Evaluation of Aniseikonia in Patients with Successfully Treated Anisometropic Amblyopia Using Spatial Aniseikonia Test.

Anisometropic amblyopia is decreased visual acuity in one eye, and treatment consists of wearing complete corrective spectacles. Aniseikonia occurs with complete correction of anisometropia using spectacles. Aniseikonia has been ignored when treating pediatric anisometropic amblyopia because of the prevailing belief that anisometropic symptoms are suppressed by adaptation. However, the conventional direct comparison method for evaluating aniseikonia significantly underestimates the degree of aniseikonia. This study investigated whether the adaptation occurs due to long-term anisometropic amblyopia treatment in patients who have had successful amblyopia treatment using a spatial aniseikonia test with high accuracy and repeatability compared with the conventional direct comparison method. The amount of aniseikonia was not significantly different between the patients with successful amblyopia treatment and individuals with anisometropia without a history of amblyopia. In both groups, the aniseikonia per 1.00 D of anisometropia and the aniseikonia per 1.00 mm of aniso-axial length were comparable. The repeatability of the amount of aniseikonia using the spatial aniseikonia test did not differ significantly between the two groups, indicating a high degree of agreement. These findings suggest that aniseikonia is not adapted to amblyopia treatment and that aniseikonia increases as the difference between spherical equivalent and axial length increases.

Effect of Paracentesis on Retinal Function Associated With Changes in Intraocular Pressure Caused by Intravitreal Injections.

Purpose: Intravitreal injections of antivascular endothelial growth factor agents are widely performed, and subsequent intraocular pressure increase may cause retinal nerve fiber damage. This study aimed to determine the effects of paracentesis before intravitreal injection of an antivascular endothelial growth factor on electroretinograms. Methods: This was a retrospective observational study in a university hospital. Twenty-five eyes of 25 patients who underwent intravitreal injections of antivascular endothelial growth factor agents were selected for evaluation. Intraocular pressures and electroretinograms were recorded before surgery (baseline), after anterior chamber paracentesis, and after intravitreal injection. The amplitudes and latencies of the a- and b-waves, photopic negative response, and oscillatory potential were measured. Changes in each component of the electroretinograms, intraocular pressure, and relationships between these two factors were investigated. The preoperative and postoperative ocular perfusion pressure was calculated based on blood pressure. Results: The amplitudes of the b-waves were significantly smaller after intravitreal injection than at baseline (P = 0.02), while no significant change was found in the other components during surgery. There were no significant changes in the latencies of any component during surgery. The intraocular pressure was significantly lower (P < 0.001) after anterior chamber paracentesis (6.8 ± 4.3 mm Hg) compared to baseline (24.1 ± 8.1 mm Hg) or after intravitreal injection (17.1 ± 9.6 mm Hg; P < 0.001). Conclusions: Performing anterior chamber paracentesis before an intravitreal injection can prevent the intraocular pressure elevation and thus minimize the electrophysiological retinal dysfunction. Translational Relevance: Anterior chamber paracentesis before an intravitreal injection mitigates the adverse effects on retinal function.

Endogenous Endophthalmitis successfully treated with Intravitreal Povidone-iodine injection: a case report.

BACKGROUND: The usefulness of povidone-iodine as an alternative to antimicrobial agents, for endophthalmitis, has recently been documented. We report a case of endogenous endophthalmitis successfully treated with intravitreal injection of povidone-iodine. CASE PRESENTATION: An 88-year-old woman underwent small bowel bypass surgery for postoperative ileus following rectal cancer resection. She developed a fever during total parenteral nutrition and was diagnosed with gram-positive cocci bacteremia of central venous catheter origin. The patient was referred to our department with chief complaints of ocular pain, hyperemia and decreased vision in the right eye, which had manifested during the febrile period. The initial examination revealed the visual acuity in her right eye to be finger counting and that in her left eye 0.2. The right eye showed a severe inflammatory reaction in the anterior chamber, fibrin deposition, and hypopyon. The fundus was difficult to visualize. Endogenous endophthalmitis due to bacteria was diagnosed. Surgical treatment was judged to be difficult based on the patient's poor general condition and mental status, and intravitreal injection of 0.1 ml of 1.25% povidone-iodine was performed on the same day. The inflammation rapidly diminished, and the hypopyon had disappeared 4 days after treatment. The fundus became visible 7 days after treatment and there was no recurrence of endophthalmitis findings. The visual acuity in her right eye recovered to that in the left eye (0.2). CONCLUSION: Intravitreal injection of povidone-iodine is potentially useful and effective as an alternative treatment of antibiotics for endogenous endophthalmitis patients, especially in whom surgical therapy is difficult.

