Dry age-related macular degeneration in the Japanese population.

PURPOSE: To elucidate the clinical characteristics of eyes with dry age-related macular degeneration (AMD) in Japan. STUDY DESIGN: Retrospective. METHODS: We performed a nationwide survey of dry AMD. A questionnaire on dry AMD was sent to 3,801 major hospitals and eye clinics nationwide. Whenever both eyes met the diagnostic criteria, only the eye with more advanced geographic atrophy was included. RESULTS: In the current survey, 81 patients (81 eyes) with dry AMD were included. Of the 81 patients, 56 (69.1%) were men, and the mean age of the patients was 76.6 ± 8.4 (range, 54-94) years. Twenty-four patients (29.6%) had a history of smoking. The decimal best corrected-visual acuity (BCVA) was equal to or better than 0.7 in 25 eyes (30.9%), but worse than 0.1 in 17 eyes (21.0%). The mean BCVA was 0.62 ± 0.59 in logarithm of the minimum angle of resolution. Lesion size (the greatest linear dimension of the largest geographic atrophy) was ≥ 2 disc diameter in 33 eyes (40.7%) and < 1 disc diameter in 21 eyes (25.9%). Soft drusen was observed in 27 eyes (33.3%), and reticular pseudodrusen was observed in 31 eyes (38.3%). Of the 81 patients, the other eye was diagnosed as dry AMD in 26 eyes (32.1%), neovascular AMD in 16 eyes (19.8%), and intermediate AMD in 18 eyes (22.2%). CONCLUSION: Dry AMD in the Japanese population has characteristics of male predominance, older age, high prevalence of reticular pseudodrusen, and high bilaterality.

Clinical Parameters Reflecting Globe/orbit Volume Imbalances in Japanese Acquired Esotropia Patients with High Myopia but without Abduction Limitations.

In high myopia, eye dislocation due to increased globe volume or tight orbital volume causes acquired esotro-pia. GOR (globe/orbit volume ratio), an indicator of the degree of progression of this pathology, was investi-gated the relationships among easily obtained clinical parameters. In this retrospective study, 20 eyes from 10 acquired esotropia patients with high myopia but without abduction limitations were examined. The mean age of the patients was 63.7 ± 8.2 years (mean ± standard deviation). Volumes were measured on the three-dimen-sional fast imaging employing steady-state acquisition magnetic resonance imaging images using the vol-ume-measurement function. Correlations between GOR and the displacement angle of the globe (DA), axial length (AL), and equatorial diameter (ED) were investigated. Mean DA, AL, ED, and GOR values were 107.5 ± 8.5°, 28.86 ± 1.92 mm, 25.00 ± 1.16 mm, and 0.36 ± 0.05, respectively. Only AL was correlated with GOR (p < 0.0001, R2 = 0.6649); DA (p = 0.30, R2 = 0.0633) and ED (p = 0.91, R2 = 0.0008) were not. AL was the only clinically available parameter to indicate globe/orbit volume imbalances in acquired esotropia with high myopia but without abduction limitation. AL may be important for the clinical assessment of the progression of this pathology.

Cytotoxic effects of alteplase, a recombinant tissue plasminogen activator, on human retinal pigment epithelial cells.

