Oxidative stress in the levator aponeurosis in Asian involutional blepharoptosis.

PURPOSE: To analyze the histopathology and expression of 8-hydroxydeoxyguanosine (OHdG), a marker of oxidative stress, in the levator aponeurosis tissues of involutional aponeurotic and congenital blepharoptosis patients, and adult subjects with no history of blepharoptosis. METHODS: Fourteen and 4 levator aponeurosis tissues obtained from Asian patients with involutional and congenital blepharoptosis and 3 normal adult tissues were examined. All tissues were fixed in 4% paraformaldehyde, embedded in paraffin, and then submitted for hematoxylin and eosin staining and immunohistochemistry with anti-8-OHdG antibody. RESULTS: The levator aponeurosis tissues contained spindle smooth muscle fibers and striated muscles. Nuclear immunoreactivity for 8-OHdG was noted in striated and smooth muscle cells in all the tissues. The 8-OHdG-positive rate was significantly lower in congenital blepharoptosis than involutional blepharoptosis (p < 0.05). Moreover, the number of 8-OHdG-positive striated muscle cells was significantly higher in the involutional blepharoptosis than normal tissues (p < 0.05). In contrast, there was a rare positive 8-OHdG-immunoreactivity of smooth muscle cells in the aponeurotic tissues of the involutional blepharoptosis patients. CONCLUSIONS: Levator aponeurosis in involutional aponeurotic blepharoptosis tissues showed oxidative stress in the muscle, indicating that oxidative stress plays a potential role in the pathologic study of the disease.

Spontaneous regression of IgG4-related dacryoadenitis.

This is the first report showing the clinical course of a patient with bilateral IgG4-related dacryoadenitis, which spontaneously regressed after excision of the left lacrimal gland. A 65-year-old female had been aware of bilateral eyelid swelling without pain for 5 years. Magnetic resonance imaging revealed enlargement of bilateral lacrimal gland. Laboratory tests showed high IgG4 concentrations, measuring 394 mg/dl. The biopsied specimen of the left lacrimal gland revealed marked lymphoplasmacytic infiltration with mild fibrosis. Marked IgG and IgG4-positive plasma cells surrounded the lymphoid follicles. Although the patient did not wish to undergo any treatments, lacrimal gland lesions showed gradual remission. This case highlights the potential of spontaneous improvement in IgG4-related dacryoadenitis, indicating that careful observation may be one of the therapeutic options for such patients.

Immunolocalization of vascular adhesion protein-1 in human conjunctival tumors.

OBJECTIVE: We analyzed the expression and immunolocalization of vascular adhesion protein (VAP)-1 in conjunctival tumors and normal conjunctival tissue of humans. METHODS: Nine conjunctival tumors, including pyogenic granuloma and extranodal marginal zone B-cell lymphoma (EMZL), and 2 normal conjunctivas were analyzed by immunohistochemistry for VAP-1 and CD31 expression. RESULTS: Immunoreactivity for VAP-1 was detected in the lumen of microvessels in pyogenic granuloma and in EMZLs. In contrast, normal bulbar conjunctival tissues demonstrated weak cytoplasmic immunoreactivity for VAP-1 in the blood vessels. CONCLUSIONS: The immunolocalization of VAP-1 varied in the histopathology of the conjunctiva, involving the pathology of inflammatory conjunctival disorders.

Conjunctival lymphoma arising from reactive lymphoid hyperplasia.