Clinical Stages of Occult Macular Dystrophy Based on Optical Coherence Tomographic Findings.

Purpose: To determine the course of occult macular dystrophy (OMD, Miyake's disease) and to propose stages of OMD based on the optical coherence tomographic (OCT) findings. Methods: Sixty-one patients from 33 families with OMD who carried one of the proven variants of the RP1L1 gene were studied at seven centers in Japan. Ophthalmological examinations including the best-corrected visual acuity (BVCA) and OCT were performed. Results: The median age at the last visit was 50 years with a range of 10 to 88 years, and the median age at the symptom onset was 30 years with a range of 3 to 60 years. There were significant negative correlations between the duration of OMD and BCVA, the central retinal thickness (CRT) and the thickness between external limiting membrane and retinal pigment epithelium (ERT). The BCVA gradually decreased for 10 years after symptom onset and was stable thereafter. Kaplan-Meier survival curves of the BCVA and retinal thickness showed that all of the patients had retained a vision of 1.0 logMAR, and over 80% of the patients had retained 50% thickness of the normal CRT and ERT for at least 60 years after symptom onset. The stages of OMD based on the visual symptoms and OCT findings are proposed. Conclusions: The photoreceptors do not become completely atrophic even at the late stage, which may account for the good retinal pigment epithelium (RPE) structure and normal-appearing fundus. The proposed stages facilitate the investigation of the pathogenicity of OMD and provide information to determine the effectiveness of therapeutic procedures.

Clinical course and risk factors of recurrent corneal erosion: Observational study.

Recurrent corneal erosion (RCE) is a common disorder causing ocular pain, tearing, photophobia, and visual impairments. Various factors such as ocular trauma, ocular surgery, corneal dystrophy, contact lens wear, and diabetes mellitus (DM) can cause RCE. The purpose of this study was to determine the causative factors and clinical course of RCE.We retrospectively examined 21 eyes of 21 patients with RCE and investigated the patients' background, type of treatments, and clinical course after the treatments. All patients were treated with eye drops, ocular lubrication, or contact lens bandage for the RCE.Among the 21 patients with RCE, 9 were caused by trauma (Trauma group), 8 by DM (DM group), 1 by bacterial corneal ulcer, 1 by lagophthalmus and bacterial corneal ulcer, 1 by bandkeratopathy, and 1 by eyelid tumor (one eye). The mean age of the patients was 57.8 years with a range 34-91 years. The mean duration from the trauma to the onset of RCE was 5.2 ±â€Š5.0 months (mean ±â€ŠSD). The time required for a complete recovery of RCE was longer in the DM group (10.3 ±â€Š3.1 weeks) than in the Trauma group (2.7 ±â€Š1.1 weeks, P < .01). The presence of DM was significantly associated with the recovery duration of RCE (r = 0.72; P < .01). Multivariate analyses showed that the recovery duration of RCE was associated with the presence of DM (odds ratio = 139.8, P = .04). On the other hand, the type of treatments had no effect on the recovery duration of RCE.These findings suggest that trauma and DM are important causes of RCE. Wound recovery after RCE may be delayed in patients with DM.

Conjunctival Eosinophilic Masses With Chronic Eosinophilic Pneumonia.

PURPOSE: To report a case of ocular findings associated with chronic eosinophilic pneumonia (CEP). CASE: A 63-year-old man was referred to the National Institution of Hospital Organization Tokyo Medical Center with bilateral eyelid swelling due to giant papillomatous changes, each measuring approximately 10 mm in diameter with severe hyperemia on the tarsal conjunctiva. He was followed for CEP for 8 years and systemically treated with 6 mg oral prednisolone for an average of 5 years. Because the lesions did not respond to topical 0.1% tacrolimus and 0.025% levocabastine treatment and because an increase in intraocular pressure was found to occur as a side effect of 0.01% betamethasone instillation for several months, we performed surgical resection of the bilateral conjunctival lesions. Histopathological findings revealed extreme eosinophil, plasma cell, and lymphocytic infiltration and interstitial fibrosis. These conjunctival specimen findings were similar to those seen in the alveolar lesions in CEP. Topical antiinflammatory therapy using 0.1% tacrolimus eye drops was administered after surgery, which relieved the patient's lid swelling and itching. However, the lesions concurrently changed to be consistent with exacerbation and remission of systemic CEP. CONCLUSIONS: Based on the clinical course and histopathology, the conjunctival proliferative masses in our case were assumed to be associated with CEP.

Evaluation of cone function by a handheld non-mydriatic flicker electroretinogram device.

