A Case of Paracentral Corneal Perforation Treated with One-Bite Mini-Keratoplasty.

A 61-year-old man presented with corneal perforation of 1.0 mm in diameter in his right eye caused by a metallic foreign body fragment. We used the "one-bite mini-keratoplasty" technique, which uses a cornea patch with a single host-graft-host suture to stop aqueous humor leakage. Postoperatively, the graft was completely epithelialized. The suture was removed and the use of soft contact lens was discontinued. Postoperative best-corrected visual acuity (BCVA) recovered to 180/200 and corneal astigmatism was 0.6 diopters. The postoperative course was unremarkable, but corneal perforation recurred due to an ocular contusion at 17 months. He was reoperated using the same technique. His BCVA was 160/200 and corneal astigmatism was 1.1 diopters after reoperation. Despite performing this surgical technique twice for corneal perforation, optimal visual function was maintained even after 2 years. For paracentral corneal perforations, our simple technique may reduce astigmatism and maintain high visual function.

Deep Neural Network-Based Method for Detecting Obstructive Meibomian Gland Dysfunction With in Vivo Laser Confocal Microscopy.

PURPOSE: To evaluate the ability of deep learning (DL) models to detect obstructive meibomian gland dysfunction (MGD) using in vivo laser confocal microscopy images. METHODS: For this study, we included 137 images from 137 individuals with obstructive MGD (mean age, 49.9 ± 17.7 years; 44 men and 93 women) and 84 images from 84 individuals with normal meibomian glands (mean age, 53.3 ± 19.6 years; 29 men and 55 women). We constructed and trained 9 different network structures and used single and ensemble DL models and calculated the area under the curve, sensitivity, and specificity to compare the diagnostic abilities of the DL. RESULTS: For the single DL model (the highest model; DenseNet-201), the area under the curve, sensitivity, and specificity for diagnosing obstructive MGD were 0.966%, 94.2%, and 82.1%, respectively, and for the ensemble DL model (the highest ensemble model; VGG16, DenseNet-169, DenseNet-201, and InceptionV3), 0.981%, 92.1%, and 98.8%, respectively. CONCLUSIONS: Our network combining DL and in vivo laser confocal microscopy learned to differentiate between images of healthy meibomian glands and images of obstructive MGD with a high level of accuracy that may allow for automatic obstructive MGD diagnoses in patients in the future.

Successful onco-testicular sperm extraction from a testicular cancer patient with a single testis and azoospermia.

Onco-testicular sperm extraction is used to preserve fertility in patients with bilateral testicular tumors and azoospermia. We report the case of a testicular tumor in the solitary testis of a patient who had previously undergone successful contralateral orchiectomy and whose sperm was preserved by onco-testicular sperm extraction. A 35-year-old patient presented with swelling of his right scrotum that had lasted for 1 month. His medical history included a contralateral orchiectomy during childhood. Ultrasonography revealed a mosaic echoic area in his scrotum, suggesting a testicular tumor. The lesion was palpated within the normal testicular tissue along its edge and semen analysis showed azoospermia. Radical inguinal orchiectomy and onco-testicular sperm extraction were performed simultaneously. Motile spermatozoa were extracted from normal seminiferous tubules under microscopy and were frozen. Eventual intracytoplasmic sperm injection using the frozen spermatozoa is planned. Onco-testicular sperm extraction is an important fertility preservation method in patients with bilateral testicular tumors or a history of a previous contralateral orchiectomy.

An infertile patient with Y chromosome b1/b3 deletion presenting with congenital bilateral absence of the vas deferens with normal spermatogenesis.

We report the case of a 46-year-old Chinese male patient who visited our clinic complaining of infertility. Semen analysis revealed azoospermia, and azoospermia factor c region partial deletion (b1/b3) was detected using Y chromosome microdeletion analysis. Testicular sperm extraction was performed after genetic counseling. The bilateral ductus deferens and a portion of the epididymis were absent, whereas the remaining epididymis was expanded. Motile intratesticular spermatozoa were successfully extracted from the seminiferous tubule. On histopathology, nearly complete spermatogenesis was confirmed in almost every seminiferous tubule. To our knowledge, this is the first case report of b1/b3 deletion with a congenital bilateral absence of the vas deferens and almost normal spermatogenesis.

