Challenges in the diagnosis of the enigmatic primary adrenal leiomyosarcoma: two case reports and review of the literature.

BACKGROUND: Primary adrenal leiomyosarcoma is a rare and aggressive mesenchymal tumor derived from the smooth muscle wall of a central adrenal vein or its tributaries; therefore, tumors tend to invade the inferior vena cava and cause thrombosis. The great majority of tumors grow rapidly, which makes the disease difficult to diagnose in its early clinical stages and needs differentiation from adrenocortical carcinomas for the selection of chemotherapy including mitotane which causes adrenal insufficiency. CASE PRESENTATION: We presented two patients with adrenal leiomyosarcoma who were referred to our hospital with abdominal pain and harboring large adrenal tumors and inferior vena cava thrombosis. The endocrine findings, including serum catecholamine levels, were unremarkable. These two patients were considered clinically inoperable, and CT-guided core needle biopsy was performed to obtain the definitive histopathological diagnosis and determine the modes of therapy. The masses were subsequently diagnosed as primary adrenal leiomyosarcoma based on the histological features and positive immunoreactivity for SMA (smooth muscle actin), desmin, and vimentin. CONCLUSIONS: Adrenal leiomyosarcoma derived from the smooth muscle wall of a central adrenal vein or its tributaries is rare but should be considered a differential diagnosis in the case of nonfunctioning adrenal tumors extending directly to the inferior vena cava. CT-guided biopsy is considered useful for histopathological diagnosis and clinical management of patients with inoperable advanced adrenal tumors without any hormone excess.

Which is More Effective and Safer? Comparison of Propensity Score-Matched Microhook Ab Interno Trabeculotomy and iStent Inject.

INTRODUCTION: The purpose of this study was to compare the surgical outcomes between ab interno trabeculotomy (LOT) and iStent inject W implantation (iStent) both combined with cataract surgery, matching the background factors including age, intraocular pressure (IOP), medication score, central corneal thickness (CCT), and axial length. METHODS: A total of 100 eyes from 75/79 patients with primary open-angle glaucoma were included in the LOT/iStent groups. The background factors were matched between the two groups using the propensity score. RESULTS: There were no significant differences in age, IOP, medication score, CCT, and axial length, preoperatively. The postoperative medication scores were 1.3 ± 1.2 and 1.2 ± 1.2 in the LOT and iStent groups. The postoperative IOPs were 12.8 ± 2.8 and 13.1 ± 2.4 mmHg in the LOT and iStent groups, respectively. The changes in the medication score were - 0.64 ± 1.4 and - 0.44 ± 1.6 in the LOT and iStent groups, respectively. The changes in the IOP were - 2.1 ± 3.3 and - 1.5 ± 3.0 mmHg in the LOT and iStent groups, respectively. These values were not significantly different between the two groups. The postoperative IOP and changes in the IOP were significantly associated with preoperative IOP and CCT. There was no significant difference in the occurrence of postoperative complications (hyphema, 11.0% and 6.0%, and transient ocular hypertension, 8.0% and 5.0%, in the LOT and iStent groups, respectively). CONCLUSION: LOT and iStent have similar surgical outcomes with sufficient safety. Postoperative IOP was significantly associated with preoperative IOP and CCT in both groups.

Randomized Multicenter Clinical Trial Comparing 0.1% Brimonidine/0.5% Timolol Versus 1% Dorzolamide/0.5% Timolol as Adjuncts to Prostaglandin Analogues: Aibeta Crossover Study.

INTRODUCTION: This multicenter, randomized, comparative, and investigator-masked crossover clinical trial sought to compare the efficacy and tolerability of fixed combinations of 0.1% brimonidine/0.5% timolol (BTFC) versus 1% dorzolamide/0.5% timolol (DTFC) as adjunctive therapies to prostaglandin analogues. METHODS: A total of 110 patients with open-angle glaucoma or ocular hypertension previously treated with prostaglandin analogue monotherapy were randomized to receive either BTFC or DTFC as adjunctive therapy for 8 weeks. These patients were then crossed over to the alternative treatment arm for another 8 weeks. The reduction in intraocular pressure (IOP) (primary outcome), occurrence of adverse events, ocular discomfort after instillation, and patient preference (secondary outcomes) were recorded through patient interviews. RESULTS: BTFC instillation for 8 weeks reduced IOP by 3.55 mmHg, demonstrating non-inferiority to DTFC instillation (3.60 mmHg; P < 0.0001, mixed-effects model). Although adverse events were rare with both combinations, patients reported greater discomfort with DTFC than with BTFC (P < 0.0001). More patients preferred BTFC (P < 0.0001) over DTFC, as BTFC caused minimal or no eye irritation. CONCLUSION: As BTFC offered better tolerability than DTFC with comparable reduction in IOP, we recommend it as an alternative for patients who experience ocular discomfort with DTFC-prostaglandin analogue combination therapy. TRIAL REGISTRATION NUMBER: jRCTs051190125.

