Micropulse transscleral cyclophotocoagulation in a Taiwanese population: 2-year clinical outcomes and prognostic factors.

PURPOSE: To evaluate the 2-year efficacy and safety of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in Taiwanese patients with glaucoma. METHODS: We included the patients who received standardized MP-TSCPC with follow-up examinations on a regular basis for 24 months. Treatment success was defined as the attainment of a postoperative intraocular pressure (IOP) between 6 and 21 mmHg or a ≥ 20% reduction in IOP from baseline without an increase in glaucoma medications. RESULTS: A total of 60 eyes from 56 patients who underwent MP-TSCPC for refractory glaucoma were included. The median age at MP-TSCPC intervention was 58.9 ± 12.4 years. The percentage of treatment success was 88.3% at 3 months, 83.3% at 6 months, 78.3% at 12 months, and 75.0% at 24 months. The mean baseline IOP prior to MP-TSCPC was 34 ± 11.9 mmHg (range 14-56 mmHg). The mean postoperative IOP decreased to 20.9 ± 10.0 mmHg, 18.0 ± 7.8 mmHg, 17.5 ± 6.4 mmHg, and 18.2 ± 7.1 mmHg after 3 months, 6 months, 12 months, and 24 months, respectively, in successful cases. The mean number of glaucoma medications at baseline was 3.8 ± 0.2, and the mean numbers of glaucoma medications at postoperative months 3, 6, 12, and 24 were 2.6 ± 0.7, 2.8 ± 0.6, 2.5 ± 1.4 and 2.6 ± 1.4, respectively, in successful cases. Younger age and prior CW-TSCPC significantly contributed to surgical failure in the multivariate model. Complications after MP-TSCPC included mild anterior chamber inflammation, conjunctival hemorrhage, hypotony, and mydriasis, and all subsided after treatment. None of the eyes developed vitreous hemorrhage, cystoid macular edema, or phthisis bulbi in the late postoperative period. CONCLUSIONS: This study demonstrated that younger age and prior CW-TSCPC were risk factors for MP-TSCPC failure within 2 years. MP-TSCPC might be safe and effective for refractory glaucoma patients with maximal antiglaucoma medications.

Lymphocytic hidradenitis: A distinctive histopathological finding of annular erythema of Sjögren syndrome.

BACKGROUND/OBJECTIVES: Lymphocytic hidradenitis is a non-specific histopathological feature observed in many dermatoses such as lupus erythematosus, morphea or scleroderma. When it occurs it is usually accompanied by the other distinctive histological features of those conditions. Isolated lymphocytic hidradenitis is uncommon and its clinical features and associated underlying medical conditions are still undetermined. METHODS: We performed a retrospective review of patients who clinically presented with annular erythema between 2000 and 2016. Altogether, 30 patients with a histopathological presentation of isolated lymphocytic hidradenitis were identified. Their following characteristics were recorded: clinical features, number and localisation of lesions, serology and other associated medical conditions. RESULTS: Isolated lymphocytic hidradenitis was found most frequently in middle-aged women. Most patients (n = 28, 93%) presented with many annular erythematous patches and plaques with mild pruritus; 22 (73%) had the SS-A antibody and 17 (57%) met the diagnostic criteria of Sjögren syndrome. Among these patients, 11 had primary and six had secondary Sjögren syndrome associated with systemic lupus erythematosus. Altogether 15 (50%) patients tested positive for a high titre of the antinuclear autoantibody. Other underlying diseases identified during the follow-up period include cryoglobulinaemia, angioimmunoblastic T-cell lymphoma, autoimmune hepatitis, hepatitis C infection and toxic thyroid goitre. CONCLUSIONS: Lymphocytic hidradenitis is a microscopic finding associated with annular erythemas of Sjögren syndrome. Systemic survey for sicca symptoms and work up for autoimmune diseases, including antinuclear antibodies, SS-A, SS-B antibodies, cryoglobulin, lymphoma, viral and autoimmune hepatitis should be performed to facilitate the correct diagnosis.

Evaluation of Laser-Assisted Trans-Nail Drug Delivery with Optical Coherence Tomography.

