Conjunctival displacement to the corneal side for oblique-parallel insertion in 25-gauge vitrectomy.

PURPOSE: To assess the usefulness of the method of oblique-parallel trocar insertion with conjunctival displacement to the corneal side in 25-gauge (G) transconjunctival vitrectomy. METHODS: 25-G vitrectomy was performed in 77 consecutive eyes. Before making obliqueparallel trocar insertions, the conjunctiva was conventionally displaced superiorly in 35 eyes, but was displaced toward the corneal side in 42 eyes. After surgery, the distance between the scleral and conjunctival wounds was measured with calipers. The frequency of scleral wound exposure was assessed. RESULTS: After cannula removal at the end of surgery, inferior repositioning of the superiorly displaced conjunctiva was observed, while marked posterior repositioning of the corneal side caused displacement of the conjunctiva due to gravity. The superior displacement distances between the sclera and conjunctival wounds were 2.4+/-0.3 mm at the infusion port, 2.0+/-0.4 mm at the superior temporal port, and 1.9+/-0.4 mm at the superior nasal port, while the corresponding distances for corneal side displacement were 3.6+/-0.5, 3.5+/-0.5, and 2.5+/-0.5mm, and were all significantly (p<0.0001) greater with corneal side displacement. The frequency of scleral wound exposure due to conjunctival damage around the cannula (infusion port) was significantly (p=0.0164) lower for corneal side displacement (0/42; 16.7%) than superior displacement (5/35; 14.3%). There was no postoperative endophthalmitis in all 77 patients studied. CONCLUSIONS: In 25-G transconjunctival vitrectomy, using oblique-parallel trocar insertions with the conjunctiva displaced toward the corneal side results in marked posterior repositioning of the conjunctiva after cannula extraction. Corneal side conjunctival displacement is technically easy and completely covers the scleral wound. This method is expected to be effective in preventing endophthalmitis.

Needle-shaped deposits on retinal surface in a case of ocular amyloidosis.

PURPOSE: To report a case in which optical coherence tomography (OCT) showed needle-shaped deposits on the retinal surface oriented toward the vitreous cavity and immunohistochemical findings suggested light chain-related amyloidosis. METHODS: A 59-year-old man with no systemic complications had bilateral neovascular glaucoma and vitreous opacities in the right eye. Vitrectomy was conducted on the right eye and the excised vitreous was examined histopathologically. RESULTS: Glass wool-like opacities were observed during vitrectomy. Postoperative fundus examination of the right eye showed retinal hemorrhage and white deposits around blood vessels and on retinal surface. Fluorescein angiography revealed hyperfluorescence of the optic disc, non-perfusion areas, and vascular focal staining. OCT depicted needle-shaped deposits perpendicular to the retinal surface oriented toward the vitreous. Histologic examination of deposits revealed positive reaction for Congo red stain, and immunohistochemical examination demonstrated positive reactivities for anti-lambda and anti-kappa light chains (precursors of amyloid protein), suggesting a diagnosis of light chain-related amyloidosis. CONCLUSIONS: In this case, OCT showed needle-shaped deposits perpendicular to the retinal surface. Special staining with Congo red revealed the deposit to be amyloid deposition. Immunohistochemical staining suggested light chain-related amyloidosis. Vascular obstructive lesions and neovascular glaucoma secondary to retinal vascular damage in amyloidosis warrant particular attention.

25-Gauge peripheral iridectomy during vitrectomy.

PURPOSE: To report peripheral iridectomy using a 25-gauge vitreous cutter in a 42-year-old man with pupillary block due to adhesion of the internal iris surface to the continuous circular capsulorhexis. METHODS: A corneal opening was made at 10 o'clock during vitrectomy. A 25-gauge vitreous cutter was inserted into the anterior chamber with the port facing downward, and peripheral iridectomy at the 12 o'clock position was performed. The vitreous cutter was set at a cutting speed of 2500 cpm and the aspiration pressure at 600 mmHg. RESULTS: A 25-gauge vitreous cutter with a fine shaft could easily be inserted into the peripheral anterior chamber, and there was no contact with the corneal endothelium even when the anterior chamber became shallow in association with iridectomy. In this patient, pupillary block resolved with peripheral iridectomy, and ocular pressure was also controlled. CONCLUSIONS: 25-gauge peripheral iridectomy is a simple technique that permits iridectomy of appropriate size at any desirable location.

