Case report: Findings of automated perimetry during a migraine episode in a patient with glaucoma.

Comorbidities like glaucoma and migraine are often observed among middle-aged individuals, especially women. Herein, we report a rare case of a patient who underwent automated perimetry during a migraine attack. A 52-year-old woman with a 1-year history of blurred vision in the nasal field of her right eye visited Miyoshi Eye Clinic. The intraocular pressures of the right and left eyes were 22 and 24 mm Hg, respectively. Retinal imaging revealed a retinal nerve fiber defect in the temporal superior macula with corresponding thinning of the superior ganglion cell complex in the right eye. The left eye appeared normal. Primary open-angle glaucoma was suspected, and the patient underwent a visual field examination on the same day. Perimetry showed that the mean deviations in the right and left eyes were -5.00 and -7.68 dB, respectively. A visual field defect in the inferior nasal aspect of the right eye corresponded to the retinal nerve fiber defect. However, right-sided homonymous hemianopia-like visual field defects were observed in both eyes. After the examination, the patient stated that a migraine attack had started 5 min before the examination and continued till after its end (attack duration was ∼20 min). In the follow-up examinations without migraine, homonymous hemianopia-like visual field defects disappeared, and only a glaucomatous visual field defect in the right eye was observed. Hence, the initial visual field examination findings reflected the effects of a migraine attack alongside glaucoma. Detailed interviews with patients may be beneficial for understanding visual field findings and preventing their untimely examination.

How to Manage the Cortex After CTR Insertion.

Capsular tension ring (CTR) realizes safe cataract surgery. However, residual cortex removal becomes difficult with CTR. Originally, the flushing technique was developed for intracameral antibiotic administration. Using this technique with larger amounts of solution enables surgeons to 1) deliver antibiotics to the anterior chamber and area behind the intraocular lens, resulting in stable, scheduled antibiotic concentration and 2) entirely irrigate and displace the area, leading to the effective cleansing of residual substances and bacterial pollution. When performing the flushing technique, the residual cortex and debris that were not eliminated by ordinary irrigation and aspiration can be pushed out to the anterior chamber. Applying flushing technique to CTR cases, the residual cortex and debris trapped between the CTR loop and capsular equator is lifted into the anterior chamber and easily removed. If the capsular bag is polluted by bacteria, it may also be lifted to the anterior chamber.

Effect of small-incision sutureless cataract surgery on the natural course of astigmatism over 10 to 20 years.

PURPOSE: To retrospectively assess astigmatic changes over 10 years and 20 years after small-incision cataract surgery. SETTING: 5 ophthalmic surgical sites in Japan. DESIGN: Retrospective case series. METHODS: Data were collected from patients who had undergone phacoemulsification and implantation of an intraocular lens through a 2.2 to 2.4 mm incision. Preoperative corneal and postoperative manifest astigmatism were converted to power vector notations: horizontal/vertical (J 0 ) and oblique (J 45 ) astigmatism components. RESULTS: 422 eyes of 422 patients were followed for 10 years, and data preoperatively and at 1 month and at 1 year, 3 years, 5 years, 8 years, and 10 years postoperatively were analyzed. The mean J 0 decreased significantly ( P < .001, repeated measures analysis of variance) with an against-the-rule (ATR) shift of 0.363 ± 0.433 diopter (D) over 10 years, but the mean J 45 did not change significantly ( P = .150). Double-angle plot analyses also showed similar ATR shifts in all astigmatism groups. In the subgroup analysis conducted in 34 patients who were followed for 20 years, J 0 declined significantly ( P < .001) by 0.649 ± 0.576 D, whereas J 45 did not ( P = .516). The postoperative changes in J 0 and J 45 were not significantly different between eyes with preoperative with-the-rule, ATR, or oblique astigmatism. CONCLUSIONS: Postoperative astigmatism continued to shift toward ATR during the follow-up period of 20 years after small-incision cataract surgery, which seems to reflect the natural course of corneal astigmatic changes that commonly occur with aging. ATR astigmatic shifts were similar in both pattern and magnitude regardless of the type of preoperative astigmatism.