Extra nodal marginal zone B-cell lymphoma (EMZL) of the conjunctiva typically arises in the marginal zone of mucosa-associated lymphoid tissue. The pathogenesis of conjunctival EMZL remains unknown. We describe an unusual case of EMZL arising from reactive lymphoid hyperplasia (RLH) of the conjunctiva. A 35-year-old woman had fleshy salmon-pink conjunctival tumors in both eyes, oculus uterque (OU). Specimens from conjunctival tumors in the right eye, oculus dexter (OD), revealed a collection of small lymphoid cells in the stroma. Immunohistochemically, immunoglobulin (Ig) light chain restriction was not detected. In contrast, diffuse atypical lymphoid cell infiltration was noted in the left eye, oculus sinister (OS), and positive for CD20, a marker for B cells OS. The tumors were histologically diagnosed as RLH OD, and EMZL OS. PCR analysis detected IgH gene rearrangement in the joining region (JH) region OU. After 11 months, a re-biopsy specimen demonstrated EMZL based on compatible pathological and genetic findings OD, arising from RLH. This case suggests that even if the diagnosis of the conjunctival lymphoproliferative lesions is histologically benign, confirmation of the B-cell clonality by checking IgH gene rearrangement should be useful to predict the incidence of malignancy.

Hybrid repair for Kommerell's diverticulum and right aortic arch with aberrant right vertebral artery.

Kommerell's diverticulum (KD) is a rare aneurysm of the origin of an aberrant subclavian artery. Hybrid aortic arch repair for KD is being performed more often. We report hybrid arch repair for KD in a 63-year-old man with a right aortic arch and aberrant right vertebral artery, an extremely rare variant. We performed total arch replacement to completely reconstruct the five cervical arteries with elephant trunk to create an adequate landing zone, followed by second-stage endovascular stent-grafting from the ascending aorta to the proximal descending aorta.

Repair of blowout orbital floor fracture by periosteal suturing.

The study objective was to evaluate the outcome of a periosteal suturing technique in eyes with orbital blowout fractures. Fifteen orbital floor fractures were classified into: type 1, linear fracture; type 2, middle fracture; and type 3, posterior fracture extending two-thirds into the orbit. The feasibility of periosteal suturing without silicone plates or one of minimal size was determined. The improvement of ocular movements and surgical complications were evaluated. A complete suture of the torn periosteum without implanting a silicone plate was achieved in 2/2 (100%) type 1 cases, 5/7 (71%) type 2 cases and 0/6 (0%) type 3 cases. A partial fixation was achieved in 3/6 (50%) type 3 cases with an implantation of a silicone plate of approximate one-third of the usual size in one case. Conventional surgery with silicone plates after failed periosteal suture was required in 2/7 (29%) type 2 cases and 3/6 (50%) type 3 cases. Eye movements were improved postoperatively in all eyes, and a complete range of eye movements was achieved in 6/7 (86%) cases with complete periosteal closure, 1/3 (33%) of cases with partial closure and 2/5 (40%) cases without closure. In conclusion, periosteal suturing can minimize the need for silicone plates especially for anterior or middle orbital floor factures.

[Two cases of conjunctival malignant melanoma treated with topical interferon alpha-2b drop as an adjuvant therapy].

BACKGROUND: Topical interferon alpha-2b (IFNalpha-2b) eye drops suppress tumor growth through the activation of host immunity on the ocular surface. Conjunctival malignant melanoma, a rare malignant tumor in Japan, develops local recurrence and lymph node metastasis. We herein report two cases with conjunctival melanoma treated with topical IFNalpha-2b eye drops. CASES: Case 1, a 77-year-old woman presented with temporal conjunctival pigmented nodules, simulating primary acquired melanosis (PAM) on the cornea and around the conjunctiva OD. Case 2, an 84-year-old woman, presented with nasal conjunctival pigmented nodules and PAM OD. Both patients underwent tumor excision and IFNalpha-2b drops four times per day for half a year. Histologically, the excised conjunctival nodules of both patients were diagnosed with malignant melanoma. There was no local recurrence or distant metastasis 24 months after tumor resection. CONCLUSIONS: Topical IFNa-2b is a useful adjuvant treatment in patients with conjunctival malignant melanoma, following tumor resection.

Assessment of Long-Term Anterior and Posterior Topographic Changes in the Cornea After Ptosis Surgery Using Fourier Harmonic Analysis.