PURPOSE: Full-field electroretinograms (ERGs) are used to evaluate retinal function in patients with various types of hereditary and acquired retinal diseases. However, ERG recordings require relatively invasive procedures, including pupillary dilation and the use of contact lens electrodes. Thus, it would be helpful to have a simpler and noninvasive screening method. The purpose of this study was to determine whether a new, handheld, portable ERG device, RETeval™, can be used to screen patients for cone dysfunction. PATIENTS AND METHODS: Thirty-five eyes of 35 patients who had reduced cone responses ascertained by a conventional ERG system using contact lens electrodes were studied. The causative diseases included achromatopsia, cone dystrophy, cone-rod dystrophy, retinitis pigmentosa, choroidal dystrophy, autoimmune retinopathy, and Stargardt disease. The flicker ERGs were recorded with the RETeval™ under undilated conditions with skin electrodes (stimulus strength, 3.0 cd·s/m(2); frequency, 28.3 Hz), and the responses were compared to that of 50 healthy eyes. The amplitudes and implicit times of the fundamental component of the flicker ERGs were analyzed in three age groups: Group A, ≤20 years; Group B, 21-40 years; and Group C, ≥41 years. RESULTS: In all of the age groups, the amplitudes of the ERGs were significantly smaller and the implicit times significantly longer in patients with cone dysfunction than in the control eyes. All but one of the patients had flicker amplitudes lower than the mean -2.0 standard deviation of control eyes. CONCLUSION: The RETeval™ has a potential of being used to screen for cone dysfunction. The entire examination takes <5 minutes and does not require pupil dilatation or a contact lens electrode. Although the flicker responses do not provide information on the scotopic functions, the RETeval™ device can be used to determine which patients require additional full-field ERG testing with dilated pupils under both scotopic and photopic conditions.

Outer retinal morphology and visual function in patients with idiopathic epiretinal membrane.

OBJECTIVE: To determine the relationship between the morphology of the fovea and visual acuity in patients with an untreated idiopathic epiretinal membrane (ERM). METHODS: We examined 52 eyes of 45 patients diagnosed with an ERM. The morphology of the foveal area was determined by spectral-domain optical coherence tomography. The relationships between the best-corrected visual acuity (BCVA) and 8 optical coherence tomography features, central retinal thickness, cone outer segment tip (COST) line, photoreceptor inner/outer segment (IS/OS) junction line, foveal bulge of the IS/OS line, external limiting membrane, inner limiting membrane, foveal pit, and ERM over the foveal center, were evaluated. RESULTS: Multiple regression analysis showed that intact COST line, IS/OS junction line, and external limiting membrane independently and significantly contributed to the BCVA. The standardized partial regression coefficient ß was 0.415 for the COST line, 0.287 for the IS/OS junction line, and 0.247 for the external limiting membrane. However, the other features, eg, foveal bulge, inner limiting membrane, foveal pit, and ERM, were not significantly associated with the BCVA. The central retinal thickness was significantly correlated with the BCVA (r2=0.274; P< .01). CONCLUSIONS: At an early stage of an ERM, only the photoreceptor structures are significantly associated with the BCVA, and the appearance of the COST line was most highly associated. Detailed examinations of the photoreceptor structures using optical coherence tomography may help find photoreceptor dysfunction in cases of idiopathic ERM.

Impact of dry eye on work productivity.

BACKGROUND: The purpose of this study was to evaluate the impact of dry eye on work productivity of office workers, especially in terms of presenteeism. METHODS: A total of 396 individuals aged ≥20 years (258 men and 138 women, mean age 43.4 ± 13.0 years) were recruited through an online survey. Data from 355 responders who did not have missing values were included in the analysis. They were classified into the following four groups according to the diagnostic status and subjective symptoms of dry eye: a definite dry eye group; a marginal dry eye group; a self-reported dry eye group; and a control group. The impact of dry eye on work productivity was evaluated using the Japanese version of the Work Limitations Questionnaire. The cost of work productivity loss associated with dry eye and the economic benefits of providing treatment for dry eye were also assessed. RESULTS: The degree of work performance loss was 5.65% in the definite dry eye group, 4.37% in the marginal dry eye group, 6.06% in the self-reported dry eye group, and 4.27% in the control group. Productivity in the self-reported dry eye group was significantly lower than that in the control group (P < 0.05). The annual cost of work productivity loss associated with dry eye was estimated to be USD 741 per person. CONCLUSION: Dry eye impairs work performance among office workers, which may lead to a substantial loss to industry. Management of symptoms of dry eye by providing treatment may contribute to improvement in work productivity.