The nail provides a functional protection to the fingertips and surrounding tissue from external injuries. The nail plate consists of three layers including dorsal, intermediate, and ventral layers. The dorsal layer consists of compact, hard keratins, limiting topical drug delivery through the nail. In this study, we investigate the application of fractional CO2 laser that produces arrays of microthermal ablation zones (MAZs) to facilitate drug delivery in the nails. We utilized optical coherence tomography (OCT) for real-time monitoring of the laser-skin tissue interaction, sparing the patient from an invasive surgical sampling procedure. The time-dependent OCT intensity variance was used to observe drug diffusion through an induced MAZ array. Subsequently, nails were treated with cream and liquid topical drugs to investigate the feasibility and diffusion efficacy of laser-assisted drug delivery. Our results show that fractional CO2 laser improves the effectiveness of topical drug delivery in the nail plate and that OCT could potentially be used for in vivo monitoring of the depth of laser penetration as well as real-time observations of drug delivery.

Evaluation of moisture-related attenuation coefficient and water diffusion velocity in human skin using optical coherence tomography.

In this study, time-resolved optical coherence tomography (OCT) scanning images of the process of water diffusion in the skin that illustrate the enhancement in the backscattered intensities due to the increased water concentration are presented. In our experiments, the water concentration in the skin was increased by soaking the hand in water, and the same region of the skin was scanned and measured with the OCT system and a commercial moisture monitor every three minutes. To quantitatively analyze the moisture-related optical properties and the velocity of water diffusion in human skin, the attenuation coefficients of the skin, including the epidermis and dermis layers, were evaluated. Furthermore, the evaluated attenuation coefficients were compared with the measurements made using the commercial moisture monitor. The results demonstrate that the attenuation coefficient increases as the water concentration increases. Furthermore, by evaluating the positions of center-of mass of the backscattered intensities from OCT images, the diffusion velocity can be estimated. In contrast to the commercial moisture monitor, OCT can provide three-dimensional structural images of the skin and characterize its optical property, which together can be used to observe morphological changes and quantitatively evaluate the moisture-related attenuation coefficients in different skin layers.

Late-Onset Bleb-Related Endophthalmitis Caused by Moraxella nonliquefaciens: A Case Report.

Moraxella species are Gram-negative coccobacilli that typically colonize the flora of the human upper respiratory tract and have low pathogenic potential. There are limited case reports implicating the organisms as the cause of endocarditis, bacteremia, septic arthritis, ocular infection, and meningitis. In cases of keratitis and conjunctivitis, Moraxella nonliquefaciens is not commonly isolated from the ocular surface. We present a case of a diabetic patient who developed late-onset bleb-related endophthalmitis caused by M. nonliquefaciens 4 years after glaucoma filtering surgery. Within one day, the patient presented with an acutely fulminant course with sudden visual loss, redness, and ocular pain. Appropriate antibiotic treatment and early vitrectomy resulted in a favorable final visual acuity of 20/100, which was his vision prior to infection. The use of Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass spectrometry (MALDI-TOF MS) enabled the rapid identification of the organism. Endophthalmitis caused by M. nonliquefaciens should be considered in patients who underwent glaucoma filtering surgery with antifibrotic agents.

Association between peripheral vascular endothelial dysfunction and livedoid vasculopathy.

BACKGROUND: Livedoid vasculopathy (LV) is a disease characterized by multiple painful and recurrent ulcerations on the feet, accompanied by atrophic scars. Many researchers suggest that a hypercoagulable status is the pathogenetic factor for LV. However, the cause of LV remains elusive. OBJECTIVE: We sought to determine if endothelial dysfunction is present in patients with LV. METHODS: This prospective study included 16 patients with LV and active ulcers and 16 matched control subjects. We reviewed detailed clinical parameters, including antinuclear antibody, high-sensitivity C-reactive protein, protein C, protein S, homocysteine, anti-SSA, anti-SSB, anticardiolipin antibody, and serum lipid profiles. Flow-mediated vasodilation of the brachial artery was used as an indicator of vascular endothelial function using high-resolution 2-dimensional ultrasonic imaging. RESULTS: Blood pressure, blood biochemistry, high-sensitivity C-reactive protein, and homocysteine were not significantly different in patients with LV and control subjects. Nitroglycerin-mediated vasodilation was not significantly different in patients with LV and control subjects. However, flow-mediated vasodilation was much less in patients with LV than in the control group (3.58 ± 2.32% vs 7.51 ± 2.40%, P < .001). LIMITATIONS: The study was performed at a single site with a limited sample size. CONCLUSION: Peripheral vascular endothelial dysfunction was demonstrated in patients with LV by reduction of brachial flow-mediated vasodilation.

