Lack of Association between Seropositivity of Vasculopathy-Related Viruses and Moyamoya Disease.

OBJECTIVES: Although the association between genetic factors, such as RNF213 mutations, and moyamoya disease (MMD) has been well investigated, environmental factors are largely undetermined. Thus, we aimed to examine whether viral infection increases the risk of MMD. MATERIALS AND METHODS: To eliminate the effect of presence or absence of the RNF213 p.R4810K mutation, the entire study population was positive for this mutation. We collected whole blood from 111 patients with MMD (45 familial and 66 sporadic cases) and 67 healthy volunteers, and we measured the immunoglobulin G titer of 11 viruses (cytomegalovirus, varicella-zoster virus, measles virus, rubella virus, herpes simplex virus, mumps virus, Epstein-Barr virus, human parvovirus B19, human herpesvirus 6 [HHV6], human herpesvirus 8, and John Cunningham virus) that were presumed to be associated with vasculopathy using the enzyme-linked immunosorbent assay. Positivity for past viral infection was determined by cut-off values obtained from previous reports and the manufacturer's instructions, and the positive rate was compared between cases and age- and sex-matched controls. We performed familial case-specific and sporadic case-specific analyses, as well as a case-control analysis. RESULTS: There was no significant difference in the positive rate between the case group and the control group in any of the analyses. A significant difference was only observed in the combined case-control analysis for HHV6 (p = 0.046), but the viral antibody-positive rate in control individuals was higher than in MMD cases. CONCLUSIONS: Our cross-sectional study suggest that the investigated 11 viruses including HHV6 are unlikely to have an impact on MMD development.

Movement of the lacrimal canalicular wall under intracanalicular pressure changes observed with dacryoendoscopy.

BACKGROUND: Movement of the lacrimal canalicular wall has been speculated to occur during blinking. Movement of the common internal ostium has been observed under nasal endoscopy, and pressure changes in the lacrimal canalicular cavity have been observed with a pressure sensor; however, lacrimal canalicular wall movement under pressure changes has not been observed. PURPOSE: To examine movement of the lacrimal canalicular wall under intracanalicular pressure changes using dacryoendoscopy. METHODS: The authors examined 20 obstruction-free lacrimal canaliculi in 10 patients. A dacryoendoscope was inserted, and water was poured into the intracanalicular cavity via the dacryoendoscope's water channel. The water was then poured or suctioned to cause positive or negative pressure changes in the intracanalicular cavity, and movement of the lacrimal canalicular wall was examined. RESULTS: The lacrimal canalicular wall moved flexibly with pressure changes. Under positive pressure, the intracanalicular cavity was dilated; however, it narrowed under negative pressure. The extent of movement was more dramatic in the common canalicular portion than the proximal canalicular portion. CONCLUSIONS: Intracanalicular pressure changes cause movement of the lacrimal canalicular wall. There was a consistent relationship between intracanalicular cavity changes and pressure changes, possibly contributing to lacrimal drainage of the canaliculus.

Intraocular pressure change with eye positions before and after orbital decompression for thyroid eye disease.

PURPOSE: To examine intraocular pressure (IOP) changes in primary and upward gazes before and after orbital decompression in patients with thyroid eye disease. METHODS: Seventy-eight orbits of 40 patients who underwent orbital decompression between June 2010 and September 2012 were retrospectively reviewed. Subjects were divided in 2 groups according to the number of orbital walls removed: deep lateral orbital wall decompression group (Group A) or balanced decompression group (Group B). IOP was measured using Goldmann applanation tonometry in primary gaze and a 20° upward gaze before and 3 months after surgery. RESULTS: Preoperative IOP in upward gaze (18.7 mm Hg) was higher than in primary gaze (15.7 mm Hg, p < 0.001). Postoperative IOP reduction in upward gaze (3.8 mm Hg) was greater than in primary gaze (1.7 mm Hg, p < 0.001). Although the overall postoperative IOP in upward gaze (14.9 mm Hg) remained higher than in primary gaze (14.0 mm Hg, p = 0.038), the gaze-related IOP demonstrated no significant difference in all subgroups (Group A, p = 0.091; Group B, p = 0.332). CONCLUSIONS: IOP in upward gaze was higher prior to orbital decompression, but reduction was greater postoperatively and approximated the IOP in primary gaze.