PURPOSE: To evaluate the cytotoxic effects of alteplase, a recombinant tissue plasminogen activator, and its additives on human retinal pigment epithelial (hRPE) cells. STUDY DESIGN: Laboratory study. METHODS: We evaluated the cytotoxic effects of alteplase on human fetal RPE (hfRPE) cells, human induced pluripotent stem cell-derived RPE (hiPS-RPE), and ARPE-19 cells, as well as the cytotoxic effects of L-arginine and polysorbate 80, two additives of alteplase, on hfRPE cells. The effects of alteplase on the production of vascular endothelial growth factor (VEGF) and pigment epithelium-derived factor (PEDF) from hfRPE cells and the transepithelial resistance (TER) of hiPS-RPE cells were also assessed. The type of cell death induced by alteplase was investigated using ethidium homodimer III and FITC-Annexin V staining and terminal transferase deoxyuridine triphosphatase nick-end labeling. RESULTS: Alteplase reduced the viability of hfRPE cells significantly in a dose- and time-dependent manner. The reaction of hiPS-RPE and ARPE19 cells to alteplase was similar to that of hfRPE cells. Out of L-arginine and polysorbate 80, only treatment with L-arginine significantly reduced the viability of hfRPE cells. Alteplase (83 µg/ml, 6 h) had no significant effect on the production of VEGF and PEDF from hfRPE cells. Alteplase decreased the TER of hiPS-RPE cells in a dose- and time-dependent manner and induced necrosis as the type of cell death. CONCLUSION: Alteplase can be cytotoxic to human RPE cells in a concentration- and time-dependent manner, with L-arginine being a possible causative factor.

Formulas to Estimate Appropriate Surgical Amounts of Unilateral Recession-Resection in Intermittent Exotropia with Distance-Near Disparity.

The purpose of this study was to derive new formulas to provide an optimal surgical procedure and optimal amount of recession-resection (RR) surgery in intermittent exotropia (IXT) with a disparity in angle of deviation depending on the fixation distance. The records of 117 consecutive patients with IXT who underwent RR surgery between March 2008 and December 2011 at Okayama University Hospital were retrospectively examined. Multivariable linear regression analysis was performed using the observed corrective angle of deviation at distance or near fixation as the dependent variable, and amounts of lateral rectus muscle (LR) recession (mm) and medial rectus muscle (MR) resection, and age at surgery (years) as independent variables. Two simultaneous formulas were derived: corrective angle of deviation at distance fixation (°)=1.8×recession (mm)+1.6× resection (mm)+0.15×age (years)-6.6, and corrective angle at near fixation (°)=1.5×recession (mm)+1.7× resection (mm)+0.18×age (years)-3.8. Comparisons of coefficient values of the formulas between distance and near fixation revealed that LR recession was more affected by the corrective angle in distance than near fixation. MR resection was more affected at near than distance fixation. We found that our new formulas estimated the appropriate amount of unilateral RR surgery.

Risk factors for excessive postoperative exo-drift after unilateral lateral rectus muscle recession and medial rectus muscle resection for intermittent exotropia.

BACKGROUND: To detect significant factors associated with excessive postoperative exo-drift in young patients with intermittent exotropia who had undergone unilateral lateral rectus muscle recession and medial rectus muscle resection. METHODS: We retrospectively examined the records of 64 consecutive patients < 18 years old who underwent surgery between April 2004 and December 2011. We sought risk factors for excessive postoperative exo-drift among patients' demographic and clinical characteristics using univariate and multivariable linear regression analysis. RESULTS: Younger patients (P = 0.007), and those with larger preoperative exo-deviation at distance (P = 0.033), a lower incidence of peripheral fusion at distance (P = 0.021) or a greater postoperative initial eso-deviation (P = 0.001), were significantly more likely to have an excessive postoperative exo-drift (> 20 prism diopters). Univariate analysis revealed significant associations between excessive postoperative exo-drift and age at surgery (P = 0.004), preoperative exo-deviation at distance (P = 0.017) and postoperative initial eso-deviation at distance (P < 0.001). Multivariable linear regression analysis showed that postoperative initial eso-deviation at distance (P = 0.008) was significantly associated with postoperative exo-drift. CONCLUSIONS: Postoperative exodrift in unilateral RR is predicted by the initial postoperative eso-deviation, which may offset the overcorrection. However, the exo-drift is greater in cases with a large preoperative exo-deviation and/or at a younger age, and should be followed carefully.

KCNJ13 Gene Deletion Impairs Cell Alignment and Phagocytosis in Retinal Pigment Epithelium Derived from Human-Induced Pluripotent Stem Cells.

