A comparison of laparoscopic procedures performed by novice medical students using 8K ultra-high-definition/two-dimensional and 2K high-definition/three-dimensional monitors.

PURPOSE: 8K Ultra-high-definition (UHD) imaging has been developed in accordance with the progression of imaging technologies. We evaluated laparoscopic procedures performed by novice medical students using 2K/two-dimensional (2D), 2K/three-dimensional (3D) and 8K/2D monitors, with a particular focus on depth perception. METHODS: Nine medical students were enrolled. They performed two tasks using 2K/2D, 2K/3D and 8K/2D monitors. In Task 1, they were asked to grasp three metal rods with forceps using each hand. In Task 2, they were asked to grasp a metal rod with forceps held in the right hand, pass the metal rod through a metal ring and transfer it to their left hand. RESULTS: In Task 1, when performed with the dominant hand, the procedures performed using 2K/3D took a significantly shorter time than those performed using 8K/2D (P = 0.04). However, there was no significant difference among the three groups in the time required for procedures performed by the non-dominant hand. In Task 2, the procedure time with 2K/2D was significantly longer than that with 2K/3D or 8K/2D (P = 0.02). CONCLUSION: 2K/3D showed superior utility to 8K/2D for performing forceps procedures using the dominant hand. However, when the movement of both hands was coordinated ("bi-hand coordination"), the laparoscopic procedures were performed almost as deftly with 8K/2D and 2K/3D.

Association of Rare CYP39A1 Variants With Exfoliation Syndrome Involving the Anterior Chamber of the Eye.

Importance: Exfoliation syndrome is a systemic disorder characterized by progressive accumulation of abnormal fibrillar protein aggregates manifesting clinically in the anterior chamber of the eye. This disorder is the most commonly known cause of glaucoma and a major cause of irreversible blindness. Objective: To determine if exfoliation syndrome is associated with rare, protein-changing variants predicted to impair protein function. Design, Setting, and Participants: A 2-stage, case-control, whole-exome sequencing association study with a discovery cohort and 2 independently ascertained validation cohorts. Study participants from 14 countries were enrolled between February 1999 and December 2019. The date of last clinical follow-up was December 2019. Affected individuals had exfoliation material on anterior segment structures of at least 1 eye as visualized by slit lamp examination. Unaffected individuals had no signs of exfoliation syndrome. Exposures: Rare, coding-sequence genetic variants predicted to be damaging by bioinformatic algorithms trained to recognize alterations that impair protein function. Main Outcomes and Measures: The primary outcome was the presence of exfoliation syndrome. Exome-wide significance for detected variants was defined as P < 2.5 × 10-6. The secondary outcomes included biochemical enzymatic assays and gene expression analyses. Results: The discovery cohort included 4028 participants with exfoliation syndrome (median age, 78 years [interquartile range, 73-83 years]; 2377 [59.0%] women) and 5638 participants without exfoliation syndrome (median age, 72 years [interquartile range, 65-78 years]; 3159 [56.0%] women). In the discovery cohort, persons with exfoliation syndrome, compared with those without exfoliation syndrome, were significantly more likely to carry damaging CYP39A1 variants (1.3% vs 0.30%, respectively; odds ratio, 3.55 [95% CI, 2.07-6.10]; P = 6.1 × 10-7). This outcome was validated in 2 independent cohorts. The first validation cohort included 2337 individuals with exfoliation syndrome (median age, 74 years; 1132 women; n = 1934 with demographic data) and 2813 individuals without exfoliation syndrome (median age, 72 years; 1287 women; n = 2421 with demographic data). The second validation cohort included 1663 individuals with exfoliation syndrome (median age, 75 years; 587 women; n = 1064 with demographic data) and 3962 individuals without exfoliation syndrome (median age, 74 years; 951 women; n = 1555 with demographic data). Of the individuals from both validation cohorts, 5.2% with exfoliation syndrome carried CYP39A1 damaging alleles vs 3.1% without exfoliation syndrome (odds ratio, 1.82 [95% CI, 1.47-2.26]; P < .001). Biochemical assays classified 34 of 42 damaging CYP39A1 alleles as functionally deficient (median reduction in enzymatic activity compared with wild-type CYP39A1, 94.4% [interquartile range, 78.7%-98.2%] for the 34 deficient variants). CYP39A1 transcript expression was 47% lower (95% CI, 30%-64% lower; P < .001) in ciliary body tissues from individuals with exfoliation syndrome compared with individuals without exfoliation syndrome. Conclusions and Relevance: In this whole-exome sequencing case-control study, presence of exfoliation syndrome was significantly associated with carriage of functionally deficient CYP39A1 sequence variants. Further research is needed to understand the clinical implications of these findings.

