A case of persistent hypotony following 23-gauge vitrectomy.

We report here a case in which ciliary detachment related to the preparation of a scleral wound was suspected as the cause of persistent hypotony following 23-gauge vitrectomy for proliferative diabetic retinopathy. Ultrasound biomicroscopy (UBM) was performed following injection of a viscoelastic substance into the anterior chamber to carefully investigate the treatment and cause of persistent hypotony. Deepening the anterior chamber by means of the viscoelastic substance enabled UBM identification of ciliary detachment that had not been detected in the shallow anterior chamber. The extent of ciliary detachment was approximately 8 degrees; however, the detachment could not be seen on gonioscopy. UBM showed no continuity between the anterior chamber and choroid, with findings suggesting that the two structures had been split by posterior traction. The ciliary detachment site was the same site at which a three-port system had been prepared. One advantage of a 23-gauge system is that few complications are associated with the insertion and retraction of instruments. However, the difference in level between the cannula and trocar may result in ciliary detachment even if no resistance is felt when the trocar is inserted.

Progression of cataracts following photodynamic therapy combined with intravitreous triamcinolone injection in cases of age-related macular degeneration.

BACKGROUND: To present long-term data on the progression of cataracts following photodynamic therapy (PDT) combined with 4 mg intravitreal triamcinolone acetonide (IVTA) for age-related macular degeneration (AMD). METHODS: Fifty-seven phakic eyes of 56 patients underwent the treatment between October 2004 and November 2006. The follow-up period ranged from 12 to 38 months with 3 months interval of observation and repeated treatment at recurrence. RESULTS: Cataract progression was noted in 40 eyes 5-21 months after treatment, consisting of 4 eyes between 3 and < 6 months after treatment, 22 eyes between 6 and < 12 months, 8 eyes between 12 and < 18 months, and 6 eyes between 18 and < 24 months. The percentage of the eyes with cataract progression began to decrease 5 months after treatment and, occurred most frequently during the period from 6 months to 12 months after treatment. There was no significant difference in age, follow-up period, or the frequency of the treatment between the cataract progression group and the non progression group. Twenty four eyes underwent surgery 10-31 months after treatment, showing significant improvement in visual acuity. CONCLUSIONS: This study showed high incidence of cataract during a long-term follow-up after PDT combined with IVTA and significant reduction of visual acuity due to cataract.

A Dynamic Costal Cartilage Platform Promotes Ocular Prosthetic Excursion: Preliminary Report.

The quality of life of the face involves mainly its configuration, and it plays an important functional role in communication skills. Thus, having artificial eyes is extremely essential in maintaining the quality of life of patients who have lost their eyeballs. We will present the details of the technique, including tips and innovations for eye socket reconstruction using spherical costal cartilage implant, which leads to dynamic and aesthetic results. METHODS: There were 19 cases of eye socket reconstruction using costal cartilages from 2008 to 2020. The patient age range was 18-77 years old. There were 10 cases of anophthalmia and 9 cases of ocular phthisis. In our operative method, we created the costal cartilage implant by harvesting the sixth costal cartilage of the affected side. If extraocular muscle remained, we sutured each muscle to the cartilage. RESULTS: Our method made application of thin artificial eyes possible in all cases. Regarding postoperative complications, there were 1 case of postoperative infection and 1 case of vascular failure of temporoparietal fascial flap. Seventeen cases were wet socket, and 2 cases were dry socket. We had attained movement of the artificial eye in 15 cases. CONCLUSIONS: Eye socket reconstruction is considered one of the most challenging operations, and various postoperative complications appear in the long term. Costal cartilages are considered as the most suitable materials to create the base of artificial eyes.

Medial orbitotomy without opening the ethmoid sinus enables wide exposure and safe removal of an orbital tumour located posterosuperomedially.

Tumours in the posterosuperomedial orbital space are hard to remove because of their site. However, medial orbitotomy without opening the ethmoid sinus produces a wide enough view and a direct route without complications. Posterosuperomedial orbital tumours can therefore be safely, accurately, and easily removed.

Relation between office intraocular pressure and 24-hour intraocular pressure in patients with primary open-angle glaucoma treated with a combination of topical antiglaucoma eye drops.

