Relationship between Image Quality and Reproducibility of Surgical Images in 3D Digital Surgery.

Objectives: Ophthalmic three-dimensional (3D) digital surgery can reproduce high-definition surgical images; however, 3D digital surgery is limited by recording capacities. We examined the relationship between the minimum image quality required to reproduce surgical images and recording capacity. Methods: Patients who underwent simultaneous vitrectomy and cataract surgery by the same surgeon using a 3D digital surgery system at Juntendo University Urayasu Hospital between February and October 2021 were evaluated. Various quality (Q) and frame rate (FR) settings were used for each case. Four vitreous surgeons evaluated the reproducibility of recorded images of macular manipulation for epiretinal membrane (ERM) and macular hole (MH) cases and those of peripheral retinal manipulation for rhegmatogenous retinal detachment (RRD) cases. The video bitrate and minimum settings required to reproduce surgical images and factors affecting surgical image reproducibility were examined. Results: A total of 129 eyes of 129 patients were observed. The minimum image quality required to reproduce surgical images was 11.67 Mbps. The Q and FR for periretinal processing and Q for macular manipulation affected surgical image reproducibility (p = 0.025, p = 0.019, and p = 0.07, respectively). The minimum recording settings required to obtain highly reproducible images were Q = 3 and FR = 40. The total file size for vitrectomy video recordings with these settings was as compact as 3.17 GB for 28 min. Conclusions: During 3D digital surgery, highly reproducible surgical images can be obtained with a small storage capacity using settings of at least Q = 3 and FR = 40.

A Case of Nephrotic Syndrome with Bilateral Serous Retinal Detachment and Shallow Anterior Chamber Associated with Ciliary Body Edema.

Nephrotic syndrome is a disease that causes fluid retention in the body due to loss of protein in the blood, which can lead to serous retinal detachment (SRD) in the macula. We report a case of severe SRD in both eyes and angle closure due to ciliary body edema caused by nephrotic syndrome. A 57-year-old man was admitted to the Department of Nephrology in our hospital for a thorough examination of his generalized edema. He was diagnosed with nephrotic syndrome but proved to be refractory to steroid treatment. Due to distortion symptoms in both eyes on the 30th day of hospitalization, the patient was referred to our department. Best-corrected visual acuity (BCVA) was 0.8 in the right eye and 1.0 in the left eye. Slit lamp examination and anterior segmental optical coherence tomography (OCT) showed shallow anterior chambers in both eyes. Fundus and macular OCT demonstrated severe SRD in the posterior pole of both eyes. After observing the presence of hypoalbuminemia, we considered the possibility of SRD and angle closure due to ciliary edema that resulted from the leaks associated with the nephrotic syndrome. Thereafter, ocular findings improved in conjunction with systemic symptom improvements associated with ultrafiltration and low-density lipoprotein apheresis. On the 60th day of hospitalization, his BCVA improved to 1.2 in both eyes, SRD disappeared, and the anterior chamber depth normalized. This case demonstrates the importance of recognizing SRD and angle closure associated with ciliary body edema as complications linked with nephrotic syndrome.

Factors Affecting a Short-Term Response to Anti-VEGF Therapy in Diabetic Macular Edema.

Diabetic macular edema (DME) is a common cause of visual impairment in patients with diabetes. Although intravitreal anti-vascular endothelial growth factor (VEGF) injections were efficacious in clinical trials, several patients exhibited a poor response. This study aimed to compare clinical features between patients who were susceptible to intravitreal anti-VEGF injections for DME and those who were not. A single-center, retrospective study of 102 such patients was conducted (123 eyes; mean ± standard deviation age, 63.4 ± 10.8 years; 57.8% males). Systemic and ocular data, assessed at baseline and after a month, were compared between good (>20% decrease in central macular thickness (CMT)) and poor (≤20% decrease in CMT) responders using the Mann-Whitney U test/Fisher's exact test. Eighty-one eyes (65.9%) were good responders. The glycosylated hemoglobin level was higher (p = 0.011) in poor (7.5% ± 0.94%) than in good (7.04% ± 1.19%) responders. The foveal avascular zone was larger (p = 0.0003) in poor (0.67 ± 0.33 µm2) than in good (0.47 ± 0.23 µm2) responders. The number of microaneurysms in the pericapillary network was higher (p = 0.0007) in poor (2.7 ± 2.2) than in good (1.4 ± 2.0) responders. Baseline glycemic control and macular ischemia may be associated with the short-term response to intravitreal anti-VEGF injections.

