, P<0.001) and corneal backward light scattering from the total cornea (R=0.54, P<0.001); however, no correlation was found between cSPK score and ocular forward light scattering (R=0.01, P=0.932).

CONCLUSIONS

Ocular forward light scattering and corneal backward light scattering from the anterior cornea were greater in dry eyes than in normal eyes. Increased corneal backward light scattering in dry eye at least partially results from cSPK overlying the optical zone.

Quantitative regional differences in corneal endothelial abnormalities in the central and peripheral zones in Fuchs' endothelial corneal dystrophy

PURPOSE

To quantitate the regional corneal differences in endothelial abnormalities in Fuchs' endothelial corneal dystrophy at multiple sites, including the peripheral zone.

METHODS

Forty-one eyes of 23 patients with Fuchs' endothelial corneal dystrophy were studied at Osaka University Hospital. The sizes of the areas of degeneration resulting from guttae were measured using a new noncontact specular microscope in the central cornea, the paracentral zone 0.6 mm from the center, and the peripheral zone 3.7 mm peripheral to the center.

RESULTS

The percentages of the images covered by the abnormal areas were 71% ± 36% in the center, 68% ± 35% in the paracentral zone, and 33% ± 36% in the peripheral zone. The values in the peripheral zone were significantly (P < 0.001) smaller than in the center and paracentral zones. The percentage of the abnormal area in the peripheral zone was correlated significantly (P < 0.001, R(2) = 0.452) with the disease grade in advanced cases, whereas those in the center or paracentral zones were not. Among the areas of the peripheral zone, the abnormal inferotemporal areas were significantly (P < 0.001) larger than superonasally.

CONCLUSIONS

In Fuchs' endothelial corneal dystrophy, the corneal endothelium is damaged more severely in the center and paracentral zones than in the peripheral zone, and peripheral measurement can objectively grade the disease. In the peripheral zones, the inferotemporal endothelium is damaged more severely. These findings might provide a new understanding of the disease mechanisms.

Rigid gas-permeable contact lens-assisted cataract surgery in patients with severe keratoconus

We describe rigid gas-permeable (RGP) contact lens-assisted cataract surgery in patients with severe keratoconus. During cataract surgery in cases with severe keratoconus, the intraocular images are distorted and visual perspective is lost because of irregular corneal astigmatism. Poor visibility can lead to complications, including posterior capsule rupture and corneal endothelial cell damage. To overcome these problems, an RGP contact lens was placed on the cornea in 2 cases. The image distortion decreased markedly, and the visual perspective improved. Intraocular manipulations such as irrigation/aspiration were performed safely. Improvement in transillumination led to good visualization of the anterior and posterior capsules. No intraoperative or postoperative complications developed in either case. This technique provided excellent visualization during cataract surgery in patients with severe keratoconus.

Development of a cell sheet transportation technique for regenerative medicine

PURPOSE

A transportation technique for cell sheets is necessary to standardize regenerative medicine. The aim of this article is to develop and evaluate a new transportation technique for cell sheets.

MATERIAL AND METHODS

We developed a transportation container with three basic functions: the maintenance of interior temperature, air pressure, and sterility. The interior temperature and air pressure were monitored by a recorder. Human oral mucosal epithelial cells obtained from two healthy volunteers were cultured on temperature-responsive culture dishes. The epithelial cell sheets were transported via an airplane between the Osaka University and Tohoku University using the developed cell transportation container. Histological and immunohistochemical analyses and flow cytometric analyses for cell viability and cell purity were performed for the cell sheets before and 12 h after transportation to assess the influence of transportation on the cell sheets. Sterility tests and screening for endotoxin and mycoplasma in the cell sheets were performed before and after transportation.