Purpose: The purpose of this study was to establish and analyze a cell model of Leber congenital amaurosis type 16 (LCA16), which is caused by mutations in the KCNJ13 gene encoding Kir7.1, an inward-rectifying potassium ion channel. Methods: The two guide RNAs specific to the target sites in the KCNJ13 gene were designed and KCNJ13 knock-out (KO) human-induced pluripotent stem cells (hiPSCs) were generated using the CRISPR/Cas9 system. The KCNJ13-KO hiPSCs were differentiated into retinal pigment epithelial cells (hiPSC-RPEs). The KCNJ13-KO in hiPSC-RPEs was confirmed by immunostaining. Phagocytic activity of hiPSC-RPEs was assessed using the uptake of fluorescently labeled porcine photoreceptor outer segments (POSs). Phagocytosis-related genes in RPE cells were assessed by quantitative polymerase chain reaction. Results: Most of the translated region of the KCNJ13 gene was deleted in the KCNJ13-KO hiPSCs by the CRISPR/Cas9 system, and this confirmed that the Kir7.1 protein was not present in RPE cells induced from the hiPSCs. Expression of RPE marker genes such as BEST1 and CRALBP was retained in the wild-type (WT) and in the KCNJ13-KO hiPSC-RPE cells. However, phagocytic activity and expression of phagocytosis-related genes in the KCNJ13-null hiPSC-RPE cells were significantly reduced compared to those of WT. Conclusions: We succeeded in generating an RPE model of LCA16 using hiPSCs. We suggest that Kir7.1 is required for phagocytosis of POSs by RPE cells and that impaired phagocytosis in the absence of Kir7.1 would be involved in the retinal degeneration found in LCA16.

Inverted Internal Limiting Membrane Flap versus Internal Limiting Membrane Peeling for Macular Hole Retinal Detachment in High Myopia.

PURPOSE: To compare surgical outcomes between the inverted internal limiting membrane (ILM) flap technique and ILM peeling for macular hole retinal detachment (MHRD) in eyes with high myopia. DESIGN: Multicenter cohort study. PARTICIPANTS: We retrospectively reviewed medical records of consecutive patients treated between June 2008 and September 2018 at 7 hospitals and included 100 eyes with MHRD associated with high myopia in our study. All eyes underwent vitrectomy with the inverted ILM flap technique (57 eyes) or ILM peeling (43 eyes) and were followed up for more than 6 months. METHODS: We estimated odds ratios and their 95% confidence intervals (CIs) for macular hole (MH) closure using multivariate logistic regression analysis. We also examined factors associated with the postoperative best-corrected visual acuity (BCVA) at the final visit using multiple linear regression analysis. MAIN OUTCOME MEASURES: Macular hole closure and postoperative BCVA at the final visit. RESULTS: The MH closure rate was significantly higher in the inverted ILM flap group (80.7%) than in the ILM peeling group (37.2%; P < 0.001). Moreover, postoperative BCVA at the final visit was significantly better in the former group (0.88 ± 0.48 vs. 0.99 ± 0.48; P = 0.03). The retinal attachment rate (ILM flap, 91.2%; ILM peeling, 79.5%; P = 0.229) and recovery rates for the external limiting membrane and ellipsoid zone line (ILM flap, 10.9%; ILM peeling, 0%; P = 0.12) showed no significant intergroup differences. After adjustment for age, axis, tamponade substance, and dye for ILM staining, the inverted ILM flap technique was associated strongly and positively with MH closure (odds ratio, 7.14; 95% CI, 2.72-18.7; P = 0.001). Moreover, the inverted ILM flap technique and preoperative BCVA were associated significantly and positively with the postoperative BCVA at the final visit. CONCLUSIONS: Our findings suggest that the MH closure rate and postoperative visual outcome for eyes with high myopia-associated MHRD are better with the inverted ILM flap technique than with ILM peeling. Thus, vitrectomy with the inverted ILM flap technique should be considered as the initial surgery for MHRD associated with high myopia.