Upper eyelid reconstruction by making a skin defect similar to skin removal in blepharoplasty.

A 49-year-old man had a sebaceous gland carcinoma in the right upper eyelid. The tumor was excised with an additional 5-mm safety margin. The posterior lamellar reconstruction was performed with a reverse modified Hughes flap and residual conjunctiva. The anterior lamellar reconstruction was performed by making a skin defect similar to a skin removal in blepharoplasty. The skin excision part was designed next to the upper portion of the defect, and the excised skin was grafted to the lower portion of the defect. The skin was closed after making 3 buried double eyelid anchors. The conjunctival pedicle was severed 2 weeks postoperatively. Three months later, the appearance was acceptable without a harmful functional outcome. The basic concepts of our procedure were to make an accustomed scenery, such as a defect similar to a skin removal in blepharoplasty, from an unfamiliar one, such as a defect after a tumor excision, and to make good use of the excised tissue.

Divergent thinking as a predictor of life skills in patients with schizophrenia: Evidence from the modified Tinkertoy Test.

Aim: Patients with schizophrenia often exhibit poor life skills, posing significant clinical challenges. Life skills comprise cognitive functions crucial for planning daily activities, including divergent thinking. However, the cognitive deficits contributing to these diminished skills among patients with schizophrenia are underexplored. This study introduces a modified Tinkertoy Test (m-TTT) to investigate the correlation between life skills, divergent thinking, and psychological assessment tools in patients with schizophrenia. Methods: Fifty-two patients with schizophrenia, alongside a control group, matched for sex, age, and education, were evaluated using psychological assessment tools. For the patient group, the Life Skills Profile (LSP) and Positive and Negative Syndrome Scale were administered to measure functional abilities and psychiatric symptoms, respectively. Additionally, duration of disease and antipsychotic daily dosage levels were assessed exclusively in the patient group. Both groups were evaluated with the m-TTT, Idea Fluency Test (IFT), Design Fluency Test (DFT), and Brief Assessment of Cognition in Schizophrenia (BACS) to comprehensively assess cognitive functions. A stepwise multiple regression model was conducted to identify significant correlates of LSP total score among the patient group. Results: The schizophrenia group scored notably lower than the neurotypical controls on the m-TTT, IFT, DFT, and BACS. Our stepwise multiple regression analysis highlighted that the LSP total score was significantly correlated with the total m-TTT score and presence of negative symptoms. Conclusion: Divergent thinking could be a crucial factor in the life skills of individuals with schizophrenia. Rehabilitation programs based on this cognitive function might enhance their daily living capabilities.

Dacryoendoscopic findings in the lacrimal passage in failed dacryocystorhinostomy.

PURPOSE: To examine the appearance of the lacrimal passage using dacryoendoscopy in failed dacryocystorhinostomies, examining the relationship between the remnant lacrimal sac mucosa and the obstruction tissue, and to detect canalicular obstruction. METHODS: Twenty failed dacryocystorhinostomies (4 right and 16 left) in 19 Japanese patients (8 males and 11 females) aged 36 to 81 years (average, 69.5 years) were reviewed. Dacryoendoscopy was used to examine the lacrimal passage of the failed dacryocystorhinostomies. RESULTS: An occluded space was found with no adhesion between the remnant lacrimal sac mucosa and the fibrous obstruction tissue in every failed dacryocystorhinostomy. None of the lacrimal canaliculi or the common internal ostia was obstructed. CONCLUSIONS: A space without adhesion between the remnant lacrimal sac mucosa and the obstruction tissue was visualized in all the failed dacryocystorhinostomies. No canalicular stenosis was seen, including the common internal ostium, in this cases. Based on these results, endoscopic revision for failed dacryocystorhinostomies is a safe procedure, performed without orbital fat prolapse.

Dacryoendoscopic findings of intracanalicular punctal plug migration with or without canaliculitis.

An 83-year-old woman with Sjögren syndrome underwent insertion of large punctal plugs in the right upper and lower puncti. Nine months later, she presented with upper canaliculitis, although the plugs were not found in the puncti. Dacryoendoscopic examination revealed punctal plug migration, granulation, and a large amount of debris in the upper canaliculus. The plug was situated parallel to the canaliculus, occluding the intracanalicular space. The lower canaliculus also showed plug migration, but little granulation and debris were present. The plug was situated perpendicular to the intracanalicular space, securing a space around the plug. The migrated plugs were pushed directly toward the nasal cavity by the dacryoendoscope. Curettage was performed in the upper canaliculi. Bicanalicular silicone intubation was performed, and removal was performed 3 months later. The patient remained symptom-free for 6 months postoperatively.