Annual direct cost of dry eye in Japan.

BACKGROUND: This study was performed to estimate the annual direct cost incurred by dry eye patients, which includes expenses for treatment and drugs, as well as the cost of punctal plugs. METHODS: The study group consisted of 118 dry eye patients aged 20 years or older who visited any of the 15 medical care facilities that participated in this prospective cohort dry eye study. We estimated annual direct costs from outpatient medical records and survey questionnaires obtained from patients. RESULTS: Of the total patients enrolled, 10 were men and 108 women, and their average age was 64.1 ± 11.2 years. The number of hospital visits made by patients was 5.8 ± 3.6 per year. Among those who used ophthalmic solutions, the numbers of bottles used per year were as follows: 32.1 ± 20.8 bottles of hyaluronic acid ophthalmic solution (87 patients), 53.1 ± 42.2 bottles of artificial tears (40 patients), and 33.2 ± 23.2 bottles of over-the-counter eyedrops (15 patients). In patients with punctal plugs, 4.1 ± 3.9 plugs were used annually. The annual drug cost was 32,000 ± 21,675 Japanese yen (323 ± 219 US dollars). The clinical cost was 16,318 ± 9961 Japanese yen (165 ± 101 US dollars). The total direct costs including punctal plug treatment amounted to 52,467 ± 38,052 Japanese yen (530 ± 384 US dollars). CONCLUSION: Although treatment modalities for dry eye in Japan were different from those in the US and in European countries, the direct cost of dry eye patients in Japan was comparable with that reported in those countries. Considering the high prevalence of dry eye, the direct cost of this chronic condition may be significant.

Keratomycosis caused by Aspergillus viridinutans: an Aspergillus fumigatus-resembling mold presenting distinct clinical and antifungal susceptibility patterns.

We report here a case of fungal keratitis caused by Aspergillus viridinutans, a member of the genus which was found to have clinical and antifungal susceptibility characteristics distinct from the species it most closely resembles, Aspergillus fumigatus. A 26-year-old woman presented with contact lens-associated keratitis, the etiologic agent of which was initially slow growing and found to be resistant to amphotericin B and voriconazole. Therapeutic keratoplasty was performed and an isolate from a corneal scraping was identified as A. viridinutans through partial DNA sequencing of the ß-tubulin gene, along with its slow growth 42°C. In contrast with A. fumigatus, A. viridinutans proved to be resistant to a wider variety of antifungal agents. To the best of our knowledge, this is the first case of keratitis caused by A. viridinutans. Clinical isolates of the genus Aspergillus include rarely encountered species such as A. viridinutans. These species may show clinical manifestations distinct from those of A. fumigatus, including clinical resistance to amphotericin B and voriconazole and relatively low susceptibility to other antifungal agents.

Clinical features of anterior segment dysgenesis associated with congenital corneal opacities.

PURPOSE: Anterior segment dysgenesis is one of the main causes of congenital corneal opacities. In this study, we investigated the clinical features and visual outcomes of patients with anterior segment dysgenesis in a large number of cases. METHODS: The medical records of patients with congenital corneal opacities in relation to anterior segment dysgenesis seen in the National Center for Child Health and Development, Japan, between April 2002 and October 2009, were retrospectively studied. RESULTS: Records of 220 eyes of 139 patients were reviewed. Mean follow-up period was 5 years. Clinical diagnoses were Peters anomaly (72.7%), anterior staphyloma (11.4%), Rieger anomaly (7.7%), sclerocornea (6.4%), and others (1.8%). Visual acuity was measured in 61 patients. The best-corrected visual acuity in the better eye of bilaterally involved patients was 20/60 to 20/1000 (low vision according to the International Classification of Diseases, Ninth Revision, Clinical Modification) in 43.2% and less than 20/1000 (legally blind) in 24.3%. Fundus examination was performed in 82 eyes, and disorders were seen in 12 (12 of 82; 14.6%). Systemic abnormalities were present in 35 patients (35 of 139; 25.2%); a family history was present in 5 patients (5 of 139; 3.6%). Of the 160 eyes of 109 patients with Peters anomaly, 51 patients (51 of 109; 46.8%) had bilateral Peters anomaly, 30 (30 of 109; 27.5%) had fellow eyes that were normal, and 28 (28 of 109, 25.7%) showed other abnormal ocular findings in the fellow eye. CONCLUSIONS: Anterior segment dysgenesis shows diverse clinical features, various severities of corneal opacities, and visual outcomes. Further understanding of the disease as an abnormality during embryogenesis and neural crest cell differentiations may be required.

Quality of life and cost-utility assessment after strabismus surgery in adults.