Agreement among Goldmann applanation tonometer, iCare, and Icare PRO rebound tonometers; non-contact tonometer; and Tonopen XL in healthy elderly subjects.

PURPOSE: To evaluate the inter-device agreement among the Goldmann applanation tonometer (GAT), iCare and Icare PRO rebound tonometers, non-contact tonometer (NCT), and Tonopen XL tonometer. METHODS: Sixty healthy elderly subjects were enrolled. The intraocular pressure (IOP) in each subject's right eye was measured thrice using each of the five tonometers. Intra-device agreement was evaluated by calculating intraclass correlation coefficients (ICCs). Inter-device agreement was evaluated by ICC and Bland-Altman analyses. RESULTS: ICCs for intra-device agreement for each tonometer were >0.8. IOP as measured by iCare (mean ± SD, 11.6 ± 2.5 mmHg) was significantly lower (p < 0.05) than that measured by GAT (14.0 ± 2.8 mmHg), NCT (13.6 ± 2.5 mmHg), Tonopen XL (13.7 ± 4.1 mmHg), and Icare PRO (12.6 ± 2.2 mmHg; Bonferroni test). There was no significant difference in mean IOP among GAT, NCT, and Tonopen XL. Regarding inter-device agreement, ICC was lower between Tonopen XL and other tonometers (all ICCs < 0.4). However, ICCs of GAT, iCare, Icare PRO, and NCT showed good agreement (0.576-0.700). The Bland-Altman analysis revealed that the width of the 95% limits of agreement was larger between the Tonopen XL and the other tonometers ranged from 14.94 to 16.47 mmHg. Among the other tonometers, however, the widths of 95% limits of agreement ranged from 7.91 to 9.24 mmHg. CONCLUSION: There was good inter-device agreement among GAT, rebound tonometers, and NCT. Tonopen XL shows the worst agreement with the other tonometers; therefore, we should pay attention to its' respective IOP. CLINICAL TRIAL REGISTRATION: Japan Clinical Trials Register; number: UMIN000011544.

Cataract surgery causes biomechanical alterations to the eye detectable by Corvis ST tonometry.

PURPOSE: Modern cataract surgery is generally considered to bring about modest and sustained intraocular pressure (IOP) reduction. However, the pathophysiological mechanism for this remains unclear. Moreover, a change in ocular biomechanical properties after surgery can affect the measurement of IOP. The aim of the study is to investigate ocular biomechanics, before and following cataract surgery, using Corvis ST tonometry (CST). PATIENTS AND METHODS: Fifty-nine eyes of 59 patients with cataract were analyzed. IOP with Goldmann applanation tonometry (IOP-G), axial length, corneal curvature and CST parameters were measured before cataract surgery and, up to 3 months, following surgery. Since CST parameters are closely related to IOP-G, linear modeling was carried out to investigate whether there was a change in CST measurements following cataract surgery, adjusted for a change in IOP-G. RESULTS: IOP-G significantly decreased after surgery (mean±standard deviation: 11.8±3.1 mmHg) compared to pre-surgery (15.2±4.3 mmHg, P<0.001). Peak distance (the distance between the two surrounding peaks of the cornea at the highest concavity), maximum deformation amplitude (the movement of the corneal apex from the start of deformation to the highest concavity) and A1/A2 velocity (the corneal velocity during inward or outward movement) significantly increased after cataract surgery (P<0.05) while radius (the central curvature radius at the highest concavity) was significantly smaller following cataract surgery (P<0.05). Linear modeling supported many of these findings, suggesting that peak distance, maximum deformation amplitude and A2 velocity were increased, whereas A2 deformation amplitude and highest concavity time were decreased (after adjustment for IOP change), following cataract surgery. CONCLUSION: Corneal biomechanical properties, as measured with CST, were observed to change significantly following cataract surgery. TRIAL REGISTRATION: Japan Clinical Trials Registry UMIN000014370.

Effect of Varicocele Repair in Patients with Nonobstructive Azoospermia.