Patients with glaucoma who require further reduction in intraocular pressure while undergoing monotherapy with prostaglandin analogue ophthalmic solution have been prescribed two enhanced treatment options: 0.1% brimonidine/0.5% timolol fixed combination ophthalmic solution (BTFC) and 1% dorzolamide/0.5% timolol fixed combination ophthalmic solution (DTFC). The Aibeta Crossover Study Group in Japan compared the efficacy and tolerability of fixed combinations of BTFC versus DTFC when an additional fixed combination ophthalmic solution was prescribed in patients with open-angle glaucoma or ocular hypertension who had been treated with prostaglandin analogue monotherapy. We recruited 110 patients previously treated with prostaglandin analogue monotherapy at 20 clinical centers in Japan, then randomly assigned them to two alternative treatment groups: the BTFC to DTFC group or the DTFC to BTFC group, as an adjunctive therapy to prostaglandin analogues for total of 16 weeks. We compared the reduction in intraocular pressure, occurrence of side effects, eye discomfort after instillation, and patient preference between BTFC versus DTFC instillations. The intraocular pressure reduction of BTFC instillation was comparable to that of DTFC instillation, showing non-inferiority to DTFC (3.55 mmHg vs. 3.60 mmHg; P < 0.0001, mixed-effects model). Both eye drops caused few side effects; however, patients felt greater eye discomfort with DTFC than with BTFC (P < 0.0001). Because of less eye irritation, more patients preferred BTFC (P < 0.0001) over DTFC. We can recommend using BTFC for patients who feel eye discomfort with DTFC­prostaglandin analogue combination therapy.

A case of two connected stents deployed during iStent inject W surgery.

BACKGROUND: We report a case with two connected stents ejected simultaneously during an iStent inject W surgery, a modified second-generation iStent Trabecular Micro-Bypass System. CASE PRESENTATION: A 57-year-old woman with primary open-angle glaucoma underwent a combined cataract and iStent inject W surgery in her left eye. After the trabecular meshwork/Schlemm's canal was pierced by the trocar of injector, the delivery button was pressed a first time, but the stent was not ejected. After the button was pressed a second time, connected two stents were ejected. After removing the dislocated stents from the anterior chamber, two stents were implanted into the desired places using another injector. Except for mild hyphema, no postoperative complication occurred. Stereomicroscopic observation showed that the two stents were connected by a broken trocar shaft. An X-ray showed that the trocar shaft was broken at the part referred to as the "sprayed trocar". Scanning electron microscopy showed that the surface features of the broken trocar and trocar tip represented tensile failure. CONCLUSIONS: Although rare, considering that the damage was seen at the structurally weak part (i.e., sprayed trocar), the same phenomenon can happen. For patient safety, surgeons are recommended to inspect the device when the deployment of either the first or second stent is unsuccessful during the iStent inject surgery.

Intra-operative challenges encountered using the zepto nano-pulse precision capsulotomy device.

Purpose: The Zepto nano-pulse precision capsulotomy is a novel device for capsulorhexis formation during cataract surgery. Few complications or challenges have been reported while using this device. The purpose of this paper is to highlight two intra-operative challenges that were encountered while using the Zepto device. Observations: CASE 1 - A 65-year-old with advanced primary open angle glaucoma (POAG) and an in situ Ahmed Glaucoma Valve located in the anterior chamber. During a planned phacoemulsification procedure, the tube became trapped between the suction cup of the Zepto device and the lens, resulting in a sudden complete collapse of the anterior chamber. The procedure was completed after appropriate interventions. On post-operative day 1 Descemet folds were visible, and corneal endothelial cell density was reduced from 2101 cells/cm2 preoperatively to 1355 cells/cm2 at 19 months postoperatively. CASE 2 - A 66-year-old female with secondary cataract from chronic inflammation post trabeculectomy for advanced POAG. During a planned phacoemulsification procedure, despite synechialysis for the 360° posterior synechiae, the iris tissue was sucked into the suction cup of the Zepto device and became incarcerated over the lens. The procedure was completed after a successful intervention. Conclusions and importance: Although not previously reported and possibly rare, intra-operative complications may be encountered while using the Zepto device, particularly in complex cataract cases. For the patient's safety and satisfactory post-operative and refractive outcomes, caution must be applied.

