Z-shaped incision without epithelial resection in pterygium surgery.

AIM: To introduce a novel surgical technique using a Z-shaped incision without epithelial resection in ophthalmic pterygia. METHODS: This was a prospective study. During pterygium surgery, all proliferative tissues were separated from the cornea and conjunctiva without resection of the tissues. The unaffected conjunctiva was incised in a Z-shape. The upper (or lower) conjunctival flap was sutured to the lower (or upper) normal conjunctiva on the limbal sclera, while the proliferative tissue was sutured to the upper conjunctiva (or lower) near the fornix. RESULTS: Ten patients with pterygia were eligible for this study. Eight patients with primary pterygia and 2 with recurrent pterygia were included. The age of patients at surgery ranged from 47 to 90y (average: 71.9y). Five patients each showed right and left-sided pterygia. The postoperative follow-up periods were from 8 to 78mo (average: 25.0mo). The surgery was successfully conducted and wounds were favorably reconstructed in all patients. The proliferative tissues sutured to the normal conjunctiva showed palor and attenuated neovessles, and never showed re-growth after surgery. Nine patients did not show recerrence. Recerrent pterygium was noted in 1 patient, but additional treatments were not required. CONCLUSION: The procedure involves the reconstruction of pterygial tissue and normal conjunctiva using a Z-shaped incision. The scleral limbal wound can be covered with non-affected conjunctiva without any excision of conjunctival epithelia in patients with primary or recurrent pterygia.

Multimodal Imaging, Including Laser Speckle Flowgraphy: A Case of Retinal Metastasis.

Background/Aim: Intraocular metastases of systemic cancer are most frequently located in the choroid, followed by the iris and ciliary body, while retinal metastases are extremely rare. Here we present a case of retinal metastasis and analyze multimodal imaging. Case Report: A 66-year-old woman with a medical history of breast cancer 5 years earlier was referred to our Department struggling with blurry vision in her right eye. At initial examination, her best-corrected visual acuity (BCVA) was 1.0 oculus dexter (OD). Fundus examination revealed a yellowish elevated lesion with irregular surface, measuring 2 papillary diameters, along with serous retinal detachment (SRD) on the temporal side of the optic disc. Optical coherence tomography showed SRD with an isointense nodule extending across all retinal layers. Fluorescein angiography showed hyperfluorescence and vigorous fluorescence leakage inside the tumor in the early and late phases, respectively. Indocyanine green angiography depicted feeder and drainage vessels within the mass. Laser speckle flowgraphy (LSFG) showed a cold signal inside the tumor. Based on these clinical findings, the mass was diagnosed as a retinal metastasis. Eight days after the initial visit, the patient underwent external beam radiation to the right eye. One month after the initial diagnosis, her BCVA was 0.7 OD, the tumor was localized, and SRD had decreased. LSFG indicated vascular remodeling with marginally warmer signals in the tumor. Conclusion: LSFG of the retinal metastasis showed a cold signal, suggesting low tumor blood flow velocity and that the tumor may have grown slowly. LSFG findings are likely to play a supportive role in clinical diagnosis and contribute to better understanding of pathogenesis in juxtapapillary tumors.

A case of choroidal melanocytoma treated by transscleral resection: A clinicopathological study.

Purpose: Choroidal melanocytoma is a rare benign melanocytic tumor. We report a case of choroidal melanocytoma that was definitively diagnosed by histopathological findings after local resection. Observation: A 71-year-old female complained of blurred vision in her left eye. Her best-corrected visual acuity (BCVA) was 1.0. A dark-brown elevated lesion, measuring 5 papilla-diameter was found in the periphery of the fundus in her left eye. The mass showed hyperfluorescence on fluorescein angiography, early hypofluorescence and late hyperfluorescence on indocyanine green angiography. B-mode echography indicated the mass was originated from the choroid. Orbital magnetic resonance imaging showed isointense signal intensity on T1-weighted images (WI) and hypointense signal intensity on T2-WI, and poor Gadolinium enhancement on T1WI. The tumor was suspected to be melanocytoma, but it was difficult to differentiate from malignant melanoma. Transscleral tumor resection combined with 25-gauge vitrectomy was performed. Histopathological examinations led to the diagnosis of choroidal melanocytoma. Two years after local resection, her BCVA was 1.0 with no tumor recurrence. Conclusions/importance: Local resection was useful as a diagnostic treatment for choroidal tumors confined to the periphery of the fundus that were difficult to clinically differentiate from malignant melanoma.