OBJECTIVE: To evaluate the efficacy of varicocele repair in patients with nonobstructive azoospermia. STUDY DESIGN: Ten patients with nonobstructive azoospermia and clinical varicoceles who underwent varicocele repair were retrospectively investigated. According to the postoperative appearance of motile spermatozoa in the ejaculate, the patients were divided into 2 groups: Responder and Nonresponder. The outcomes of each group were investigated. RESULTS: There were 4 (40%) patients in the Responder group. Serum follicle-stimulating hormone levels were significantly higher in the Nonresponder group than in the Responder group (19.9±6.4 IU/mL vs. 10.8± 4.0 IU/mL, p<0.05). Mean sperm concentration was 5.4 million spermatozoa/mL in the Responder group. One patient achieved a spontaneous pregnancy, and another achieved an assisted pregnancy. In the Nonresponder group 5 patients underwent microdissection testicular sperm extraction (micro-TESE) postoperatively. In 1 patient, motile spermatozoa were successfully retrieved. Histopathological findings in the other 4 patients were Sertoli-cell-only. CONCLUSION: The present study suggested that varicocele repair could be considered in men with nonobstructive azoospermia who have clinical varicoceles. Moreover, varicocele repair seemed to improve sperm retrieval rate during micro-TESE for those in the Nonresponder group.

Predicting the mineral composition of ureteral stone using non-contrast computed tomography.

We investigated the correlation between computed tomography (CT) density of ureteral stones and their mineral composition. A total of 346 patients who underwent ureteroscopic lithotripsy for calculi all fragments of which were acquired at a single institution from 2009 to 2011 were analyzed. The maximum and mean CT densities were measured preoperatively. A mineral analysis revealed calcium oxalate in 203 (58.7 %), mixed calcium oxalate and calcium phosphate in 78 (23.0 %), calcium phosphate in 18 (5.2 %), uric acid in 8 (2.3 %), struvite in 3 (0.9 %), and cysteine in 5 (1.4 %). The mean Hounsfield units (HUs) of the CT density were 1046 HUs in calcium oxalate, 1101 HUs in mixed calcium oxalate and calcium phosphate, 835 HUs in calcium phosphate, 549 HUs in uric acid, 729 HUs in struvite, and 698 HUs in cystine. The HUs in calcium oxalate were significantly higher than those in uric acid (p < 0.01) and struvite (p < 0.01). Those in monohydrate stones were significantly higher, compared with dehydrate stones (p < 0.05). We analyzed the largest number of stones than each published study to correlate their mineral composition and CT density. Calcium component stones showed significantly higher CT densities than other types.

[Tubeless Percutaneous Nephrolithotomy].

We assessed our initial experience with tubeless percutaneous nephrolithotomy (PCNL). Between February 2011 and December 2013, we performed 155 tubeless PCNL and 54 standard PCNL in which nephrostomy tubes were used postoperatively. Tubeless PCNL was performed when the presence of residual fragments, bleeding, and extravasation were excluded intraoperatively. The incidence of complications, hospital stay duration, analgesic requirements, visual analog scale score, decrease in hemoglobin levels, and stone-free rates were compared between the two groups. The mean hospital stay after tubeless PCNL was shorter (5.1 days) than that after standard PCNL (6.8 days, P＜0.05). Transient fever was seen in 20 patients (13.8%) in the tubeless PCNL group and 12 patients (25.5%) in the standard PCNL group. Tubeless PCNL is a safe and effective procedure, and hospital stay is shorter with tubeless PCNL than with standard PCNL.

[Case of azoospermia patient with a chromosomal abnormality considered a ring Y chromosome].

A 43-year-old man came to our clinic complaining of infertility and semen analysis showed azoospermia. Analysis of chromosomes showed a mosaic 45, XO/46, X, ＋mar1/46, X, ＋mar2 karyotype, and the marker chromosomes were considered to be two kinds of ring Y chromosomes. Y chromosome microdeletion analysis showed partial deletion of Azoospermic Factor (AZF) a, and complete deletion of AZFb and AZFc. The patient gave up having a child because these results indicated that no sperm would be collected even if Testicular Sperm Extraction (TESE) were performed.