The origins of polypoidal choroidal vasculopathy.

BACKGROUND/AIM: There are two theories on the pathogenesis of polypoidal choroidal vasculopathy (PCV): variants in choroidal neovascularisation (CNV) and inner choroidal vessel abnormalities. On indocyanine green angiography (IGA) with a video camera system, PCV has a characteristic appearance, but inadequate image quality has made detailed interpretation difficult. This study aims to improve imaging, using confocal scanning laser ophthalmoscopy (SLO), to elucidate the pathogenesis of PCV. METHODS: High speed IGA with confocal SLO of 45 eyes (44 patients) showed typical PCV findings of a branching vascular network and polypoidal lesions. RESULTS: Vessels comprising branching networks began to fill simultaneously with the surrounding choroidal arteries in 38 eyes. Small numbers of vessels filling within a branching network, in the arterial and arteriovenous phases of IGA, showed focal dilatation, constriction, and tortuousity. Vessel abnormalities, corresponding to polypoidal lesions, existed within a network in eight eyes and included loops similar in calibre to network vessels, and numerous microaneurysmal dilatations of small vessels. Vessel pulsation was seen in 24 eyes. CONCLUSION: PCV is caused by inner choroidal vessel abnormalities, not CNV.

Indocyanine green angiographic findings of chorioretinal folds.

PURPOSE: To analyze indocyanine green (ICG) angiographic findings of chorioretinal folds. METHODS: Eight patients (9 eyes) in whom chorioretinal folds had been diagnosed were enrolled in this study. Color photography, fluorescein angiography (FA) and ICG angiography (IA) were performed. RESULTS: Indocyanine green angiography demonstrated choroidal venous congestion and a filling delay of the choroidal vessels in one case with an orbital tumor. In one posterior scleritis case, IA showed a filling delay of choroidal vessels in the early phase and multiple patchy hypofluorescent lesions scattered in the posterior pole during the late phase. Idiopathic cases showed choroidal venous dilatation. No abnormalities of the choroidal vasculature in the form of radial folds, were revealed in two cases of AMD. Linear hyperfluorescent areas suggestive of chorioretinal folds seen on IA were less numerous and wider than those observed on FA in some eyes. On the other hand, they were equally numerous and wider on IA than those on FA in other eyes. CONCLUSION: Indocyanine green angiography is useful for evaluating both pathological conditions of the choroidal vasculature and the width of chorioretinal folds at the level of the choroidal vasculature.

Effects of dosing time and schedule on cisplatin-induced nephrotoxicity in rats.

Renal dysfunction induced by a single injection of cisplatin depends on the timing of the dose. However, the effects of repeated administration of cisplatin on time-dependent toxicity have not been evaluated despite the fact that in clinical practice high doses are repeatedly injected at intervals or low doses are administered daily. We studied chrononephrotoxicity in rats after weekly or daily cisplatin injections. Weekly high doses (5 mg kg(-1)) or daily low doses (1.2 mg kg(-1)) of cisplatin were injected at four time points (3, 9, 15 and 21 h after the light was turned on (HALO)) for 3 weeks. Changes in body weight after weekly cisplatin administration were independent of the timing of the doses. In the group that received daily cisplatin, the loss in body weight in the 3 HALO group was smaller than in animals receiving injections at 15 and 21 HALO (P < 0.05 and 0.001, respectively). The blood urea nitrogen and serum creatinine levels in the control rats showed a significant circadian change (peak at 15 HALO and trough at 9 HALO), but these parameters were markedly elevated in both trials and their circadian variations were disturbed. In conclusion, cisplatin-induced nephrotoxicity was the lowest at 3HALO compared with other time points of both dose regimens.

