Descemet stripping and automated endothelial keratoplasty (DSAEK) versus non-Descemet stripping and automated endothelial keratoplasty (nDSAEK) for bullous keratopathy.

PURPOSE: To investigate the long-term results of Descemet stripping and automated endothelial keratoplasty (DSAEK) versus non-Descemet stripping and automated endothelial keratoplasty (nDSAEK) for non-Fuchs bullous keratopathy. STUDY DESIGN: Retrospective comparative study. METHODS: Twenty-nine eyes of 28 patients who underwent DSAEK and 60 eyes of 56 patients who underwent nDSAEK for bullous keratopathy were retrospectively analyzed in a clinical case-control study. All the operations were done using precut donor buttons prepared by overseas eye banks. The recipient Descemet membrane was stripped in DSAEK, whilst it was left intact in nDSAEK. Donor buttons were inserted through a 4.2-mm corneal incision using the pull-through technique. Air was injected into the anterior chamber at the end of the operation. We investigated the visual acuity, refraction, endothelial cell density, and complications. RESULTS: The average best spectacle-corrected visual acuity (BSCVA) was significantly improved at all time points measured after surgery in both the DSAEK and the nDSAEK groups, and no significant differences were found between the 2 groups after surgery. No significant differences in spherical equivalent were found between the groups before and after surgery. The endothelial cell density gradually decreased after the operation in both groups; however, no significant difference between the 2 groups was found at any of the time points measured. CONCLUSIONS: DSAEK and nDSAEK provided excellent refractive and reasonable visual outcomes in our long-term observation.

[A Clinical Case Report Including In Vivo Laser Confocal Microscopic Findings of Keratitis Complicated with Takayasu's Arteritis].

BACKGROUND: We present a clinical case report including in vivo laser confocal microscopic findings of keratitis complicated with Takayasu's arteritis (aortitis syndrome). CASE: A 47-year-old woman was referred to the outpatient clinic of ophthalmology with blurred vision in her both eyes at the onset of Takayasu's arteritis. Since multifocal infiltrates in the stromal corneas with injection were observed with slit-lamp biomicroscope in the both eyes, the diagnosis was keratitis. A large amount of cells infiltrating the stromal cornea and activated keratocytes were also observed with in vivo laser confocal microscope in the both eyes. Systemic and local steroidal agents were initiated, which resolved the keratitis, and the active lesions turned into mild corneal scars. In vivo laser confocal microscopy showed no infiltrating cells in the stromal cornea of both eyes. No recurrence has been observed since. CONCLUSION: A rare case of keratitis complicated with Takayasu's arteritis is reported. An immune response to the stromal cornea as the etiology of the keratitis may be indicated by in vivo laser confocal microscopy.

Advanced dry eye screening for visual display terminal workers using functional visual acuity measurement: the Moriguchi study.

PURPOSE: To evaluate the validity of a dry eye (DE) screening method in visual display terminal (VDT) workers using functional visual acuity (VA) measurement combined with a symptoms questionnaire, and to make recommendations regarding practical use of the screening. METHODS: This prospective cross-sectional study included 369 young and middle-age office workers, who use VDTs. Subjects completed two types of DE questionnaires and underwent DE testing and functional VA measurement. Subjects were assigned to DE and non-DE groups. Sensitivity and specificity of the DE prediction value were assessed. According to the probability distribution of DE and non-DE calculated by the discriminant analysis formula, we classified subjects into three categories based on the most appropriate cut-off levels. Positive predictive value (PPV) and negative predictive value (NPV) of the DE prediction value were also assessed. RESULTS: Of 369 subjects, 218 and 151 subjects were assigned to the DE and non-DE groups, respectively. Sensitivity and specificity were 93.1% and 43.7%, respectively. Based on the probability prediction, the cut-off levels were defined as probability prediction ≥ 85%, 45% ≤ probability prediction < 85% and probability prediction < 45%. Subjects with a probability prediction ≥ 85% were defined positive (N = 130), while those with values < 45% were defined as negative (N = 73). The PPV and NPV were 83.8% and 80.8%, respectively. CONCLUSIONS: Acceptable PPV and NPV were obtained by setting three discriminate categories. This improved version of the DE screening method may be acceptable for practical use in VDT workers.

Screening of dry eye disease in visual display terminal workers during occupational health examinations: The Moriguchi study.