Linear association between aging and decreased blood thiol antioxidant activity in patients with cataract.

We comprehensively assessed the roles of systemic redox markers by including both prooxidant and antioxidant markers in 121 Japanese subjects (mean ±â€…SD age, 70 ±â€…11 years; 38 men) with no ocular pathology except age-related cataract. Serum levels of lipid peroxides, ferric-reducing activity, and thiol antioxidant activity were measured using the diacron reactive oxygen metabolite (dROM), biologic antioxidant potential (BAP), and sulfhydryl (SH) tests, respectively, using a free-radical analyzer. Univariate analyses suggested that older age, higher pulse rate, worse best-corrected visual acuity (BCVA), higher intraocular pressure, and higher cataract grade were associated with a lower SH level. Scatterplots revealed virtually linear associations between age and the SH level (estimate, -4.4 µM/year). Multivariate analyses suggested that older age, higher systolic blood pressure, and worse BCVA were associated with a lower SH level. Neither the univariate nor multivariate analyses, except between female sex and higher dROM level, were associated with the dROM or BAP level. A lower serum SH level was the driver of aging itself and age-related decline in VA due to cataract. The serum SH level may be an excellent predictor of aging status in each subject.

Antihypertensive Effects of Esaxerenone in Older Patients with Primary Aldosteronism.

Design: Retrospective cohort study. Patients. The data was obtained from a total of 87 PA patients treated with esaxerenone. The treatment group comprised 33 patients who received esaxerenone as first-line therapy and 54 patients that switched from another MRA to esaxerenone. Measurements. Blood pressure (BP), plasma aldosterone concentration (PAC), plasma renin activity (PRA), serum potassium level, estimated glomerular filtration rate (eGFR), urinary albumin-creatinine ratio (UACR), and brain natriuretic peptide (BNP) were assessed before and after treatment with esaxerenone. Patients with overall reductions in their systolic or diastolic BP by 10 mmHg, or more, were considered responders. Unpaired t-tests of the biochemical and personal parameters between responders and nonresponders were run to find the most influencing characteristic for treatment success. Results: BP overall decreased after treatment with esaxerenone (systolic BP: P=0.025, diastolic BP: P=0.096). Serum potassium levels increased, while eGFR decreased (P=0.047 and 0.043, respectively). No patients needed a dose reduction or treatment discontinuation of esaxerenone based on the serum potassium and eGFR criteria. UACR and BNP decreased insignificantly. The responders were significantly older than the nonresponders of the esaxerenone treatment (P=0.0035). Conclusions: Esaxerenone was effective in older patients with primary aldosteronism.

Surgical Results of Trabeculectomy among Groups Stratified by Prostaglandin-Associated Periorbitopathy Severity.

PURPOSE: To report the role of prostaglandin-associated periorbitopathy (PAP) severity in the surgical effectiveness of trabeculectomy (LEC). DESIGN: Retrospective observational case series. PARTICIPANTS: A total of 139 consecutive eyes of 139 Japanese subjects (74 men, 65 women; mean age ± standard deviation, 65.7 ± 10.6 years) who underwent LEC were included. All had primary open-angle glaucoma (POAG), no history of conjunctival incisional surgery, completed all postoperative visits for 12 months, and information on the PAP severity using the Shimane University PAP Grading System (SU-PAP). METHODS: Data were collected from a medical chart review at 2 hospitals. MAIN OUTCOME MEASURES: Comparison of surgical success rates among groups stratified by SU-PAP grades 0 to 3 by survival curve analysis using the definitions of failure based on surgical intervention other than laser suture lysis (LSL), intraocular pressure (IOP) reduction below 20%, postoperative IOP exceeding 15 mmHg (definition A) or 12 mmHg (definition B), and a postoperative IOP below 6 mmHg. RESULTS: Twelve months postoperatively, the success rates of grades 0, 1, 2, and 3 were 86%, 68%, 40%, and 0%, respectively, for definition A (P < 0.0001, log-rank test) and 86%, 61%, 36%, and 0%, respectively, for definition B (P < 0.0001). Interventions other than LSL (P < 0.0001, Cochran-Armitage trend test), IOP reduction less than 20% (P = 0.010), and IOP exceeding 15 mmHg (P = 0.016) or 12 mmHg (P < 0.0001) were associated with surgical failure; IOP under 6 mmHg was not (P = 0.31). The proportional hazard model for definition A showed that compared with grade 0, grade 2 (risk ratio [RR], 5.82, P = 0.0043) and grade 3 (RR, 12.2, P = 0.0003) were associated with surgical failure. For definition B, grade 1 (RR, 3.53, P = 0.040), grade 2 (RR, 6.65, P = 0.0021), and grade 3 (RR, 12.0, P = 0.0003) were associated with surgical failure. Differences in age, gender, preoperative IOP and medications, refractive error, and simultaneous cataract surgery were not associated with surgical failure in both models. CONCLUSIONS: The preoperative presence of severe PAP worsens the 1-year success rate of LEC in patients with POAG. To retain the surgical effectiveness, treating physicians should prevent patients from progressing to severe PAP, an avoidable side effect, by switching or stopping the causative medications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Roles of Toric intraocular Lens implantation on visual acuity and astigmatism in glaucomatous eyes treated with iStent and cataract surgery.