Indocyanine green angiography and histopathology of choroidal neovascular membrane in age-related macular degeneration.

PURPOSE: Histopathological investigation of the choroidal neovascular membrane (CNM) in age-related macular degeneration (AMD) patients who showed various findings in indocyanine green angiography (IA). METHODS: Before surgery, 20 eyes of 20 patients were classified into four types based on IA findings (Type I: both early and late phase hyperfluorescence; Type II: hyperfluorescence only in the early phase; Type III: hyperfluorescence only in the late phase; Type IV: virtually no hyperfluorescence in any phase). Seventeen surgically excised specimens stained with hematoxylin-eosin and azan, were examined by light microscopy. Three other specimens were examined by electron microscopy. RESULTS: Type I membrane showed many vascular channels not present in the surrounding retinal pigment epithelium (RPE) cells, and little fibrous tissue. Type II membrane had many vascular channels but RPE cells surrounded the CNM. Type III membrane showed few vascular channels and RPE cell proliferation. Type IV membrane showed dense fibrous tissue. CONCLUSION: The IA findings in AMD agreed with the CNM membrane structure in regard to the number of vascular channels, maturity of vessels, the extent of envelopment of RPE cells and the amount of fibrous tissue.

[Correlation of indocyanine green angiography findings and expression of vascular endothelial growth factor in surgically excised age-related macular degeneration-related choroidal neovascular membranes].

PURPOSE: We investigated the relationship between clinical classification by indocyanine green angiography (IA) and pathologic findings including the expression of vascular endothelial growth factor (VEGF) in age-related macular degeneration-related choroidal neovascular membranes. SUBJECT AND METHODS: The subjects were 15 patients with age-related macular degeneration who underwent surgical excision for choroidal neovascular membrane. The patients were classified into 4 types: Type I, hyperfluorescence in both early and late phases (n = 7); Type II, hyperfluorescence in the early phase only (n = 2); Type III, hyperfluorescence in the late phase only (n = 3); and Type IV, no hyperfluorescence in any phase (n = 3). The excised choroidal neovascular membranes were fixed and stained by hematoxylin-eosin and azan. They were also examined by immunohistochemical staining for VEGF. RESULTS: VEGF was expressed markedly in vascular endothelial cells and fibroblast-like cells of interstitial tissue of Types I, II and III. Its expression was weak in Type IV. CONCLUSION: Clinical classification by IA for age-related macular degeneration is consistent with the pathologic findings including the expression of VEGF.

Comparison between indocyanine green angiography and outcome of surgical removal of choroidal neovascular membrane in age-related macular degeneration

Purpose: To review the outcome of surgical removal of choroidal neovascular membranes in age-related macular degeneration as classified by indocyanine green angiographic findings.Subjects and Method: Surgery was performed in 42 eyes. They were divided into four types by indocyanine green angiographic findings prior to surgery. Type I comprised 29 eyes showing hyperfluorescence throughout the angiographic phases. Type II comprised 3 eyes showing hyperfluorescence during the early phase only. Type III comprised 5 eyes showing hyperfluorescence in the late phase only. Type IV comprised 5 eyes without hyperfluorescence throughout the angiographic phases. The results were evaluated according to the visual acuity expressed as log MAR before and after surgery.Results: Visual acuity improved significantly in Types I, II, and III after surgery. Visual acuity did not improve in Type IV.Conclusion: The findings of indocyanine green angiography are thought to reflect the histological characteristics of the choroidal neovascular membrane. Neovascular membranes of Type IV may contain a smaller number of vessels and abundant fibrous tissue. Eyes of Type IV will have atrophies in the neurosensory retina, retinal pigment epithelium, and choriocapillaris. Surgical removal of the choroidal neovascular membrane in Type IV is not effective in improving visual acuity.

[Intra-arterial infusion chemotherapy for superficial bladder cancer].