PURPOSE: To determine the relation between office intraocular pressure (IOP) and 24-hour IOP in patients with primary open-angle glaucoma (POAG) treated with 3 kinds of antiglaucoma eye drops. PATIENTS AND METHODS: Subjects were 42 patients with POAG (71 eyes). All were being treated with 3 different topical antiglaucoma eye drops (latanoprost, beta-blocker, and carbonic anhydrase inhibitor). Twenty-four-hour IOP values were obtained in the sitting position with a Goldmann applanation tonometer at 3-hour intervals. RESULTS: Maximum 24-hour IOP (mean+/-SD) was 19.76+/-5.65 mm Hg, minimum 24-hour IOP was 13.06+/-4.75 mm Hg, mean 24-hour IOP was 16.30+/-4.90 mm Hg, and 24-hour IOP fluctuation was 6.70+/-2.81 mm Hg. Office IOP was 16.23+/-4.58 mm Hg, and office IOP fluctuation was 2.75+/-1.68 mm Hg. There was no significant difference between office IOP and mean 24-hour IOP (P=0.93). There was no correlation between office IOP and 24-hour IOP fluctuation (r=0.15; P=0.25) or between office IOP fluctuation and 24-hour IOP fluctuation (r=0.19; P=0.17). Maximum 24-hour IOP occurred during office hours in 22 eyes (33.8%). The frequency of maximum 24-hour IOP occurring during office hours was significantly less than that of minimum 24-hour IOP (P<0.001). CONCLUSIONS: In POAG patients treated with 3 kinds of antiglaucoma eye drops, office IOP was similar to mean 24-hour IOP. However, it was difficult to estimate 24-hour IOP fluctuation and maximum 24-hour IOP on the basis of office IOP.

Iris prolapse after non-penetrating trabeculectomy with sinusotomy and mitomycin C.

Non-penetrating trabeculectomy (NPT) is effective in preventing numerous postoperative complications encountered with trabeculectomy. Recently, NPT has been modified to further reduce intraocular pressure (IOP) by combining other techniques. However, these modified NPT methods would make the globe even weaker than NPT alone. Here, we report a case of iris prolapse caused by blunt ocular trauma after NPT with sinusotomy and mitomycin C treatment. A 68-year-old man, who underwent NPT with sinusotomy and mitomycin C treatment, suffered from blunt ocular trauma to his left eye 28 days after surgery. The iris prolapsed from the sinusotomy site. Iridectomy, scleral suturing, and pars plana vitrectomy were performed. The bleb was absent post-re-operatively. Iris prolapse occurs uncommonly following simple NPT. However, additional sinusotomy and mitomycin C treatment render the globe weaker, and iris prolapse might occur. Iris prolapse increases risks in developing secondary infections and a loss of the filtration bleb. Thus, precautions are needed postoperatively.

A case of multiple evanescent white dot syndrome treated by steroid pulse therapy.

Multiple evanescent white dot syndrome (MEWDS) is characterized by acute visual loss which is usually spontaneously restored after a few months. While occasional treatments with local or oral steroids have been reported, these are hardly effective. A 25-year-old man, a Sumo wrestler, was diagnosed with MEWDS, and as he wanted a quick recovery to compete in an upcoming tournament treatment with steroid pulse therapy was initiated 8 days after the symptoms appeared. Before treatment, visual acuity in his left eye was 20/400. Multiple white dots were seen at the level of the deep retina or retinal pigment epithelium, and the Mariotte's blind spot extended to the center of the visual field. Immediately after the end of steroid pulse therapy, left visual acuity increased to 20/25, and left visual field recovered remarkably. No white dots were seen funduscopically. Steroid pulse therapy might provide early improvement of visual functions, and we believe it could be a treatment option for initiating an early recovery from MEWDS. However, steroid pulse therapy may also result in lethal damage including disorders of the circulatory organs. Thus, it should only be applied in limited situations in which patients had rapid decline in visual function and needs for social return at an early stage like that of our patient.

A simple, safe bimanual technique for subincisional cortex aspiration.

We developed a bimanual manipulation technique to facilitate the removal of the subincisional lens cortex in small-incision phacoemulsification cataract surgery. A separate aspiration handpiece, not connected to an aspiration tube, is passed into the anterior chamber through a side-port corneal incision. Under irrigation with a standard infusion/aspiration (I/A) handpiece through a tunnel incision, the cortex is stripped off with the separate handpiece and removed with the I/A handpiece. In 227 eyes, subincisional cortex removal and subsequent capsule polishing was performed safely with the separate handpiece. Rupture of the posterior lens capsule occurred in 3 high-risk eyes.

Subretinal fluid drainage via original retinal breaks for rhegmatogenous retinal detachment.

OBJECTIVE: To evaluate the outcome of vitrectomy using only original retinal breaks for subretinal fluid (SRF) drainage during the repair of primary rhegmatogenous retinal detachment (RRD). DESIGN: A retrospective consecutive interventional case series. PARTICIPANTS: A consecutive series of 112 eyes of 112 patients. METHODS: Patients underwent 23-gauge vitrectomy without the use of posterior retinotomy and perfluorocarbon liquids for uncomplicated primary RRD at Osaka City University Hospital between September 2007 and March 2011. Exclusion criteria included eyes with giant retinal tears, grade C2 or worse proliferative vitreoretinopathy (PVR), ocular trauma, and the presence of other vitreoretinal diseases. RESULTS: Single-operation success rate was 92.9%, whereas final anatomical success rate was 100%. Median visual acuity improved significantly from the preoperative logMAR of 0.51 ± 0.78 to the postoperative logMAR of 0.03 ± 0.26 (p < 0.01). No significant differences were observed for the single-operation success rate between the 62 eyes (95.2%) in which some SRF remained at the end of the operation and the rest of the 50 eyes (90.0%, p = 1.000) in which the SRF had been completely aspirated. Complications included transient intraocular pressure rise (12 eyes, 10.7%), epiretinal membrane (5 eyes, 4.5%), and PVR (1 eye, 0.9%). Ocular hypotony and endophthalmitis were not observed. CONCLUSIONS: Uncomplicated primary RRD can be successfully repaired by performing vitrectomy using only the original retinal breaks for SRF drainage. In addition, successful outcomes are not dependent on achieving complete reattachment of the retina throughout the fundus.

