[A Case of Emphysematous Pyelonephritis Complicated by Bacterial Endophthalmitis in which Multidisciplinary Therapy Led to Preservation of the Kidney].

A 49-year-old male with untreated diabetes mellitus type 2 experienced eyesight deterioration and general malaise, and was treated for uveitis and orbital cellulitis. Later, he was taken to a local hospital via ambulance for a consciousness disorder and was diagnosed with bilateral infectious endophthalmitis, a right ureteral stone, and emphysematous pyelonephritis. He was then referred to our hospital for further examination and treatment. We immediately initiated intravenous antibiotic therapy with meropenem and glycemic control with continuous subcutaneous insulin infusion, and placed a ureteral and percutaneous drain tube into the right ureter and the emphysema, respectively. We performed a diagnostic and therapeutic vitrectomy on the patient's left eye. Urinary, blood, and vitreous cultures were positive for Klebsiella aerogenes. Abdominal contrast-enhanced computed tomography showed bilaterally comparable renal contrast enhancement. On the 60th hospital day, we performed endoscopic combined intrarenal surgery (ECIRS) and completely removed the urinary stone. Although he lost light sensitivity in his right eye, his left eyesight improved, and his blood glucose level was adequately managed by oral medication. Three months after the surgery, he was discharged from our hospital and he showed no sign of recurrence of the infection at ten months after surgery.

Ocular Behçet's disease is less complicated with allergic disorders. A nationwide survey in Japan.

OBJECTIVES: Behçet's disease (BD) is a systemic inflammatory disorder polarised to the Th1 and Th17 immune systems. Allergic diseases are polarised to the Th2 immune system. The aim of the present study is to investigate the prevalence of allergic diseases in patients who have BD. METHODS: The study involved a large-scale interview survey of Japanese patients with BD at 21 institutes of ophthalmology; 353 patients (255 males and 98 females) were recruited for this study. We analysed the history of allergic diseases such as atopic dermatitis (AD), allergic rhinitis (AR), bronchial asthma (BA) and drug/food allergies (FA). RESULTS: Oral aphthous ulcers, ocular lesions, skin lesions, genital ulcers, arthritis, neurological lesions, intestinal lesions, deep vein thrombosis and epididymitis were reported in 95.8%, 98.6%, 72.5%, 44.8%, 13.9%, 6.8%, 6.2%, 3.7% and 1.4% of the patients, respectively. It was also reported that 73 patients (20.7%) had histories of allergic diseases: AD (5 cases, 1.4%), AR (36 cases, 10.2%), BA (19 cases, 5.4%) and FA (30 cases, 8.5%). This percentage was significantly lower than in a survey that Japan's Ministry of Health, Labour and Welfare conducted for healthy population (47.6%) (odds ratio = 0.29, 95% confidence interval = 0.22-0.38, p=4.9×10-22). Frequencies of posterior/pan-uveitis, relatively severe ocular findings, and visual prognosis were not affected by a history of allergic diseases in BD. CONCLUSIONS: Patients with BD had fewer complications from allergic diseases than did the entire population of Japan.

Geographic pattern of central retinal sensitivity after intravitreal triamcinolone for diabetic macular edema.

PURPOSE: To evaluate the geographic pattern of central retinal sensitivity and its resolution shortly after intravitreal injection of triamcinolone acetonide (IVTA) for diabetic macular edema (DME). METHODS: Twenty eyes of 20 patients who underwent IVTA for the treatment of DME were reviewed retrospectively. Early changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), photoreceptor inner and outer segments (IS/OS) line and central retinal sensitivity were analyzed. Retinal sensitivity was measured at 40 points within the central 10 degrees of the macula with the Micro Perimeter 1 before treatment, and at 1 week and 1 month after IVTA. RESULTS: Mean BCVA and CMT improved significantly at 1 week and 1 month after IVTA. Mean retinal sensitivity, however, showed no significant improvement at 1 week (P = 0.238), but did show significant improvement at 1 month (P = 0.0003). Mean retinal sensitivity of the points at the central 2 degrees, which was significantly lower than that at 6 and 10 degrees before treatment, showed improvement similar to those of 6 and 10 degrees after IVTA. Mean retinal sensitivity in the nasal quadrant of the macular area had the best sensitivity at all time points, and improved more than it did in the other quadrants. Mean retinal sensitivity in the central 2 degrees was better in the eyes with complete IS/OS line (P < 0.0001). CONCLUSIONS: BCVA and CMT improved significantly after IVTA for DME. Retinal sensitivity also showed significant, albeit relatively slow, improvement. The nasal quadrant of the macular area showed more improvement than did any other quadrant.

