Spontaneous reattachment of dislocated endothelial graft after non-Descemet stripping automated endothelial keratoplasty: a case report.

BACKGROUND: Graft detachment is a complication of non-Descemet stripping automated endothelial keratoplasty (nDSAEK). We report a case of spontaneous reattachment of an extensively dislocated graft after nDSAEK. CASE PRESENTATION: A 54-year-old male underwent penetrating keratoplasty (PKP) for keratoconus in his left eye in 2001. Following graft opacity due to rejection, a second PKP was implemented in May 2014. The graft was kept in good condition after the reoperation and yet, visual acuity (VA) declined due to cataract. PEA+IOL was then performed in May 2015. Because edema appeared in the graft 6 months after the PEA+IOL, nDSAEK was carried out in May 2016. Although the donor graft well attached immediately after the nDSAEK, the graft was almost completely dislocated 3 h later except a temporal part. Air was reinjected into the anterior chamber on the following day and the detachment was resolved. Despite of the treatment, about 1/5 of the graft remained detached and the detachment deteriorated to 3/4 of the graft 9 days later. Because the patient could not decide whether to undergo another operation immediately, we decided to follow him up first and found that the partially detached graft reattached spontaneously 1 month later during the follow-up. Although the cornea had a mild edema remaining in the superior temporal area, his BCVA improved to 1.0. Three months later, the graft remained in position and the cornea kept its transparency. CONCLUSIONS: Spontaneous reattachment was observed during the follow-up in a case that had shown a comparatively extensive graft dislocation after nDSAEK.

Enhancement in Corneal Permeability of Dissolved Carteolol by Its Combination with Magnesium Hydroxide Nanoparticles.

We prepared magnesium hydroxide (MH) nanoparticles, and investigated their effect when combined with dissolved carteolol on the bioavailability and intraocular pressure (IOP)-reducing effect of carteolol. The carteolol was solved in saline containing additives (0.5% methylcellulose, 0.001% benzalkonium chloride, 0.5% mannitol; CRT-solution). MH nanoparticles were prepared by a bead mill method with additives. Then carteolol/MH microparticle and carteolol/MH nanoparticle fixed combinations (mCMFC and nCMFC) were prepared by mixing the CRT-solution and MH particles. The transcorneal penetration and IOP-reducing effect of carteolol was evaluated in rabbits. The mean particle size of mCMFC was 7.2 µm, and the particle size was reduced to 73.5-113.5 nm by the bead mill treatment. The MH particles in nCMFC remained in the nano size range for 8 days after preparation, and the amounts of lacrimal fluid and corneal damage were unchanged by repetitive instillation of nCMFC (twice a day for 4 weeks). The transcorneal penetration of carteolol was enhanced by the combination with MH nanoparticles, and the IOP-reducing effect of nCMFC was significantly higher than that of CRT-solution or mCMFC. In conclusion, we designed nCMFC, and showed that the high levels of dissolved carteolol can be delivered into the aqueous humor by the instillation of nCMFC. Combination with MH nanoparticles may achieve an enhancement of corneal penetration for water-soluble drugs. These findings provide significant information that can be used to design further studies aimed at developing anti-glaucoma eye drugs.

Instillation of Sericin Enhances Corneal Wound Healing through the ERK Pathway in Rat Debrided Corneal Epithelium.

Sericin is a major constituent of silk produced by silkworms. We previously found that the instillation of sericin enhanced the proliferation of corneal epithelial cells, and acted to promote corneal wound healing in both normal and diabetic model rats. However, the mechanisms by which sericin promotes the proliferation of corneal cells have not been established. In this study, we investigated the effects of sericin on Akt and ERK activation in a human corneal epithelial cell line (HCE-T cells) and rat debrided corneal epithelium. Although Akt phosphorylation was not detected following the treatment of HCE-T cells with sericin, ERK1/2 phosphorylation was enhanced. The growth of HCE-T cells treated with sericin was significantly increased, with the cell growth of sericin-treated HCE-T cells being 1.7-fold higher in comparison with vehicle-treated HCE-T cells. On the other hand, both of an ERK inhibitor U0126 (non-specific specific inhibitor) and SCH772984 (specific inhibitor) attenuated the enhanced cell growth by sericin, and the growth level in the case of co-treatment with sericin and ERK1/2 inhibitor was similar to that of cells treated with ERK1/2 inhibitor alone. In an in vivo study using rat debrided corneal epithelium, the corneal wound healing rate was enhanced by the instillation of sericin, and this enhancement was also attenuated by the instillation of U0126. In addition, the corneal wound healing rate in rats co-instilled with sericin and U0126 was similar to that following the instillation of U0126 alone. In conclusion, we found that the instillation of sericin enhanced cell proliferation via the activation of the MAPK/ERK pathway, resulting in the promotion of corneal wound healing in rat eyes. These findings provide significant information for designing further studies to develop potent corneal wound-healing drugs.

