Risk Factors for Legal Blindness in 237 Japanese Patients with Exogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST.

PURPOSE: We investigated potential risk factors for visual prognosis in Japanese patients with exogenous endophthalmitis. METHODS: In this retrospective observational multicenter cohort study, risk factors for legal blindness at 12 weeks after treatment initiation were evaluated based on patient characteristics, initial BCVA, causative events, pathogens, ocular symptoms, duration from symptom onset to initial treatment, and selected treatments. RESULTS: Overall, 23.1% of eyes developed legal blindness. The six risk factors for legal blindness were presence of eye pain, pathogen identification, poor BCVA at the initial visit, longer duration from symptom onset to initial treatment, type of causative event, and type of causative pathogen. Regarding the type of causative pathogen, coagulase-negative staphylococci was associated with a better visual impairment outcome. CONCLUSION: Exogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatment, as well as other advances in medical knowledge and technology.

Risk Factors for Legal Blindness in 77 Japanese Patients with Endogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST.

PURPOSE: We investigated potential predictive factors for visual prognosis in Japanese patients with endogenous endophthalmitis. DESIGN: Retrospective observational multicenter cohort study. METHODS: We examined the characteristics of 77 Japanese patients with endogenous endophthalmitis and performed statistical analyses of these real-world data. The primary endpoint was the identification of factors associated with visual prognosis. We examined differences between patients in the better vision and legal blindness groups at 12 weeks after treatment initiation. RESULTS: The five risk factors for visual impairment at 12 weeks after treatment initiation were presence of pressure injuries, severe clinical symptoms (presence of eye pain and ciliary injection), pathogen identification, and poor best-corrected visual acuity at baseline. Staphylococcus aureus and fungus were associated with a better visual impairment outcome. CONCLUSIONS: Endogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatments, as well as other advances in medical knowledge and technology.

Visual impairment associated with choroidal macroaneurysm in a patient with presumed anomalous short posterior ciliary artery.

Purpose: To report the clinical findings and treatment outcomes of a patient with a choroidal macroaneurysm associated with a presumed anomalous short posterior ciliary artery. Observations: A 74-year-old woman with anomalous choroidal vessels had mild visual impairment. Best-corrected visual acuity (BCVA) was 20/25 in the left eye. Funduscopic examination showed a protruded orange lesion temporal to the fovea with exudative changes and retinal hemorrhage. An extensive, thick choroidal vessel network was observed in the superficial choroid. Optical coherence tomography showed a steep protruded lesion beyond the retinal pigment epithelium (RPE) and RPE elevations corresponding to an anomalous choroidal vessel network located at the RPE/Bruch's membrane complex. Optical coherence tomography angiography showed decorrelation signals corresponding to the steep protruding lesion and anomalous choroidal vessel network. Fluorescein angiography and indocyanine green angiography revealed an aneurysmal lesion and anomalous choroidal vessel network in the choroidal arterial phase. A choroidal macroaneurysm associated with a presumed anomalous short posterior ciliary artery was diagnosed. Regardless of repeated treatment with intravitreal injections of aflibercept/broluzumab and photodynamic therapy, the patient's BCVA decreased to 20/50. Finally, direct photocoagulation for choroidal macroaneurysm was performed, which resolved the exudative change, and the patient's BCVA improved to 20/25. Conclusions and importance: A choroidal macroaneurysm associated with an anomalous short posterior ciliary artery could be a differential diagnosis of polypoidal choroidal vasculopathy. When visual impairment develops due to exudative changes, direct photocoagulation may be the most appropriate treatment option.

Multimodal Imaging of a Severe Case of Neonatal Acute Retinal Necrosis and Lens Vacuoles Associated with Herpes Simplex Virus Infection.

PURPOSE: To report a case of a neonate with acute retinal necrosis, lens vacuoles, and encephalitis associated with herpes simplex virus (HSV) infection. DESIGN: Case report. METHODS: Retrospective chart review. RESULTS: A male neonate was brought for screening for retinopathy of prematurity at the corrected age of 32 weeks. Slit-lamp examination showed lens vacuoles in both eyes. Fundus examination revealed extensive retinal detachments with prominent retinal whitening, subretinal exudates, and retinal hemorrhage. Computed tomography of the brain showed encephalomalacia. Polymerase chain reaction of cerebrospinal fluid and anterior chamber fluid was both positive for HSV-1. Despite systemic anti-viral therapy, a rhegmatogenous retinal detachment and subsequent proliferative vitreoretinopathy developed in the patient's right eye. The retinal detachment in the left eye resolved, but significant chorioretinal degeneration occurred. With time lens vacuoles decreased in number. CONCLUSIONS: Clinicians should remember this rare, but devastating condition without specific prodromal symptoms.