BACKGROUND: To assess the efficacy of toric intraocular lenses (IOLs) in combined cataract and minimally invasive glaucoma surgery (MIGS), visual and refractive outcomes were compared between eyes implanted with non-toric and toric IOLs during iStent triple procedures. METHODS: In this retrospective study, open angle glaucoma eyes with preexisting corneal astigmatism of -1.5 diopter (D) or more and implanted with non-toric (n = 9) or toric (n = 9) IOLs were included. The main outcome measures were the intergroup difference in the uncorrected visual acuity (UCVA) and refractive astigmatism at 3 months postoperatively. RESULTS: Preoperatively, the logarithm of the minimum angle of resolution (logMAR) UCVAs and refractive astigmatism were equivalent between the groups. Postoperatively, the logMAR UCVA (non-toric, 0.45 ± 0.31; toric, 0.14 ± 0.15; P = 0.021) was significantly better and the refractive astigmatism (non-toric, -2.03 ± 0.63 D; toric, -0.67 ± 0.53 D; P = 0.0014) significantly less in the toric group. The toric group had postoperative improvements in the logMAR UCVA (-0.21, P = 0.020) and refractive astigmatism (+ 1.72 D, P = 0.0039). Vector analyses showed the postoperative centroid magnitude and confidence eclipses of refractive astigmatism was less in the toric group (0.47 D at 173°±0.73D) than the non-toric group (1.10 D at 2°±1.91D). Postoperatively, 78% of eyes in the toric group had 1.0 D or less refractive astigmatism compared with 11% in the non-toric group. Surgically induced astigmatism (non-toric, 0.18 D at 65°; toric, 0.29 D at 137°) did not differ between groups. CONCLUSION: Use of toric IOLs is a reasonable option for better visual outcomes when the combined cataract and iStent surgery is performed in glaucomatous eyes with corneal astigmatism.

Isolated traumatic aniridia with full and partial iris expulsion in pseudophakic eyes.

BACKGROUND: Total aniridia after ocular trauma without disruption of the intraocular lens (IOL) has been reported in patients with a history of small-incisional cataract surgery. We report one case each of total and partial aniridia after accidental falls experienced by two elderly Japanese women. CASE PRESENTATIONS: Case 1. A 76-year-old woman with a history of small-incisional cataract surgery more than 10 years previously fell onto concrete and had a contusion that affected the left side of her face. At the initial visit, the best-corrected visual acuity (BCVA) was hand motions and the intraocular pressure (IOP) was 38 mmHg in her left eye (OS). A blood clot was present in the well-formed anterior chamber and expulsed iris tissue was seen beneath the conjunctiva. Exploratory surgery showed no scleral laceration other than the previous sclerocorneal tunnel. After hyphema removal, total aniridia and an intact in-the-bag fixed IOL were seen. By 4 months, the BCVA was 1.2 and the IOP was 13 mmHg OS. CASE 2: An 88-year-old woman with a history of small-incisional cataract surgery more than 10 years previously had a fall that resulted in right-sided zygomatic and maxillary bone fractures. The BCVA was light perception and the IOP was 29 mmHg in her right eye (OD). Exploratory surgery showed no scleral laceration and the previous sclerocorneal tunnel was found; iris strand prolapsing from the sclerocorneal tunnel was seen. After hyphema removal, partial iris loss and an intact lens position were seen. By 1 week postoperatively, the BCVA was 0.05 OD and the IOP was 12 mmHg OD. CONCLUSIONS: It has been postulated that previously created small-incision tunnels can function as release valves during blunt trauma by preventing further global rupture and limiting IOL prolapse or retinal injury. Our cases suggested this can happen even long periods after cataract surgery. The case with partial aniridia demonstrated the process of the expulsive aniridia, and its findings do not contradict the postulated mechanisms.