PURPOSE: We aimed to assess the corneal refractive changes induced by ptosis surgery in patients with acquired ptosis using Fourier harmonic analysis. METHODS: This retrospective observational study enrolled consecutive patients who underwent levator aponeurotic surgery for acquired ptosis at the Department of Ophthalmology in the University of Tokyo Hospital from May 2016 to January 2018. Best corrected visual acuity, central corneal thickness, average keratometric corneal power (AvgK), corneal astigmatism, and topographic data using Fourier analysis were analyzed preoperatively and 6 months postoperatively. RESULTS: Thirty-two eyes of 32 patients (age, 72.6 ± 8.5 years) were included in this study. There were no significant differences in best corrected visual acuity and central corneal thickness. However, there were significant decreases in anterior AvgK, anterior corneal astigmatism, and posterior corneal astigmatism 6 months postoperatively (all, P < 0.001). Fourier harmonic analysis showed that the anterior spherical component significantly decreased 6 months postoperatively (P < 0.001). There were no significant differences in other components of the anterior and posterior cornea. There was a significant negative correlation between preoperative posterior AvgK and changes in posterior AvgK (r = -0.891, P < 0.001) and between preoperative posterior corneal astigmatism and changes in posterior corneal astigmatism at 6 months (r = -0.858, P < 0.001). CONCLUSIONS: Anterior and posterior corneal keratometry and posterior corneal astigmatism significantly changed 6 months after ptosis surgery for acquired ptosis.

Relation of Fractional Flow Reserve With Transit Time Coronary Artery Bypass Graft Flow Measurement.

BACKGROUND: Transit-time flow measurement (TTFM) is frequently used for intraoperative graft flow analysis during coronary artery bypass grafting (CABG). Although the TTFM results may be influenced by fractional flow reserve (FFR) of the target coronary artery as a determinant of coronary lesion-specific ischemia, the data have been limited. METHODS: We retrospectively investigated the relationships between the intraoperative TTFM variables and preoperative FFR values of the target coronary arteries in 40 in situ left internal thoracic artery (LITA) grafts to the left anterior descending artery (LAD), which were revealed to be patent on postoperative computed tomographic angiography. RESULTS: The Spearman correlation coefficients of the TTFM variables with FFR were maximum flow, -0.12 (P = .301); minimum flow (Qmin), -0.43 (P = .004); mean flow (Qm), -0.30 (P = .036); pulsatility index, 0.37 (P = .012); diastolic filling, -0.36 (P = .012); percentage insufficiency, 0.45 (P = .002); and fast Fourier transform (FFT) ratio, -0.07 (P = .329). While Min and Qm showed significant negative correlation, the pulsatility index and percentage insufficiency showed significant positive correlation with FFR. CONCLUSIONS: Most TTFM variables, including Qm, of the LITA graft to the LAD during CABG are strongly affected by preoperative FFR values. Because the FFT ratio is not influenced by FFR, FFT analysis of the TTFM may be recommend in the case of the in situ LITA graft to the LAD with moderate stenosis with a higher FFR exceeding 0.75.

Remote simulator training of coronary artery bypass grafting during the coronavirus disease 2019 pandemic.

OBJECTIVES: The coronavirus disease 2019 pandemic presents in-person exposure risk during surgical education. We aimed to validate the feasibility of fully remote faculty-supervised surgical training sessions focused on coronary artery bypass grafting using a synthetic simulator and online videochat software. METHODS: This observational study organized 24 sessions of 2-hour remote training. Each session involved 3 trainees, 1 faculty member, and 1 host. A total of 70 trainees and 24 faculty members were enrolled. The participants joined the remote sessions via online videochat and performed focused training in coronary artery anastomosis using a commercially available simulator. A survey was conducted to validate the feasibility of the remote sessions. Performance improvement of the trainees who repeatedly participated (n = 13) were analyzed comparing initial and final scores of various performance indicators. RESULTS: All trainees and faculty members were satisfied with the efficacy of the remote session. Additionally, most trainees (79%) and faculty members (95%) agreed that the remote training sessions were equivalent to conventional onsite training seminars. A significant improvement between initial and last sessions was observed in the scoring components of near side (3.4 ± 1.0 vs 4.1 ± 0.9; P = .02), far side (3.3 ± 0.8 vs 3.9 ± 0.8; P = .03), external appearance (3.5 ± 0.8 vs 4.2 ± 0.7; P = .01), and internal appearance (2.8 ± 0.9 vs 4.0 ± 0.9; P = .004). CONCLUSIONS: Faculty-supervised remote surgical training sessions were executed with satisfactory results. This methodology may have important implications for surgical education during the coronavirus disease 2019 pandemic.