Endoscope-assisted vitrectomy in the management of pseudophakic and aphakic retinal detachments with undetected retinal breaks.

PURPOSE: To demonstrate the efficacy of endoscope-assisted pars plana vitrectomy in treating patients with retinal detachments with no retinal breaks detected preoperatively. METHODS: Medical records of 20 consecutive eyes with pseudophakic and aphakic rhegmatogenous retinal detachments but without retinal breaks detected preoperatively were reviewed. In each case, endoscope-assisted pars plana vitrectomy was performed. RESULTS: In 19 of 20 eyes, breaks were identified with the help of an endoscope during surgery. To treat breaks, transscleral cryopexy or endolaser was performed under the endoscopic vision. The retina was reattached after a single surgery in all cases. No serious complication related to the operation was experienced. CONCLUSION: Endoscope-assisted vitrectomy is useful in the management of pseudophakic and aphakic retinal detachments with undetected retinal breaks preoperatively.

Sub-Tenon Injection of Triamcinolone Acetonide for Choroidal Mass in Sarcoidosis: A Case Report.

PURPOSE: To report the clinical course of a sub-tenon injection of triamcinolone acetonide for treatment of an asymptomatic choroidal mass in sarcoidosis. METHODS: This was a retrospective, non-comparative interventional case study. RESULTS: A 36-year-old Japanese man with sarcoidosis presented with an asymptomatic choroidal mass lesion associated with subretinal fluid accumulation in his left eye, but without any other sign of intraocular inflammation in either of his eyes. He had started systemic steroid administration for thrombocytopenia 2 days prior to being examined. After a single sub-tenon injection of triamcinolone acetonide (20 mg) the subretinal fluid was completely absorbed and the choroidal granuloma began to shrink in size. After the injection, the granuloma became a scar without any complication or recurrence over the next 34 months. CONCLUSION: Sub-tenon injection of triamcinolone acetonide might be an effective treatment for choroidal granuloma in sarcoidosis.

Scleral Buckle Infection Caused by Mycobacterium chelonae: A Case Report.

A 63-year-old female with a history of retinal detachment repair with scleral buckle from 28 years prior presented with exposure of the buckle in her right eye. After removing the buckle and anchoring sutures, the operation field was washed with 0.25% polyvinyl alcohol-iodine, vancomycin, and ceftazidime. Cultures revealed Mycobacterium chelonae. Systemic meropenem was discontinued on postoperative day 5. The retina remained attached, and there was no recurrence over a 1-year follow-up. We report a case of NTM buckle infection that responded well to thorough washings with polyvinyl alcohol-iodine and antibiotic solutions instead of using a prolonged course of systemic antibiotics.

[Evaluation of revised diagnosis criteria for sarcoidosis].

PURPOSE: Based on diagnostic criteria revised in 2006, we investigate whether a simple examination will provide a diagnosis for uveitis of sarcoidosis. SUBJECTS AND METHODS: Two hundred and six patients with uveitis suspected of having sarcoidosis who visited 4 hospitals from 1978 to 2008 were evaluated according to Their ocular and systemic findings. RESULTS: One hundred and six patients were diagnosed as having sarcoidosis. Most patients had more than 4 ocular criteria. Bilateral hilar lymphadenopathy (BHL) was seen in 103 (97.2%) of the patients. When BHL was not detected with conventional chest X-rays, chest computerized tomography (CT) was useful in detecting BHL, especially in patients who were tuberculin negative. CONCLUSIONS: When sarcoidosis is suspected from ocular findings, chest X-rays, a tuberculin skin test and serum angiotensin converting enzyme should be performed first. Even if BHL is not detected, a chest CT is useful in cases that are tuberculin negative.

Acute Vogt-Koyanagi-Harada disease in enhanced spectral-domain optical coherence tomography.