A case of mycotic endophthalmitis after triamcinolone acetonide-assisted pars plana vitrectomy.

Only two cases of bacterial endophthalmitis after triamcinolone acetonide (TA)-assisted pars plana vitrectomy (PPV) have been reported. As far as we are aware there has been no report of fungal endophthalmitis occurring after TA-assisted PPV. We report a case of endophthalmitis due to Fusarium after TA-assisted PPV. An otherwise healthy 61-year-old woman suffered from branch retinal vein occlusion with macular edema, which led to reduced visual acuity and metamorphopsia. Because she complained of severe discomfort, TA-assisted PPV was performed to reduce the macular edema. At the end of the surgery 4 mg TA was injected into the vitreous cavity. Two weeks after the surgery her visual acuity had improved to 20/20. Six weeks after the surgery her visual acuity decreased to 20/200 but without pain. Slit lamp examination showed no conjunctival hyperemia and no inflammatory cell infiltration in the anterior chamber. Fundus examination showed several small, creamy-white, circumscribed retinal lesions, epiretinal membranes, vitreoretinal traction, and rhegmatogenous retinal detachment. PPV was performed again. Intra-operative light microscopy revealed filamentous fungi in the epiretinal membrane, which was removed during the second PPV. Five days after the second surgery, retinal detachment recurred. A third PPV with encircling procedures and silicone oil tamponade was performed. Fungal cultures from the epiretinal membrane were identified as Fusarium sp. Seven months after the third surgery the silicone oil was removed. The retina remained attached and visual acuity was 20/200. Any patient who has undergone TA-assisted PPV should be carefully followed up for possible post-operative endophthalmitis, even if the anterior segment abnormality is minor.

Quantification and anatomic distribution of choroidal abnormalities in patients with type I neurofibromatosis.

BACKGROUND: Choroidal abnormality manifesting as a bright patchy lesion under infrared monochromatic light has previously been described in neurofibromatosis type I patients in whom the choroid appears normal under conventional ophthalmoscopic examination or on the fluorescein angiogram. We investigated the correlation between patient age and the number of choroidal abnormalities, as well as the anatomic distribution of choroidal abnormalities in the fundus. METHODS: We examined the fundus of 28 eyes in 14 patients with neurofibromatosis type I. Patients ranged in age from 2 to 38 years and were examined between April 2001 and April 2002 by confocal scanning laser ophthalmoscopy with infrared monochromatic light (780 nm wavelength). We divided the fundus into five regions (one within the retinal vascular arcade and those supero-temporal, infero-temporal, supero-nasal, and infero-nasal to it), and lesions on the border between regions were assigned to the region containing the greater part of the lesion. We studied the total number of choroidal abnormalities and the correlation between the total number and age. RESULTS: A positive correlation was found between the total number of choroidal abnormalities and age (Spearman rank correlation coefficient, r=0.6209, P=0.0178). There was a significantly greater number of choroidal abnormalities in the arcade region than in the other four regions (ANOVA, P<0.001). CONCLUSIONS: Choroidal abnormalities tend to increase with age and are most often observed within the vascular arcade.

Histopathological study of the anterior lens capsule with a double-ring sign.

BACKGROUND: A 'double-ring' sign may be seen during continuous curvilinear anterior capsulorhexis in cataract surgery. This sign has been attributed to partial splitting of the anterior lens capsule at the continuous curvilinear anterior capsulorhexis edge. Because horizontal intracapsular splits away from the capsule edge have also been reported, a double-ring sign has been hypothesized to be a precursor to true exfoliation. We report new histopathological findings for both anterior capsule and lens epithelium changes, the latter being similar to those of true exfoliation. METHODS: Three anterior capsules from two patients with a double-ring sign during capsulorhexis were examined via light and transmission electron microscopy. RESULTS: Light microscopy revealed step formations in the capsule edges and surface-parallel intracapsular splits in the anterior capsules. Transmission electron microscopy revealed stratified, banded structures consisting of alternating electron-dense and -lucent granular belts (300-400 nm) at the central area of the anterior capsule, as well as vacuole-like spaces and expansion of intercellular spaces in the lens epithelium. CONCLUSIONS: The thickened, stratified structure of the anterior capsule suggests abnormal lens epithelium in patients with a double-ring sign. The horizontal splits in the anterior capsule, with concomitant epithelial changes, i.e., the vacuole-like spaces and widened intercellular spaces, support the relation between a double-ring sign and true exfoliation.