[Clinical investigation of male infertile patients with chromosomal anomalies].

We investigated 470 male patients who came to the Reproduction Medical Center of Yokohama City University Medical Center complaining of infertility between April 2,000 and August 2013. We analyzed the chromosomes of 90 patients whose sperm concentration was below 1.0 × 107/ml. Nineteen of the 90 (21.1%) patients showed sex chromosomal anomalies including 12 Klinefelter syndrome (47, XXY or 46, XY/47, XXY), Robertsonian translocation, 2 autosome-autosome translocation, Y-autosome translocation, 46, X with marker chromosome (46, Xmar⁺), XX male and Y chromosome macrodeletion (46, XYq-). While patients with chromosomal abnormalities except XX male or some of 46, XYq- may succeed in reproduction using testicular sperm extraction-intracytoplasmic sperm injection, we need to inform the patients about the risks of chromosomal abnormalities in the resulting fetus.

Changes in choroidal thickness after cataract surgery.

PURPOSE: To evaluate changes in choroidal thickness before and after cataract surgery and factors affecting the changes. SETTING: Tsukazaki Hospital, Himeji, Japan. DESIGN: Prospective interventional study. METHODS: Patients having cataract surgery without other eye pathology were studied. The corrected distance visual acuity (CDVA), intraocular pressure (IOP), axial length (AL), and enhanced-depth-imaging optical coherence tomography (OCT) were measured preoperatively. The choroidal thickness was measured at 5 points (subfoveal and 1.5 mm nasal, temporal, superior, and inferior to the fovea) using the OCT device's software. Enhanced-depth-imaging OCT and IOP measurements were obtained 3 days, 1 and 3 weeks, and 3 and 6 months postoperatively and compared with the baseline values. Stepwise analysis determined which factors (ie, age, CDVA, preoperative IOP, AL, operative time, changes in IOP) were associated with changes in choroidal thickness. RESULTS: One hundred eyes were analyzed. The postoperative IOP significantly decreased at 3 weeks, 3 months, and 6 months. The postoperative choroidal thickness significantly increased at the foveal and inferior regions throughout the follow-up; at the nasal region at 3 days, 1 week, and 6 months; at the temporal region at 1 week; and at the superior region at 6 months. These changes negatively correlated with those in IOP early after surgery. The changes in choroidal thickness later negatively correlated with the AL in all regions. CONCLUSION: Cataract surgery caused changes in choroidal thickness. The AL and changes in the IOP are critical for evaluating the changes in choroidal thickness. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

[Retrospective analysis of predicting biochemical recurrence after initial radical prostatectomy].

We evaluated clinical outcomes of radical prostatectomy in 244 patients who had undergone radical prostatectomy as initial treatment from January 2000 to December 2011, and were followed up for more than 6 months. Biochemical recurrence after prostatectomy was defined as prostate-specific antigen (PSA) level of at least 0. 2 ng/ml. We evaluated potential risk factors for significant associations with biochemical recurrence. Median follow-up period after prostatectomy was 49 months (range, 6-144). Of the total, 192, 31, and 20 patients were at pathological stage pT2, pT3a, and pT3b, respectively. In 83 patients with the positive surgical margin, apexes were mostly in the positive area. Of the 68 patients with PSA recurrence, PSA non-relapse rate was 66.6% for 5 years. Multivariate analysis was performed for seminal vesicle invasion, PSA nadir, surgical margins, and Gleason score. Thirty-two patients with PSA recurrence underwent salvage radiotherapy, and the biochemical recurrence rate at 5 years was 73.8%. The group in which the PSA level before salvage radiotherapy was ＜0.5 ng/ml had a low rate of biochemical recurrence. We must consider the recurrence of poorly differentiated or non-confined cancer after radical prostatectomy. These results suggest that early use of salvage radiotherapy is effective for patients with biochemical recurrence after radical prostatectomy.

[A case of pneumomediastinum during BEP (bleomycin, etoposide, cisplatin) chemotherapy for testicular cancer].