Relationship between fractional flow reserve and graft patency after coronary artery bypass grafting.

BACKGROUND: Bypass for moderately stenosed coronary arteries may cause graft failure (string phenomenon or occlusion). We examined the effects of fractional flow reserve (FFR) on the efficacy of coronary artery bypass grafting (CABG) in preventing graft failure. METHODS: Between January 2013 and December 2017, 48 patients underwent CABG after FFR was measured. Twenty-five grafts in 23 patients were evaluated for graft patency after the procedure. We studied stenosis of native coronary arteries, FFR, graft flow, graft patency, and the presence of pre-procedure and post-procedure myocardial ischemia. RESULTS: Three internal thoracic arteries showed the string sign, and two saphenous vein grafts showed occlusion. All target coronary arteries for these grafts had moderate (50-75%) stenosis. Of the 25 grafts, five failed, and 20 were successful. All grafts with the string sign had been bypassed for target coronary arteries with the gray-zone FFR value (0.75-0.80). No difference in graft flow was observed between the failed and successful grafts. Patients with graft failure had no postoperative myocardial ischemia in target areas despite graft condition. CONCLUSION: Internal thoracic artery graft for coronary arteries with the gray-zone FFR value may exhibit the string phenomenon. We believe that graft failure occurred because the target area had no ischemia before CABG. FFR is useful in pre-operative ischemic evaluation including scintigraphy and will influence the success of revascularization, including the selection of grafts.

[Pyogenic granuloma developing rapidly after excision of corneal/conjunctival intraepithelial neoplasia].

BACKGROUND: Pyogenic granuloma is a benign tumor presenting with a smooth hemorrhagic surface that develops on the ocular surface after trauma or ophthalmic surgery. Abnormal wound healing due to physical and/or chemical stimulation may contribute to the pathogenesis of the tumor. We herein report the usefulness of brushing cytology for diagnosis of pyogenic granuloma, which rapidly developed after surgical resection of corneal/conjunctial intraepithelial neoplasia (CIN). CASE: A 70-year-old man presented with a flat tumor on the left lower conjunctiva in conjunction with the cornea. The patient underwent excision of the tumor and cryotherapy. The primary tumor was histologically diagnosed with CIN. A hemorrhagic mass developed on the conjunctiva one month after the excision. Brushing cytology demonstrated vascular endothelial cells with spindle-shaped nuclei mixed with prominent neutrophils without abnormal squamous epithelial cells. The secondary tumor was diagnosed as pyogenic granuloma. CONCLUSIONS: It is possible to diagnose a secondary tumor based on information of the clinical course, slit-lamp examination and brushing cytology before the excision of CIN.

Lower body ischaemic time is a risk factor for acute kidney injury after surgery for type A acute aortic dissection.