Clinical Usefulness of the Growth Hormone-Releasing Peptide-2 Test for Hypothalamic-Pituitary Disorder.

Context: Growth hormone deficiency (GHD) develops early in patients with hypothalamic-pituitary disorder and is frequently accompanied by other anterior pituitary hormone deficiencies, including secondary adrenal insufficiency (AI). A growth hormone-releasing peptide-2 (GHRP2) test, which is widely used for the diagnosis of patients with GHD, is thought to induce release of not only growth hormone (GH) but also ACTH. However, its clinical usefulness in hypothalamic-pituitary disorder is unclear. Objective: We aimed to determine the clinical utility of the GHRP2 test in patients with hypothalamic-pituitary disorders, particularly for AI concomitant with GHD. Methods: The GHRP2 test, a cosyntropin stimulation test, corticotropin-releasing hormone (CRH) tests, and/or insulin tolerance tests (ITTs) were performed on 36 patients with hypothalamic-pituitary disorder. Results: Twenty-two (61%) had severe GHD, and 3 (8%) had moderate GHD by GHRP2. There was no difference in baseline ACTH and cortisol between non-GHD, moderate GHD, and severe GHD participants. However, a cosyntropin stimulation test and subsequent CRH tests and/or ITTs revealed that 17 (47%) had secondary AI and 16/17 (94%) cases of secondary AI were concomitant with severe GHD. ROC curve analysis demonstrated that the ACTH response in the GHRP2 test was useful for screening pituitary-AI, with a cutoff value of 1.55-fold (83% sensitivity and 88% specificity). Notably, the combination of ACTH response and the peak cortisol level in the GHRP2 test using each cutoff value (1.55-fold and 10 µg/dL, respectively) showed high specificity (100%) with high accuracy (0.94) for diagnosis of pituitary-AI. Conclusion: We recommend measuring ACTH as well as GH during the GHRP2 test to avoid overlooking or delaying diagnosis of secondary AI that frequently accompanies GHD.

Hallermann-Streiff syndrome diagnosed in the seventh decade of life.

Purpose: Hallermann-Streiff syndrome (HSS) is a rare congenital disorder characterized by dyscephaly, hypotrichosis, microphthalmia, dental anomalies, and cutaneous atrophy. Because of the presence of a characteristic facial appearance, severe visual disturbance, and/or upper airway obstruction, most patients with HSS are diagnosed as having a congenital anomaly as a newborn or early in life. We report a case of HSS that was first recognized when the patient was in her seventh decade of life. Observations: A 68-year-old woman presented to our department for decreased vision in both eyes (OU). Her ocular medical history included "ocular injections" in her left eye (OS); laser iridotomies OU, cataract surgery OS, and removal of corneal opacity OU; she did not have a remarkable systemic medical history. At the initial visit to our department, her best-corrected visual acuity was 0.5 in her right eye (OD) and 0.1 OS with +4.0-diopter hyperopic correction OU, corneal opacity due to calcification OU, a shallow anterior chamber and iridotrabecular contact OD were observed. During the surgical intervention OD, the surgeon recognized a "blue sclera," and the physicians initially suspected an underlying systemic malformation. Although mild, she presented with a thin beak-like nose and receding chin. In combination with the ocular features, the proportionate short stature, and a characteristic facial appearance, she was diagnosed with HSS. Conclusions and importance: Patients with HSS who had no clinically significant cosmetic, visual, and respiratory problems early in life may not be recognized as having HSS. The presence of corneal opacity, short axial length, and a blue sclera recognized by ophthalmologists can lead to the correct diagnosis of this congenital disorder.

Effects of water chestnut (Tarpa bispinosa Roxb.) extract/lutein on fingertip-measured advanced glycation endproduct/carotenoid levels.