Application and Validation of LUXIE: A Newly Developed Virtual Reality Perimetry Software.

PURPOSE: To report the application of LUXIE and validate its reliability by comparing the test results with those of Humphrey Field Analyzer 3 (HFA3). METHODS: In this pilot study, we prospectively recruited participants who had received HFA3 SITA standard 30-2 perimetry and tested them with LUXIE on the same day. LUXIE is a software designed for visual field testing cooperating with HTC Vive Pro Eye, a head-mounted virtual reality device with an eye-tracking system. The test stimuli were synchronized with eye movements captured by the eye-tracking system to eliminate fixation loss. The global, hemifields, quadrants, glaucoma hemifield test (GHT) sectors, and point-by-point retinal sensitivities were compared between LUXIE and HFA3. All participants were asked to fill out a post-test user survey. RESULTS: Thirty-eight participants with 65 eyes were enrolled. LUXIE demonstrated good correlations with HFA3 in global (r = 0.81), superior hemifield (r = 0.77), superonasal, superotemporal, and inferonasal quadrants (r = 0.80, 0.78, 0.80). The user survey showed that participants were more satisfied with LUXIE in operating difficulty, comfortability, time perception, concentration, and overall satisfaction. CONCLUSIONS: LUXIE demonstrated good correlations with HFA3. Fixation loss could be eliminated in LUXIE with the eye-tracking system. The application of virtual reality devices such as the HTC Vive Pro Eye makes telemedicine and even home-based self-screening visual field tests possible. KEY MESSAGES: 1. Virtual reality perimetry is a developing technology that has the potential in telemedicine, and home self-screening visual field tests. 2. LUXIE demonstrated good correlations with Humphrey Field Analyzer 3 in visual field retinal sensitivities.

Brimonidine related acute follicular conjunctivitis: Onset time and clinical presentations, a long-term follow-up.

ABSTRACT: To evaluate the duration of topical brimonidine therapy before the onset of brimonidine-related allergic conjunctivitis and the clinical characteristics associated with the development of brimonidine allergy.We retrospectively enrolled patients who presented brimonidine allergy from December 1, 2008 to November 30, 2020. The duration of brimonidine treatment, concomitant medications, benzalkonium chloride (BAK) exposure, change in IOP, and season of onset were evaluated.292 patients were included, among which 147 were female and 145 were male. The mean age was 58.3 ± 13.6 years old. The mean (median) duration of brimonidine therapy was 266.6 (196) days, with a peak at 60-120 days. The duration was similar whether the patients received brimonidine monotreatment or in combination with other glaucoma drugs, with or without BAK. The IOP increased by 5.6% after brimonidine allergy (P < .001), which was even higher in the brimonidine monotherapy group (9.2%, P < .001). There was no significant IOP elevation in patients treated with multiple glaucoma medications.Around half of brimonidine allergy occurred within 6 months, with a peak in 2 to 4 months. The duration did not differ in patients receiving brimonidine monotherapy or multiple glaucoma medications. The presence of BAK did not affect the duration either. When brimonidine allergy occurred, there was a loss of IOP control, especially in patients receiving brimonidine monotherapy. It is recommended to switch to other types of glaucoma medications for better IOP control.

Corneal superinfection in acute viral conjunctivitis in young children.

Two children suffered from corneal superinfection following acute viral keratoconjunctivitis. Group A beta-hemolytic streptococci were isolated in one child and cultures were negative in the other child. The corneal ulcers resolved with prompt antibiotic therapy, but both patients developed amblyopia. Visual outcome following corneal superinfection in acute viral conjunctivitis may be poor when it occurs in young children.