Horizontal orientation of the bony lacrimal passage: an anatomical study.

PURPOSE: To examine the horizontal orientation of the bony lacrimal passage. METHODS: The orbits and bony nasolacrimal canals (BNLCs) from 28 Japanese cadavers (11 men and 17 women; average age at death, 83.6 years; range, 70-99 years) were fixed and exenterated before use. After exposing the posterior halves of the lacrimal fossa (LF) and the BNLC, the authors measured the angles of the longitudinal axes of the LF and the BNLC relative to the sagittal line. Based on these values, the relative horizontal orientation of the LF and the BNLC was determined (ΔBNLC-LF). Positive angles of LF and BNLC were defined when the LF and BNLC were directed laterally against the sagittal line. A positive ΔBNLC-LF was defined as having a greater angle for the LF than for the BNLC. RESULTS: The mean LF and BNLC angles, and the ΔBNLC-LF were 11.9°, 0.1°, and 11.8°, respectively. The LF inclined laterally against the sagittal plane for all sides and the BNLC ran almost parallel to sagittal plane on average. The BNLC inclined inward against the sagittal line (0° or negative BNLC angle) for 28 sides (50.0%) and inclined outward (positive BNLC angle) for 28 sides (50.0%). The angle of the LF in women was statistically greater than that in men, though no gender BNLC angle or ΔBNLC-LF differences were determined. CONCLUSIONS: The horizontal angle of the bony lacrimal passage differs among individuals, with an equal split between medial and lateral inclinations of the BNLC with reference to the sagittal line.

Anatomy of secretory glands in the eyelid and conjunctiva: a photographic review.

The eyelid and conjunctiva are main targets in ophthalmic plastic surgery. Although dry eyes are known to occasionally occur after ophthalmic plastic surgery, little attention has been paid to the secretory glands in the eyelid and conjunctiva. The secretary glands in the eyelid and conjunctiva contain the main lacrimal gland, accessory lacrimal glands of Wolfring and Krause, goblet cells, ciliary glands of Moll and Zeis, and the meibomian gland of the tarsal plate. Understanding the details of these glands is helpful in preventing and managing secretion reduction after oculoplastic procedures.

The narrowest part of the bony nasolacrimal canal: an anatomical study.

PURPOSE: To determine the narrowest diameter of the bony nasolacrimal canal. METHODS: Fifty-eight bony nasolacrimal canals from 29 Japanese cadavers (12 men and 17 women; average age at death, 83.4 years; range, 70-99 years) had been fixed in 10% buffered formalin before use. After exposing the medial (44 canals) or posterior half (14 canals) of the bony nasolacrimal canal, the part with the shortest anteroposterior or transverse diameter was determined on inspection. These positions from the canal entrance were measured, and the distance ratio, indicating where the shortest diameter was located in relation to the total length of the canal, was calculated. RESULTS: The shortest anteroposterior and transverse diameters were at the entrance to the canal in 32 of 44 canals (72.7%) and in 9 of 14 canals (64.3%), respectively. In the other canals, the shortest anteroposterior and transverse diameters were located at an average of 3.6 and 5.6 mm from the entrance, and the distance ratios were 29.0% and 46.7%, respectively. The mean shortest anteroposterior and transverse diameters were 5.6 and 5.6 mm, respectively. CONCLUSIONS: The shortest anteroposterior and transverse diameters were at the entrance of the canal in most of the bony nasolacrimal canals. These results are comparable with the rate of obstruction at the canal entrance in primary acquired nasolacrimal duct obstruction.

Dacryoendoscopic findings of lacrimal passage with congenital punctal atresia.

A 43-year-old woman presented with epiphora caused by upper and lower congenital punctual atresia with papilla. She underwent 2-snip punctoplasty and intubation under local anaesthesia. During the surgery, a dacryoendoscopic examination was performed. After performing the punctoplasty, the lacrimal passage was confirmed to have complete canalisation to the nasal cavity. Both upper and lower canaliculi appeared to be narrower and had difficult expansion compared with canaliculi in congenital nasolacrimal duct obstruction or primary acquired nasolacrimal duct obstruction without canalicular stenosis. The lacrimal sac and the nasolacrimal duct also showed complete canalization with normal colour.