Visual Outcome and Treatment Frequency of Anti-VEGF Therapy Using the Treat-and-Extend and Treatment Cessation Regimen for Exudative Age-Related Macular Degeneration and Pachychoroid Neovasculopathy.

PURPOSE: To report the results of anti-vascular endothelial growth factor (VEGF) therapy using treat-and-extend (TAE) and treatment cessation regimens for exudative age-related macular degeneration (AMD) and pachychoroid neovasculopathy (PN). METHODS: We retrospectively studied 101 treatment-naïve eyes of 101 patients with exudative AMD and PN that underwent anti-VEGF therapy using TAE and treatment cessation regimen with a follow-up period of ≥12 months. Best-corrected visual acuity (BCVA), treatment frequency, and number of eyes with successful treatment cessation were measured. Successful treatment cessation was defined as dry macula retention without treatment for >16 weeks after the last injections. Factors related to the successful treatment cessation were evaluated. RESULTS: BCVA was maintained at the last visit with a mean follow-up period of 49.9 ± 26.9 months. The injection number decreased from 6.8 ± 2.31 at the first year to 3.7 ± 3.64 at the fifth year. At the last visit, 48 (47.5%) eyes were being treated at an interval of ≥12 weeks or were under treatment cessation. Successful treatment cessation during the follow-up period and at the last visit were achieved in 56 (55.4%) and 27 (26.7%) eyes, with a median treatment-free period of 66 and 126 weeks, respectively. Good early treatment response and a small recurrence number were associated with successful treatment cessation at the last visit. CONCLUSION: Patients with good early response to treatment and fewer recurrences may achieve treatment cessation. This information could help physicians predict the achievement of treatment cessation for a considerable period.

Clinical Characteristics and Outcomes in 314 Japanese Patients with Bacterial Endophthalmitis: A Multicenter Cohort Study from J-CREST.

Bacterial endophthalmitis is an intraocular infection that causes rapid vison loss. Pathogens can infect the intraocular space directly (exogenous endophthalmitis (ExE)) or indirectly (endogenous endophthalmitis (EnE)). To identify predictive factors for the visual prognosis of Japanese patients with bacterial endophthalmitis, we retrospectively examined the bacterial endophthalmitis characteristics of 314 Japanese patients and performed statistics using these clinical data. Older patients, with significantly more severe clinical symptoms, were prevalent in the ExE group compared with the EnE group. However, the final best-corrected visual acuity (BCVA) was not significantly different between the ExE and EnE groups. Bacteria isolated from patients were not associated with age, sex, or presence of eye symptoms. Genus Streptococcus, Streptococcus pneumoniae, and Enterococcus were more prevalent in ExE patients than EnE patients and contributed to poor final BCVA. The presence of eye pain, bacterial identification, and poor BCVA at baseline were risk factors for final visual impairment.

Incidence of endophthalmitis after intravitreal injection of an anti-VEGF agent with or without topical antibiotics.

Intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF) is the standard treatment modality in various types of retinal diseases. However, endophthalmitis remains the most serious complication. Despite the lack of evidence that antibiotics prevent endophthalmitis, topical antibiotics are still used routinely in Japan. We conducted a retrospective multicenter study by analyzing records from patients who underwent IVI of anti-VEGF agents with or without antibiotic treatment. In the analysis of a total of 147,440 eyes, the incidence of endophthalmitis was 0.007%: 0.005% with no use of antibiotics, 0.009% with antibiotic pretreatment, 0.012% with posttreatment, and 0.005% with pre- and posttreatment. There was no statistically significant difference among the four groups (chi-square test, p = 0.57). Most facilities used masks, sterilized gloves, and drapes. Nine of the 10 eyes that developed endophthalmitis received topical antibiotics, and all infected eyes underwent IVI with aflibercept, not the prefilled syringe delivery system. In four patients who received multiple IVI, the detection of causative bacteria revealed resistance to used antibiotics. Data from this large population, treated with or without antibiotics, suggests that antibiotic prophylaxis does not reduce the rate of endophthalmitis after IVI.

Clinical characteristics and visual outcomes of work-related open globe injuries in Japanese patients.