Interocular symmetry of the foveal avascular zone area in healthy eyes: a swept-source optical coherence tomography angiography study.

PURPOSE: To determine the presence or absence of interocular differences in the foveal avascular zone (FAZ) area in healthy eyes. STUDY DESIGN: Cross-sectional study. METHODS: We examined 236 healthy eyes of 118 consecutive subjects (mean age, 39.1 ± 18.9 years). We used swept-source optical coherence tomography angiography (OCTA) images of the FAZ to measure its area from both the superficial capillary plexus (SCP-FAZ) and the whole retinal capillary plexus (WCP-FAZ). We also investigated the relationship between interocular differences in SCP-FAZ and other factors such as: axial length, spherical equivalent, central retinal thickness, and retinal vascular density. RESULTS: There was no significant difference in the FAZ area between the right and left eyes in either the SCP-FAZ (P = 0.61) or WCP-FAZ (P = 0.80), and the FAZ areas of both eyes showed significant positive correlations (SCP-FAZ; P < 0.001, R2 = 0.884, WCP-FAZ; P < 0.001, R2 = 0.856). Bland-Altman plots showed that the mean interocular difference in SCP-FAZ area was 0.002 ± 0.037 mm2 (95% confidence interval, -0.072-0.075 mm2), and in the WCP-FAZ area, 0.050 ± 0.044 mm2 (95% confidence interval, -0.036-0.137 mm2). Multivariate regression analysis showed that none of the investigated factors were significantly associated with interocular differences in SCP-FAZ (P = 0.61, R2 = 0.138). CONCLUSIONS: There was no significant interocular difference in SCP- and WCP-FAZ areas in healthy eyes. The normal range of values for interocular difference in SCP-FAZ area was 0.002 ± 0.037 mm2 and in the WCP-FAZ area, 0.050 ± 0.044 mm2.

ADVERSE EFFECT OF MACULAR INTRARETINAL HEMORRHAGE ON THE PROGNOSIS OF SUBMACULAR HEMORRHAGE DUE TO RETINAL ARTERIAL MACROANEURYSM RUPTURE.

PURPOSE: To investigate the clinical course of submacular hemorrhage associated with ruptured retinal arterial macroaneurysm using swept-source optical coherence tomography. METHODS: This study included 23 eyes of 23 consecutive patients diagnosed with submacular hemorrhage associated with ruptured retinal arterial macroaneurysm. Cases underwent displacement of submacular hemorrhage (vitrectomy + subretinal injection of tissue plasminogen activator + air tamponade) and were followed up for 6 months after surgery. Localization of the preoperative hemorrhage and its effect on preoperative and postoperative best-corrected visual acuity, central retinal thickness, and continuity of the ellipsoid zone were measured. RESULTS: Macular intraretinal hemorrhage (IRH) was observed in 17 eyes (73.9%, IRH [+] group) and was not observed in 6 eyes (26.1%, IRH [-] group). The IRH (+) group showed worse postoperative best-corrected visual acuity values compared with the IRH (-) group (0.89 ± 0.47 in logarithm of the minimal angle of resolution units, Snellen equivalent 20/155 and 0.16 ± 0.23, 20/29, respectively; P < 0.01), smaller central retinal thickness values (97.7 ± 53.5 µm, 173.0 ± 32.3 µm, respectively; P < 0.01), and a higher rate of ellipsoid zone disruption (100%, 33.3%, respectively; P < 0.01). CONCLUSION: Patients with preoperative macular IRH showed lower postoperative visual acuity and worse macular contour after submacular hemorrhage displacement compared with patients without macular IRH.

EN FACE IMAGE-BASED ANALYSIS OF RETINAL TRACTION CAUSED BY EPIRETINAL MEMBRANE AND ITS RELATIONSHIP WITH VISUAL FUNCTIONS.