Identification of vitreous proteins in retinopathy of prematurity.

Retinopathy of prematurity (ROP) is a disorder of blood vessels in the retina developed in premature infants and the leading cause of the blindness in children. Proteomic analysis was performed to identify vitreous proteins specific to patients with ROP. Vitreous humor samples were obtained from three patients with ROP and two patients with congenital cataract, the latter included as a control group. The vitreous samples were separated by 2D-PAGE and the proteins running as definitive spots were identified by MALDI-TOF MS spectrometry. We identified 13 and 6 proteins in the vitreous from ROP and cataract patients, respectively. Albumin, transferrin, pigment epithelium-derived factor (PEDF) and transthyretin were found in both patient groups. In the samples from ROP patients, PEDF and transthyretin levels were lower than in those from cataract patients, and retinol binding protein 3 and prostaglandin D synthase were not detected. Of the 13 proteins, 9 proteins including α-2-macroglobulin, ceruloplasmin, α-fetoprotein, vitamin D-binding protein, α-1-antitrypsin, α-1-ß-glycoprotein, hemopexin, apolipoprotein A-1 and A-lV were found in vitreous samples of only the ROP patients. PEDF has anti-angiogenic and neurotrophic functions. Whether PEDF is increased or decreased in diabetic retinopathy has been controversial but we observed lower PEDF in the ROP samples than in the controls. The proteins specific to or decreased in ROP, if confirmed in future studies, may provide clue to understanding its pathogenesis.

Co-instillation of nano-solid magnesium hydroxide enhances corneal permeability of dissolved timolol.

We prepared magnesium hydroxide (MH) nanoparticles by a bead mill method, and investigated whether the co-instillation of MH nanoparticles improves the low transcorneal penetration of water-soluble drugs, such as the anti-glaucoma eye drug timolol maleate (TM). MH particle size was decreased by the bead mill treatment to a mean particle size of 71 nm. In addition, the MH nanoparticles were highly stable. Next, we demonstrated the effect of MH nanoparticles on the corneal surface. MH shows only slight solubility in lacrimal fluid, and the instillation of MH nanoparticles for 14 days did not affect the behavior (balance of secretion and excretion) of the lacrimal fluid in rabbit corneas. Moreover, there was no observable corneal toxicity of MH nanoparticles, and treatment with MH nanoparticles enhanced the intercellular space ratio in the eyes of rats. MH alone did not permeate into the cornea; however, the co-instillation of MH nanoparticles and dissolved TM (nMTFC) enhanced the corneal penetration of TM. In addition, the intraocular pressure (IOP)-reducing effect of nMTFC was significantly higher than those of the TM solution or the co-instillation of MH microparticles and TM. In conclusion, we found that MH nanoparticles enhance the corneal penetration of dissolved TM with no observable corneal stimulation or obstruction of the nasolacrimal duct by the MH nanoparticles. It is possible that the co-instillation of MH nanoparticles may provide a useful way to improve the bioavailability of water-soluble drugs in the ophthalmic field. These findings provide significant information that can be used to design further studies aimed at developing anti-glaucoma eye drugs.

A super-infection in the cornea caused by Stemphylium, Acremonium, and α-Streptococcus.