This pilot study tested the effects of the supplements containing water chestnut extract and carotenoids on antiglycation and carotenoid levels. Twenty Japanese subjects (mean age, 67 ± 7 years; 13 men) ingested 200 mg of Tarpa bispinosa Roxb. extract (containing >50 mg of polyphenols), 20 mg of lutein, and 3 mg of zeaxanthin daily for 3 months. Advanced glycation end product (AGEs) levels were estimated by fingertip skin autofluorescence using the AGEs Sensor; carotenoid levels were estimated by pressure-mediated reflection spectroscopy of the fingertips using the Veggie Meter. Compared to baseline, the mean AGEs score decreased significantly (0.55 ± 0.04 arbitrary units (AU) vs. 0.52 ± 0.07 AU, p = 0.03); the mean carotenoid score increased significantly (256 ± 68 optical density (OD) vs. 302 ± 109 OD, p = 0.02) at 3 months. Blood pressure, body weight, visual acuity, refractive error, and intraocular pressure were equivalent between baseline and 3 months. Compared to baseline, 13 (65%) patients had decreased AGEs scores, and 14 (70%) had increased carotenoid scores at 3 months; 9 (45%) subjects had both decreased AGEs scores and increased carotenoid scores, and two (10%) subjects had an inverse response. Co-administration of water chestnut extract and lutein for 3 months decreased the AGEs and increased the carotenoids estimated in the fingertip skin of humans.

Aphakic Pupillary Block by an Intact Anterior Vitreous Membrane after Total Lens Extraction by Phacoemulsification.

An 85-year-old Japanese woman with acute primary angle closure in her right eye underwent cataract extraction. Because of the weakness of the Zinn's zonules, all of the lens tissue including the lens capsule was removed by phacoemulsification. Because of the absence of vitreous prolapse into the anterior chamber, vitrectomy was not performed. Nine days postoperatively, acute angle closure due to pupillary block by an anterior vitreous membrane developed. To resolve the pupillary block, anterior vitrectomy was performed on the same day. Postoperatively, her symptoms resolved, the anterior chamber deepened, and the intraocular pressure normalized. Although rare, acute angle closure due to pupillary block by an anterior vitreous membrane can occur after total lens extraction with phacoemulsification. If no vitreous prolapse occurs with total lens extraction, an intentional hyaloidotomy using an anterior vitreous cutter or iridectomy should be considered to avoid secondary angle closure.

Comparison of Postoperative Hyphemas between Microhook Ab Interno Trabeculotomy and iStent Using a New Hyphema Scoring System.

We have been using our in-house scoring system of hyphemas, i.e., Shimane University RLC postoperative hyphema scoring system (SU-RLC), which we designed to classify postoperative hyphema. SU-RLC classifies the severities of hyphemas based on three factors, i.e., red blood cells (RBCs) (R) 0-3, layer formation (L) 0-3, and clot (C) 0-1, by slit-lamp observation. To test the clinical usefulness of the SU-RLC for quantifying the postoperative hyphema severity, the SU-RLC scores were compared between eyes that underwent different minimally invasive glaucoma surgery (MIGS) procedures, i.e., Tanito microhook ab interno trabeculotomy and cataract extraction (TMH-CE) (n = 64 eyes of 64 subjects; mean age ± standard deviation, 72.4 ± 8.1 years) and iStent-CE (n = 21 eyes of 21 subjects; 76.1 ± 10.6 years). Compared to the iStent-CE, higher hyphema scores with the TMH-CE were found for the R scores on postoperative days 1, 2, and 3; for the L score on postoperative day 1; and for the C score on postoperative day 2. The sums of the R, L, and C scores (RLC) on postoperative day 1 were 3.2 ± 1.1 with the TMH-CE and 1.1 ± 1.3 with the iStent-CE; the scores reached almost 0 by 2 weeks in both groups. Significant differences in the RLC scores between the surgical groups were found on postoperative days 1, 2, and 3. Multivariate analyses showed that the TMH-CE rather than iStent-CE was associated with higher R, C, and RLC scores; anticoagulant/antiplatelet use was associated with higher R score; and myopia was associated with a higher C score. In the TMH-CE group, myopia was associated with a higher C score. In the iStent-CE group, anticoagulant/antiplatelet use was associated with higher R and RLC scores; and higher postoperative 1-day intraocular pressure was associated with a higher C score. The SU-RLC successfully detected the difference in hyphema severity between different MIGS procedures; thus, we concluded that our classification system may be feasible to evaluate hyphemas after glaucoma surgery.

Proposal of a simple grading system integrating cosmetic and tonometric aspects of prostaglandin-associated periorbitopathy.