Hydro-dispersion of subincisional cortex.

BACKGROUND: A simple technique to facilitate removal of subincisional cortex in cataract surgery is presented. METHODS: A disposable 27-gauge blunt needle attached to a 5.0-ml syringe containing balanced salt solution (BSS) is introduced through the side port incision into the anterior chamber. The tip of the needle is directed toward the capsule fornix beneath the incision site, and BSS is flushed to disperse the remaining cortex. Thereafter, the coaxial irrigation/aspiration device is used to remove the loosened cortex. RESULTS: This technique was used in 60 eyes of 60 patients with difficulty of removing cortical remnant in the subincisional space. Subincisional cortical material was successfully removed in 93.3% (56/60 eyes). There were no intraoperative and postoperative complications related to this procedure. CONCLUSIONS: The hydro-dispersion technique is a simple and safe approach to remove the subincisional cortical material that is difficult to manage with the standard coaxial irrigation/aspiration device.

Prospective assessment of plate-haptic rotationally asymmetric multifocal toric intraocular lens with near addition of + 1.5 diopters.

BACKGROUND: To prospectively evaluate surgical results following implantation of rotationally asymmetric, plate-haptic, refractive segmented multifocal toric intraocular lenses (IOLs) with near addition of + 1.5 diopters (D) (Lentis Comfort LS-313 MF15T, Oculentis GmbH). METHODS: In 59 eyes of 41 patients, ocular examinations were conducted before and 1 day, 1 week, 1, 3, and 6 months after surgery. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, uncorrected (UIVA) and distance-corrected (DCIVA) intermediate visual acuity at 70 cm, and uncorrected (UNVA) and distance-corrected (DCNVA) near visual acuity at 30 cm were tested. A defocus curve was drawn, and the degree of disturbing photic phenomena were questioned. RESULTS: The IOL showed excellent rotational stability; the average absolute rotation was 1.66 ± 1.17 degrees from 1 day 1 to 6 months postoperatively, and 98.1 and 100% of eyes yielded rotation of less than 5 and 10 degrees, respectively. Postoperative distance and intermediate visual acuity were highly satisfactory; UDVA, CDVA, UIVA, and DCIVA were about 20/20, 20/16, 20/25, 20/25, respectively. Near visual acuity was suboptimal; UNVA and DCNVA were at approximately 20/60. The defocus curve analysis showed that 20/25 and 20/40 uncorrected visual acuity was attained at as close as 60 and 40 cm, respectively. Contrast sensitivity was within a normal range, and subjective photic phenomena were minimum. CONCLUSIONS: The refractive segmented, rotationally asymmetric multifocal toric IOLs with + 1.5 D near addition showed superb rotational stability and highly satisfactory distance and intermediate vision. Contrast sensitivity was high and incidence of photic symptoms was very low. TRIAL REGISTRATION: This study was registered at JAPIC Clinical Trials Information, ID: JapicCTI-183,877, https://www.clinicaltrials.jp/cti-user/trial/Search.jsp (February 5, 2018).

Effects of capsular tension ring on surgical outcomes of premium intraocular lens in patients with suspected zonular weakness.

PURPOSE: To assess the influence of capsular tension ring (CTR) on surgical outcomes of toric and multifocal intraocular lenses (IOLs) in eyes at high risk of zonular instability. METHODS: Fifty-five eyes of 43 patients who had undergone phacoemulsification and IOL implantation were included in the analysis. They had some risk of zonular weakness, such as pseudoexfoliation, shallow anterior chamber, high myopia, and phacodonesis, or were judged to have unstable zonules during surgery. Toric IOL was implanted in 9 eyes with CTR and 22 eyes without CTR, while multifocal IOL was used in 9 eyes with CTR and 15 eyes without CTR. Manifest refraction, refractive astigmatism, visual acuity, and degree of IOL decentration and tilt measured using swept-source anterior segment optical coherence tomography were analyzed. Axis misalignment of toric IOLs were also evaluated. RESULTS: In toric IOLs, co-implantation of CTR significantly reduced decentration and axis misalignment of IOL, resulting in better uncorrected and corrected visual acuity after surgery. In multifocal IOLs, combined use of CTR significantly prevented IOL tilt, leading to better intermediate visual acuity. Spherical equivalent and residual astigmatism were not significantly affected by the use of CTR. CONCLUSIONS: CTR reduces decentration and axis misalignment of toric IOL and tilt of multifocal IOL, achieving improvement of postoperative visual function in eyes with suspected zonular instability.