BACKGROUND: Polymicrobial keratitis with fungus and bacteria can lead to blindness and is challenging to treat. Here, we introduce a case of fungal keratitis caused by two different strains in addition to definite bacterial super-infection caused by an α-Streptococcus sp., and describe the importance of microscopic examination. CASE PRESENTATION: A 74-year-old woman, who had a past history of infection with leprosy, presented with conjunctival hyperaemia, pain, and corneal opacity in her right eye. Under the presumptive diagnosis of infectious keratitis, corneal scrapings were stained by various reagents and inoculated on several agar plates. Microscopic findings of the scrapings revealed fungi and a small number of Gram-positive cocci. Multiple anti-fungal therapies with levofloxacin ophthalmic solution were administered. Although empiric treatment was initially effective, keratitis recurred 10 days after its initiation. Repeated corneal scraping revealed an abundance of Gram-positive chain cocci and a small amount of fungi, resulting in the switching of an antibiotic medication from levofloxacin to moxifloxacin and cefmenoxime. Keratitis resolved gradually after the conversion. Stemphylium sp., Acremonium sp., and α-Streptococcus sp. were simultaneously isolated from the corneal scrapings. CONCLUSIONS: To the best of our knowledge, this is the first case of fungal keratitis caused by Stemphylium sp., and also the first case of super-infection in the cornea caused by two different fungi and one bacterium. Microscopic examination of the corneal scrapings was beneficial in rapid decision of changing to appropriate drug according to the dominancy of pathogenicity.

A Nanoparticle-Based Ophthalmic Formulation of Dexamethasone Enhances Corneal Permeability of the Drug and Prolongs Its Corneal Residence Time.

We designed ophthalmic formulations containing dexamethasone-loaded solid nanoparticles (DEXnano dispersion), and investigated corneal permeability and toxicity. 0.1% dexamethasone (DEX) powder (DEX microparticles), 0.026% methyl p-hydroxybenzoate (MP), 0.014% propyl p-hydroxybenzoate (PP), and 0.5% methylcellulose were used, and the DEXnano dispersion was prepared by the bead mill method. The mean particle size of DEXnano dispersion was 78 nm. Antimicrobial activity of the DEXnano dispersion were measured by using Escherichia coli, and the corneal epithelium-debrided rat model and HCE-T cells (immortalized human corneal epithelial cell line) were used to estimate the corneal toxicity. The transcorneal penetration of the DEXnano dispersion were evaluated in the corneas of rabbit. The DEXnano dispersion was found to be highly stable until 14 d after its preparation. Although DEX itself did not exhibit antimicrobial activity, the DEXnano dispersion containing parabens (MP and PP) showed high antimicrobial activity, approximately equal to that of the solution containing parabens without DEX. The corneal penetration rate (Jc) and mean residence time (MRT) of DEX from the DEXnano dispersion were approximately 5.1- and 1.3-fold higher, respectively, than those of a dispersion containing DEX microparticles (mean particle size, 11.3 µm). In addition, no significant difference was found in corneal stimulation between the vehicle and DEXnano dispersion. In conclusion, we successfully prepared high quality dispersion containing DEX solid nanoparticles, and the nanoparticle-based ophthalmic formulation of DEX enhanced the corneal permeability and residence time of the drug. It is possible that DEXnano dispersion will show increased effectiveness in treating ocular inflammation.

Cosmetic Cleansing Oil Absorption by Soft Contact Lenses in Dry and Wet Conditions.

OBJECTIVES: Previous reports showed that cosmetic cleansing oil for removing makeup, which contains mineral oil and surfactant, can deform some silicone hydrogel contact lenses (SHCLs) when applied directly to the lenses, although plasma-coated SHCLs (lotrafilcon A and B) were not affected. In the present study, we investigated hydrogel lenses and SHCLs in both wet and dry conditions. METHODS: Several brands of hydrogel and SHCLs were immersed in a cleansing oil solution containing Sudan Black B for 5 min under wet and dry conditions. The lenses under the wet condition were simply picked up from the saline, whereas those under the dry condition were blotted with paper wipes. After immersing, the excess solution remaining on the lenses was removed by finger rubbing with a multipurpose solution. The lenses were then examined using a stereomicroscope, and their mean brightness was measured and compared. RESULTS: The cosmetic cleansing oil was not absorbed by the hydrogel lenses under wet or dry conditions. However, four of seven brands of SHCLs absorbed the cosmetic cleansing oil under both conditions (dry and wet), whereas asmofilcon A absorbed it only under the dry condition. Lotrafilcon B and delefilcon A did not absorb cleansing oil even under the dry condition. CONCLUSIONS: Hydrogel lenses resist cosmetic cleansing oil. However, SHCLs have different degrees of resistance depending on the lens material. Some SHCLs absorbed cosmetic cleansing oil more under dry conditions than under wet conditions.