OBJECTIVE: To demonstrate unique membranous structures seen on enhanced spectral domain optical coherence tomography (SD-OCT) images of eyes with acute Vogt-Koyanagi-Harada (VKH) disease. DESIGN: Retrospective, observational case series. PARTICIPANTS: Twenty eyes of 10 consecutive patients diagnosed with acute VKH disease. METHODS: We reviewed fundus photographs, conventional OCT images, fluorescein angiograms (FA), and enhanced SD-OCT images, including serial sections through the macula, obtained at the initial visit and periodically after steroid treatment until complete resolution of serous retinal detachment. MAIN OUTCOME MEASURES: Findings on enhanced SD-OCT imaging and FA in eyes with VKH disease. RESULTS: All 20 eyes had multifocal serous retinal detachment in the posterior fundus that appeared as multilobular dye pooling on late-phase FA. In 17 of the 20 eyes (85%), some areas of dye pooling corresponded to cystoid spaces on enhanced SD-OCT images and in 14 of the 20 (70%) eyes, there were areas of dye pooling and cystoid spaces in the fovea. The floors of the cystoid spaces consisted of a membranous structure of uniform thickness (mean thickness in the fovea of 14 eyes, 62.5+/-3.3 microm). The membranous structure, on SD-OCT, seemed to include a highly reflective line, which was continuous with the line representing the junction of the photoreceptor inner and outer segments (IS/OS) in attached areas of the retina. Intraretinal split was seen to overlie the abnormal IS/OS line in the vicinity of cystoid spaces involving the fovea in 9 of the 20 eyes (45%). During the course of steroid therapy, the membranous structure changed to a granular structure. CONCLUSIONS: The membranous structure that can be seen in eyes with acute VKH disease seems to represent a portion of the outer segment layer that has become separated from the inner segment layer by cystoid spaces. We hypothesize that the membranous form of the outer segment is bound with the action of inflammatory products, such as fibrin, and this membranous structure changes to a granular structure as steroid therapy "dissolves" the fibrin holding the outer segments together. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Association between foveal photoreceptor status and visual acuity after resolution of diabetic macular edema by pars plana vitrectomy.

UNLABELLED: We retrospectively investigated the relationship between the appearance of IS/OS line on OCT images and visual acuity after resolution of DME by vitrectomy. Postoperative visual acuity of eyes with complete IS/OS after resolution of DME was significantly better than that without complete IS/OS, though macular edema was completely resolved in both groups. PURPOSE: To evaluate the correlation between photoreceptor layer status following resolution of diabetic macular edema (DME) by pars plana vitrectomy (PPV) and final visual acuity (VA). METHODS: We retrospectively studied a series of 69 eyes from 58 patients with DME who were treated with PPV. Of the 69 eyes, 37 that were examined by optical coherence tomography (OCT) for at least 6 months and that showed a final macular thickness of less than 250 microm were included in this study. We assessed the integrity of the photoreceptor inner and outer segments (IS/OS) line in the fovea, using OCT in relation to their VA and other characteristics. RESULTS: There were no differences in initial VA or in foveal thickness between eyes with or without complete IS/OS at final observation. However, final VA without complete IS/OS was significantly poorer (P = 0.004). VA had improved by more than 2 lines in eight of ten eyes with complete IS/OS and in ten of 27 eyes without complete IS/OS; the groups differed significantly with regard to this percentage (P = 0.03). CONCLUSIONS: The postoperative photoreceptor status of the fovea is closely related to the final VA after resolution of DME by PPV.

Retinal structural changes associated with retinal arterial macroaneurysm examined with optical coherence tomography.