PURPOSE: To evaluate the relationship between retinal traction caused by epiretinal membrane and visual functions. METHODS: In this institutional study, en face swept-source optical coherence tomography images of 141 eyes of 130 patients with epiretinal membrane were analyzed to investigate maximum depth of retinal folds, which represents retinal traction strength and the distribution pattern of retinal folds. We investigated the relationships between the maximum depth and distribution pattern of retinal folds and visual functions as well as the effects of membrane peeling. RESULTS: Maximum retinal fold depth was significantly correlated with the metamorphopsia score (P < 0.001). Fifteen eyes showed retinal folds radially extending from the macular epiretinal membrane (radiating folds group), whereas 126 eyes showed a multidirectional pattern of retinal folds (multidirectional folds group). The radiating folds group showed a significantly lower metamorphopsia score (P = 0.014). Multiple regression analysis revealed that the metamorphopsia score was significantly related to maximum retinal fold depth (P = 0.003), distribution pattern (P = 0.015), and central retinal thickness (P < 0.001). One month after membrane peeling, parafoveal retinal folds resolved completely in all cases, and both visual acuity (P < 0.001) and average metamorphopsia score (P = 0.036) were significantly improved. CONCLUSION: Both the strength and the distribution pattern of retinal traction are significantly related to metamorphopsia in epiretinal membrane patients.

RELATIONSHIP BETWEEN PREOPERATIVE FOVEAL MICROSTRUCTURE AND VISUAL ACUITY IN MACULA-OFF RHEGMATOGENOUS RETINAL DETACHMENT: Imaging Analysis by Swept Source Optical Coherence Tomography.

PURPOSE: To visualize foveal microstructures in macula-off rhegmatogenous retinal detachment using swept source optical coherence tomography preoperatively and postoperatively and to investigate the relationship between foveal microstructures and postoperative visual acuity. METHODS: We retrospectively analyzed 42 eyes of 42 consecutive patients diagnosed with macula-off rhegmatogenous retinal detachment who underwent anatomically successful repair surgery and were followed up for 6 months. We used swept source optical coherence tomography to investigate the relationship between preoperative and postoperative continuity of both the external limiting membrane (ELM) and ellipsoid zone (Ez) and preoperative and postoperative best-corrected visual acuity. RESULTS: Both preoperative ELM and Ez were continuous in 9 eyes (21%; ELM+/Ez+ eyes), only the ELM was continuous in 25 eyes (60%; ELM+/Ez- eyes), and neither was continuous in 8 eyes (19%; ELM-/Ez- eyes). Postoperative best-corrected visual acuity in ELM+/Ez+ eyes (-0.05 ± 0.04 logarithm of the minimum angle of resolution units, Snellen equivalent 20/18) was significantly better than that in both ELM+/Ez- (0.16 ± 0.16, 20/29; P = 0.03) and ELM-/Ez- (0.86 ± 0.37, 20/145; P < 0.001) eyes. Postoperative best-corrected visual acuity was significantly better in ELM+/Ez- than in ELM-/Ez- eyes (P < 0.001). CONCLUSION: In macula-off rhegmatogenous retinal detachment, preoperative continuity of the ELM and Ez may be a predictor of postoperative best-corrected visual acuity.

Two-year Results of Intravitreal Ranibizumab Injections Using a Treat-and-extend Regimen for Macular Edema due to Branch Retinal Vein Occlusion.

We investigated the effectiveness of a treat-and-extend regimen (TAE) of intravitreal ranibizumab injections for macular edema (ME) due to branch retinal vein occlusion (BRVO). We retrospectively examined 2-year results of 32 eyes of 32 patients who underwent TAE to treat ME due to BRVO. The patients whose treatment interval extended to ≥ 12 weeks were switched to a pro re nata regimen (PRN). For the patients whose treatment interval was <12 weeks, TAE was continued. At 2 years, 10 eyes had required no additional injections after the initial treatment period [recurrence(-) group], whereas the other 22 eyes required additional treatment [recurrence(+) group]. Among the recurrence(+) patients, 11 eyes (34.4% of total) were eventually switched from TAE to PRN; the other 11 eyes (34.4%) continued TAE for 2 years. Visual acuity and central retinal thickness were significantly improved in both the recurrence(+) and (-) groups, and there was no significant betweengroup difference in visual acuity at 2 years. Univariate analyses revealed significant differences in visual acuity (p=0.004), age (p=0.014), and vessel occlusion site (p=0.018) between these groups. Our results suggest that TAE may be effective for BRVO patients with lower visual acuity, older age, and occlusion of a major vein.