Comparison of incidence of repositioning surgery to correct misalignment with three toric intraocular lenses.

PURPOSE: To compare the incidence of re-orientating surgery to improve misalignment of three models of acrylic toric intraocular lenses: AcrySof toric intraocular lens (Alcon Laboratories, Inc.), TECNIS toric intraocular lens (Johnson & Johnson Vision, Inc.) and HOYA 355 toric intraocular lens (HOYA). METHODS: In this retrospective, multicenter case series, medical charts were reviewed for collecting data on realignment surgery of toric intraocular lenses at 10 ophthalmic surgical sites in Japan. RESULTS: Over all, intraocular lens repositioning surgery was conducted in 89 of 9430 eyes (0.944%) at an average of 10.5 ± 9.7 days after the initial cataract surgery. The incidence was 0.213% (11/5155), 1.797% (62/3451) and 1.942% (16/824) with AcrySof, TECNIS and HOYA toric intraocular lenses, respectively. The incidence was significantly lower with AcrySof than with other two brands of toric intraocular lenses (p < 0.0001). In those eyes which underwent reorientation surgery, the amount of misalignment was 26.4 ± 21.9°, 29.7 ± 15.4° and 28.1 ± 20.7° with AcrySof, TECNIS and HOYA toric intraocular lenses, respectively; there was no significant difference among groups (p = 0.821). The repositioning surgery significantly reduced misalignment in all three groups. CONCLUSION: The rotational stability was considerably different among toric intraocular lenses of different manufacturers. The incidence of repositioning surgery was significantly lower with AcrySof than with TECNIS and HOYA toric intraocular lenses.

[Clinical efficacy of travoprost-timolol fixed combination on ocular hypotensive agents and ocular surface agents in Japanese glaucoma patients].

PURPOSE: To investigate the clinical effects of travoprost-timolol fixed combination on ocular hypotensive agents, ocular surface agents and adherence in Japanese glaucoma patients. METHODS: 28 Japanese glaucoma patients, who had used topical prostaglandin F2alpha analogue (28 eyes; PG group), were assigned to treatment with travoprost-timolol fixed combination. Reduction of intraocular pressure (IOP), grades of conjuctival follicle, conjuctival injection and keratoepitheliopathy, as well as interviews for topical administration, were evaluated. 38 patients, who switched from the topical prostaglandin F2alpha analogue and a beta-blocker to travoprost-timolol fixed combination (38eyes: PG+BB group) were also evaluated in the same manner. RESULTS: While IOP was significantly reduced in the PG group, IOP was not changed in the PG+BB group. Both groups showed no significant changes in scores for conjuctival follicle, keratoepitheliopathy, or interview. CONCLUSION: These results suggest that travoprost-timolol fixed combination reduces IOP and produces low toxicity on the ocular surface.

Efficacy and safety of prophylactic intracameral moxifloxacin injection in Japan.