Macular capillary recovery in systemic lupus erythematosus complicated by Kikuchi-Fujimoto disease.

PURPOSE: Few case reports have described vaso-occlusive retinopathy in systemic lupus erythematosus (SLE) using optical coherence tomography (OCT) angiography. Here we report the clinical features of a patient with SLE, complicated by Kikuchi-Fujimoto disease, who developed vaso-occlusive retinopathy. We then describe the subsequent recovery of the macular capillaries as assessed by OCT angiography. CASE: A 16-year-old male was referred to us with fever, a 1-month history of violaceous red papules and erythematous plaques on his face and a painful nodule in his right neck. We diagnosed him with SLE complicated by Kikuchi-Fujimoto disease through physiological assessment and histology from his neck lymph node and chin skin. Systemic steroids were prescribed as treatment. After remission, his fever and cervical lymph node swelling with pain recurred and he developed blurred inferior vision in his left eye. His best-corrected visual acuities were 1.0 and 0.1 in the right and left eyes, respectively. Extensive cotton wool spots were observed in the right fundus, and retinal capillary occlusions were detected by OCT angiography of the left eye. We diagnosed this case as vaso-occlusive retinopathy with SLE and increased immunosuppressive treatment together with anticoagulation therapy. Macular capillaries, observed by OCT angiography, gradually recovered function following assessment at 7 and 16 months post-onset of the vaso-occlusive retinopathy. CONCLUSIONS: We reported a 1½-year course of vaso-occlusive retinopathy in a patient with SLE complicated by Kikuchi-Fujimoto disease. Occlusion of the retinal vasculature and the subsequent recovery of circulation are clearly observed by OCT angiography.

Reperfusion of the choriocapillaris observed using optical coherence tomography angiography in hypertensive choroidopathy.

PURPOSE: Optical coherence tomography angiography (OCTA) can visualize the vascular status of the choriocapillaris noninvasively and separately from the other vascular beds. We describe focal ischemia in the choriocapillaris and reperfusion of the area in hypertensive choroidopathy using en-face OCTA. CASE: A 32-year-old woman diagnosed with pregnancy-induced hypertension presented with acute anorthopia in the right eye after delivery via Caesarian section. Fundus examination showed an Elschnig's spot and serous retinal detachment (SRD) in the inferior perifoveal region. Early-phase fluorescein angiography and indocyanine green angiography images showed focally delayed choroidal perfusion, i.e., regional absence of choroidal flush. OCTA also showed a focal dark area in a slab of the choriocapillaris corresponding to the angiographic observation. After oral antihypertensive treatment, the dark area on the OCTA image of the choriocapillaris resolved over time in association with the resolving SRD. CONCLUSION: En-face OCTA is a useful technology to follow noninvasively the circulatory status of the choriocapillaris in hypertensive choroidopathy.

Short-term effects of intravitreal ranibizumab therapy on diabetic macular edema.

BACKGROUND: The short-term effects of intravitreal ranibizumab (IVR) on diabetic macular edema (DME) remains unclear. We assessed the short-term effects of IVR on DME. METHODS: Eighteen eyes of 14 patients with DME were enrolled in this prospective interventional case series. After intravitreal ranibizumab was injected into treatment-naïve eyes with DME, we measured the foveal thickness (FT) before and 2 h, 1 day, 1 week, and 1 month later and the best-corrected visual acuity (BCVA) at all times except 2 h and compared the changes to baseline (ΔFT and ΔVA). RESULTS: The mean FT decreased significantly (p < 0.0001) from 452 ± 77 to 429 ± 65 microns after 2 h. The mean logarithm of the minimum angle of resolution BCVA improved significantly (p = 0.032) after 1 month from 0.41 ± 0.24 to 0.32 ± 0.21 (20/51 to 20/42, Snellen equivalent). The ΔFT after 2 h was significantly (r = 0.53, p = 0.025) correlated with the ΔFT after 1 month. The ΔVA after 1 day was significantly (r = 0.59, p = 0.01) correlated with the ΔVA after 1 month. CONCLUSIONS: The structural effects of IVR for DME occurred within 2 h, whereas the functional effects occurred after 1 month. The short-term effects (within 1 day) of IVR may predict the therapeutic outcome 1 month after IVR in patients with DME. TRIAL REGISTRATION: The trial registration number: UMIN000026118 (Feb/13/2017). Retrospectively registered.