Intraoperative optical coherence tomography (RESCAN® 700) for detecting iris incarceration and iridocorneal adhesion during keratoplasty.

There is no report focusing on the visualization of the iris incarceration or the iridocorneal adhesion during keratoplasty by use of microscope-integrated intraoperative optical coherence tomography (MIOCT). The purpose of this study is to report the usefulness of MIOCT for detecting iris incarceration and iridocorneal adhesions during penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK). MIOCT system was applied both in a patient who underwent PK for corneal leukoma and in a patient who underwent DALK for keratoconus. During the surgeries, we obtained cross-sectional images around the host-graft interface by operating the foot switch of microscope without discontinuing the surgical procedure. Intraoperative MIOCT findings and postoperative outcomes were examined. An iris incarceration at the host-graft interface was visualized during surgery after corneal suture in PK, which allowed surgeons to return the iris to its original position instantly. In DALK, misdirected air into the posterior chamber could also be seen at the end of the DALK. This iridocorneal adhesion was resolved by fluid injection through paracentesis. Secondary glaucoma and graft rejection have not occurred postoperatively in both cases. The MIOCT system provides advantages such as prevention of secondary glaucoma and rejection following PK and DALK.

Size effect of rebamipide ophthalmic nanodispersions on its therapeutic efficacy for corneal wound healing.

In a variety of tissues including gastrointestinal mucosa, rebamipide (REB) provides cytoprotection, prevents inflammation, and promotes wound healing. Clinically, REB ophthalmic dispersions are used to treat diabetic keratopathy. In this study, we investigated the optimal particle size of REB to promote corneal wound healing using a model of diabetic keratopathy, the debrided corneal epithelium from Otsuka Long-Evans Tokushima Fatty (OLETF) rats. First, we prepared three dispersions with different REB particle sizes (REB735, REB150, REB45) by treatment with zirconia beads and Bead Smash 12 (a bead mill). The mean particle sizes of the REB735, REB150, REB45 dispersions were approximately 735 nm, 150 nm and 45 nm, respectively. Next, we measured the amounts of REB in the corneal and conjunctival tissues of rats following the instillation of the REB dispersions. The amounts of REB in the corneal and conjunctival tissues following the instillation of REB dispersions was increased by using the mill method, and the amount of REB in rats instilled with the REB150 dispersion was significantly higher than in rats instilled with the REB45 dispersion. Moreover, the corneal wound healing rate for rats instilled with the REB150 dispersion was significantly higher than for rats instilled with the REB735 or REB45 dispersions. In addition, these REB dispersions enhanced corneal epithelial cell growth, resulting an enhancement of corneal wound healing rate. Thus, we found that the ocular drug accumulation and therapeutic effect on corneal wound healing of REB dispersions is enhanced by preparing particles with a size of ca. 150 nm. These findings provide significant information that can be used to design further studies aimed at developing ophthalmic dispersions.

[Multicenter Prospective Observational Study of Fungal Keratitis--Identification and Susceptibility Test of Fungi].

PURPOSE: To investigate the causative fungi of fungal keratitis in Japan and their drug susceptibility. METHODS: Identification and antifungal susceptibility test for 8 drugs (micafungin, amphotericin B, flucytosine, fluconazole, itraconazole, voriconazole, miconazole and pimaricin) were performed using isolated fungi from patients with fungal keratitis treated at 27 facilities in Japan between November 1, 2011 and October 31, 2013. RESULTS: Fungal strains were detected in 72 (50.7%) out of 142 samples. The major isolates were Fusarium spp. (18), Candida parapsilosis (12), C. albicans (11) and Alternaria spp. (6), in all, fungi of 31 species were identified by gene analysis. In the yeast-like fungi, susceptibility rates were evident for more than 80% in voriconazole, pimaricin, flucytosine, micafungin, amphotericin B and fluconazole. In filamentous fungi, the susceptibility rate was less than 50% except for PMR (90%). Fusarium spp., which were susceptible to amphotericin B and pimaricin, showed lower susceptibility rates compared with other genera. CONCLUSIONS: Although various genera and species of fungi cause fungal keratitis, the obtained drug susceptibility data in this study demonstrates the different susceptibility patterns among the major isolates (Fusarium spp., C. parapsilosis, C. albicans and other groups). This is important evidence useful for fungal keratitis treatment.