PURPOSE: To investigate the clinical characteristics and visual outcomes of patients with work-related open globe injuries (OGIs) and compare them with patients with non-work-related OGIs. DESIGN: Retrospective, observational, multicentre, case-control study. METHODS: A total of 374 patients with work-related OGIs and 170 patients with non-work-related OGIs who presented to hospitals that belong to the Japan-Clinical Research of Study group from 2005 to 2015 were included in this study. Clinical data including age, sex, initial and final visual acuity, type of open globe injury, lens status, zone of injury, wound length, and presence of proliferative vitreoretinopathy, retinal detachment, expulsive haemorrhage, and endophthalmitis were recorded. MAIN OUTCOME MEASURES: Visual acuity. Results Work-related OGIs were associated with younger age, male sex, better initial and final visual acuity, more laceration, smaller wounds, presence of retinal detachment, and expulsive haemorrhage, compared with non-work-related OGIs. Multiple regression analysis revealed that final visual acuity is significantly associated with initial visual acuity, wound length, and the presence of proliferative vitreoretinopathy in work-related OGIs. CONCLUSIONS: Work-related OGIs showed better visual outcomes than other OGIs. Initial visual acuity, wound length, and the presence of proliferative vitreoretinopathy are predictors of visual outcomes in patients with work-related OGIs.

Systemic and Ocular Determinants of Choroidal Structures on Optical Coherence Tomography of Eyes with Diabetes and Diabetic Retinopathy.

Knowledgeof the choroidal structures in eyes with diabetes and diabetic retinopathy (DR) should provide information on the pathogenesis of DR. A prospective study was performed to determine the systemic and ocular factors that affect the choroidal structures in eyes with diabetes. Two-hundred consecutive diabetic subjects consisted of 160 treatment-naïve patients with different stages of DR and 40 patients with proliferative DR with prior panretinal photocoagulation (PRP). All underwent blood and urine tests and enhanced depth imaging optical coherence tomography (EDI-OCT). The cross-sectional EDI-OCT images of the subfoveal choroid were binarized to measure the total choroidal area (TCA), luminal area, and stromal area. Multivariate regression analyses were performed to determine the systemic and ocular factors that were significantly correlated with the choroidal structures. The subfoveal choroidal thickness, TCA, luminal area, and stromal area were larger at more advanced stage of DR, and smaller in eyes with PRP than those without (P < 0.001). The TCA and stromal area were significantly and positively correlated with the degree of albuminuria (P = 0.034, P = 0.025, respectively). The choroidal lumen and stroma may increase as the stages of DR progress and decrease after PRP. Albuminuria may be associated with the choroidal stromal edema.

TRAFFIC ACCIDENT-RELATED OPEN GLOBE INJURIES.

PURPOSE: To evaluate the clinical characteristics and visual outcomes of patients with traffic accident-related open globe injuries, and to examine preoperative factors influencing the visual prognosis after pars plana vitrectomy, as compared with common open globe injuries. METHODS: Patients with open globe injuries, who underwent pars plana vitrectomy, were identified. Patients' demographic and clinical data were entered into a computerized database for review and analysis; data included age, sex, initial visual acuity, duration between onset of injury and surgery, information about the type and cause of injury, wound location and length, presence of ocular complications, and final visual acuity. RESULTS: Of the 355 open globe injuries, 14 were sustained during a traffic-related accident; the average age was 50.4 years (range: 20-85) and most (78.6%) were men. Of these 14 patients, 9 (64.3%) presented with rupture and 5 (35.7%) with laceration. Injuries were caused while driving (6 eyes; 42.9%), riding a bicycle (5 eyes; 35.7%), involved in car accident while walking (2 eyes; 14.3%), and riding a motorbike (1 eye; 7.1%). Initial visual acuity was significantly related to final visual acuity (P = 0.003, R = 0.80). The final visual acuity in patients with traffic accident-related open globe injuries was significantly better than that of the total group (P = 0.01). CONCLUSION: Traffic accident-related open globe injuries had better visual outcomes than common open globe injuries. Visual outcomes in patients with traffic accident-related open globe injuries were related to the initial visual acuity. No eyes developed endophthalmitis in patients with traffic accident-related open globe injuries.

Effects of Exercise on the Structure and Circulation of Choroid in Normal Eyes.

AIMS: To determine the effects of dynamic exercise on the circulation and the luminal and stromal areas of the choroid in normal eyes. METHODS: This was a prospective interventional study of 38 eyes of 38 normal subjects enrolled by invitation. The systolic and diastolic blood pressures, heart rate, intraocularpressure, mean ocular perfusion pressure (MOPP), choroidal blood velocity, and enhanced depth imaging optical coherence tomographic (EDI-OCT) images were recorded before, and immediately after mild dynamic exercise. The same measurements were recorded after 10 min of rest. The choroidal blood velocity was measured bylaser speckle flowgraphy, and the mean blur rate was used for the evaluations. The horizontal EDI-OCT images of the subfoveal choroid were converted to binary images. The central choroidal thickness (CCT), total cross sectional choroidal area, luminal areas, stromal areas, and the ratio of luminal area to total choroidal area (L/C ratio) were determined from these images. RESULTS: The systolic and diastolic blood pressures, heart rate, MOPP, and the mean blur rate were significantly increased immediately after the exercise and significantly decreased 10 minutes after the exercise. There wereno significant changes in the mean CCT, the mean total choroidal area, the mean luminal and stromal areas, and the mean L/C ratio after the exercise. CONCLUSIONS: Our results suggest that a rest period is needed before measurements of blood flow velocity but not necessary for the EDI-OCT imaging to determine the choroidal thickness and area.