ABSTRACT: The distribution of prostaglandin-associated periorbitopathy (PAP) graded using the Shimane University PAP Grading System (SU-PAP) among glaucoma/ocular hypertension subjects using a topical FP or EP2 receptor agonist was reported. A 460 consecutive 460 Japanese subjects (211 men, 249 women; mean age ±â€Šstandard deviation, 69.9 ±â€Š14.5 years) who had used either a FP agonist (0.005% latanoprost, 0.0015% tafluprost, 0.004% travoprost, 0.03% bimatoprost, or fixed combinations of these) or EP2-agonist (0.002% omidenepag isopropyl) for more than 3 months in at least 1 eye were retrospectively enrolled. Age, sex, prostaglandin, intraocular pressure (IOP) measured by Goldmann applanation tonometry (IOPGAT) and iCare rebound tonometry (IOPRBT), difference between IOPGAT and IOPRBT (IOPGAT-RBT), PAP grade, and PAP grading items were compared among groups stratified by PAP grade or prostaglandins. Of the study patients, 114 (25%) had grade 0 (no PAP), 174 (38%) grade 1 (superficial cosmetic PAP), 141 (31%) grade 2 (deep cosmetic PAP), and 31 (7%) grade 3 (tonometric PAP). The IOPGAT was significantly higher in grade 3 (17.5 ±â€Š5.4 mm Hg) than grades 0 (15.0 ±â€Š5.1 mm Hg, P = .032) and 1 (14.5 ±â€Š4.2 mm Hg, P = .008), and the IOPGAT-RBT was significantly higher in grade 3 (5.8 ±â€Š3.2 mm Hg) than the other 3 grades (1.3-1.9 mm Hg, P < .001 for all comparisons); the IOPRBT was equivalent among the 4 grades. The PAP grade was significantly higher associated with travoprost (2.0 ±â€Š0.8) and bimatoprost (2.0 ±â€Š0.7) than latanoprost (1.0 ±â€Š0.8, P < .001 for both comparisons) and tafluprost (1.0 ±â€Š0.7, P < .001 for both comparisons), but significantly lower associated with omidenepag (0.0 ±â€Š0.0, P < .001 for all comparisons) than the other 4 prostaglandins. Multivariate analyses showed older age (standard ß = 0.11), travoprost (0.53, referenced by latanoprost) and bimatoprost (0.65) were associated with higher PAP grades, while tafluprost (-0.18) and omidenepag (-0.73) were associated with lower PAP grades. The PAP graded using SU-PAP reflects the degree of overestimation of the IOPGAT and different severities of PAP among the different prostaglandins. SU-PAP, the grade system constructed based on the underlining mechanisms of PAP, is a simple grading system for PAP that is feasible for use in a real-world clinical situation.

Bilateral Optic Disc Swelling with Preserved Visual Function Associated with Giant Cell Arteritis.

A 68-year-old Japanese man was introduced to our hospital for optic disc swelling (ODS) in his both eyes (OU). Other than floaters in his right eye, he did not report any symptoms including blurred vision, visual field defect, and ocular pain. Light reflex was prompt and complete OU, and critical flicker frequency was within the normal range OU. By fluorescein angiography, hyperfluorescence was detected on optic discs OU; however, no fluorescein leakage or filling defect was observed. By Goldmann perimetry, enlargement of the Mariotte blind spot was revealed OU, while no central scotoma or remarkable visual field defects were detected. By neuroimaging and lumbar puncture, papilledema due to intracranial pressure elevation was denied. Based on the reassessment of fundus findings, narrowing and segmental whitening/sheathing of peripapillary vessels predominantly to arterioles were realized, and systemic arteritis was suspected. Based on the subject age, elevation of erythrocyte sedimentation rate, positron emission tomography findings in the aorta, and MRI findings in temporal arteries, underlying giant cell arteritis (GCA) was diagnosed. After the start of systemic and local steroid therapies, ODS improved OU. Although rare, bilateral ODS with no visual disturbance can occur in patients with GCA. This case emphasizes the importance of careful assessment of ocular findings to reach the correct diagnosis of even a rare cause of ODS.

ICAM1-Negative Intravascular Large B-Cell Lymphoma of the Pituitary Gland: A Case Report and Literature Review.

OBJECTIVE: Intravascular large B-cell lymphoma (IVLBCL) is a rare and aggressive type of B-cell lymphoma with large cells growing within the lumen of blood vessels. Although previous reports revealed highly variable symptoms resulting from small-vessel occlusion by neoplastic cells in a variety of organs, there are few reports of IVLBCL with pituitary involvement. METHOD: We present a case of IVLBCL with pituitary infiltration from our institution together with a literature review of similar cases to better understand this rare case of IVLBCL involving the pituitary gland. RESULTS: Our case and the pertinent literature demonstrated that IVLBCL with pituitary involvement predominantly occurred in women at a mean age of 64 years, and most of them showed panhypopituitarism that was reversible after standard therapy of rituximab-containing chemotherapy with intrathecal methotrexate. Notably, the pituitary biopsy in our case revealed that atypical large B-cells found within blood vessels and the pituitary gland were negative for intercellular adhesion molecule 1. Intercellular adhesion molecule 1-negative lymphoid cells may have contributed to panhypopituitarism by extravasation into the pituitary tissues, which do not have a blood-brain barrier and receive abundant blood flow. CONCLUSION: IVLBCL of the pituitary gland is a rare lymphoma with nonspecific manifestations and a dismal prognosis. Recognition of the clinicopathological features is necessary for early clinical diagnosis and appropriate treatment.