In vivo detection of UV-induced acute skin effects using optical coherence tomography.

Ultraviolet (UV) rays have been identified as a carcinogen with long-term irradiation and are an important risk factor for skin cancer. Here, we report the use of optical coherence tomography/optical coherence tomography angiography (OCT/OCTA) to study acute UV-induced effects on skin in vivo. To understand the relationship between the acute effects and irradiated UV power density, three groups were irradiated with different power densities in our experiments. Furthermore, the same skin area was repeatedly scanned with OCT during UV irradiation to investigate the progress of the induced acute effects and after irradiation for observation of skin recovery. Subsequently, the OCT/OCTA results were quantitatively analyzed to acquire skin thickness and blood-vessel density for comparison. UV-induced acute effects on morphology and microcirculation can be identified from OCT/OCTA results, which showed the increases in the skin thickness and blood-vessel density and even severe damage types such as blisters. The results of quantitative analyses also illustrated that the severity of damage induced by UV irradiation can be distinguished and the skin recovery can be monitored with OCT. Our results indicate that OCT can be a promising tool for early detection of UV-induced acute skin damage.

Aggressive small choroidal melanoma presenting as a dense cataract.

A 58-year-old woman with an aggressive, invasive, small post-equatorial choroidal melanoma presented with progressively blurred vision and a dense cataract in the affected eye. During phacoemulsification surgery, heavily pigmented retrolental vitreous was identified. Fine needle aspiration biopsy revealed heavily pigmented epithelioid cells without diagnostic features of malignancy. Small epithelioid-type choroidal melanoma (2.5 mm x 2.5 mm x 1.5 mm) was confirmed following enucleation. Diffuse preretinal space seeding, vitreous infiltration, forward spreading of tumor cells into the lens capsule and trabecular meshwork resulted in a complicated cataract.

Toxic keratopathy-related corneal dehydration after laser in situ keratomileusis.

A 33-year-old woman had progressive blurred vision 2 weeks after uneventful laser in situ keratomileusis surgery. Initial satisfactory uncorrected visual acuity (UCVA) was complicated by postoperative dry eye and drug toxicity. Slitlamp biomicroscopy revealed diffuse punctate epithelial keratitis and inferior corneal epithelial defect with rolled-up epithelium on the flaps and the inferior unoperated cornea in both eyes. Diffuse inflammatory cell infiltrates were evident in the stroma. Stromal thinning was evident on serial Orbscan (Bausch & Lomb) and pachymetry examinations, and a hyperopic shift of almost +6 diopters was observed in the refractive error in both eyes. These examinations showed a gradual recovery of stromal thickness after copious hydration with balanced salt solution. The UCVA was 1.0 in both eyes after corneal rehydration.

Ultrasound biomicroscopy in pigmented conjunctival cystic nevi.

PURPOSE: To report the use of ultrasound biomicroscopy in the clinical diagnosis and management of pigmented conjunctival cystic nevi. METHOD: Two patients, aged 11 and 18 years, with rapidly growing raised conjunctival melanocytic lesions suspected to be inflamed juvenile conjunctival nevus underwent ultrasound biomicroscopic and histopathologic examinations. RESULTS: Ultrasound biomicroscopic examination of the lesions revealed multiple areas of cystic tissue, which is compatible with pathologic finding of compound nevus with epithelial inclusion cysts formation. Furthermore, clear interface was found between the mass and the underlying sclera. CONCLUSION: Pigmented conjunctival nevi may obscure cysts under slit-lamp examination. Ultrasound biomicroscopy is a useful diagnostic adjunct to distinguish cysts in conjunctival lesions. Additionally, this technique may be helpful in delineating the extent of lesions prior to excision biopsy.

Mid-term follow-up of Nd:YAG laser iridotomy in Asian eyes.