RESULTS

During transportation via an airplane, the temperature inside the container was maintained above 32°C, and the changes in air pressure remained within 10 hPa. The cell sheets were well stratified and successfully harvested before and after transportation. The expression patterns of keratin 3/76, p63, and MUC16 were equivalent before and after transportation. However, the expression of ZO-1 in the cell sheet after transportation was slightly weaker than that before transportation. The cell viability was 72.0% before transportation and 77.3% after transportation. The epithelial purity was 94.6% before transportation and 87.9% after transportation. Sterility tests and screening for endotoxin and mycoplasma were negative for all cell sheets.

CONCLUSION

The newly developed transportation technique for air travel is essential technology for regenerative medicine and promotes the standardization and spread of regenerative therapies.

Development of the Department of Ophthalmology at Osaka University

Osaka University is one of the largest national universities and the sixth oldest university in Japan. Its academic roots extend to Tekijuku and Kaitokudo in the Edo period. Osaka University has the motto, "Live Locally, Grow Globally." This means that they work for their own local community and also work worldwide at the same time.The Osaka University Graduate School of Medicine is famous for basic research in immunology, including research on interleukin 6 and innate immunity, and translational research for regenerative medicine. Osaka University Hospital has 31 clinical departments and 2159 staff members, including 834 physicians. It serves 2515 outpatients and 940 inpatients per day. Approximately 8500 surgeries are performed every year. The Department of Ophthalmology at Osaka University is one of the largest ophthalmology departments in Japan. It has 24 faculty members, 9 graduate school students, and 9 residents. It has had 9 professors throughout its history. Their department has also produced active professors in the wide field of ophthalmology.Their department is known for a large amount of high clinical activity. Their advanced clinical practice performs translational research on the regenerative medicine of the cornea, artificial retina, diagnostic instruments and tools, apoptosis of photoreceptors, and drug discovery. Many ophthalmologists and staff members have contributed to the development of the Department of Ophthalmology at Osaka University.

Validation system of tissue-engineered epithelial cell sheets for corneal regenerative medicine

Recently, regenerative therapy with tissue-engineered epithelial cell sheets has been performed for treating ocular surface disease. It would be required to develop the validation method for these cell sheets to standardize and spread the regenerative therapy. In the present study, we developed a validation system for cultivated epithelial cell sheets. Human limbal epithelial cells and human oral mucosal epithelial cells were cultured with 3T3 feeder layer cells on temperature-responsive culture inserts for three different culture periods, and subjected to cell sheet harvest and validation. Epithelial cells cultured for a short period were not successfully harvested as intact contiguous cell sheets. On the other hand, total cell number and viability of epithelial cell sheets harvested after prolonged culture period decreased. Further, these cells also lost epithelial barrier function. These results showed the potential effectiveness of the proposed validation system that can evaluate fabricated cell sheets before transplantation.

Incidence of fellow eye retinal detachment resulting from macular hole

PURPOSE

To determine the incidence of retinal detachment resulting from macular hole (MHRD) in fellow eyes.

DESIGN

Observational case series.

METHODS

The medical records of 59 normal fellow eyes of cases with MHRD diagnosed between 1994 and 2004 at Osaka Rosai Hospital were retrospectively reviewed. Thirty-nine of the 59 fellow eyes were highly myopic. The average follow-up period was 42 months with a range of seven to 132 months. The incidence of MHRD in fellow eyes, and the interval between the onset of MHRD in the first eye and the fellow eye were determined. The Kaplan-Meier method was used to estimate the probability of the fellow eye developing MHRD at 18 months and five years, and the probability of high myopia in the development of MHRD with log-rank test.

RESULTS

Five eyes (8.5%) developed MHRD during the follow-up period. All affected eyes were highly myopic, and the incidence of MHRD among the highly myopic fellow eyes was 12.8%. The average interval was 51 months. The Kaplan-Meier estimated probability of the fellow eye developing MHRD was 3.7% (0% to 8.7% for 95% confidence interval [CI]) at 18 months and 8.0% (0% to 17.7% for 95% CI) at five years. The probability of the fellow eyes with high myopia developing MHRD was significantly higher than that of eyes without high myopia (P = .0304).