Correlation between short- and long-term effects of intravitreal ranibizumab therapy on macular edema after branch retinal vein occlusion: a prospective observational study.

BACKGROUND: The correlation between the short- and long-term effects of intravitreal ranibizumab (IVR) on macular edema after branch retinal vein occlusion (BRVO) remains unclear. We assessed the correlation between the short- and long-term effects of IVR on macular edema after BRVO. METHODS: Twenty-one eyes with macular edema after BRVO were enrolled in this prospective observational study. We measured the foveal thickness (FT) and the best-corrected visual acuity (BCVA) before, 1 day after, and 1 month after IVR (0.5 mg) and then at least every 2 months thereafter until 6 months after the injection. If the macular edema recurred, another injection was administered. The primary endpoint was the change from baseline in the BCVA (ΔVA). RESULTS: The mean logarithm of the minimum angle of resolution VA improved significantly (p = 0.01, p < 0.0001, respectively) after 1 day from 0.65 ± 0.28 to 0.51 ± 0.21 (20/89 to 20/63, Snellen equivalent) and after 6 months to 0.29 ± 0.24 (20/39, Snellen equivalent). The mean FT decreased significantly (p < 0.0001) after 1 day from 482 ± 85 µm to 349 ± 75 µm and after 6 months to 305 ± 84 µm. The 1-day VA was significantly (r = 0.68, p = 0.0007) positively correlated with the 6-month VA. The 1-day ΔVA was significantly (r = 0.79, p < 0.0001) positively correlated with the 6-month ΔVA. CONCLUSIONS: The short-term effects of IVR may predict the long-term effects of IVR in macular edema secondary to BRVO. TRIAL REGISTRATION: Trial registration number: UMIN000027003 . Retrospectively registered. (April/15/2017).

Amniotic Membrane Transplantation for Corneal and Conjunctival Diseases: Classification of Application and Outcomes from Analysis of 95 cases.

Purpose: To evaluate the indications and outcomes of amniotic membrane (AM) transplantation for corneal and conjunctival diseases. Subjects and methods: Ninety-five eyes of ninety patients who underwent AM transplantation between January 2007 and May 2016 were included in this study. The surgical procedures, diagnosis and postoperative outcomes were investigated retrospectively. Results: Transplantation was conducted in three surgical procedures. AM patch, for the promotion of corneal re-epithelialization, was performed in 14 cases with persistent epithelial defects. Thirteen cases healed with total epithelialization. Corneal perforation was noted in Stevens-Johnson syndrome and cured with keratoplasty. AM graft for basement membrane supply, was performed in 72 cases. Of these, 32 cases had been followed for at least one year after AM graft out of which pterygium recurred at one year in 5. Conjunctival tumor recurred in 3 out of 17 cases, and was treated with a repeated of AM graft. AM stuff for substrate supply to the deep corneal layer, was performed in 9 cases with corneal perforation. Leakage of aqueous humor was cured in all 9 cases. Seven cases had keratoplasty performed after the AM stuff and recovered completely. The other 2 cases were observed without additional surgery. There were no complications due to the AM transplantation during the course of treatment in any of the 95 cases. Conclusion: AM transplantation is applied in three different procedures. Each of these was effective in achieving the corneal and conjunctival reconstruction designed for it.

Vascular rarefaction at the choriocapillaris in acute posterior multifocal placoid pigment epitheliopathy viewed on OCT angiography.