Intra-arterial infusion chemotherapy (AI) is widely used in the treatment of invasive bladder cancer, but few studies have been reported on its efficacy for superficial bladder cancer. We retrospectively examined the anti-tumor effect and prophylactic effect of AI in 18 cases which were either a case with multiple or extensive tumors which could not be controlled completely by transurethral resection (TUR), a case with grade 3 tumors or a recurrent case after TUR and/or intravesical chemotherapy. Fifty mg of adriamycin and 100 mg of cisplatin were administered into bilateral internal iliac arterys. This treatment was repeated 1-3 times every three weeks. Concerning the anti-tumor effect, 8 showed a complete response, 5 showed partial response and 5 showed no change; the overall response rate (CR + PR) was 72%. Concerning the prophylactic effect, 1-, 2- and 3-year recurrence-free rates were 58.8%, 41.1% and 32.9%, respectively. This study demonstrated the efficacy of AI in the anti-tumor treatment, but not in the prophylactic treatment of superficial bladder cancer.

[Comparison between indocyanine green angiography and outcome of surgical removal of choroidal neovascular membrane in age-related macular degeneration].

PURPOSE: To review the outcome of surgical removal of choroidal neovascular membranes in age-related macular degeneration as classified by indocyanine green angiographic findings. SUBJECTS AND METHOD: Surgery was performed in 42 eyes. They were divided into four types by indocyanine green angiographic findings prior to surgery. Type I comprised 29 eyes showing hyperfluorescence throughout the angiographic phases. Type II comprised 3 eyes showing hyperfluorescence during the early phase only. Type III comprised 5 eyes showing hyperfluorescence in the late phase only. Type IV comprised 5 eyes without hyperfluorescence throughout the angiographic phases. The results were evaluated according to the visual acuity expressed as log MAR before and after surgery. RESULTS: Visual acuity improved significantly in Types I, II, and III after surgery. Visual acuity did not improve in Type IV. CONCLUSION: The findings of indocyanine green angiography are thought to reflect the histological characteristics of the choroidal neovascular membrane. Neovascular membranes of Type IV may contain a smaller number of vessels and abundant fibrous tissue. Eye of Type IV will have atrophies in the neurosensory retina, retinal pigment epithelium, and choriocapillaris. Surgical removal of the choroidal neovascular membrane in Type IV is not effective in improving visual acuity.

[Comparison with indocyanine green angiography and immunohistochemical study of choroidal neovascular membrane in age-related macular degeneration].

PURPOSE: We classified choroidal neovascular membranes (CNMs) (48 eyes) in age-related macular degeneration (AMD) into four types using indocyanine green angiography. METHODS: Surgically extracted CNMs were examined immunohistochemically. Specimens were stained with glial fibrillary acidic protein (GFAP), von Willebrand factor, Ki-67 antigen, actin, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (b-FGF), and transforming growth factor (TGF-beta 1). RESULTS: All types of CNM were positively stained with GFAP on the side opposite the retinal pigment epithelial (RPE) cells. This suggests the adherence of neurosensory retina to the CNM. Type I membranes which showed hyperfluorescence in the early and late phase of ICG angiography were significantly stained with Ki-67 antigen. CONCLUSION: These results indicate that CNMs in AMD are extracted with neurosensory retina and RPE cells during surgery. Type I membranes have a high capability for proliferation.

[Gastrocystoplasty for severely contracted bladder following high dose pelvic irradiation: a case report].

A 24-year-old female who had received hysterectomy and adnexectomy of bilateral appendages for yolk sac tumor at the age of 12 years, followed by repeated surgery and pelvic irradiation over a total of 100 Gy for relapse of tumor, suffered from a severely contracted bladder and renal dysfunction of serum creatinine level over 2.0 mg/dl. The diagnosis was radiation-induced contracted bladder with renal dysfunction due to vesicoureteral reflux. Since the small intestine was not considered suitable after high dose irradiation, the stomach was used to reconstruct the bladder. The vesical pressure, which was 70 cmH2O at the capacity of 30 ml, was decreased to 22 cmH2O at the capacity of 100 ml, 5 weeks after surgery. The renal function was stable with a serum creatinine level below 1.4 mg/dl and the bladder capacity was 200 ml, 15 months after surgery. This method using the stomach was considered valuable for bladder reconstruction after large dose pelvic irradiation.