PURPOSE: To study the retinal structural changes associated with a retinal arterial macroaneurysm and their association with visual prognosis. METHODS: We studied retrospectively the medical records of 44 eyes of 44 patients with a retinal arterial macroaneurysm; all eyes showed hemorrhagic and/or exudative changes of the fovea with a visual disturbance. The retinal structural changes were examined by optical coherence tomography (OCT). RESULTS: At the initial visit, 30 eyes (68%) showed severe hemorrhagic complications. In eyes with subretinal hemorrhage beneath the fovea, retinal structure was relatively preserved at the initial visit. At the final visit, however, foveal structure was often degenerated, especially in its outer aspect, with limited visual recovery. The 14 eyes (32%) with minimal hemorrhagic complications showed an extensive exudative change caused by the aneurysm. In 13 of these eyes, OCT examination revealed extensive retinal edema, predominantly in the outer retina. Retinal edema beneath the fovea caused a focal serous retinal detachment in 12 eyes. Eight eyes with extensive exudative change showed an accumulation of hard exudates in the macular area, and visual recovery of these eyes was often limited. CONCLUSION: Subretinal hemorrhage or extensive exudative change from a retinal arterial macroaneurysm can cause destruction of the foveal outer photoreceptor layer, resulting in a poor visual outcome.

Spectral-domain optical coherence tomography imaging of the detached macula in rhegmatogenous retinal detachment.

PURPOSE: To assess detached macula in rhegmatogenous retinal detachment by using spectral-domain optical coherence tomography. METHODS: This retrospective study included 15 eyes of 15 patients with macula-off rhegmatogenous retinal detachment and 16 eyes of 16 patients with acute central serous chorioretinopathy. These patients were examined with a prototype spectral-domain optical coherence tomography system. RESULTS: Spectral-domain optical coherence tomography of eyes with rhegmatogenous retinal detachment revealed macular structural abnormalities, such as small cystoid cavities in the inner nuclear layer (2/15 eyes, 13%), cystoid and/or diffuse edema in the outer nuclear layer (10/15 eyes, 67%), undulations of the photoreceptor layer (7/15 eyes, 47%), and dropout of the photoreceptor inner and outer segment layers in the fovea (6/15 eyes, 40%); such changes were not seen in eyes with acute central serous chorioretinopathy. The dropout of foveal photoreceptor inner and outer segment layers was correlated with preoperative and postoperative visual acuities (rs = 0.78, P < 0.005 and rs = 0.63, P < 0.05, respectively), thickness of the outer nuclear layer at the fovea (rs = -0.69, P < 0.01), and height of the retinal detachment at the fovea (rs = 0.60, P < 0.05). CONCLUSION: Dropout of the foveal photoreceptor inner and outer segment layers seen on spectral-domain optical coherence tomography imaging may be involved in incomplete recovery of visual acuity after successful retinal reattachment surgery.

Lamellar macular hole formation in patients with diabetic cystoid macular edema.

PURPOSE: To report lamellar macular hole formation in four patients with diabetic cystoid macular edema (CME). METHODS: A review of the medical records of four patients with diabetic CME in whom lamellar macular hole formation was observed. The morphologic changes of CME, seen using optical coherence tomography (OCT), and best-corrected visual acuity were evaluated. RESULTS: Lamellar macular hole formation had occurred, as determined by slit-lamp biomicroscopy and OCT. Although the inner retinal layer had disappeared, the outer retinal layer was preserved. On OCT, the reflective line of an epiretinal membrane or a posterior hyaloid membrane was seen on the surface of juxtafoveal retina, and visual acuity remained unchanged in all four patients. CONCLUSION: In diabetic patients with CME, the CME occasionally changes spontaneously to a lamellar macular hole. Although the central cystoid space disappears and foveal thickness decreases after this transformation, visual acuity may be little affected as long as the structure of the outer retina remains intact.

Retinal sensitivity after intravitreal injection of bevacizumab for the treatment of macular edema secondary to retinal vein occlusion.

PURPOSE: To evaluate the change in macular function after intravitreal injection of bevacizumab for the treatment of macular edema associated with retinal vein occlusion. METHODS: For this interventional case series, 20 eyes of 20 patients with macular edema associated with retinal vein occlusion were treated with an intravitreal injection of bevacizumab. Microperimetry in the macular area was performed with a Micro Perimeter 1 before and at 1, 3, and 6 months after treatment. RESULTS: Improvement in macular function was detected immediately after treatment and lasted for at least 6 months. As measured by the Micro Perimeter 1, mean retinal sensitivities within the central 10 degrees field (4.9 +/- 2.7 dB at baseline) improved to 7.2 +/- 3.1 dB at 1 month, to 7.6 +/- 3.4 dB at 3 months, and to 7.7 +/- 3.9 dB at 6 months (P < 0.001). Of the 20 eyes, a recurrence of macular edema was observed in 14 (70%), but with the use of optical coherence tomography, integrity of the outer aspect of the foveal photoreceptors was detected at 3 months to 6 months in 15 (75%) eyes. CONCLUSION: In eyes with macular edema associated with retinal vein occlusion, improvement in macular function was detected immediately after intravitreal injection of bevacizumab and lasted for at least 6 months.