Giant conjunctival melanoma with rich vascularization causing persistent bleeding.

The present study reported a rare case of persistent bleeding caused by conjunctival melanoma containing abundant vascular channels. A 44-year-old Japanese woman presented with a left upper eyelid nodule in February 2023. A pigmented conjunctival mass was present in the upper palpebral conjunctiva. Enhanced computed tomography demonstrated marked enhancement in the left eyelid in the artery phase, indicating hemangioma. The patient suffered blunt trauma to the face in May 2023 and continuous bleeding occurred. Doctors in the emergency room attempted hemostasis by diathermy and suture, but the bleeding could not be stopped. The patient eventually underwent emergent orbital exenteration of the left eye. At high magnification of the histology sample of the bleeding site, small-to-large vascular channels with various vascular lumens made up of endothelial cells within the conjunctival melanoma tissue could be observed. The tumor cells were positive for SOX10, Melan A, S100 and HMB45. We herein propose a novel variant of conjunctival melanoma with rich vascularization, clinically causing persistent bleeding.

Acute acquired comitant esotropia associated with Lhermitte-Duclos disease: a case report.

BACKGROUND: Acute acquired comitant esotropia caused by prolonged near work, such as the use of digital devices, has been frequently reported in recent years. However, intracranial examination is necessary even for patients with nonparalytic comitant esotropia. Lhermitte-Duclos disease is a rare tumor that grows in layers in the cerebellum. Among those with this disease, cases of esotropia have been reported due to abduction limitation of the eye, but there have been no reports of comitant esotropia. Here, we report the case of a young woman with acute acquired comitant esotropia who was found to have Lhermitte-Duclos disease. CASE PRESENTATION: A 16-year-old Japanese female patient, whose ethnicity was Asian, was referred to our hospital for acute acquired comitant esotropia. Fundus examination revealed papilledema in both eyes, and magnetic resonance imaging of the head revealed a cerebellar tumor in the right cerebellum with obstructive hydrocephalus. She underwent partial tumor resection, and a histopathological diagnosis of Lhermitte-Duclos disease was obtained. However, comitant esotropia status remained unchanged, and she underwent strabismus surgery. Finally, diplopia disappeared completely. CONCLUSION: Neurological and intracranial imaging examinations are essential when acute acquired comitant esotropia is observed. Acute acquired comitant esotropia by Lhermitte-Duclos disease did not improve with partial tumor resection and required strabismus surgery, but good surgical results were obtained.

Clinicopathological findings in refractory diabetic macular edema: A case report.