[Appropriate intravesical retention time of pirarubicin concentration based on its level in tumor tissue, anti-tumor effect and side effect in intravesical instillation therapy for bladder tumor].

The present study was designed to investigate the appropriate intravesical retention time of pirarubicin (THP) for the treatment of bladder tumor in terms of its anti-tumor effect and side effect. We administered THP to 22 patients with superficial bladder tumor intravesically and measured the THP concentration in the tumor tissues. Patients were divided into 3 groups by retention time; 8 for 30 minutes, 8 for 1 hour and 7 for 2 hours. Tumor tissues were obtained by transurethral resection 30 min., 1 or 2 hours after the intravesical instillation of THP at the fixed concentrations of 30 mg/30 ml. There was no significant difference in THP concentration between 3 groups. This indicates that the anti-tumor effect of intravesical instillation of the THP would be expected by only 30 min. of intravesical retention time at the THP concentration of 30 mg/30 ml. Then, we administered 30 mg/30 ml of THP solution for 30 min. to 10 patients intravesically 6 times every 48 hours to investigate its clinical anti-tumor effect and side effect. There were 2 complete responses, 3 partial responses and 5 cases with no changes for a total response rate of 50%. No side effect was observed. It is considered that 30 min. of intravesical retention time at the THP concentration of 30 mg/30 ml would be appropriate in terms of its anti-tumor effect and side effect.

[A case of colo-vesico-vaginal fistula caused by sigmoid colon diverticulitis].

A 74-year-old woman was referred to our hospital with the chief complaints of pneumaturia, fecaluria and discharge of feces and urine from vagina. Fistulography on the vaginal side showed the presence of contrast medium both in the sigmoid colon and bladder. Colonoscopy revealed multiple diverticulosis of the sigmoid colon. Under diagnosis of colo-vesico-vaginal fistula due to sigmoid colon diverticulitis, a one-stage operation removing sigmoid colon, uterus-vaginal wall and urinary bladder wall including the fistula and careful reconstruction was performed. Postoperatively, urinary leakage from vagina in large amounts continued due to the recurrence of vesico-vaginal fistula. An attempt to use human fibrin glue in the recurrent fistula was successful, and the patient was asymptomatic at 21 months of follow-up. Colovesical fistula has been reported in about 10-20% of patients undergoing surgery for complicated diverticulitis, but a combined fistula is a rare condition. Furthermore, we recommend the use of human fibrin glue for a recurrent fistula.

[Intravesical instillation of epirubicin in the prophylactic treatment of recurrent superficial bladder cancer].

A retrospective study was performed to determine the efficacy of intravesical instillation of epirubicin in the prophylactic treatment for recurrent superficial bladder cancer when compared with no treatment controls. Seventeen patients with recurrent superficial bladder cancer received epirubicin (30 mg/40 ml in normal saline) seventeen times after transurethral resection (TUR). Historical controls consist of sixteen patients with recurrent superficial bladder cancer who received no adjuvant treatment after TUR. In the epirubicin group, 1-, 2- and 3-year recurrence free rates were 64.7%, 41.2% and 5.9%, respectively. In controls all of them recurred and 1- and 2-year recurrence free rates were 17.6% and 0%, respectively. The recurrence-free rate was significantly higher in the epirubicin group than in the controls (p < 0.05). We investigated whether intravesical instillation of epirubicin prolonged recurrence-free intervals when compared with recurrence-free intervals without adjuvant treatment after TUR in each patient. The 1- and 2-year recurrence free rates after initial TUR were 25% and 12.5%, respectively, and those with epirubicin treatment after TUR were 62.5% and 37.5%, respectively. Recurrence-free intervals were significantly prolonged by intravesical instillation of epirubicin as compared with those without adjuvant treatment in each patient. This study demonstrated the efficacy of intravesical instillation of epirubicin in the prophylactic treatment for superficial recurrent bladder cancer.