Fellow-Eye Comparison between Phaco-Microhook Ab-Interno Trabeculotomy and Phaco-iStent Trabecular Micro-Bypass Stent.

The aim of this study is to compare the surgical efficacy and safety between microhook ab-interno trabeculotomy (µLOT) and iStent trabecular micro-bypass stent implantation when both were combined with cataract surgery in both eyes of patients. Sixty-four glaucomatous eyes (32 participants; mean age, 75.9 ± 7.6 years; 15 men, 17 women) were included retrospectively. Intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), anterior chamber flare (ACF) and corneal endothelial cell density (CECD) were evaluated preoperatively, as well as 2, 3, 6, and 12 months postoperatively. Surgical complications and interventions were compared between the procedures. The preoperative IOP and medications with µLOT (18.8 ± 5.7 mmHg and 3.0 ± 1.2, respectively) were higher than with the iStent (15.5 ± 3.4 mmHg and 2.7 ± 1.2, respectively) (p = 0.0001 and p = 0.0437, respectively). At 12 months, the µLOT values (12.6 ± 2.3 mmHg and 2.3 ± 0.9, respectively) were identical to iStent (12.8 ± 2.5 mmHg and 2.3 ± 0.9, respectively) (p = 0.0934 and p = 0.3251, respectively). At 12 months, the IOP decreased more with µLOT (6.2 mmHg, 29.5%) than iStent (2.7 mmHg, 15.6%) (p = 0.0003). The decrease in medications was greater with µLOT (0.7) than iStent (0.4) (p = 0.0437). Survival rate of IOP control ≤15 mmHg and IOP reduction ≥20% was significantly higher after µLOT (40.6% at 12 months) than iStent (18.8%) (p = 0.0277). The frequency of layered hyphema was significantly greater with µLOT (8 eyes, 25%) than iStent (0 eyes, 0%) (p = 0.0048). The increase in the ACF at 2 weeks postoperatively was significantly greater with µLOT than iStent (p = 0.0156), while changes in the BCVA and CECD were identical between groups. The fellow-eye comparison showed that the IOP reduction was greater with µLOT than iStent when combined with cataract surgery.

Characteristics of benign adrenocortical adenomas with 18F-FDG PET accumulation.

INTRODUCTION: Although 18F-FDG PET was originally developed to evaluate benign and malignant tumors, the frequency of detection of benign adrenocortical adenomas showing FDG-PET accumulation has increased. However, the details of FDG-PET-accumulated benign adrenocortical adenomas have not been elucidated. METHODS: To elucidate the pathophysiology of FDG-PET-positive cortisol-producing adrenal tumors, we performed clinicopathological and genetic analyses of adrenocortical adenomas examing FDG-PET in 30 operated patients with unilateral cortisol-producing adrenal tumors (26 adrenal adenomas and 4 adrenal cancers). RESULTS: All adrenocortical carcinomas and 17/26 (65%) benign adrenocortical adenomas showed high FDG accumulation (SUVmax ≥ 3). In adrenocortical adenomas with high FDG accumulation (SUVmax ≥ 3), SUVmax showed a positive correlation with the CT Hounsfield units. A higher SUVmax showed a clear black adenoma appearance with predominantly compact cells, which exhibited high T1 and T2 signals, a lack of signal drop on out-of-phase imaging on MRI, and less accumulation on 131-I adsterol scintigraphy. Furthermore, RNA-sequencing analysis revealed significant increases in the lysosomal and autophagy pathways and metabolic pathways, including glycolysis through glucose transporter (GLUT) 1 and 3, in black adenomas with high-level FDG accumulation. DISCUSSION: A black adenoma is blackish due to lipofuscin, which accumulates as a result of damaged mitochondria or proteins that escape lysosomal degradation or autophagy. Since FDG in PET is taken up via GLUTs, alteration of the intracellular metabolic dynamics associated with mitochondrial damage in black adenomas may increase PET accumulation. CONCLUSION: Black adrenal adenomas should be considered with adrenal tumors showing PET accumulation and low lipid contents.