Relationship between Recurrence of Macular Edema Due to Branch Retinal Vein Occlusion and Changes in Choroidal Thickness.

INTRODUCTION: The role of vascular endothelial growth factor in macular edema (ME) due to branch retinal vein occlusion (BRVO) by enhancing vascular permeability has been well studied. ME due to BRVO often recurs; however, there has been no report on the relationship between this recurrence and choroidal thickness (CT), considering the high vascularity of the choroid. This study was designed to investigate this relationship. METHODS: In this retrospective consecutive case series, patients with recurrence of ME within 6 months of receiving intravitreal aflibercept injection treatment for naive ME due to BRVO at Juntendo University Urayasu Hospital were included. Retinal thickness (RT) and CT were measured in the fovea and on the occlusion, non-occlusion, nasal, and temporal sides at baseline, after the first intravitreal aflibercept administration, and before and after recurrence. We also examined the change for each side before and after reinjection. RESULTS: This study included 11 patients and 11 eyes. The subfoveal CT and RT at baseline were 261.9 ± 93.4 µm and 691.5 ± 254.4 µm, respectively, which significantly decreased to 208.5 ± 70.3 µm and 188.6 ± 33.8 µm, respectively, at 1 month after the first injection (p = 0.001 and p < 0.01, respectively). These values also significantly decreased at all the other sites after treatment. There were 14 recurrences within the 6 months following intravitreal aflibercept injection; RT significantly changed at all sites before and after recurrence and reinjection. CT significantly changed at the subfovea and on the occlusion and non-occlusion sides; however, there was no significant change on the nasal and temporal sides. CONCLUSION: In patients with BRVO, the CT around the macula after initial treatment was significantly reduced; however, at the time of ME recurrence and reinjection, there were site-dependent differences in the changes observed in the CT. These findings suggest that the pathologies of ME at initial occurrence and at the time of recurrence are different.

Twenty-four-month results of intravitreal aflibercept for macular edema due to branch retinal vein occlusion.

PURPOSE: To investigate 24-month results of intravitreal aflibercept (IVA) for macular edema due to branch retinal vein occlusion (BRVO-ME). STUDY DESIGN: Retrospective study. METHODS: Subjects were treatment-naïve BRVO-ME patients at the Ophthalmology Department of Juntendo University Urayasu Hospital from November 2015 to March 2017 who received IVA treatment for 24 months. After the first injection, reinjection was performed as needed when ME had recurred or was prolonged beyond 300 µm. Data included changes in best corrected visual acuity and central foveal thickness, total number of injections, and the case background factors that required reinjection after 12 months. ME remission was defined as patients without additional injections for 6 months. RESULTS: Forty eyes of 40 patients (64.5 ± 11.5 years), 21 men and 19 women, were included. Average best corrected visual acuity and central foveal thickness at baseline were logMAR 0.42 ± 0.21, 601.4 ± 181.3 µm, logMAR 0.08 ± 0.25, 214.6 ± 62.7 µm at 12 months, logMAR 0.02 ± 0.16, 216.6 ± 97.8 µm at 24 months, all significantly improved from baseline. The average number of injections was 2.2 ± 1.0 times in the first year and 0.4 ± 0.8 times in the second year. The rate of ME remission was 60.0% at 12 months and 87.5% at 24 months. Period between onset and injections was significantly associated with reinjection after 12 months (p =.030). CONCLUSIONS: IVA was effective over 24 months for ME due to BRVO in many cases. Early injection treatment may reduce the need for later injections.

Three Cases of Creutzfeldt-Jakob Disease with Visual Disturbances as Initial Manifestation.

We report our findings in 3 cases of Creutzfeldt-Jakob disease (CJD) with visual disturbances as the initial manifestations. These cases were found to have the Heidenhain variant of CJD. Two cases initially presented with progressively blurred vision and homonymous hemianopia. The other case initially presented with blurred vision and a decrease in the central sensitivity in both eyes. These 3 cases developed neurological symptoms about 4 weeks after the onset of visual symptoms. All were diagnosed with the Heidenhain variant of CJD based on the clinical course and confirmed by positive assays of the cerebrospinal fluid for the 14-3-3 protein and tau protein. In addition, the diagnosis was confirmed by the findings of diffusion-weighted magnetic resonance imaging and electroencephalography. Patients can present with isolated visual symptoms which precede a decline in cognition by weeks due to the predominantly occipital lobe disease. The 3 patients were referred to the neurology department within 1 month of onset. The early diagnosis was necessary to avoid spread of the infection. In cases of suspected CJD, it is important to consult a neurologist quickly to make a definitive diagnosis of CJD. Ophthalmologists should be aware that visual impairments may be the first indication of CJD.