Twist Knot: A New Sliding Noose in Adjustable Suture Strabismus Surgery.

To permit noose movement without fraying the sutures following strabismus surgery, we designed a new sliding noose, the "twist knot" and investigated its advantages and disadvantages. We measured the tensile strength required to move the twist knot in a tightly tied state (134±19 gf) and in a loosened state (21±7 gf), and that required to move the conventional sliding noose in a tightly tied state (48±14 gf), and used the Kruskal-Wallis test to compare them. A significant difference was observed among the three tensile strengths (p<0.001). The twist knot technique allowed easy sliding without the multifilament braided suture becoming frayed and a knot to be firmly fixed without slipping. However, if the 2 strings of the pole sutures exit from the sclera at 2 widely separated positions, the sliding noose may become slack. Therefore, the distance between the pole sutures should be small. The simple twist knot technique was found to be an effective approach following adjustable surgery of strabismus.

Localization of the ultraviolet-sensor Opn5m and its effect on myopia-related gene expression in the late-embryonic chick eye.

Recent studies show that exposure to ultraviolet (UV) light suppresses ocular elongation, which causes myopia development. However, the specific mechanisms of this process have not been elucidated. A UV-sensor, Opsin 5 (Opn5) mRNA was shown to be present in extraretinal tissues. To test the possibility that UV-signals mediated by Opn5 would have a direct effect on the outer connective tissues of the eye, we first examined the expression patterns of a mammalian type Opn5 (Opn5m) in the late-embryonic chicken eye. Quantitative PCR showed Opn5m mRNA expression in the cornea and sclera. The anti-Opn5m antibody stained a small subset of cells in the corneal stroma and fibrous sclera. We next assessed the effect of UV-A (375 nm) irradiation on the chicken fibroblast cell line DF-1 overexpressing chicken Opn5m. UV-A irradiation for 30 min significantly increased the expression of Early growth response 1 (Egr1), known as an immediate early responsive gene, and of Matrix metalloproteinase 2 (Mmp2) in the presence of retinal chromophore 11-cis-retinal. In contrast, expression of Transforming growth factor beta 2 and Tissue inhibitor of metalloproteinase 2 was not significantly altered. These results indicate that UV-A absorption by Opn5m can upregulate the expression levels of Egr1 and Mmp2 in non-neuronal, fibroblasts. Taken together with the presence of Opn5m in the cornea and sclera, it is suggested that UV-A signaling mediated by Opn5 in the extraretinal ocular tissues could influence directly the outer connective tissues of the chicken late-embryonic eye.

Results of lamellar macular hole-associated epiretinal proliferation embedding technique for the treatment of degenerative lamellar macular hole.