Changes in Choroidal Structures in Eyes with Chronic Central Serous Chorioretinopathy after Half-Dose Photodynamic Therapy.

PURPOSE: To determine the structural changes in the choroid after half-dose photodynamic therapy (hPDT) in eyes with chronic central serous chorioretinopathy (CSC). METHODS: This was a retrospective interventional study of 29 eyes of 29 patients who underwent hPDT for chronic CSC with serous retinal detachment (SRD) and were followed for ≥3 months. Enhanced depth imaging optical coherence tomographic (EDI-OCT) images of the subfoveal choroid were converted to binary images. The central choroidal thickness (CCT), the cross sectional subfoveal choroidal area, the hyporeflective and hyperreflective areas of the inner, outer, and whole choroid were determined at the baseline, and at 1, 3, and 12 months after the hPDT. RESULTS: The SRDs were resolved in 26 (89.7%) eyes at 3 months after the hPDT. The mean CCT (P = 0.001), the total choroidal area (P = 0.001), and the hypo-reflective area (P = 0.003) of the whole choroid were significantly decreased from the baseline at 3 months. The hyperreflective area of whole choroid was not significantly changed during the study period (P = 0.083). The hyperreflective but not the hyporeflective area of the inner choroid was significantly decreased at 3 months (P = 0.001, P = 1.000, respectively). The hyporeflective but not the hyperreflective area of the outer choroid was significantly decreased at 3 months (P = 0.001, P = 1.000, respectively). CONCLUSIONS: The hyperreflective area of the inner choroid and hyporeflective area of the outer choroid were significantly decreased after hPDT for chronic CSC. Because the hyperreflective and hyporeflective area correspond to the choroidal stroma and vessels, respectively, the decreased CCT and subfoveal choroidal area after hPDT may be attributed to a decrease in the exudative changes in the inner choroidal stroma and the reduction of the dilation of the outer choroidal vessels.

Daily concentrations of trace metals in aerosols in Beijing, China, determined by using inductively coupled plasma mass spectrometry equipped with laser ablation analysis, and source identification of aerosols.

This paper describes the daily concentrations of trace metals and ionic constituents in the aerosol of Beijing, China from March 2001 to August 2003. Daily PM10 concentrations were also measured from September 2001 to August 2003. The daily average PM10 concentration at Beijing, China from September 2001 to August 2003 was 171+/-117 microg m(-3) (n = 673), which is 5-fold higher than at Yokohama, Japan. Trace metal concentrations were analyzed by using inductively coupled plasma mass spectrometry equipped with a laser ablation sample introduction (LA/ICP-MS), which is a rapid and simultaneous method for multi-element analysis. The daily average metal concentrations in TSP in Beijing from March 2001 to August 2003 were: Al: 3.5+/-2.4 (n = 727), Ti: 0.47+/-0.35 (n = 720), V: 0.013+/-0.010 (n = 716), Cr: 0.019+/-0.015 (n = 618), Mn: 0.24+/-0.16 (n = 730), Fe: 5.5+/-3.9 (n = 728), Co: 0.0046+/-0.0055 (n = 629), Ni: 0.022+/-0.024 (n = 680), Cu: 0.11+/-0.11 (n = 660), Zn: 0.77+/-0.60 (n = 726), As: 0.048+/-0.047 (n = 731), Se: 0.010+/-0.010 (n = 550), Cd: 0.0068+/-0.0082 (n = 709), Sb: 0.033+/-0.036 (n = 687), and Pb: 0.43+/-0.50 (n = 728) (unit, microg m(-3)). All the metal concentrations in TSP in Beijing, China were 1.7-21.8 times higher than those in TSP in the center of Tokyo, Japan. Notably, As concentrations in TSP in Beijing were 20-fold higher than those in Tokyo. Source identification of aerosols in Beijing was carried out by using the chemical mass balance (CMB) receptor model, with the daily concentration of metals in the aerosol. The major primary sources of the aerosol of Beijing were considered to be soil dust and coal combustion. Vehicle exhaust contribution tended to increase.