Intra-sac portion of the lacrimal canaliculus.

PURPOSE: The aim of this study was to examine the length and diameter of the intra-sac portion of the lacrimal canaliculus and to propose a modified functional valve model at the common internal ostium. METHODS: We examined 14 eyelid and orbital specimens from 10 cadavers (seven right, seven left; aged 45-85 years at death), fixed in 10% buffered formalin. Sliced specimens were dehydrated and embedded in paraffin, cut into 7 µm thickness sections, and stained with Masson's trichrome. We then measured the length and diameter of the intra-sac portion of the lacrimal canaliculus. RESULTS: The average length of the intra-sac portion of the lacrimal canaliculus was 1344.9 µm (range, 920.2-1821.5 µm), and its average diameter was 287.5 µm (range, 199.1-523.3 µm). CONCLUSION: The intra-sac portion of the lacrimal canaliculus had an average length and diameter of 1344.9 µm and 287.5 µm, respectively. The lacrimal sac mucosa changes its thickness with autonomic stimulation, and the length and diameter of the intra-sac portion of the lacrimal canaliculus is likely changed concurrently. The long length and small diameter of the intra-sac lacrimal canaliculus presumably contribute to it acting as an autonomic functional valve at the common internal ostium.

Increased abundance of Ruminococcus gnavus in gut microbiota is associated with moyamoya disease and non-moyamoya intracranial large artery disease.

Moyamoya disease (MMD) is a rare cerebrovascular disease endemic in East Asia. The p.R4810K mutation in RNF213 gene confers a risk of MMD, but other factors remain largely unknown. We tested the association of gut microbiota with MMD. Fecal samples were collected from 27 patients with MMD, 7 patients with non-moyamoya intracranial large artery disease (ICAD) and 15 control individuals with other disorders, and 16S rRNA were sequenced. Although there was no difference in alpha diversity or beta diversity between patients with MMD and controls, the cladogram showed Streptococcaceae was enriched in patient samples. The relative abundance analysis demonstrated that 23 species were differentially abundant between patients with MMD and controls. Among them, increased abundance of Ruminococcus gnavus > 0.003 and decreased abundance of Roseburia inulinivorans < 0.002 were associated with higher risks of MMD (odds ratio 9.6, P = 0.0024; odds ratio 11.1, P = 0.0051). Also, Ruminococcus gnavus was more abundant and Roseburia inulinivorans was less abundant in patients with ICAD than controls (P = 0.046, P = 0.012). The relative abundance of Ruminococcus gnavus or Roseburia inulinivorans was not different between the p.R4810K mutant and wildtype. Our data demonstrated that gut microbiota was associated with both MMD and ICAD.

Influence of Intrauterine Inflammation, Delivery, and Postnatal Feeding on the Temporal Changes of Serum Alpha 1 Acid Glycoprotein Levels in Extremely-Low-Birth-Weight Infants.

Infection remains the primary cause of death in extremely-low-birth-weight infants (ELBWIs). Alpha 1 acid glycoprotein (α1AG), an acute-phase protein, has been shown to be elevated in sporadic cases of septic ELBWIs prior to abnormal clinical signs. To delineate the roles of inflammation, delivery, and feeding in postnatal α1AG changes in ELBWIs, 75 ELBWIs of 26.5 ± 2.2 weeks of gestation born between May 2011 and August 2017 were retrospectively studied. The dependence of α1AG levels obtained on days 0−5 on the clinical variables was examined by incorporating interactions with age, followed by estimations of regression coefficients between clinical variables and α1AG levels at the early and late postnatal ages, defined by their standard deviation. Chorioamnionitis (p < 0.001), funisitis (p = 0.045), vaginal delivery (p = 0.025), enteral feeding (p = 0.022), and probiotics (p = 0.005) were associated with early α1AG elevations. Hypertensive disorder of pregnancy (p < 0.001) and gestational age (p = 0.001) were associated with late α1AG elevation; premature rupture of membranes (p < 0.001), funisitis (p = 0.021), body weight z-scores (p < 0.001), and enteral feeding (p = 0.045) were associated with late α1AG reduction. Postnatal α1AG changes in ELBWIs were associated with variables representative of age, growth, delivery, inflammation, and enteral feeding, potentially reflecting the process of sensitization to extrinsic microbes in utero, at birth, and thereafter.