[Comparison between indocyanine green angiography and histopathological observations of choroidal neovascular membrane in age-related macular degeneration].

We classified choroidal neovascular membrane (CNM) (20 eyes) in age-related macular degeneration into four types (Type I: hyperfluorescence in both early and late phases, Type II: hyperfluorescence only in the early phase, Type III: hyperfluorescence only in the late phase, Type IV: virtually no hyperfluorescence in any phase) using indocyanine green angiography (IA). We performed surgery to remove CNM with these IA findings. After 17 surgically extracted specimens had been stained with hematoxylin-eosin and azan, they were examined by tight microscopy. Three other specimens were examined by electron microscopy. Type I showed many vascular channels, not present in the surrounding retinal pigment epithelium (RPE) cells, and little fibrous tissue. Type II had many vascular channels but RPE cells surrounded the CNM. Type III showed few vascular channels and RPE cell proliferation. Type IV showed abundant fibrous tissue. The IA findings of CNM were thought to be determined by the number of vascular channels, maturity of vessels, degree of surrounding by RPE cells, and the amount of fibrous tissue within the CNM.

Smoking and neovascular form of age related macular degeneration in late middle aged males: findings from a case-control study in Japan. Research Committee on Chorioretinal Degenerations.

AIMS: The risk of smoking habits for developing the neovascular form of age related macular degeneration (neovascular form of AMD) were studied by a case-control study in Japan. METHODS: 56 male patients with the neovascular form of AMD and 82 healthy male controls, aged 50 to 69 years, were enrolled. A self administered questionnaire provided necessary information for the study subjects. Questions on smoking included whether the study subjects have ever smoked or not, and if smoked, depth of smoke inhalation, use of extra filter, age at starting smoking, average number of cigarettes smoked per day, and duration of smoking. When a smoker had stopped smoking, age at cessation was also recorded. Unconditional logistic analysis was adapted to calculate age adjusted odds ratios and their 95% confidence intervals (CIs) for smoking related factors. RESULTS: Age adjusted odds ratio of developing the neovascular form of AMD was 2.97 (95% CI 1.00-8.84) for current smokers and 2.09 (0.71-6.13) for ex smokers, compared with non-smokers. All smoking habit/smoking history related variables such as use of extra filter, smoke inhalation level, age at starting smoking, duration of smoking, and Brinkman index were found to be significantly related to an increased risk of the neovascular form of AMD. CONCLUSIONS: Suggested is the strong possibility that cigarette smoking enhances the neovascular form of AMD risk in late middle aged males, though the magnitude of risk by smoking variables might be overestimated, in part, because of health oriented controls.

Factors influencing visual acuity after photocoagulation for subfoveal choroidal neovascularization of exudative age-related macular degeneration.

PURPOSE: To evaluate factors influencing visual acuity after laser photocoagulation for subfoveal choroidal neovascularization of exudative age-related macular degeneration. METHODS: Subfoveal choroidal neovascular membranes were photocoagulated. Factors favoring a visual acuity of 20/200 or better were analyzed using Fisher's exact probability test or chi-square test on 28 eyes in which visual acuity was 20/200 or better, and 23 eyes with a visual acuity below 20/200 at the most recent follow-up examination. RESULTS: Factors predicting a postoperative visual acuity of 20/200 or better were (1) distance between one lateral margin of the neovascular membrane and the center of the foveal avascular zone was one-third disc diameter or less, and (2) pretreatment retinal sensitivity at the fixation point was 10 dB or more. CONCLUSION: Good indications for photocoagulation treatment of subfoveal choroidal neovascular membrane were a neovascular membrane margin near the center of the foveal avascular zone and relatively good retinal sensitivity at the fixation point adjacent to the scotoma. These factors predict a visual acuity of 20/200 or better after treatment.