The present study describes the case of a patient with refractory diabetic cystoid macular edema who underwent vitrectomy with en bloc removal of the cystoid lesion component. The current study also performed histopathological and immunohistochemical analyses of the cystoid lesion component to assess fibrin/fibrinogen and advanced glycation end-products (AGEs) immunoreactivity. A 69-year-old Japanese man presented with visual loss in the left eye due to residual cystoid macular edema (CME) refractory to anti-vascular endothelial growth factor therapy. Best-corrected visual acuity was 1.2 in the right eye (OD) and 0.5 in the left eye (OS). Fundus examination showed dot hemorrhages and hard exudates in the peri-macular region with pan-retinal photocoagulation scars in both eye. Swept-source optical coherence tomography revealed CME with slight hyperreflectivity in the cyst OS. A total of 3 months after the initial visit, pars plana vitrectomy was performed, and the translucent solidified component within the cystoid lesion was isolated. Histopathologically, the excised component was elliptical in shape, measuring 0.7x0.4 mm and exhibited homogeneous eosinophilic material without cellular components. No membranous structure was observed surrounding the component. Immunohistochemistry demonstrated that the tissue was positive for fibrin/fibrinogen and weakly positive for AGEs, but was negative for glial fibrillary acidic protein, type 1 collagen and receptor for AGEs. To the best of our knowledge, the present case report is the first to histopathologically examine the contents of refractory CME, and to immunohistochemically demonstrate that fibrin in diabetic CME may be post-translationally modified by AGEs. These results suggested that fibrin in CME may escape degradation by plasmin due to post-translational modifications.

Stratified choroidal vascular structure in treatment-naïve diabetic retinopathy.

OBJECTIVE: To analyze the anatomical choroidal vascular layers in topical treatment-naïve diabetic retinopathy (DR) eyes. DESIGN: A retrospective, clinical case-control study. METHODS: A total of 328 eyes from 228 patients with treatment-naive DR and 192 eyes matched for axial length from 174 healthy controls were enrolled in the study. Choroidal structure was quantitatively analyzed using enhanced depth imaging optical coherence tomography (EDI-OCT). Each choroidal vascular layer was divided into the choriocapillaris, Sattler's layer, and Haller's layer, and then the choroidal area (CA), luminal area (LA), stromal area (SA), and central choroidal thickness (CCT) were calculated using binarization techniques. The ratio of LA to CA was defined as the L/C ratio. RESULTS: In the choriocapillaris, CA was significantly lower in the mild/moderate non-proliferative DR (mNPDR) group than in the control group, and SA was significantly higher in all DR groups (each P < 0.01). The L/C ratio was significantly lower in all DR groups than controls (P < 0.01). In Sattler's layer, CA, LA, and SA were significantly higher in the severe NPDR (sNPDR) and PDR groups than in the control group (P < 0.01). In Haller's layer, the L/C ratio was significantly high among the PDR groups (P < 0.05). CONCLUSIONS: The choroidal parameters of DR patients by the binarization method were associated with the stage of DR, in which the choriocapillaris lumen decreased in all the DR stages. The expansion of CA seen in more advanced DR eyes mainly resulted from changes in the Sattler's and Haller's layers.

Effects of age and axial length on choroidal stratified structure in normal eyes.

To quantify the choroidal structures of normal eyes by optical coherence tomography (OCT)-based binarization and evaluate the relationships among age, refractive power, and ocular axial length. This was a retrospective observational study. One hundred and eighty nine eyes of 189 subjects without ocular diseases were examined by enhanced depth imaging (EDI)-OCT. A choroidal OCT horizontal image with a width of 1500 µm centered on the fovea was binarized. The lumen, stroma, and total choroidal area in the choriocapillaris (CC), Sattler's layer (SL), and Haller's layer (HL) were measured, and the ratio of the luminal area to total choroidal area (L/C ratio) was calculated. Multiple regression analysis was performed for choroidal parameters in each choroidal layer and for age, refractive power, and ocular axial length. Multiple regression analysis showed that an older age was significantly correlated with a lower choroidal area and the L/C ratio in all choroidal layers (each P < 0.05). A Long axial length was significantly associated with lower SL and HL (P < 0.05), but not with refractive power. In the choroid of normal eyes, age-related decreases in the choroidal area and L/C ratio were associated with all choroidal layers, and elongation of the axial length was associated with thinning of SL and HL.

Rationale and Design of VOYAGER: Long-term Outcomes of Faricimab and Port Delivery System with Ranibizumab for Neovascular Age-Related Macular Degeneration and Diabetic Macular Edema in Clinical Practice.