Evaluation of potential visual acuity in eyes with macular oedema secondary to retinal vein occlusion.

PURPOSE: To evaluate the potential visual acuity (VA) of eyes with macular oedema (MO) associated with retinal vein occlusion (RVO). METHODS: Thirty-one eyes of 31 patients with MO associated with RVO were examined and then treated with an intravitreal injection of bevacizumab. Of these 31 eyes, 22 showed complete resolution of the MO at 1 month after treatment, at which time potential VA was determined; 12 eyes had good function and 10 had poor function at this time. Optical coherence tomography was used to detect the junctions between inner and outer segments of the photoreceptors (IS/OS) as a hallmark of integrity of the outer photoreceptor layer. RESULTS: In the poor function group, pretreatment VA was significantly worse (P = 0.0106) and pretreatment central macular thickness was significantly greater (P = 0.0121). Preservation of the foveal photoreceptor layer before treatment was associated closely with good visual function after resolution of MO, and IS/OS line beneath the fovea was detected more frequently before treatment in eyes with good function (P = 0.0053). CONCLUSIONS: In eyes with MO associated with RVO, when the IS/OS line was detected beneath the fovea, they would be expected to have good vision after resolution of the MO.

[Intravitreal tissue plasminogen activator for treatment of central retinal vein occlusion associated with diabetic retinopathy].

PURPOSE: To evaluate the effects of intravitreal injection of tissue plasminogen activator (tPA) on central retinal vein occlusion(CRVO) associated with diabetic retinopathy (DR). METHODS: A retrospective study of 42 eyes of 42 patients(mean age: 68 years, female/male = 20/22, 5 eyes associated with DR) with macular edema caused by CRVO treated with tPA. Best corrected visual acuity (BVCA or logarithm of the minimal angle of resolution: logMAR), macular thickness was mea sured by optical coherence tomography (OCT), and several variables were evaluated. RESULTS: The mean logMAR and macular thickness improved significantly in the DR (-) group, but, no significant changes were observed in the DR (+) group. Post-operative posterior vitreous detachment (PVD) developed in 62% of the DR (-) group and none of the DR (+) group. CONCLUSION: There may be no beneficial effects of intravitreal tPA on CRVO associated with diabetic retinopathy.

Three-dimensional ocular endoscope system for vitrectomy.

PURPOSE: To introduce a new three-dimensional (3D) endoscope system for vitrectomy. SUBJECTS AND METHODS: We report a single-center, retrospective, consecutive surgical case series of 391 eyes that underwent 25G hybrid vitrectomy. To create 3D endoscopic images, a 3D converter HD-3D-A was connected to a monocular endoscopic system. RESULTS: The 3D endoscope system was successfully used to perform hybrid vitrectomy. No intra- or postoperative complications related to this system were encountered in any of the cases. CONCLUSION: This 3D endoscope system appears to be a valuable and promising tool for use in vitrectomy.

Updated chandelier illumination-assisted scleral buckling using 3D visualization system.

PURPOSE: To assess the updated chandelier illumination-assisted scleral buckle procedures using a 3D visualization system. SUBJECTS AND METHODS: We report a single-center, retrospective, consecutive surgical case series of 18 eyes of 16 patients that underwent scleral buckle procedures combining the use of chandelier endoillumination, a noncontact wide-angle viewing system, an anti-drying contact lens, and a recently developed 3D visualization system. The mean age of the patients was 30.2 years, and the mean follow-up time was 11.3 months. RESULTS: Retinal reattachment was achieved after the first surgery in all cases. There were no cases that required conversion of the 3D visualization to a conventional microscopic view. This updated chandelier-assisted scleral buckle procedure was successfully performed without any intraoperative or postoperative complications, except for the occurrence of postoperative diplopia in one case in which a supplementary radial buckle was used for a deep tear. CONCLUSION: The updated chandelier illumination-assisted scleral buckling surgery using a 3D visualization system appears to be a valuable and promising method for managing rhegmatogenous retinal detachment due to atrophic holes in lattice degeneration or ciliary tears in younger cases.