PURPOSE: To investigate the outcomes of embedding lamellar hole-associated epiretinal proliferation (LHEP) into retinal cleavage for the surgical treatment of degenerative lamellar macular hole (LMH). METHODS: We retrospectively reviewed the medical records of 34 consecutive eyes of degenerative LMH patients who underwent vitrectomy with LHEP embedding and who were followed up for at least 12 months. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), and macular structure preoperatively and at the final follow-up were compared. RESULTS: The mean (±SD) follow-up period was 30.0 ± 17.7 months. Twelve patients (35.3%) were men, and the mean age was 69.6 ± 10.1 years. Twenty-three eyes (67.6%) underwent simultaneous cataract surgery. BCVA was significantly improved at the final visit, from 0.31 ± 0.25 logarithm of the minimum angle of resolution units to 0.10 ± 0.25 (P < 0.01). This improvement in mean BCVA at the final postoperative visit occurred regardless of whether the eyes underwent simultaneous cataract surgery, from 0.30 ± 0.26 preoperatively to 0.04 ± 0.16 (P < 0.01) in the "with cataract surgery" group and from 0.32 ± 0.26 preoperatively to 0.21 ± 0.35 (P < 0.05) in the "without cataract surgery" group. CRT was also significantly improved at the final visit, from 123.2 ± 42.6 µm preoperatively to 191.2 ± 42.6 µm (P < 0.01). External limiting membrane and ellipsoid zone defects were detected in 17 (50.0%) and 15 (44.1%) eyes, respectively, but these were resolved in 10 (58.8%) and 7 (46.7%) eyes, respectively, at the final visit. No intraoperative or postoperative complications were observed. CONCLUSIONS: Embedding LHEP may be an effective and safe procedure to treat degenerative LMH.

Outcomes of vitrectomy combined with subretinal tissue plasminogen activator injection for submacular hemorrhage associated with polypoidal choroidal vasculopathy.

PURPOSE: To examine the outcomes of vitrectomy with subretinal tissue plasminogen activator (tPA) injection and postoperative intravitreal antivascular endothelial growth factor (VEGF) injection for submacular hemorrhage (SMH) associated with polypoidal choroidal vasculopathy (PCV). STUDY DESIGN: Retrospective, consecutive case series. METHODS: Patients who underwent vitrectomy for SMH associated with PCV and who were followed up for at least 12 months were included. Surgery consisted of vitrectomy with subretinal tPA and air tamponade. Postoperative intravitreal anti-VEGF was administered pro re nata. The following were examined: best-corrected visual acuity (BCVA) at baseline, at 1 month, and at the final visit; the percentage of patients requiring anti-VEGF postoperatively; and the number of injections administered. RESULTS: This study included 23 eyes of 23 patients (21 men, 2 women) with a mean age of 72.5 ± 9.0 years. The mean duration from disease onset to surgery was 9.0 ± 6.6 days. The mean maximum SMH size was 5.8 ± 4.8 disc diameters. The mean follow-up period was 33 ± 14 months. The BCVA was significantly improved when compared with baseline 1 month after surgery and at the final visit. Postoperative anti-VEGF was required for 91% of the eyes. In eyes that underwent anti-VEGF therapy until the final visit, the mean injection number was 4.1/year. CONCLUSIONS: Vitrectomy with subretinal tPA and air tamponade improved visual acuity in patients with SMH associated with PCV. Postoperative intravitreal anti-VEGF injection maintained the improved BCVA throughout a mean period of 33 months.

Lights-out Surgery for Strabismus Using a Heads-Up 3D Vision System.

During strabismus surgery using illumination from a light source, patients complain of photophobia. The NGENUITYⓇ (Alcon) system is equipped with a high-dynamic-range (HDR) camera. A 4K display viewed by wearing circularly polarized glasses provides clear three-dimensional images of the operative field. A light source is usually required for surgeries of the anterior segment (including strabismic surgery), but the digital processing function of the NGENUITYⓇ system allows image display in relatively dark regions even without a light source. We devised a novel 'lights-out' surgery that does not use a microscope's light source, and we examined the usefulness of this technique in 2 cases of strabismic surgery. We performed strabismus surgery using the NGENUITYⓇ system in two patients between January and June 2018. The HDR function was used, and the aperture was opened to the maximum while the gain was adjusted. Surgery was conducted without using the microscope's light source. We report the 2 cases' results and evaluate the novel method. The surgeries were performed without problem even though the microscope's light source was not used. The patients' photophobia was alleviated. Lights-out surgery is a potentially useful modality for strabismus surgery.

Congenital Multiple Ocular Motor Nerve Palsy Complicated by Splitting of the Lateral Rectus Muscle.