Upregulation of Mir-21 Levels in the Vitreous Humor Is Associated with Development of Proliferative Vitreoretinal Disease.

MicroRNAs (miRNAs) are small noncoding RNAs that regulate gene expression by post-transcriptional inhibition of mRNA translation. Dysregulation of miRNAs, including circulating miRNAs, has been reported to play an important role in the development of various diseases, including fibrotic diseases. Aberrant expression of miRNAs in the vitreous humor of vitreoretinal diseased eyes has been reported. However, the expression pattern of miRNAs present in the vitreous humor of proliferative vitreoretinal disease (PVD) patients, including proliferative diabetic retinopathy (PDR), and proliferative vitreoretinopathy (PVR), remains unknown. To investigate the factors important for the development of PVD, we characterized the miRNAs present in the vitreous humor of PVD patients and analyzed the expression profiles of 377 miRNAs using quantitative polymerase chain reaction-based miRNA arrays. The expression of a specific subset of miRNAs, previously reported to be associated with the development of angiogenesis and fibrosis, was significantly altered in the vitreous of PVD patients. Among these miRNAs, we identified miR-21 as a candidate fibrotic miRNA with an important role in the pathogenesis of PVD. Increased miR-21 levels in the vitreous were associated with retinal fibrosis, including PVR and PDR. Because epithelial-mesenchymal transition (EMT) of retinal pigment epithelial cells (RPECs) plays a critical role in retinal fibrosis, the expression of miR-21 in human RPECs was determined. Its expression in RPECs was induced by transforming growth factor-ß, a key growth factor involved in fibrogenesis, and was enhanced by high glucose culture conditions, suggesting that miR-21 expression positively correlates with disease progression. Gain- and loss-of-function studies revealed that miR-21 promoted cell proliferation and migration of ARPE-19 cells without affecting EMT-related gene expression. Together, our studies have identified miR-21 as a potential disease-modifying miRNA in the vitreous humor that is involved in the development of retinal fibrosis and may be a novel marker of PVD.

[Effects of vitrectomy as a treatment for proliferative diabetic retinopathy in young patients].

PURPOSE: To investigate the effects of vitrectomy as a treatment for the proliferative diabetic retinopathy (PDR) in patients under 40 years old. METHODS: Sixty eyes of 37 patients under 40 years old with PDR who had undergone vitrectomy for the first time in Juntendo University Urayasu Hospital were included in this study. Preoperative condition, operation methods, visual acuity after operation and complications both during or after operation, especially neovascular glaucoma (NVG), were reviewed retrospectively. RESULTS: Visual acuity improved in 43 eyes (72%) by more than 0.2 logMAR compared to that before the operation, remained stable in 4 eyes (6%) and deteriorated in 13 eyes (22%) by more than 0.2 logMAR compared to that before operation. Optic atrophy and phthisis caused by NVG constituted 69% of the causes of complicated final visual acuity. Male patients and patients who had both hypertension and proteinuria had significantly higher prevalence of NVG after vitrectomy (p < 0.05), and patients who retained their lens after the first vitrectomy had a significantly lower prevalence of NVG after the operation (p < 0.05). CONCLUSIONS: In young PDR patients under 40 years old, postoperative NVG was the main reason for severe visual impairment. Multifactorial causes, both general and ophthalmic seem to be implicated in the onset and progression of NVG derived from PDR.

Intravitreal injection of autologous plasmin enzyme for macular edema associated with branch retinal vein occlusion.