[Multicenter Prospective Observational Study of Fungal Keratitis--Current Status of Patients' Background, Clinical Findings, Treatment and Prognosis].

PURPOSE: To investigate the current status of fungal keratitis in Japan. METHODS: The patients with fungal keratitis were examined at 27 facilities in Japan from November 1st 2011 to October 31st 2013, concerning isolates, patient background, clinical findings, treatment and prognosis. RESULTS: Out of 139 cases, 133 were diagnosed as fungal keratitis, of which fungi were isolated from 72 samples of 71 cases (yeast-like fungi 32 strains and filamentous fungi 40 strains). The corrected visual acuity at the first visit of 88 cases (66.2%) was less than 20/200 and 42 cases (31.6%) were involved with deep stromal lesions, indicating high proportion of severe cases in this study. Three months later, 56 cases (42.1%) were still under treatment, and corrected visual acuity of 57 cases (42.9%) was less than 20/200. In cases with yeast-like fungi, there were significantly more cases with past history of corneal diseases, ocular surgery including keratoplasty, and eye drops' use such as steroids than those with filamentous fungi. On the other hand, there were significantly more cases of filamentous fungi, with trauma on the onset and with intervention of previously attending doctors than those with yeast-like fungi. Logistic regression analyses revealed that contact lens wearing was a significant factor of good prognosis, and yeast-like fungi as one of poor outcome compared with no fungal isolation. CONCLUSION: Although the choice of antifungal drugs has been increasing, fungal keratitis is still severe, refractory and vision-threatening disease.

Long-lasting, dense scotoma under light-adapted conditions in patient with multiple evanescent white dot syndrome.

To report the light- and dark-adapted perimetric findings in a patient with multiple evanescent white dot syndrome (MEWDS). The patient was a 25-year-old Japanese woman who underwent comprehensive ophthalmological examinations including measurements of the visual acuity, dilated ophthalmoscopy, Goldmann kinetic perimetry, electroretinography (ERG), indocyanine green fundus angiography (ICGA), and optical coherence tomography (OCT). Kinetic perimetry was performed under light- and dark-adapted conditions. The patient was diagnosed with MEWDS by the fundus and visual field findings, and the ICGA abnormalities. Light-adapted perimetry showed an enlargement of the blind spot; however, the size of the blind spot was normalized with dark-adaptation. Amplitude of cone ERG was more reduced than that of rod ERG in the affected eye. The OCT images showed multiple disruptions of the ellipsoid and interdigitation zones. These abnormalities were still present 9 months after the onset although the fundus appeared normal. These findings indicate a persistent cone-dominated dysfunction in a patient with MEWDS.

A nanoparticle formulation of disulfiram prolongs corneal residence time of the drug and reduces intraocular pressure.

The goal in the search for successful therapies for glaucoma is the reduction of intraocular pressure (IOP), and the search for effective eye drops that reduce IOP is a high priority. We previously reported the potential of a 2-hydroxypropyl-ß-cyclodextrin (HPßCD) solution containing 0.5% DSF (DSF solution) to provide effective anti-glaucoma treatment in eye drop form. In this study, we designed new ophthalmic formulations containing 0.5% DSF nanoparticles prepared by a bead mill method (DSFnano dispersion; particle size 183 ± 92 nm, mean ± S.D.), and compared the IOP-reducing effects of a DSFnano dispersion with those of a DSF solution. The high stability of the DSFnano dispersion was observed until 7 days after preparation, and the DSFnano dispersion showed high antimicrobial activity against Escherichia coli (ATCC 8739). In transcorneal penetration experiments using rabbit corneas, only diethyldithiocarbamate (DDC) was detected in the aqueous humor, while no DSF was detected. The DDC penetration level (area under the curve, AUC) and corneal residence time (mean residence time, MRT) of the DSFnano dispersion were approximately 1.45- and 1.44-fold higher than those of the DSF, respectively. Moreover, the IOP-reducing effects of the DSFnano dispersion were significantly greater than those of the DSF solution in rabbits (the IOP was enhanced by placing the rabbits in a dark room for 5 h). In addition, DSFnano dispersion are tolerated better by a corneal epithelial cell than DSF solution and commercially available timolol maleate eye drops. It is possible that dispersions containing DSF nanoparticles will provide new possibilities for the effective treatment of glaucoma, and that an ocular drug delivery system using drug nanoparticles may expand their usage as therapy in the ophthalmologic field. These findings provide significant information that can be used to design further studies aimed at developing anti-glaucoma drugs.