We report a case of drug-induced pneumomediastinum by bleomycin in testicular cancer, which is extremely rare ; to our knowledge, only 3 cases have been reported. A 28-year-old man presented with a left testicular mass. He underwent radical left inguinal orchiectomy that demonstrated a seminoma, pT3N0M0. Ten months after surgery, para-aortic lymph node metastasis appeared, and he received three cycles of bleomycin, etoposide and cisplatin (BEP) chemotherapy. On day 13 of the fourth course of BEP, he complained of snowball crepitation of the neck and computed tomography revealed subcutaneous emphysema, extensive mediastinal air, and intraspinal air accumulation without pneumothorax. The pneumomediastinum and subcutaneous emphysema tended to deteriorate until 15 days after the onset of pneumomediastinum, but fortunately he had no signs or symptoms of infection. These findings resolved spontaneously after 1 month.

Early ureteral catheter removal after ureteroscopic lithotripsy using ureteral access sheath.

A ureteral access sheath (UAS) can facilitate ureteroscopy (URS) and the retrieval of stone fragments while reducing the intrarenal pressure, thereby improving irrigate flow and decreasing the length of an operation. Ureteral stenting after URS is unnecessary for uncomplicated cases. This study examined the early removal of postoperative ureteral catheterization after URS for cases that used a UAS. A total of 93 patients underwent ureteroscopic lithotripsy with the early removal of ureteral catheterization. Sixty-three of these patients underwent surgery with the use of UAS and were analyzed in this study. Postoperative hydronephrosis was assessed using ultrasonography 3 days after the operation and computed tomography 2 weeks after operation in all patients. Post-operative complications including fever, prolonged hospitalization, frequent usage of painkillers and the re-insertion of ureteral stent were also investigated. Hydronephrosis was detected 3 days after the operation in 34 patients (54.0 %) and 2 weeks after the operation in four patients (6.3 %). No hydronephrosis was detected after a 2-month follow-up in these four patients. The mean operation time in the hydronephrosis group was significantly higher at 58.9 min than in the non-hydronephrosis group at 45.5 min (p < 0.05). Post-operative fever (38 °C) was seen in one case, the frequent usage of painkillers was seen in four cases, a prolonged hospital stay was seen in five cases, and ureteral stent re-insertion was observed in one case. The early removal of ureteral catheterization can be safely performed for the patients that undergo URS with UAS.

Case of cytomegalovirus retinitis aggravated by sub-Tenon injection of triamcinolone acetonide with subsequent metastatic liver cancer.

We report a case of cytomegalovirus (CMV) retinitis in an immunocompetent patient who was resistant to antiviral treatment, and in whom fatal metastatic liver cancer was later detected. A 74-year-old Japanese man visited our ophthalmology clinic in May 2011. He had a history of well controlled type 2 diabetes and colon cancer, and underwent successful surgical treatment in 2008. In April 2011, he was diagnosed with uveitis affecting his left eye and received posterior sub-Tenon injection of triamcinolone acetonide. He was referred to us because of aggravation of the retinal lesion. Funduscopic examination of the left eye revealed arcuate, whitish, necrotizing retinitis with hemorrhage along the temporal arcade of the retina. Polymerase chain reaction of the aqueous fluid was positive for CMV DNA. Because of diagnosis of CMV retinitis in his left eye, he was referred to an internist and investigated for systemic CMV infection or any serious disease which could cause immunocompromise, but neither was detected. Despite an intensive course of intravitreous ganciclovir and oral valganciclovir, the retinitis did not resolve. In June 2012, 14 months after the initial ocular symptoms, metastatic liver cancer was found and the patient passed away. When CMV retinitis is resistant to antiviral treatment or recurs in an immunocompetent patient, it is important that ophthalmologists undertake systemic investigation for occult malignancy.

Correlation between the operation time using two different power settings of a Ho: YAG laser: laser power doesn't influence lithotripsy time.