PURPOSE: The aim of this study was to estimate the prevalence of dry eye disease (DED) in Japanese visual display terminal (VDT) workers and identify simple methods for screening DED during occupational health examinations. METHODS: This study involved 369 (331 men and 38 women; mean age, 44.4 [8.8] years) workers engaged in PC development with approximately 6 hours of VDT use daily. The participants completed questionnaires on dry eye and physical symptoms affecting QoL, and their ability to keep their eyes open for 10 seconds was tested for DED screening. They also underwent assessment of conjunctival and corneal vital staining with lissamine green and fluorescein, measurement of tear film breakup time, and Schirmer's test for DED diagnosis. Sensitivity, specificity, and positive predictive value of the screening methods were assessed. RESULTS: The DED group included 218 (definite, 14; probable, 204) participants. They had markedly high frequencies of 11 dry eye symptoms, especially ocular fatigue (OR, 17.1; 95% CI, 9.9 to 29.7) and dry sensation (OR, 8.2; 95% CI, 3.6 to 18.4), and were more often unable to keep their eyes open for 10 s. With either ocular fatigue or dry sensation as the cutoff criterion, the sensitivity, specificity, and positive predictive value were 89.9, 66.9, and 79.7%, respectively. CONCLUSIONS: Approximately 60% of the VDT workers were diagnosed with DED on the basis of diverse eye symptoms affecting their ability to work. The dry eye symptom questionnaire and 10-s eye-opening test are simple, noninvasive, and inexpensive methods for screening DED during occupational health examinations.

Possible involvement of epithelial-mesenchymal transition in fibrosis associated with IgG4-related Mikulicz's disease.

OBJECTIVE: Immunoglobulin G4 (IgG4)-related Mikulicz's disease (MD) is a fibrosis-associated inflammatory disease, often accompanied by lacrimal gland swelling. Although much attention has been paid to the inflammatory aspects of this disease, the mechanisms of the fibrotic processes are still unclear. We focused on the fibrotic changes occurring in the lacrimal glands of IgG4-related MD patients, by examining molecules involved in the epithelial-mesenchymal transition (EMT). METHODS: Lacrimal gland tissue specimens were obtained from 3 IgG4-related MD patients and 3 control patients with Sjögren's syndrome (SS). The glands were examined by immunohistochemistry and transmission electron microscopy. RESULTS: Storiform fibrosis, a characteristic of IgG4-related MD, was observed in the lacrimal glands of IgG4-related MD, but rarely in those of SS. Reduced E-cadherin expression, increased phalloidin-stained filamentous actin, and increased α-smooth muscle actin, snail, and heat-shock protein 47 levels were observed in the lacrimal glands of IgG4-related MD compared with those of SS. Transmission electron microscopy revealed an abnormal periodicity of collagen bundles, and basal membrane thickening in the IgG4-related MD compared with that in the SS tissues. CONCLUSION: EMT-like changes were frequently observed in the lacrimal gland epithelia from patients with IgG4-related MD. Thus, EMT may be involved in the pathology of IgG4-related MD fibrosis.

Short break-up time type dry eye has potential ocular surface abnormalities.

PURPOSE: To describe a case series in which corneal fluorescein staining (CFS) development occurred in short break-up time (s-BUT) dry eyes after a short period during prolonged opening of the eye. METHODS: The study was designed as a clinical case series. Ocular surface evaluations were performed on 13 individuals with s-BUT dry eye. Tear function examinations included Schirmer's test and BUT evaluation. RESULTS: In all 13 cases, the BUT was short, but the tear quantity was not so bad. In all cases, CFS developed following a single eye opening, and the staining was observed at sites that showed as dark spots. In several cases, the CFS disappeared later. CONCLUSION: In this study, we demonstrated that CFS could develop following a single eye opening. Based on our findings, CFS is a dynamic phenomenon rather than a stable indicator of ocular surface abnormalities. Moreover, s-BUT dry eye has the potential to show ocular surface abnormalities.

Combination therapy with diquafosol tetrasodium and sodium hyaluronate in patients with dry eye after laser in situ keratomileusis.

PURPOSE: To evaluate the possible advantages of combination therapy with diquafosol tetrasodium and sodium hyaluronate for dry eye after laser in situ keratomileusis (LASIK). DESIGN: Prospective randomized comparative trial. METHODS: A total of 206 eyes of 105 patients who underwent LASIK were enrolled in this study. Patients were randomly assigned to 1 of 4 treatment groups according to the postoperative treatment: artificial tears, sodium hyaluronate, diquafosol tetrasodium, and a combination of hyaluronate and diquafosol. Questionnaire responses reflecting subjective dry eye symptoms, uncorrected and corrected visual acuity, functional visual acuity, manifest refraction, tear break-up time, fluorescein corneal staining, Schirmer test, and corneal sensitivity were examined before and 1 week and 1 month after LASIK. RESULTS: Distance uncorrected visual acuity was significantly better in the combination group than in the hyaluronate group 1 week and 1 month after LASIK. Near uncorrected visual acuity was significantly better in the combination group than in the artificial tear and diquafosol groups 1 week and 1 month after LASIK. Distance functional visual acuity improved significantly only in the combination group 1 month after LASIK. The Schirmer value in the combination group was significantly higher than that in the hyaluronate group at 1 month after LASIK. Subjective dry eye symptoms in the combination group improved significantly compared with those in the other groups 1 week after surgery. CONCLUSIONS: Our results suggest that hyaluronate and diquafosol combination therapy is beneficial for early stabilization of visual performance and improvement of subjective dry eye symptoms in patients after LASIK.