OBJECTIVES: Postoperative acute kidney injury (AKI) is known as a risk factor for death after surgery for Stanford type A acute aortic dissection under hypothermic circulatory arrest. It may also adversely affect long-term survival. We searched for modifiable risk factors for postoperative AKI, focusing on lower body ischaemic time. METHODS: We reviewed 191 patients undergoing surgical repair for Stanford type A acute aortic dissection. The distal anastomosis depended on excluding the primary tear location, resulting in ascending/hemiarch (n = 119), partial arch (n = 18) and total arch replacement (n = 54). We defined an increase in the serum creatinine level to ≧2 times the baseline level as AKI. The incidence of AKI was investigated with multivariate analysis of its risk factors. RESULTS: Postoperative AKI was observed in 49 patients (26%), 31% of whom required renal replacement therapy. The overall hospital mortality rate was 8.5%. Postoperative AKI, preoperative shock and organ malperfusion were predictors of hospital death. Multivariate stepwise logistic regression analysis identified age, body mass index, preoperative chronic kidney disease and lower body ischaemic time as risk factors for postoperative AKI. CONCLUSIONS: Although surgical repair for Stanford type A acute aortic dissection showed favourable results, the incidence of postoperative AKI is still high, closely associated with hospital death. Lower body ischaemic time should be recognized specifically as a modifiable surgical risk factor for postoperative AKI.

Predictors of Outcomes After Surgery for Chronic Thromboembolic Pulmonary Hypertension.

BACKGROUND: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is technically demanding. We tried to identify the predictors for short- and long-term outcomes after PEA for CTEPH with aggressive use of pulmonary vasodilators, including epoprostenol sodium. METHODS: From 2005 to 2013, 122 CTEPH patients, whose preoperative mean pulmonary artery pressure (mPAP) was 47 ± 10 mm Hg and pulmonary vascular resistance was 847 ± 373 dynes/s/cm5, underwent PEA with hypothermic circulatory arrest. Before PEA, all patients underwent pulmonary vasodilator therapy, including epoprostenol sodium of 2 to 6 ng/kg/min. We collected the perioperative and follow-up data retrospectively to identify the predictors for early and late outcomes after PEA. RESULTS: In-hospital mortality was 7.4% (n = 9). Predictors for in-hospital death were age older than 65 years and New York Heart Association Functional Classification IV. Among the 113 PEA survivors, the mPAP and pulmonary vascular resistance significantly decreased. After the median follow-up of 6.8 years, the overall survival rates were 91.8%, 89.2%, 89.2%, 89.2%, and 86.1%, and the cardiac events-free rates were 100%, 98.1%, 95.8%, 85.5%, and 49.0%, at 1, 3, 5, 7, and 10 years, respectively, in the Kaplan-Meier model. A multivariate Cox proportional hazard model identified postoperative mPAP exceeding 30 mm Hg as the only predictor for late cardiac events. CONCLUSIONS: Early and late outcomes of PEA for CTEPH with perioperative aggressive pulmonary vasodilator treatment seem satisfactory. However, residual pulmonary hypertension remains challenging to achieve further improvement of late outcomes.

Evaluation of surgical outcomes for ptosis surgery by face recognition software.

PURPOSE: This study was aimed to use the age estimation segment of face recognition software to determine whether patients appeared younger after surgery for aponeurotic ptosis and dermatochalasis. DESIGN: This is a prospective interventional case series. METHODS: Face recognition software was used to estimate the age of 12 Japanese patients who had surgery to repair aponeurotic ptosis or dermatochalasis. Photographs of the faces before and 1 month after the surgery were taken and uploaded to the face recognition software to estimate the age of the subjects. RESULTS: The preoperative estimated age significantly correlated with the actual age (r = 0.647, P = 0.023), and the postoperative estimated age also significantly correlated with the actual age (r = 0.727, P = 0.007). The scores of the palpebral fissure width of the right eyes (P = 0.003) and left eyes (P = 0.002) significantly improved postoperatively. However, the postoperative estimated age was not significantly younger than the preoperative estimated age (P = 0.173). CONCLUSIONS: The face recognition software may not be influenced by the lid plastic surgery. Many factors other than the width of the palpebral fissure influence the estimation of age by the face recognition software.

Mid-term outcomes of cardiovascular surgery for patients with Marfan syndrome.