BACKGROUND AND OBJECTIVE: To assess the long-term results of Nd:YAG laser iridotomy in the treatment of patients with primary angle-closure glaucoma and occludable angles to evaluate the risk-benefit ratio and the role of gonioscopy in predicting the outcome after Nd:YAG laser iridotomy. PATIENTS AND METHODS: The records of 138 consecutive patients (231 eyes) who underwent Nd:YAG laser iridotomy in one hospital during 3 years (from 1989 to 1991) were reviewed. The mean follow-up period was 51 months. RESULTS: Of all eyes, 25.1% were treated for chronic angle-closure glaucoma and 10.8% were treated for acute angle-closure glaucoma; most eyes (64.1%) underwent prophylactic iridotomy for occludable angles. Decreased intraocular pressure (IOP) was noted in most eyes after Nd:YAG laser iridotomy; only 10 eyes required further filtration surgery. Visual acuity was unchanged or improved in 97.9% of all eyes at the 6-month visit. Cataract progression was primarily responsible for those eyes with decreased acuity. Ninety-seven percent of eyes had quantitatively wider angles after laser treatment; 8 of 14 eyes with peripheral anterior synechiae of more than 270 degrees underwent further surgery to control IOP. Transient elevated IOP and iris bleeding occurred in 23.5% and 12.2% of the eyes, respectively; other complications were rare. CONCLUSION: Nd:YAG laser iridotomy is a safe and effective procedure for the treatment and prevention of angle-closure glaucoma. Gonioscopy is useful to predict the outcome after Nd:YAG laser iridotomy.

Feasibility of ablative fractional laser-assisted drug delivery with optical coherence tomography.

Fractional resurfacing creates hundreds of microscopic wounds in the skin without injuring surrounding tissue. This technique allows rapid wound healing owing to small injury regions, and has been proven as an effective method for repairing photodamaged skin. Recently, ablative fractional laser (AFL) treatment has been demonstrated to facilitate topical drug delivery into skin. However, induced fractional photothermolysis depends on several parameters, such as incident angle, exposure energy, and spot size of the fractional laser. In this study, we used fractional CO2 laser to induce microscopic ablation array on the nail for facilitating drug delivery through the nail. To ensure proper energy delivery without damaging tissue structures beneath the nail plate, optical coherence tomography (OCT) was implemented for quantitative evaluation of induced microscopic ablation zone (MAZ). Moreover, to further study the feasibility of drug delivery, normal saline was dripped on the exposure area of fingernail and the speckle variance in OCT signal was used to observe water diffusion through the ablative channels into the nail plate. In conclusion, this study establishes OCT as an effective tool for the investigation of fractional photothermolysis and water/drug delivery through microscopic ablation channels after nail fractional laser treatment.

Monitoring of wound healing process of human skin after fractional laser treatments with optical coherence tomography.

Fractional photothermolysis induced by non-ablative fractional lasers (NAFLs) or ablative fractional lasers (AFLs) can remodel the skin, regenerate collagen, and remove tumor tissue. However, fractional laser treatments may result in severe side effects, and multiple treatments are required to achieve the expected outcome. Thus, the treatment outcome and downtime after fractional laser treatments are key issues to determine the following treatment strategy. In this study, an optical coherence tomography (OCT) system was implemented for in vivo studies of wound healing after NAFL and AFL treatments. According to the OCT scanning results, the laser-induced photothermolysis including volatilization and coagulation could be morphologically identified. To continue monitoring the wound healing process, the treated regions were scanned with OCT at different time points, and the en-face images at various tissue depths were extracted from three-dimensional OCT images. Furthermore, to quantitatively evaluate the morphological changes at different tissue depths during wound healing, an algorithm was developed to distinguish the backscattering properties of untreated and treated tissues. The results showed that the coagulation damage induced by the NAFLs could be rapidly healed in 6 days. In contrast, the tissue volatilization induced by AFLs required a longer recovery time of 14 days. In conclusion, this study establishes the feasibility of this methodology as a means of clinically monitoring treatment outcomes and wound healing after fractional laser treatments.

Peripheral vascular endothelial dysfunction in glaucomatocyclitic crisis: a preliminary study.