PURPOSE: To understand the functional and psychosocial aspects of strabismus surgery, an evaluation based on the patient's perspective is essential. In this study, we assessed quality of life and utility in adult patients who had undergone strabismus surgery, and we modeled the cost of providing this intervention in order to calculate the cost-utility of strabismus surgery in adults. METHODS: The study population comprised 226 patients with strabismus aged 18 years or older who were scheduled for ocular alignment surgery at 12 facilities of the Strabismus Surgery Study Group in Japan. Survey questionnaires consisting of the Japanese versions of the Visual Function Questionnaire-25 (VFQ-25) and 8-Item Short-Form Health Survey (SF-8) and utility assessment by a time trade-off method were administrated preoperatively and 3 months postoperatively. On the basis of the cost model and measured utility data, the gains in quality-adjusted life years (QALYs) and $/QALY were estimated. RESULTS: Postoperatively, the subscale scores of the VFQ-25 and the physical and mental component summary scores of the SF-8 showed a statistically significant improvement. A significant improvement of utility was also noted: 0.82 ± 0.28 postoperatively versus 0.76 ± 0.31 preoperatively. On the basis of the life expectancy of these patients and the cost model, the surgery resulted in a mean value gain of 0.99 QALYs and a cost-utility for strabismus surgery of 1,303 $/QALY. CONCLUSIONS: By using standard tools to assess vision-associated and general health status, we confirmed the psychosocial benefits of corrective surgery for adults with strabismus. Our study concurrently demonstrated that strabismus surgery in adults is very cost-effective.

Association between clinical diagnostic tests and health-related quality of life surveys in patients with dry eye syndrome.

PURPOSE: This study was performed to assess the impact of dry eye on patients' quality of life (QOL) and to analyze the association between subjective symptoms and ocular surface findings of dry eye. METHODS: The study population consisted of 158 patients with dry eye aged 20 years or older who visited any of the 15 medical care facilities enrolled in the study. The backgrounds and ocular findings of the patients were investigated, and their QOL was evaluated with the Japanese version of the 25-item National Eye Institute Visual Functioning Questionnaire (VFQ-25) and of the Medical Outcomes Study (MOS) 8-item Short-Form Health Survey (SF-8) to examine the association between subjective symptoms and ocular surface findings. RESULTS: Of the patients enrolled, 15 were men and 143 were women, and their average age was 62.5 +/- 12.6 years. Sixty patients (38.0%) had comorbid Sjögren syndrome (SS). The results of Schirmer testing, fluorescein staining, and rose bengal staining for SS patients were significantly worse than those for the non-SS patients, but the VFQ-25 and SF-8 scores were not significantly different between the SS and non-SS patients. In the ocular surface findings, a weak association between the fluorescein staining scores and general vision scores, a subscale of the VFQ-25, was found. However, the ocular surface findings and VFQ-25/SF-8 results in the simple correlation analysis as well as in the multiple linear regression analysis showed no significant associations. CONCLUSIONS: Ocular surface findings and QOL scores of patients with dry eye appear to disagree. Therefore, it is necessary to address subjective symptoms and QOL scores in addition to examination findings when evaluating dry eye.

A multicenter study on the health-related quality of life of cataract patients: baseline data.

PURPOSE: This study examines the impact of cataracts on health-related quality of life (HR-QOL) and health events in the older population. METHODS: The study population consisted of 439 unoperated cataract patients aged 60 years or older who visited any of the facilities affiliated with the Cataract Survey Group of the National Hospital Organization of Japan, which has been conducting a prospective multicenter cohort study on cataract patients. HR-QOL of the patients was assessed using the Japanese version of Visual Function Questionnaire-25 (VFQ-25) and the 8-Item Short-Form Health Survey (SF-8). The health condition and health events of the patients were also investigated. RESULTS: The average age of the 439 patients enrolled (126 men and 313 women) was 73.0 +/- 7.1 years. There were 323 patients with comorbidities (73.6%), 81 of whom (23.7%) felt it was hard to visit the hospital owing to their visual impairment. In the previous year, 74 patients (16.9%) had experienced a fall and 14 (3.2%) had been in a traffic accident. Of those, 43.2% and 8.3% respectively answered that the falls and the accident could have been triggered by their visual impairment. When the patients were classified according to visual acuity, most of the VFQ-25 subscale scores declined significantly with decreasing visual acuity, whereas the SF-8 scores showed no significant change. CONCLUSIONS: The participants of this study were patients with unoperated cataract, and thus the decline of HR-QOL was modest. The survey of health events, however, revealed that the visual constraint has a certain impact on the daily lives of the older population.