Reduced rod electroretinograms in carrier parents of two Japanese siblings with autosomal recessive retinitis pigmentosa associated with PDE6B gene mutations.

PURPOSE: To present the clinical and genetic findings in two siblings with autosomal recessive retinitis pigmentosa (RP) and their non-symptomatic parents. METHODS: We studied two siblings, a 48-year-old woman and her 44-year-old brother, and their parents. They had general ophthalmic examinations including ophthalmoscopy, perimetry, and electroretinography (ERG). Their whole exomes were analyzed by the next-generation sequence technique. RESULTS: The two siblings had night blindness for a long time, and clinical examinations revealed diffuse retinal degeneration with bone spicule pigmentation, constriction of the visual field, and non-recordable ERGs. Their parents were non-symptomatic and had normal fundi; however, their rod ERGs were reduced. Genetic examination revealed compound heterozygous mutations of I535N and H557Y in the PDE6B gene in the siblings, and the parents were heterozygous carriers of the mutations. CONCLUSIONS: Heterozygous mutation in the PDE6B gene can cause a reduction in the rod function to different degrees. The retinal function of non-symptomatic carriers of autosomal recessive RP should be evaluated with care.

Novel nonsense and splice site mutations in CRB1 gene in two Japanese patients with early-onset retinal dystrophy.

PURPOSE: To report novel mutations in the CRB1 gene in two patients with early-onset retinal dystrophy (EORD) and the longitudinal clinical course of EORD. PATIENTS AND METHODS: The patients were two unrelated Japanese children. Standard ophthalmic examinations including perimetry, electroretinography, and optical coherence tomography were performed on both patients. Whole exomes of the patients and their nonsymptomatic parents were analyzed using a next-generation sequence (NGS) technique. RESULTS: Patient 1 was noted to have esotropia and hyperopia at age 3. His decimal best-corrected visual acuity (BCVA) was 0.6 OD and 0.3 OS at age 6 with de-pigmentation of the retinal pigment epithelium (RPE). At age 19, his central vision was still preserved; however, numerous pigment granules were present in the retina. NGS analysis revealed a p.R632X nonsense and c.652 + 1_652 + 4delGTAA splice site mutations in the CRB1 gene. Patient 2 was noted to have hyperopia at age 3. His decimal BCVA at age 6 was 0.3 OD and 0.4 OS with de-pigmented RPE. The degree of retinal pigmentation was increased but his BCVA was good until the age of 14 years. NGS analysis revealed c.652 + 1_652 + 4delGTAA and c.652 + 1_652 + 2insT splice site mutations in the CRB1 gene. CONCLUSIONS: The phenotypes of these novel mutations for EORD are typical of CRB1-associated EORD (LCA8). They were slowly progressive until the second decade of life.

Hypercalcemia Leads to Delayed Corneal Wound Healing in Ovariectomized Rats.

Hypercalcemia is often observed in postmenopausal women as well as in patients with primary hyperparathyroidism or malignant tumors. In this study, we investigated the relationship between calcium ion (Ca(2+)) levels in lacrimal fluid and the rate of corneal wound healing in hypercalcemia using ovariectomized (OVX) rat debrided corneal epithelium. We also determined the effects of Ca(2+) levels on cell adhesion, proliferation and viability in a human cornea epithelial cell line (HCE-T). The calcium content in bones of OVX rats decreased after ovariectomy. Moreover, the Ca(2+) content in the blood of OVX rats was increased 1 month after ovariectomy, and decreased. The Ca(2+) content in the lacrimal fluid of OVX rats was also increased after ovariectomy, and then decreased similarly as in blood. Corneal wound healing in OVX rats was delayed in comparison with Sham rats (control rats), and a close relationship was observed between the Ca(2+) levels in lacrimal fluid and the rate of corneal wound healing in Sham and OVX rats (y=-0.7863x+8.785, R=0.78, n=25). In addition, an enhancement in Ca(2+) levels caused a decrease in the viability in HCE-T cells. It is possible that enhanced Ca(2+) levels in lacrimal fluid may cause a decrease in the viability of corneal epithelial cells, resulting in a delay in corneal wound healing. These findings provide significant information that can be used to design further studies aimed at reducing corneal damage of patients with hypercalcemia.