We report a case of congenital multiple ocular motor nerve palsy combined with splitting of the lateral rectus muscle (LR). A 59-year-old Japanese female was investigated for worsening esotropia after corrective surgery. She presented with left hypertropia (35Δ) and esotropia (45-50Δ). Orbital magnetic resonance imaging (MRI) showed reduced belly sizes in the superior rectus, inferior rectus, and superior oblique muscles and splitting of the LR, extending from the origin to the belly, in the left eye. Splitting of the LR belly was detected on MRI in a case of congenital multiple ocular motor nerve palsy.

Impact of Cataract Surgery on Filtering Bleb Morphology Identified Via Swept-source 3-dimensional Anterior Segment Optical Coherence Tomography.

PRéCIS:: Analysis of filtering bleb morphology using swept-source 3-dimensional anterior segment optical coherence tomography (3D AS-OCT) indicates that phacoemulsification can negatively impact the morphology of preexisting filtering blebs. PURPOSE: To identify the cross-sectional morphologic changes in successful filtering blebs after phacoemulsification using swept-source 3D AS-OCT. MATERIALS AND METHODS: In total, 30 phakic eyes of 29 patients with successful filtering blebs after primary trabeculectomy were included in this retrospective cohort study. Success was defined as intraocular pressure (IOP)≤15 mm Hg and a>20% reduction in IOP without glaucoma medication or additional glaucoma surgery after trabeculectomy. The subjects were classified into 2 groups according to whether they had undergone phacoemulsification or not after trabeculectomy: a phaco group and a control group. Filtering blebs were examined using swept-source 3D AS-OCT and evaluated for quantitative parameters, including maximum bleb height, maximum bleb wall thickness, and the ratio of the hyporeflective space of the bleb wall. RESULTS: Sixteen eyes were assigned to the phaco group and 14 eyes to the control group. The eyes in the control group showed no significant differences in IOP or in any of the 3D AS-OCT parameters at any of the follow-up timepoints. In the phaco group, the mean IOP increased significantly after phacoemulsification (P=0.003). Furthermore, the eyes in the phaco group showed a significant decrease in maximum bleb height (P=0.030), maximum bleb wall thickness (P=0.006), and the ratio of the hyporeflective space of the bleb wall (P=0.011) between prephacoemulsification and 1-year postphacoemulsification. CONCLUSION: Phacoemulsification can have a negative impact on filtering bleb morphology, which may lead to an IOP increase.

Magnetic resonance imaging findings of age-related distance esotropia in Japanese patients with high myopia.

PURPOSE: This study aimed to investigate the characteristics of the extraocular muscles and the orbital connective tissue pulleys in Japanese patients with age-related distance esotropia (ARDE) and high myopia using magnetic resonance imaging (MRI). METHODS: This was a retrospective case-series study. High-resolution coronal MRI scans of 12 orbits were obtained in 6 patients with ARDE and high myopia (age range: 51-69 years). We analyzed the images to determine the positions of the rectus muscle pulleys relative to the center of the globe, the integrity of the lateral rectus-superior rectus muscle (LR-SR) band, and the LR angle (the angle between the major axis of the LR and the vertical plane). RESULTS: The distance esotropia ranged from 4 to 25∆, and 3 cases exhibited vertical deviations. The mean (±standard deviation (SD)) axial length was 28.5 (± 1.6) mm. The mean positions of the medial rectus muscle pulley and LR pulley were 1.3 mm inferior and 1.4 mm inferior, respectively, to those seen in the normal control group in our previous study (P = 0.002 and P = 0.05, respectively). All 12 orbits had abnormal elongated LR-SR bands, and 8 orbits (67%) displayed ruptured LR-SR bands. The LR angle (mean±SD; 18.8° ± 8.5°) increased significantly with the inferior displacement of the LR pulley (R2 = 0.77, P = 0.0002). CONCLUSIONS: Inferior displacement of the LR pulley and abnormal LR-SR bands were seen in Japanese ARDE patients with high myopia, as was found in ARDE patients without high myopia. The LR angle might be useful for judging the degree of LR pulley displacement.