PURPOSE: To report endophthalmitis rates after cataract surgery and the incidence of complications after intracameral moxifloxacin injection. SETTING: Nineteen clinics in Japanese institutions. DESIGN: Retrospective survey cohort study. METHODS: The number of surgeries and endophthalmitis cases in the past 4 years before and after the introduction of intracameral moxifloxacin was evaluated. The survey was performed by mail or interview in February 2013. RESULTS: All institutions used total-replacement administration rather than small-volume injection. At 3 institutions, 50 to 100 µg/mL moxifloxacin; at 9 institutions, 100 to 300 µg/mL moxifloxacin; and at 7 institutions, 500 µg/mL moxifloxacin was administered. The highest concentration (500 µg/mL) was administered in 14,124 cases. Endophthalmitis cases occurred 1 month or sooner postoperatively in 8 of 15,958 cases (ie, 1 in 1955) without intracameral moxifloxacin administration and in 3 of 18,794 cases (ie, 1 in 6265) with intracameral moxifloxacin administration. CONCLUSIONS: Intracameral moxifloxacin (50 to 500 µg/mL) administration decreased the risk for endophthalmitis by 3-fold. In more than 18,000 cases, moxifloxacin administration of 500 µg/mL or less did not result in severe complications, such as toxic anterior segment syndrome or corneal endothelial cell loss.

Emulsification action of longitudinal and torsional ultrasound tips and the effect on treatment of the nucleus during phacoemulsification.

PURPOSE: To compare the results of emulsification of test materials when applying torsional and longitudinal emulsification tips as well as to define emulsification and determine how it occurs by examining the effect of phacoemulsification. SETTING: Miyoshi Eye Hospital, Fukuyama, Japan. METHOD: An ultra-high-speed digital video camera was used to record emulsification of chestnuts and human nuclei in a test chamber, simulating real phacoemulsification. The treatment of the nucleus as a result of phacoemulsification was analyzed visually. RESULTS: Visual comparison of video data showed that the test chamber materials were completely desiccated by the torsional phaco device. Longitudinal phacoemulsification resulted in cutting and coring of the test chamber materials, but not total disruption. CONCLUSIONS: Visual comparisons showed that complete obliteration and desiccation of the nucleus, or emulsification, occurs only with torsional phacoemulsification. These observations open the way to understanding the best approach to new tip design and surgical strategy development. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Ultra-high-speed digital video images of vibrations of an ultrasonic tip and phacoemulsification.

PURPOSE: To visually compare ultrasonic tip vibrations during continuous-mode ultrasound (US), micropulse-mode US, and phacoemulsification using ultra-high-speed digital video imaging. SETTING: Miyoshi Eye Center, Fukuyama, Hiroshima, Japan. METHOD: An ultra-high-speed digital video camera was used to record different modes of ultrasonic oscillation. Samples used in the test chamber during phacoemulsification included a pig lens, a human lens nuclear fragment, and a piece of chestnut. RESULTS: The ultra-high-speed digital video camera clearly captured vibrations of the ultrasonic tip and allowed successful visualization of cavitation during continuous-mode and micropulse-mode US, chattering motion during continuous mode, and hyper-followability during micropulse mode. CONCLUSION: The study visually showed that continuous-mode US produces chattering motion, while micropulse-mode US produces hyper-followability.

Incidence of intraoperative floppy iris syndrome in patients on either systemic or topical alpha(1)-adrenoceptor antagonist.

PURPOSE: To evaluate the incidence of Intraoperative Floppy Iris syndrome (IFIS) in relation to the usage of alpha(1)-adrenoceptor antagonists. DESIGN: Prospective, interventional case series. METHODS: In 2,643 consecutive eyes of 1,968 patients undergoing cataract surgery, occurrence of IFIS and use of alpha(1) antagonists were recorded. RESULTS: IFIS was observed in 29 eyes (1.1%) of 25 male patients, all of whom were receiving alpha(1) antagonists. In those receiving systemic tamsulosin, alpha(1A) selective antagonist, IFIS developed in 25 (43.1%) of 58 eyes. In those receiving systemic naftopidil, alpha(1A) and alpha(1D) antagonists, IFIS was found in 4 (19.0%) of 21 eyes. There was no case of IFIS in patients who received other systemic alpha(1) antagonists and in eyes treated with bunazosin eyedrops, a nonselective alpha(1) antagonist. CONCLUSIONS: IFIS occurred in 1.1% of cases treated with systemic alpha(1A)-adrenoceptor antagonists for benign prostatic hypertrophy. Topical nonselective alpha(1) antagonist did not induce IFIS.