CONCLUSIONS

The high incidence of MHRD developing in the fellow eye indicates that the fellow eyes should be examined and followed carefully.

Effect of Indocyanine Green Staining in Peeling of Internal Limiting Membrane for Retinal Detachment Resulting from Macular Hole in Myopic Eyes

PURPOSE

To investigate the effect of using indocyanine green (ICG) to stain the internal limiting membrane (ILM) during vitrectomy in eyes with retinal detachment resulting from macular hole (MHRD).

DESIGN

Nonrandomized comparative trial.

PARTICIPANTS

Thirty-two cases of MHRD.

INTERVENTION

The medical records of the cases were reviewed retrospectively. During the initial vitrectomy, the ILM was peeled in 22 eyes with ICG (group A) and in 10 eyes without ICG (group B).

MAIN OUTCOME MEASURES

Anatomic reattachment, visual acuity, and optical coherence tomography-determined macular hole closure were measured.

RESULTS

The initial reattachment rate in group A (86%) was significantly higher than in group B (40%; P = 0.013, Fisher exact test). The postoperative visual acuity at 6 months and the visual improvements at 6 and 12 months in eyes with an initial reattachment were not significantly different between the 2 groups (P = 0.123, Mann-Whitney rank-sum test; P = 0.17, t test; P = 0.237, t test). The postoperative visual acuity at 12 months with an initial reattachment in group A was significantly better than in group B (P = 0.039, t test). The macular hole closure rate with an initial reattachment was 6 of 17 eyes (35%) in group A and 0 of 4 eyes (0%) in group B, and this difference was not significant (P = 0.281, Fisher exact test).

CONCLUSIONS

These results show that ICG staining improves the initial reattachment rate and is associated with better postoperative visual acuity at 12 months. Therefore, ICG staining should be used during vitrectomy for MHRD because the complete removal of the ILM with ICG ensures the removal of the tangential traction by an epiretinal membrane and the inverse traction by the retina that cannot follow the posterior enlargement of a staphyloma.

Surgical Excision of Retinal Macroaneurysms with Submacular Hemorrhage

PURPOSE

To report the visual outcome following the surgical excision of retinal macroaneurysms with submacular hemorrhage.

METHODS

Two patients presented with decreased vision caused by submacular hemorrhage from retinal macroaneurysms. In the first case, the macroaneurysm was too large to be treated by photocoagulation, and in the second case the direct photocoagulation during the first vitrectomy did not prevent the recurrence of hemorrhages. Vitrectomy with surgical excision of the retinal macroaneurysm using scissors and diathermy with a drainage of the submacular hemorrhage was then performed.

RESULTS

In the first patient, the visual acuity was light perception before treatment and 2/200 16 months after the excision. In the second patient, the visual acuity was 20/667 before treatment and 20/40 11 months after the excision. No hemorrhage has recurred in either case after the second vitrectomy.

CONCLUSIONS

The surgical excision of retinal macroaneurysms might be an effective procedure in cases where the macroaneurysm is too large or cannot be treated by photocoagulation during vitrectomy.

Relation of Posterior Staphyloma in Highly Myopic Eyes with Macular Hole and Retinal Detachment

PURPOSE

To investigate whether the type of posterior staphyloma (PS) affects the development of macular hole and retinal detachment (MHRD) in high myopia.

METHODS

Included in this retrospective study were 28 highly myopic eyes with MHRD (MHRD group) and 47 highly myopic eyes without MHRD (control group). The presence or absence of PS and the type of PS according to the classification of Curtin, the postoperative visual acuity, and the retinal reattachment rate were investigated.

RESULTS

The percentage of eyes with PS was significantly higher in the MHRD group than in the control group (P < 0.001). The rate of type II PS was significantly higher in the MHRD group (P = 0.01). There were no significant differences among the types of PS regarding the retinal reattachment rates and visual outcome.

CONCLUSIONS

Eyes with type II PS have a higher risk for the development of MHRD. However, the type of PS did not seem to affect the anatomic and visual outcome.