Few cases have been reported describing choroidal vasculature in acute posterior multifocal placoid pigment epitheliopathy (APMPPE) using optical coherence tomography (OCT) angiography. We report choroidal vasculature changes in an APMPPE patient with the clinical course characterized by OCT angiography. A 39-year-old female was referred to us for bilateral multiple white spots in bilateral fundus. The best-corrected visual acuity was 20/20 in the right eye and 20/50 in the left eye. Multiple yellowish-white placoid lesions were observed in bilateral fundus, and fluorescein angiography showed a "block early, stain late" pattern at the placoid lesions characteristic of APMPPE. The placoid lesion represented vascular rarefaction at the choriocapillaris in the OCT angiography en face view. While the clinical course of symptoms and most of the low vascular rarefaction lesions regressed in 6 months, some new lesions were subclinically noted. Blurred vision recurred at 9 months from the first visit, and the vascular rarefaction lesions developed in different areas than those observed in the initial visit. Multiple yellowish-white placoid lesions in an APMPPE patient represented vascular rarefaction at the choriocapillaris in OCT angiography. The vascular rarefaction recovered and then recurred during the clinical course. OCT angiography can visualize changes of the choroidal vessels during APMPPE.

Comparison of intraocular pressure variability in glaucoma measured by multiple clinicians with those by one clinician.

To compare the intraocular pressure (IOP) variability measured by multiple clinicians with those by one clinician. Forty-seven of 227 consecutive patients with glaucoma who had been examined routinely for over 12 months without changes in antiglaucoma medications at Asahikawa Medical University were included. Patients were assigned to one of two groups based on whether they had been followed by multiple or one clinician. One eye of each patient was evaluated. The IOPs obtained using Goldmann applanation tonometry were evaluated. We used the IOP standard deviation (SD, mmHg) and coefficient of variation (CV, %) as parameters of IOP variability. The main outcome measures were the differences in SD and CV between the groups. Multiple linear regression analysis evaluated factors associated with the SD and CV. Twenty-four (51.1 %) patients were assigned to the multiple-clinicians group and 23 (48.9 %) to the single-clinician group. The mean ± SD and CV were higher in the former (1.9 ± 0.5 and 12.0 ± 3.7, respectively) than in the latter group (1.4 ± 0.3 and 10.1 ± 2.5; P = 0.0005 and 0.044, respectively). The number of treating clinicians was the factor most associated with the SD and CV (ß = 0.455, P = 0.002 and ß = 0.387, P = 0.008, respectively). The variability in the IOP measurements of patients who had been monitored by multiple clinicians was higher than in patients followed by one clinician. The factor most associated with IOP variability was the number of clinicians involved.

Long-term outcome of amniotic membrane transplantation combined with mitomycin C for conjunctival reconstruction after ocular surface squamous neoplasia excision.

The aim of the study is to evaluate the long-term clinical results of amniotic membrane transplantation (AMT) combined with mitomycin C (MMC) for reconstruction of conjunctival defects created during the excision of ocular surface squamous neoplasia (OSSN). Eight consecutive eyes of seven patients (five males and two females; mean age, 64 ± 19 years) treated by one surgeon (KH) were included in this study. AMT was performed after excision of a mass region, along with 0.04 % MMC treatment for the exposed sclera. The tumor size, histopathological retrieval, AM graft size after tumor excision, recurrence, and postoperative complications were recorded. During a mean postoperative follow-up period of 60.9 ± 14.6 months (range 36-78 months), the ocular surfaces completely re-epithelialized in all cases. The median size of the tumor was 44.4 ± 21.2 mm2 (range 13-67 mm2). The histopathological diagnoses were five cases of squamous cell carcinoma in situ (SCC in situ) and three cases of dysplasia. The median size of the AM graft after tumor excision was 100.8 ± 32.7 mm2 (range 49-151 mm2). A case of recurrent SCC in situ with a preoperative history of using MMC eye drops developed further corneal limbal deficiency and was treated with therapeutic soft contact lenses. A case of dysplasia with a history of large pterygial excision developed symblepharon postoperatively was treated with AMT 6 months after tumor excision. The tumors recurred in two eyes with SCC in situ and were successfully treated with continuous AMT and MMC. No severe complications, such as infections, corneal or scleral thinning, or ulceration developed in all cases. The combination of AMT and MMC is effective for safe reconstruction over the long-term after the excision of OSSN with postoperative careful observation and treatment. In recurrent tumor excision cases, AMT is a suitable technique for repeated ocular surface reconstruction.