Erythropoietin as a retinal angiogenic factor in proliferative diabetic retinopathy.

BACKGROUND: Although vascular endothelial growth factor (VEGF) is a primary mediator of retinal angiogenesis, VEGF inhibition alone is insufficient to prevent retinal neovascularization. Hence, it is postulated that there are other potent ischemia-induced angiogenic factors. Erythropoietin possesses angiogenic activity, but its potential role in ocular angiogenesis is not established. METHODS: We measured both erythropoietin and VEGF levels in the vitreous fluid of 144 patients with the use of radioimmunoassay and enzyme-linked immunosorbent assay. Vitreous proliferative potential was measured according to the growth of retinal endothelial cells in vitro and with soluble erythropoietin receptor. In addition, a murine model of ischemia-induced retinal neovascularization was used to evaluate erythropoietin expression and regulation in vivo. RESULTS: The median vitreous erythropoietin level in 73 patients with proliferative diabetic retinopathy was significantly higher than that in 71 patients without diabetes (464.0 vs. 36.5 mIU per milliliter, P<0.001). The median VEGF level in patients with retinopathy was also significantly higher than that in patients without diabetes (345.0 vs. 3.9 pg per milliliter, P<0.001). Multivariate logistic-regression analyses indicated that erythropoietin and VEGF were independently associated with proliferative diabetic retinopathy and that erythropoietin was more strongly associated with the presence of proliferative diabetic retinopathy than was VEGF. Erythropoietin and VEGF gene-expression levels are up-regulated in the murine ischemic retina, and the blockade of erythropoietin inhibits retinal neovascularization in vivo and endothelial-cell proliferation in the vitreous of patients with diabetic retinopathy in vitro. CONCLUSIONS: Our data suggest that erythropoietin is a potent ischemia-induced angiogenic factor that acts independently of VEGF during retinal angiogenesis in proliferative diabetic retinopathy.

Three-dimensional imaging of cystoid macular edema in retinal vein occlusion.

OBJECTIVE: To study the pathomorphologic features of cystoid macular edema (CME) associated with retinal vein occlusion by three-dimensional (3D) optical coherence tomography (OCT) and to study the relationship of the ocular findings to visual function. DESIGN: Observational case series. PARTICIPANTS: Twenty eyes of 20 patients with retinal vein occlusion. METHODS: A prototype 3D OCT system based on Fourier-domain OCT technology was fabricated for patient examination in this study. This system uses a superluminescent diode, which has a center wavelength of 830 nm and a bandwidth of 50 nm, as the light source, resulting in 4.3-microm axial resolution in tissue. Data acquisition rates of approximately 18 700 axial scans per second and a sensitivity of 98 dB were achieved. Three-dimensional imaging was performed by volume rendering based on the 3D data set acquired with a raster scan of 256x256 axial scans. MAIN OUTCOME MEASURES: Images of CME pathologic features obtained by 3D OCT and by Stratus OCT (Carl Zeiss, Dublin, CA). RESULTS: The 3D OCT imaging system generates a realistic 3D image of CME with high resolution. In 16 eyes, 3D OCT showed large foveal cystoid spaces, most of which were accompanied by small cystoid spaces in the parafoveal region. Cystoid spaces were seen often in the inner nuclear layer and outer plexiform layer, but were detected to some extent in all retinal layers. The 3D OCT showed clearly a thin back-reflecting line corresponding to the external limiting membrane (ELM) in 18 eyes; of these, cystoid spaces were located on the inside of the ELM in 7 eyes and appeared to be in contact with the ELM in 9 eyes. In 2 eyes, the ELM line could not be seen clearly beneath the large foveal cystoid spaces. Integrity of the ELM in the foveal region had a direct correlation with visual acuity. CONCLUSIONS: Observation of CME using 3D OCT enabled visualization of its spatial extent in each retinal layer and discernment of its relationship to the ELM. The use of 3D OCT thus may improve the monitoring of CME progression and its response to treatment.