[Battle with herpes for 37 years].

Herpes simplex virus type 1(HSV-1) remains latent in the human trigeminal ganglion after primarily infecting the cornea and conjunctiva. Mental stress, heat stimulation, ultraviolet ray and immunosuppression are among the reactivating factors of HSV-1, which can lead to epithelial herpetic keratitis, stromal herpetic keratitis, and other complications. I have been working with HSV-1 for a long time, concentrating especially on its latency and reactivation. I would like to introduce some of the recent research results. 1. Herpetic keratitis cases at the Department of Ophthalmology, Kinki University. There were 129 eyes of 128 patients who visited the Cornea Service in our university hospitals at Osayasayama, Sakai and Nara over 13 years and were diagnosed with herpetic keratitis and followed up for at least one year. They were investigated as to the type of herpetic keratitis at the initial visit and its recurrence. Initial types of herpetic keratitis and number of eyes of each type were: Epithelial type, 65 eyes (50%); Stromal type, 30 eyes (23%); Combined epithelial and stromal types, 18 eyes (14%). Recurrence was seen in 47% of the total 129 eyes. Recurrent cases of the epithelial type were mostly epithelial type. Frequently recurrent cases of the stromal type presented with repeated epithelial, stromal, and combined types. 2. Effects of antiherpetics on mouse epithelial herpetic keratitis. Acyclovir (ACV) eye ointment is usually prescribed for several weeks to treat human epithelial herpetic keratitis. Our question is: Is this long administration really necessary? To find the answer to this question, we investigated time-dependent effects of antiherpetics on mouse epithelial herpetic keratitis. Mouse corneas were infected with HSV-1 and either ACV eye ointment, oral valaciclovir (VACV) or oral famciclovir (FCV) was administered. No virus was detected in the tear fluid examined by viral culture 4 days after start of ACV eye ointment or oral VACV and 6 days after start of oral FCV. Real-time PCR revealed significant decrease of HSV DNA copy number in the eyeball or trigeminal ganglion compared to saline instillation 4 and 6 days after start. These results suggest that antivirals for 5 days could sufficiently decrease the HSV amount in the ocular surface and eyeball. 3. Corneal latency. In order to prove latency of HSV in the human cornea, virological and molecular biological techniques were used to ensure the following 3 prerequisites. 1) Positive HSV DNA in the human cornea. 2) Negative homogenate, positive explant. 3) Only latency-associated transcript (LAT) detected and transcriptional products of other virus genes (α, ß, γ) not detected in the cornea. As a result, all the 3 prerequisites have been satisfied in the 3 corneas that had a past history of herpetic keratitis. This result suggests that HSV could remain latent in the human cornea. 4. Detection of HSV-1, HHV-6, and HHV-7 DNA in the anterior segment and aqueous humor using multiplex real-time PCR. Multiplex real-time PCR was applied for the first time ever in opththalmology to human herpes virus 6 (HHV-6) and 7(HHV-7). Samples taken from tear fluid before and 3 days after phacoemulsification and aspiration (PEA) or penetrating keratoplasty (PKP), and aqueous humor aspirated during PEA were used. The results of multiplex real-time PCR showed HSV-1, HHV-6 and HHV-7 DNA present in tear fluid both before and after PEA or PKP. 5. Gene expression when reactivation is suppressed. Nuclear factor-κB (NF-κB) has recently been reported to be involved in reactivation of HSV-1. IkappaB kinase-ß (IKK2) inhibitors, which inhibit the activity of NF-κB, were used to examine gene expression during HSV reactivation in a mouse model. Significant decrease of HSV DNA copy number was observed at the trigeminal ganglion with real-time PCR in a group which was given IKK2 inhibitors intraperitoneally. Microarray method demonstrated 2-fold or more increased expression of 1812 probe. By Pathway analysis, eased immunosuppressive effects were observed in the group which was given IKK2 inhibitor intraperitoneally. 6. Immunoresponse involved in herpetic keratitis. Chemokine expression profiles in human corneal herpetic cases and mouse herpetic keratitis were analyzed. The results were similar to previously published reports: Cxcl9, Cxcl10, Ccl5, which are Th1 type chemokines, and Ccl20, a Th17 type chemokine, were observed to increase. On the other hand, Th2 type chemokine did not show an increase. Immunoresponse occurred mainly in the trigeminal ganglion. With these results, we suggest herpetic keratitis could be prevented by actively inducing Th17 type immunoresponse.