Purpose: To describe the rationale and design of the VOYAGER (NCT05476926) study, which aims to investigate the safety and effectiveness of faricimab and the Port Delivery System with ranibizumab (PDS) for neovascular age-related macular degeneration (nAMD) or diabetic macular edema (DME) in clinical practice. VOYAGER also aims to understand drivers of clinical practice treatment outcomes by gaining novel insight into the intersection of treatment regimens, decisions, anatomic outcomes, and vision. Design: Primary data collection, noninterventional, prospective, multinational, multicenter clinical practice study. Participants: At least 5000 patients initiating/continuing faricimab or PDS for nAMD/DME (500 sites, 31 countries). Methods: Management will be per usual care, with no mandated scheduled visits/imaging protocol requirements. Using robust methodologies, relevant clinical and ophthalmic data, including visual acuity (VA), and data on treatment clinical setting/regimens/philosophies, presence of anatomic features, and safety events will be collected. Routinely collected fundus images will be uploaded to the proprietary Imaging Platform for analysis. An innovative investigator interface will graphically display the patient treatment journey with the aim of optimizing treatment decisions. Main Outcome Measures: Primary end point: VA change from baseline at 12 months per study cohort (faricimab in nAMD and in DME, PDS in nAMD). Secondary end points: VA change over time and per treatment regimens (fixed, treat-and-extend, pro re nata, and other) and number. Exploratory end points: VA change in relation to presence/location of anatomic features that impact vision (fluid, central subfield thickness, fibrosis, atrophy, subretinal hyperreflective material, diabetic retinopathy severity, and disorganization of retinal inner layers) and per treatment regimen/philosophies. The impact of regional and practice differences on outcomes will be assessed as will safety. Results: Recruitment commenced in November 2022 and will continue until late 2027, allowing for up to 5 years follow-up. Exploratory interim analyses are planned annually. Conclusions: VOYAGER is an innovative study of retinal diseases that will assess the effectiveness and safety of faricimab and PDS in nAMD and DME and identify clinician- and disease-related factors driving treatment outcomes in clinical practices globally to help optimize vision outcomes. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinicopathologic features of conjunctival MALT lymphomas refractory to radiation therapy.

OBJECTIVE: Clinicopathologic features of patients with limited-stage mucosa-associated lymphoid tissue (MALT) lymphoma refractory to radiotherapy have not been fully elucidated. This study aimed to elucidate clinicopathologic features of localized conjunctival MALT lymphoma concerning radiosensitivity by analyzing cell proliferation and expression of mismatch repair proteins. METHODS: We enrolled 26 patients with localized conjunctival MALT lymphoma treated with radiotherapy from November 2007 to March 2020. Monoclonal immunoglobulin H gene rearrangement was tested in addition to histopathologic evaluation. Thirty-six specimens were immunostained with antibodies to Ki-67 and MutL protein homologue 1 (MLH1), MutS protein homologue 2 (MSH2), and MutS protein homologue 6 (MSH6). Positive rates under a high-power field at a hot spot were counted manually. RESULTS: After radiotherapy, 21 patients showed clinical disappearance of the tumour without recurrence (effective group). Three patients showed temporary disappearance of the tumour, which later recurred (relapse group). Two patients did not show disappearance of the tumour (ineffective group). The 2 ineffective patients were young, had bilateral lesions, and received x-ray beam therapy. The mean positive rates of Ki-67, MLH1, MSH2, and MSH6 were higher in tumours with complete remission (CR) than in those without CR (23.4% ± 4.0% and 18.7& ± 4.7%, 14.7% ± 2.3% and 7.1% ± 3.7%, 23.9% ± 4.7% and 14.4% ± 5.2%, and 11.5% ± 3.2% and 5.4% ± 2.2%; p > 0.05 for each, respectively). CONCLUSIONS: A few patients could not achieve CR following radiotherapy, whereas there were no significant differences in proliferation activity and mismatch repair proteins between tumours with and without CR.