PURPOSE: Glaucomatocyclitic crisis (GCC) is a syndrome of recurrent unilateral increased intraocular pressure associated with mild cyclitis and few clinical symptoms. This study was undertaken to assess brachial artery endothelium-dependent flow-mediated vasodilation (FMD) as an indicator of vascular endothelial function, to describe the association between GCC and endothelial dysfunction excluding age effects. METHODS: This prospective study was conducted from January 2007 to April 2009 and included 12 patients with GCC and 15 age-matched normal control subjects. Detailed clinical parameters were reviewed, including highly sensitive C-reactive protein (hs-CRP), homocysteine, anti-SSA, anti-cardiolipin antibodies, and HLA type. Brachial artery FMD and endothelium-independent, nitroglycerin-mediated vasodilation (NMD) were studied by using high-resolution, two-dimensional (2-D) ultrasonic imaging. RESULTS: Twelve patients with GCC were evaluated. The mean age of the patients was 36.3 years including 5 (41.6%) women and 7 (58.4%) men. There were no significant differences between patients with GCC and control subjects with regard to basal data, including body mass index, smoking, blood pressure, complete blood count, and routine blood biochemistries. Homocysteine and hs-CRP were within normal limits. Two (16.7%) patients were positive for HLA-B27, anti-SSA, and anti-cardiolipin antibodies. The nitroglycerin-mediated vasodilation in the patients with GCC was not significantly different from that of the control group. The FMD was much lower in the GCC group than in the control groups (mean 4.81% vs. 7.89%, P < 0.01). CONCLUSIONS: The significantly lower FMD in patients with GCC implies peripheral vascular endothelial dysfunction. However, in the 16.7% positive for the HLA-B27, anti-SSA, and anti-cardiolipin antibodies, these parameters are associated with GCC and abnormal FMD.

Warm and neutral tumescent anesthetic solutions are essential factors for a less painful injection.

BACKGROUND: Tumescent local anesthesia is widely used in dermatologic surgery. Minimizing pain associated with injections is crucial to successful surgical procedures. OBJECTIVE: This study investigates the pain associated with warm and room temperatures in neutralized or nonneutralized tumescent anesthetic solutions injection. METHODS: Thirty-six patients with axilla osmidrosis who underwent local anesthesia for surgery were randomly assigned to three groups. Group A received warm neutral (40 degrees C) and room-temperature neutral (22 degrees C) tumescent injections to each axillary region. Group B received warm neutral (pH 7.35) and warm nonneutral (pH 4.78) tumescent injections on each side of axilla. Group C received warm nonneutral and room-temperature nonneutral tumescent injections on each side of axilla. Pain associated with infiltration of anesthesia was rated on a visual analog scale (VAS). RESULTS: A statistically significant decrease (p < .001) in pain sensation was reported on the warm, neutral injection side (mean rating, 32.7 mm) compared with the room-temperature, neutral injection side (mean rating, 53.3 mm). Patient-reported pain intensity was significantly lower on the side that received warm, neutral tumescent anesthesia (mean rating, 26.8 mm) than on the side receiving warm, nonneutral tumescent anesthesia (mean rating, 44.9 mm; p < .001). The difference in VAS scores between warm neutral (mean rating, 23.9 mm) and room-temperature nonneutral (mean rating, 61.2 mm) was statistically significant (p < .001). CONCLUSION: The warm, neutral tumescent anesthetic preparation effectively suppressed patient pain during dermatologic surgical procedures.

Regressed subungual melanoma simulating cellular blue nevus: managed with sentinel lymph node biopsy.

BACKGROUND: Subungual melanoma, a not uncommon presentation of cutaneous melanoma in Asian populations, is easily overlooked as benign and thus is improperly treated. OBJECTIVE: To present two cases with clinical suspicion of subungual melanoma. Skin biopsies failed to demonstrate the diagnostic features of malignancy. METHODS: Lymphoscintigraphy and sentinel lymph node (SLN) biopsies were performed to determine regional lymph node status. RESULTS: Both hematoxylin-eosin and HMB45 staining revealed melanoma cells in the SLN of the patient. The second patient's SLN was negative for malignant cells, but her excised primary lesion showed extensive regressed melanoma. CONCLUSION: Regression phenomena are not uncommon for subungual melanoma. An extention biopsy techniques are useful for determining nodal basin status in regressed subungual melanoma.