Longitudinal clinical course of three Japanese patients with Leber congenital amaurosis/early-onset retinal dystrophy with RDH12 mutation.

PURPOSE: To report the longitudinal clinical course of three Japanese patients from two families with Leber congenital amaurosis/early-onset retinal dystrophy (LCA/EORD), and the results of next-generation DNA sequences on them. PATIENTS AND METHODS: The patients were three Japanese children: a 4-year-old girl, a 6-year-old boy, and a 3-year-old girl. Patients 1 and 2 were siblings, and patient 3 was from an unrelated family. Standard ophthalmic examinations including perimetry, electroretinography, optical coherence tomography, and ultrasonography were performed on each patient. The patients were observed for 28, 16, and 10 years. Whole exomes of the patients and their non-symptomatic parents were analyzed using a next-generation sequence technique. RESULTS: The decimal visual acuity varied between 0.07 and 0.6 at the initial visit and decreased to counting finger to hand motion in their teens. Funduscopy showed diffuse retinal and macular degeneration. During the follow-up period, a posterior staphyloma developed and the macular area became atrophic. Patient 1 developed cataracts in her early twenties. Genetic analysis revealed a homozygous A126V substitution in the RDH12 gene in all patients. CONCLUSIONS: The three patients with LCA/EORD had a progressive decrease of their vision with the formation of a posterior staphyloma. This is the first report of Japanese patients with LCA/EORD with a RDH12 mutation.

Combined treatment for Coats' disease: retinal laser photocoagulation combined with intravitreal bevacizumab injection was effective in two cases.

BACKGROUND: The exact pathogenetic mechanisms of Coats' disease remain unknown. In this report, we show two cases of Coats' disease that achieved a favorable prognosis with the combined treatment of intravitreal bevacizumab (IVB) injection prior to photocoagulation, although both initially resisted photocoagulation therapy. CASE PRESENTATIONS: Case 1 was a 15-year-old boy with initial visual acuity of 0.4 OD. At the temporal retina, aneurysms and abnormal telangiectatic vessels were observed. Hard exudates and an exudative retinal detachment extended to the fovea. He was diagnosed as having Coats' disease at stage 3A and we performed laser photocoagulation as an initial approach to treat peripheral aneurysms and telangiectatic vessels. After the treatment, the exudative retinal detachment was eased and visual acuity improved to 1.0; however, recurrence occurred after 5 months. The exudative change was resistant against laser photocoagulation therapy and we therefore added IVB as an adjuvant before photocoagulation. Fourteen days after IVB injection phased laser photocoagulation was given to cover the abnormal capillaries, aneurysms and the leakage area spotted in FA. A good prognosis was obtained with decreased exudation and improved visual acuity.Case 2 was an 11-year-old boy with decreased visual acuity of 0.15 OS at the initial visit. Hard exudates, retinal edema and serous retinal detachment were seen at the macula and peripheral retina. Fluorescein angiography revealed telangiectatic capillaries at the temporal retina. Our diagnosis was Coats' disease at stage 3A. Extensive photocoagulation was performed as an initial treatment to the lesion. However, the exudative change was severe and resistant against the photocoagulation treatment. Therefore, we added IVB as an adjuvant before photocoagulation. Exudative change in the retina seemed to be eased 7 days after IVB injection, therefore, phased laser phototherapy was added to cover the abnormal capillaries. After the combination therapy, exudative change was remarkably ameliorated and better visual acuity was achieved. CONCLUSION: Bevacizumab is considered an effective adjuvant for Coats' disease with exudative change resistant to retinal photocoagulation therapy.