PURPOSE: To investigate the effects of an intravitreal injection of autologous plasmin enzyme for macular edema associated with a branch retinal vein occlusion (BRVO). DESIGN: Prospective, interventional case studies. METHODS: Twenty-six eyes of 26 patients (14 men and 12 women) with macular edema resulting from a BRVO were studied. None of the eyes had a posterior vitreous detachment (PVD). The average age at the onset of BRVO was 58.7 ± 6.6 years. The interval between onset of the macular edema and injection of autologous plasmin enzyme was 4.2 months. One international unit of autologous plasmin enzyme in 0.1 mL was injected into each vitreous. The presence of a PVD was evaluated 1 week after the injection, and the visual acuity and macular thickness were measured before and 1 week and 1, 3, 6, and 12 months after the autologous plasmin enzyme injection. RESULTS: After the autologous plasmin enzyme injection, a total PVD was observed in 23 eyes and no PVD was observed in 3 eyes. The visual acuity gradually recovered after the injection, improved by 2 lines or more in 23 eyes, and remained unchanged in the 3 eyes. The retinal thickness also recovered gradually at 1, 3, 6, and 12 months. The mean retinal thickness was reduced from 602.12 to 253.62 µm at 12 months after surgery. It was reduced significantly after 1, 3, 6, and 12 months (P < .0001). CONCLUSIONS: Intravitreal autologous plasmin enzyme may lead to an improvement of visual acuity and a reduction of macula edema in eyes with BRVO.

Advantages of using newly developed quartz contact lens with slit illumination from operating microscope.

The purpose of this article is to report the characteristics and advantages of using a newly designed quartz contact lens with slit illumination from an operating microscope for intraocular surgery. The new contact lens is made of quartz. The lens is convex-concave and is used in combination with slit illumination from an operating microscope. The optical properties of quartz make this lens less reflective with greater transmittance. The combination of a quartz contact lens with slit illumination provided a brighter and wider field of view than conventional lenses. This system enabled us to perform bimanual vitrectomy and scleral buckling surgery without indirect ophthalmoscope. Small intraocular structures in the posterior pole or in the periphery were detected more easily. In conclusion, the newly designed quartz lens with slit beam illumination from an operating microscope provided a bright, clear and wide surgical field, and allowed intraocular surgery to be performed more easily.

Two cases of severe degeneration of the macula following vitrectomy with indocyanine green-assisted internal limiting membrane peeling for idiopathic macular hole.

We describe three eyes of two cases of severe degeneration of the macula following vitrectomy with indocyanine green-assisted internal limiting membrane peeling for idiopathic macular hole. We need to remember the possibility of these complications and have to select the procedures that are safest to use for macular hole surgery.

Measurement of retinal thickness from three-dimensional images obtained from C scan images from the optical coherence tomography ophthalmoscope.

BACKGROUND: One of the unique features of the optical coherence tomography (OCT) ophthalmoscope is that it can record C scan images of the retina. The purpose of this study was to determine the best recording time to measure the retinal thickness with the OCT ophthalmoscope. In addition, the accuracy of the measurements was examined by comparing the values obtained by the OCT ophthalmoscope with those obtained with the Stratus OCT Model 3000 (OCT III) assuming that the OCT III gives an accurate measurement of retinal thickness. METHODS: The topography mode of the OCT ophthalmoscope was used. First, the average retinal thickness recorded with 2-s scans was compared with that recorded with 4-s scans for a recording area of 15 degreesx15 degrees. Next, the average retinal thickness recorded by the OCT ophthalmoscope was compared with that obtained by the Fast Macular Thickness program of the OCT III in patients with macular oedema. RESULTS: The mean retinal thickness of the central area was 208.1 microm for both 2 and 4 s recording times. The average retinal thickness obtained by the OCT ophthalmoscope was highly correlated and not significantly different from the values obtained by the OCT III. The largest differences obtained by the two instruments were seen in the parts of the retina with accumulation of hard exudates. CONCLUSIONS: Accurate measurements of retinal thickness can be obtained with the OCT ophthalmoscope by 2-s scans, and thus, the OCT ophthalmoscope can be a valuable instrument for clinical assessments of retinal thickness.

In vivo and in vitro feasibility studies of intraocular use of seprafilm to close retinal breaks in bovine and rabbit eyes.