Evaluation of lipid oxidative stress status in Sjögren syndrome patients.

PURPOSE: We evaluated the levels of lipid oxidative stress markers and inflammatory cells from tears and conjunctiva of patients with Sjögren syndrome (SS) and normal subjects. METHODS: We examined 31 eyes of 16 patients (16 females) with SS and 15 eyes of 10 healthy controls (2 males and 8 females) in this prospective study. All subjects underwent a Schirmer test, measurement of tear film break-up time, vital stainings, confocal microscopy of the conjunctiva, tear collection for hexanoyl-lysine (HEL), ELISA, and conjunctival brush cytology. Brush cytology samples underwent immunohistochemistry (IHC) staining with HEL and 4-hydroxy-2-nonenal (4HNE). Hematoxylin-eosin and IHC staining with HEL and 4HNE also were performed on conjunctival samples of SS patients and controls. RESULTS: The tear stability and vital staining scores were significantly worse in eyes of SS patients compared to the controls. Conjunctival inflammatory cell density was significantly higher in SS subjects compared to controls. The numbers of conjunctival cells stained positively for HEL and 4HNE were significantly higher in SS patients compared to controls. Tear HEL concentrations correlated significantly with staining scores and inflammatory cell density in confocal microscopy. Conjunctival specimens also revealed higher numbers of cells stained positively for inflammatory markers, as well as HEL and 4HNE in the IHC stainings. CONCLUSIONS: Increase of the oxidative stress status in the conjunctiva of SS patients appears to have a role in the pathogenesis of dry eye disease. A close relationship may exist between reactive oxygen species (ROS) production, lipid peroxidation related membrane damage, and inflammatory processes in dry eye.

Simultaneous deep anterior lamellar keratoplasty and limbal allograft in bilateral limbal stem cell deficiency.

PURPOSE: To report the efficacy of simultaneous keratolimbal allograft (KLAL) surgery and deep anterior lamellar keratoplasty (DALK) for limbal stem cell deficiency (LSCD). METHODS: We conducted a retrospective, interventional case series of six consecutive eyes of five patients with LSCD and stromal opacity due to gelatinous drop-like dystrophy (two eyes), Stevens-Johnson syndrome (SJS, two eyes), or aniridia (two eyes). Only patients with normal lid anatomy and Schirmer test values greater than 3 mm were enrolled. DALK was performed by viscodissection followed by a thin, 360° KLAL designed by using an artificial anterior chamber. KLAL sutures were removed after 2 weeks. RESULTS: DALK and KLAL were successfully performed in all eyes, which were followed for an average of 17.2 ± 10.8 months. All eyes recovered a smooth corneal epithelium, although one SJS patient developed a persistent epithelial defect (PED) leading to opacification of the central cornea. Visual acuity improved by more than 2 lines in all eyes except that of the SJS patient with PED. No other complications were observed. CONCLUSION: Simultaneous DALK and thin-section KLAL is an effective treatment for ocular surface disease in patients with residual tear function and normal lid anatomy.

[The short-term results of Descemet's stripping and automated endothelial keratoplasty].

PURPOSE: To investigate the short-term results of Descemet's stripping and automated endothelial keratoplasty (DSAEK) for endothelial dysfunction. MATERIALS AND METHODS: Twenty-three eyes of 23 patients with corneal edema following DSAEK were retrospectively analyzed. Corneal edema following laser iridotomy was the most common cause (13 eyes) followed by pseudophakic bullous keratopathy (5 eyes). Donor buttons prepared by the oversea eye banks were used (pre-cut donor button). They were inserted through a 5-mm incision using either the taco technique (7 eyes) or pull-through technique (16 eyes). After surgery air was injected into the anterior chamber at the end of surgery. Ten patients underwent simultaneous phacoemulsification and posterior chamber intraocular lens implantation. Corneal clarity, visual acuity, astigmatism, and endothelial cell density were investigated. RESULTS: Mean decimal preoperative best-corrected visual acuity was 0.05. Postoperatively, 13/23 (56.5%) patients achieved visual acuity of 0.5 or better at last follow-up. Mean postoperative astigmatism was within 2 D. Mean endothelial cell density of donor corneas was 2567 +/- 294 cells/mm2, and the mean density was 957 +/- 314 cells/mm2 6 months after DSAEK. CONCLUSIONS: DSAEK provided excellent refractive and reasonable visual outcomes in this shortterm observation. Prevention of endothelial loss seems to be the key to long-term success.