BACKGROUND: This study investigated the correlation between the operation time using two different power settings of a Ho: YAG laser. FINDINGS: A total of 68 patients underwent cystolithotripsy from April 2010 to October 2011 In Fifty-six of these patients underwent cystolithotripsy by one surgeon using a Ho: YAG laser for bladder calculi. This study assessed these patients in two groups; the 30 W laser generator group with the settings of 2.5 J x 5 Hz (30 W group) and the 100 W laser generator group as the settings of 3.5 J x 5 Hz (100 W group). The operation time in these two groups were assessed.A total of 56 patients including 45 male and 11 female patients that underwent cystolithotripsy using a Ho: YAG laser for bladder calculi by one surgeon were enrolled in this study. The patients' characteristics including age (mean; 68.8 vs 68.4 yr), gender (male; 74.2 vs 88.0%), stone burden (mean; 34.9 vs 41.3 mm), number of stones (mean; 3.2 vs 2.0) and stone's CT density (mean; 981.5 vs 902.0 HU) showed no significant differences. All patients were stone free following treatment. The median total length of the operation was 19 minutes (mean: 34.6 ± 36.1) in the 30 W group and 29 minutes (mean: 44.4 ± 38.8) in the 100 W group, which was not significantly different. CONCLUSIONS: The results showed that the power settings of Ho: YAG laser show no differences in the operation time for bladder calculi lithotripsy.

[A case of male infertility caused by drug-induced hyperprolactinemia].

A 46-year-old man complaining of infertility was referred to our hospital. He was diagnosed with oligozoospermia, asthenozoospermia and hyperprolactinemia probably induced by sulpiride for depression, because semen quality gradually improved after cessation of sulpiride administration. Five months after the cessation, his serum prolactin level declined to the normal level, and his wife achieved spontaneous pregnancy.

Retinal pigment epithelium folds as a diagnostic finding of Vogt-Koyanagi-Harada disease.

OBJECTIVE: To examine using the folds of the retinal pigment epithelium (RPE) to diagnose Vogt-Koyanagi-Harada (VKH) disease. METHODS: Retrospective clinical review of 57 Japanese patients between July 2005 and April 2009. Optical coherence tomography (OCT), fundus photographs and fluorescein angiography (FA) were studied to investigate Kendall's coefficients of concordance in seven findings by four ophthalmologists. The sensitivity and specificity of each finding were examined to confirm its efficacy. Each result was defined as positive when more than three of the ophthalmologists judged that the finding existed. RESULTS: The folds of the RPE on OCT were observed in 30/42 (71.4 %) eyes having VKH disease, but none in the other 72 eyes. Kendall's coefficient of concordance in the detection of the folds of the RPE was 0.90 and was the highest among all other findings. Sensitivity was higher in the detection of the RPE folds on OCT and in optic nerve staining on FA than other findings and the specificity was 100 % for the RPE folds and 26.7 % for the optic nerve staining. CONCLUSION: The detection of the folds of the RPE on OCT is a simple and effective method to help diagnose VKH disease at its acute stage which does not require pupil dilation.

Effectiveness of ureteroscopy-assisted retrograde nephrostomy (UARN) for percutaneous nephrolithotomy (PCNL).

OBJECTIVE: To determine the impact of ureteroscopy-assisted retrograde nephrostomy (UARN) during percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: From April 2009 to September 2011, a total of 50 patients underwent PCNL for large renal stones (stone burden >2 cm). We performed UARN in the Galdakao-modified Valdivia position for 27 patients (UARN PCNL) and ultrasonography-assisted percutaneous nephrostomy in the prone position for 23 patients (prone PCNL). RESULTS: UARN PCNL significantly improved the stone-free rate (81.5% vs 52.2%) and the rate of residual stones (<4 mm, 92.6% vs 65.2%, P<0.05). The median length of the operation was significantly shorter for UARN PCNL, at 160 min, compared to 299 min for prone PCNL (P<0.001). There was one intraoperative complication in prone PCNL, namely a hemorrhage that resulted in stopping the initial treatment, but it was cured conservatively. The postoperative complications included a high grade fever that persisted for three days in two UARN PCNL patients (7.4%) and six prone PCNL patients (26.1%). The Clavien grading scores showed significantly lower postoperative complications for UARN PCNL compared to prone PCNL. CONCLUSION: UARN is associated with a higher stone-free rate, shorter operation time, and fewer complications during PCNL than prone PCNL.