PURPOSE: Seprafilm, a sodium hyaluronate/carboxymethylcellulose absorbable barrier developed to prevent adhesions after abdominal surgery, adheres well to wet tissue. The authors studied the efficacy of this film for sealing retinal breaks in animals. METHODS: In an in vitro study, a retinal detachment with a hole was created in bovine eyecups after the vitreous gel was removed. Seprafilm was placed over the retinal hole, and the strength of the retinal adhesion was measured by pulling the film. Permeability was tested by applying methylene blue to the film covering the retinal break. Seprafilm also was soaked in balanced salt solution (BSS) incubated at 37 degrees C, and the pH of the BSS containing Seprafilm was measured as it melted. In an in vivo study, Seprafilm was powdered and mixed in BSS solution, and 0.1 mL was injected into the right vitreous cavity in study rabbits. The same amount of BSS was injected into the right vitreous cavity in control rabbits. Ophthalmologic examinations were performed. Bilateral electroretinograms were recorded simultaneously before and 6 weeks after injection. Both eyes were enucleated for histologic evaluation. RESULTS: Seprafilm adhered well to the retina, was impermeable to methylene blue, and remained solid in BSS for 30 days before it dissolved, and its pH ranged from 7.2 to 8.0. No intraocular inflammatory reaction occurred after intravitreous injection of Seprafilm solution. There was no significant difference in amplitudes or implicit times of electroretinogram a-waves, b-waves, and oscillatory potentials before and after injection and between study and control groups. No significant retinal abnormality was detected by light microscopy in either group. CONCLUSIONS: The film adhered well to the retina with no signs of ocular toxicities. Further study is warranted for possible means of patching retinal breaks.

Is transpupillary thermotherapy applicable to the treatment of age-related macular degeneration with pigment epithelial detachment?

The cause of pigment epithelial tears at the edge of a pigment epithelial detachment (PED) following transpupillary thermotherapy in eyes with associated age-related macular degeneration is unclear. We have treated 2 eyes which had a PED with TTT. Our findings suggest pigment epithelial tears are probably related to the shape of the PED and TTT should not applied to a balloon-shaped PED.

Is transpupillary thermotherapy applicable to the treatment of age-related macular degeneration with pigment epithelial detachment?

The cause of pigment epithelial tears at the edge of a pigment epithelial detachment (PED) following transpupillary thermotherapy (TTT) in eyes with a PED associated with age-related macular degeneration has not been conclusively determined. We have treated two eyes that had a PED with TTT. A pigment epithelial tear developed in one eye but not in the other. Our findings suggest that pigment epithelial tears are probably related to the shape of the PED, and TTT should not be applied to a balloon-shaped PED.

Safety of in vivo pharmacologic vitreolysis with recombinant microplasmin in rabbit eyes.

PURPOSE: To investigate the safety of intravitreal microplasmin in rabbits and to confirm previous findings of posterior vitreous detachment (PVD). METHODS: Different doses of microplasmin, from 12.5 microg to 250 microg, in 0.1 mL balanced salt solution (BSS) were injected into the vitreous cavity of rabbit eyes to induce PVD. Fellow eyes were injected with the same volume of BSS. Slit-lamp biomicroscopy, ophthalmoscopic fundus examinations, A- and B-mode ultrasonography, and electroretinography were performed to assess the retina. Electroretinograms (ERGs) were recorded up to 90 days after injection. Morphologic alterations were assessed by light microscopy, scanning electron microscopy (SEM), and transmission (TEM) electron microscopy. RESULTS: A slight aqueous flare and cells were observed in the anterior chamber after microplasmin and BSS injection. A slight inflammatory reaction was also observed transiently in the vitreous cavity. In control eyes, B-mode ultrasonography and SEM examination demonstrated that PVD did not develop after BSS injection. Intravitreal injections of 125 microg or greater of microplasmin induced complete PVD with an internal limiting membrane (ILM) devoid of vitreous collagen fibrils. Eyes injected with 12.5 microg microplasmin had partial PVD, and SEM showed residual fibrils covering the ILM. In all eyes, there was a transient reduction in the a- and b-waves of the ERG on days 2 through 7. The ERGs showed less effect with < 250 microg microplasmin. CONCLUSIONS: Intravitreal injection of recombinant microplasmin in the rabbit induces no ERG or retinal ultrastructural abnormalities. Pharmacologic vitreolysis with this agent may be a useful adjunct to vitreous surgery and could be used to induce PVD without vitreous surgery.

[Preparation of high-purity and safe autologous plasmin and its clinical application].