OBJECTIVES: Cardiovascular manifestations determine the prognosis and survival of patients with Marfan syndrome (MFS). We assessed the early and mid-term outcomes of cardiovascular surgery for this patient population. PATIENTS AND METHODS: We conducted a retrospective evaluation of patients with MFS who underwent surgery in our department. The endpoint was the requirement for a second cardiovascular surgery, and death from any cause. RESULTS: From February 2002 to March 2013, we performed 24 surgeries on 13 patients with MFS. At the time of initial surgery, the patients' aged ranged from 19 to 64 years of age (mean 34.7 ± 11.3 years) and included 5 men (38.5 %). Five of 13 initial surgeries (38.5 %) were emergencies. Seven patients (53.8 %) presented with aortic dissection at initial surgery, and one of the remaining six patients suffered from new aortic dissection during follow-up. Eight patients (61.5 %) underwent a second surgery, and a second surgery was not required for 100, 75.0, and 53.6 % of patients at 1, 3, and 5 years, respectively. The mean time interval between the first and the second surgeries was 52.8 ± 28.2 months. No patient died while hospitalized, and three subsequently died from unknown causes. Survival rates were 100, 90.9 and 64.9 % at 3, 5, and 7 years, respectively. CONCLUSION: Although we obtained satisfactory early outcomes for patients with MFS, there were three late deaths from unknown causes. Therefore, we recommend that patients with MFS should remain under close surveillance.

Adenosquamous carcinoma of the conjunctiva: A case report.

Adenosquamous carcinoma (ASC) is a rare form of malignancy which consists of two types of cell, including squamous cells and glandular-like cells. The current report presents the first known case of ASC in the conjunctiva and analyzes the histological findings. A 76-year-old female presented with right eyelid swelling in 2001. A right conjunctival tumor was noted and a biopsy was performed. Histologically, the tumor was diagnosed as a squamous cell carcinoma. The patient underwent radiotherapy, but the tumor rapidly relapsed. Subsequently, the patient underwent orbital exenteration. Histologically, the conjunctival tissues had been replaced with invasive tumor cells. A number of tumor cells demonstrated squamous differentiation with a keratinizing tendency, while other tumor cells exhibited mucin-producing activity with glandular formation. The conjunctival tumor was diagnosed as an ASC. At the time of writing, the patient is well without local recurrence or distant metastases. ASC typically exhibits aggressive biological behavior, and is associated with worse prognosis than conventional adenocarcinoma. Therefore, complete surgical excision is considered a key treatment for ASC of the conjunctiva.

Expression of vascular endothelial growth factor in human ocular adnexal lymphoma.

PURPOSE: To examine the expression of VEGF in extranodal marginal zone B-cell lymphoma (EMZL) and reactive lymphoid hyperplasia (RLH) of human ocular adnexa, and analyze the correlation with the intratumoral microvessel density (MVD). METHODS: Twenty-two EMZL and 16 RLH tissues were examined in this study. Paraformaldehyde-fixed, paraffin-embedded tissue sections were processed for immunohistochemistry with antibodies against VEGF and CD20. Vascular endothelial growth factor expression was analyzed using the ELISA and RT-PCR in the EMZL tissues. Microvessel density was determined based on the immunoreactivity for anti-CD34 antibody. RESULTS: Vascular endothelial growth factor immunoreactivity was detected in the cytoplasm of lymphoid cells in EMZL and RLH. ELISA and RT-PCR confirmed VEGF protein and mRNA expressions in the EMZL tissue, respectively. Vascular endothelial growth factor-immunopositive rate in B-cells was significantly higher in 12 conjunctival EMZLs than four RLHs (P < 0.01) and 10 orbital EMZLs than 12 RLHs (P < 0.05). The MVD showed a significant positive correlation with the VEGF-immunopositive rate in conjunctival and orbital EMZLs. CONCLUSIONS: This study demonstrated increased VEGF expression in human conjunctival and orbital EMZL compared with that in RLH, suggesting that VEGF plays a significant role in the pathogenesis and tumor angiogenesis of ocular adnexal lymphoma.