Repair of blowout orbital floor fracture by periosteal suturing.

The study objective was to evaluate the outcome of a periosteal suturing technique in eyes with orbital blowout fractures. Fifteen orbital floor fractures were classified into: type 1, linear fracture; type 2, middle fracture; and type 3, posterior fracture extending two-thirds into the orbit. The feasibility of periosteal suturing without silicone plates or one of minimal size was determined. The improvement of ocular movements and surgical complications were evaluated. A complete suture of the torn periosteum without implanting a silicone plate was achieved in 2/2 (100%) type 1 cases, 5/7 (71%) type 2 cases and 0/6 (0%) type 3 cases. A partial fixation was achieved in 3/6 (50%) type 3 cases with an implantation of a silicone plate of approximate one-third of the usual size in one case. Conventional surgery with silicone plates after failed periosteal suture was required in 2/7 (29%) type 2 cases and 3/6 (50%) type 3 cases. Eye movements were improved postoperatively in all eyes, and a complete range of eye movements was achieved in 6/7 (86%) cases with complete periosteal closure, 1/3 (33%) of cases with partial closure and 2/5 (40%) cases without closure. In conclusion, periosteal suturing can minimize the need for silicone plates especially for anterior or middle orbital floor factures.

The parafascicular nucleus relays spinal inputs to the striatum: an electron microscope study in the rat.

A disynaptic projection from the spinal cord to the striatum was observed in the rat light and electron microscopically. An anterograde tracer, wheat germ agglutinin conjugated to horseradish peroxidase was injected into the ventral gray matter of the upper cervical spinal cord, and a retrograde tracer, biotinylated dextran amine was injected into the striatum of a rat. Then the parafascicular nucleus was examined. Some anterogradely labeled axon terminals originating in the spinal cord were observed to synapse with retrogradely labeled dendrites of parafascicular nucleus neurons which sent axons to the striatum. We concluded that information from the spinal cord was transmitted to the striatum, being relayed by parafascicular nucleus neurons.

Reconstructive Surgery of the Upper Eyelid Using the Residual Tarsus after Excision of Sebaceous Gland Carcinoma.

PURPOSE: To report a successful eyelid reconstruction performed using the residual tarsus after excision of a sebaceous gland carcinoma. CASE REPORT: An 86-year-old woman presented with a sebaceous gland carcinoma of the upper eyelid margin. After excision of the tumor, she underwent reconstructive surgery of the superior eyelid performed using the residual tarsus. Because the tumor was localized on the upper lid margin, a tarsus of about 4-5 mm in height remained after the excision; we therefore used the residual tarsus to reconstruct the upper eyelid. No functional or cosmetic problems arose as a result of this method. CONCLUSIONS: Reconstructive surgery of the upper eyelid using the residual tarsus may be a viable option provided that surgeons can ensure a sufficient safety margin, and that more than 4 mm of the tarsus remains.

Carcinosarcoma of the lacrimal gland arising from a pleomorphic adenoma.

PURPOSE: To report a case of the lacrimal gland tumor diagnosed as carcinosarcoma (true mixed tumor) arising from a pleomorphic adenoma. DESIGN: Interventional case report. METHODS: An 80-year-old Japanese woman was referred with a well-circumscribed tumor in the lacrimal fossa. RESULTS: The tumor was excised, but the deepest portion remained because of heavy bleeding. Histopathologically, the tumor consisted of osteosarcomatous cells. No epithelial or myoepithelial component was identified by immunohistochemistry. Two months later, the tumor progressed further and was excised completely with lateral orbitotomy. The tumor consisted primarily of osteosarcomatous component but also had epithelial components including carcinoma and pleomorphic adenoma. Examinations did not detect local recurrence and metastasis at 10 post-operative months. CONCLUSION: The tumor was diagnosed as true carcinosarcoma of the lacrimal gland arising from a pleomorphic adenoma. When lacrimal gland tumors containing sarcomatous components are encountered, carcinosarcoma should be included in the differential diagnosis.