PURPOSE: To report an improved preparation of safer and highly-purified autologous plasmin and to demonstrate its clinical applications. METHODS: Prior to clinical application, animal experiments were carried out. In addition, the activity of plasmin in the vitreous cavity after injection was measured serially. In preparation for clinical use, the proteinase inhibitors aprotinin and benzamidine were used for suppression of protein denaturation. The samples were incubated for 48 hours to check for contamination. The preparation was applied to patients with idiopathic macular hole and diabetic macular edema. RESULTS: The plasmin detached the vitreous body from the inner limiting membrane of the retina without any ill effects in animal experiments. The specific activity reached a peak in 5-10 minutes and decreased rapidly thereafter. By adding a suppressor of protein denaturation in the purification process, 0.2 IU (0.1 ml) of high-purity plasmin could be prepared from each patient. No bacterial contamination was noted. Complete vitreous detachment could be induced in two clinical cases. Urokinase was used instead of streptokinase to activate plasminogen. CONCLUSIONS: Vitreous detachment is considered to be induced safely and consistently by injection of plasmin prepared using a protein denaturation suppressor and activated with urokinase. This method is expected to be of clinical value.

Efficacy of daunorubicin encapsulated in liposome for the treatment of proliferative vitreoretinopathy.

BACKGROUND AND OBJECTIVE: To investigate the efficacy of daunorubicin encapsulated in liposome as a drug delivery system to treat proliferative vitreoretinopathy (PVR). MATERIALS AND METHODS: An experimental PVR model was made in pigmented rabbits by injecting a suspension of conjunctival fibroblasts and platelet-rich plasma into the vitreous cavity. Daunorubicin was encapsulated in newly developed empty liposome by mixing the empty liposome with the drug solution. Studies were performed 24 hours, 1 week, and 1 month after injection of daunorubicin encapsulated in empty liposome in an experimental PVR model. RESULTS: Compared with the control PVR model, daunorubicin prevented the formation of PVR. Although pathologic changes were observed in the eyes injected with daunorubicin alone, there were no adverse effects observed in the eyes injected with daunorubicin encapsulated in empty liposome. CONCLUSIONS: Daunorubicin encapsulated in empty liposome seems to be effective in preventing PVR without causing any adverse effects to the retina.

Retinal vessel changes in a patient with primary systemic nonfamilial amyloidosis.

A case is described that demonstrates retinal vessel changes and suggests the favorable effects of hemodialysis to treat pathology in a patient with primary systemic nonfamilial amyloidosis. A 47-year-old woman diagnosed as having primary systemic nonfamilial amyloidosis at the age of 30 years had linear and dot hemorrhage, venous dilatation, and tortuosity in the right eye. Fluorescein angiography revealed low-density amorphous areas in the walls of dilated veins near the optic disc. These findings diminished with hemodialysis.

Penetrating keratoplasty surgery combined with vitrectomy after failing previous corneal surgery.

PURPOSE: The preoperative and postoperative factors influencing visual outcome were analyzed in 15 eyes of 15 patients with graft opacity after keratoplasty associated with vitreoretinal disease who underwent combined surgery of fresh corneal retransplantation and vitrectomy. MATERIALS AND METHODS: The data obtained consisted of diagnosis, preoperative visual acuity, corneal and vitreoretinal findings at the time of surgery, interval between the first visit and surgery, intraocular pressure before surgery, gonioscopic findings, results of bacterial culture of surgical specimens, surgical procedure for vitrectomy, corneal and vitreous findings after surgery, visual acuity 6 months after surgery, intraocular pressure after surgery, and additional surgical techniques. RESULTS: The cause of corneal opacity was graft rejection in all patients, who had been treated with high-dose administrations of steroids and cyclosporin. The preoperative diagnosis was proliferative vitreoretinopathy (PVR) in eight eyes and fungal endophthalmitis in seven eyes. Corneal transparency was achieved in 7 eyes (46.6%) 6 months after surgery. Vitreoretinal findings improved in 9 eyes (60%) and PVR recurred in 6 eyes (40%). Visual acuity improved in 7 eyes (46.6%), did not change in 2 eyes (13.3%), and deteriorated in 6 eyes (40%). The six eyes with decreased visual acuity developed phthisis bulbi. Preoperative intraocular pressure was 2.1 mmHg on average in the phthisis bulbi group, significantly lower than in the group with superior prognosis. Goniosynechia was noted before surgery and did not improve after surgery in all six eyes. CONCLUSIONS: The outcome was poor in eyes with goniosynechia and ocular hypotony, and combined surgery is not indicated for either anatomic or visual preservation in such cases. Care should be taken not to overlook intraocular infection in patients undergoing immunosuppressive therapy against graft rejection. The early detection of retinal detachment is also important in eyes exhibiting hypotony after surgery.