Hiroko Bissen-Miyajima

Treatment of severe ocular-surface disorders with corneal epithelial stem-cell transplantation.

BACKGROUND Conditions that destroy the limbal area of the peripheral cornea, such as the Stevens-Johnson syndrome, ocular pemphigoid, and chemical and thermal injuries, can deplete stem cells of the corneal epithelium. The result is scarring and opacification of the normally clear cornea. Standard corneal transplantation cannot treat this form of functional blindness. METHODS We performed and evaluated 70 transplantations of corneal epithelial stem cells from cadaveric eyes into 43 eyes of 39 patients with severe ocular-surface disorders and limbal dysfunction. Medical treatment had failed in all patients. The patients had a mean preoperative visual acuity of 0.004 (only being able to count the number of fingers presented by the examiner) in the affected eyes, which satisfies the criteria for legal blindness in most countries. In 28 eyes, we also performed standard corneal transplantation. Stem-cell transplantations were performed as many as four times on 1 eye if the initial results were not satisfactory; 19 eyes had multiple transplantations. Patients were followed for at least one year after transplantation. RESULTS A mean of 1163 days after stem-cell transplantation, 22 of the 43 eyes (51 percent) had corneal epithelialization; of the 22 eyes, 7 eyes had corneal stromal edema and 15 eyes had clear corneas. Mean visual acuity improved from 0.004 to 0.02 (vision sufficient to distinguish the largest symbol on the visual-acuity chart from a distance of 1 m) (P<0.001). The 15 eyes in which the cornea remained clear had a final mean visual acuity of 0.11 (the ability to distinguish the largest symbol from a distance of 5 m). Complications of the first transplantation included persistent defects in the corneal epithelium in 26 eyes, ocular hypertension in 16 eyes, and rejection of the corneal graft in 13 of 28 eyes. The epithelial defects eventually healed in all but two of the eyes. CONCLUSIONS Transplantation of corneal epithelial stem cells can restore useful vision in some patients with severe ocular-surface disorders.

Intact corneal epithelium is essential for the prevention of stromal haze after laser assisted in situ keratomileusis

AIMS To determine the effect of intact corneal epithelium on stromal haze and myofibroblast cell formation after excimer laser surgery. METHODS Denuded epithelium alone, photorefractive keratectomy (PRK), laser in situ keratomileusis (LASIK), or LASIK with denuded epithelium was performed in rabbit eyes. Postoperative anterior stromal haze was assessed employing a standard scale. Immunohistochemical methods were used to detect alpha smooth muscle actin (α-SMA), a marker for myofibroblastic cells, and type III collagen in subepithelial corneal tissue. RESULTS Three weeks after surgery, the presence of α-SMA positive long extended and spindle-shaped stromal cells, and synthesis of type III collagen were observed in the subepithelial stromal layer corresponding to corneal haze in PRK and LASIK with denuded epithelium, but not in denuded epithelium alone and LASIK. CONCLUSION The intact corneal epithelium may play an important part curbing subepithelial haze and differentiation of myofibroblasts in corneal wound healing.

Multifocal Intraocular Lens Explantation: A Case Series of 50 Eyes

OBJECTIVE To assess the visual complaints, reasons, and patient satisfaction for multifocal intraocular lens (IOL) explantation. DESIGN Retrospective observational case series. METHODS This study evaluated 50 eyes of 37 patients who underwent multifocal IOL explantation followed by IOL implantation. Before and 3 months after IOL exchange surgery, we investigated the symptoms, reasons, patient demographics, clinical results, and patient satisfaction in eyes undergoing multifocal IOL explantation. Data collected included preoperative subjective and objective findings, reasons, IOL type, postoperative course, and patient satisfaction. RESULTS The most common complaints for IOL explantation were waxy vision, followed by glare and halos, blurred vision at far, dysphotopsia, blurred vision at near, and blurred vision at intermediate. The most common reasons for IOL explantation were decreased contrast sensitivity, followed by photic phenomenon, unknown origin including neuroadaptation failure, incorrect IOL power, preoperative excessive expectation, IOL dislocation/decentration, and anisometropia. The axial length was 25.13±1.83 mm. Of the explanted multifocal IOLs, 84% were diffractive and 16% were refractive. Monofocal IOLs accounted for 90% of the exchanged IOLs. Patient satisfaction was significantly improved from 1.22±0.55 preoperatively to 3.78±0.97 postoperatively, which was graded on a scale of 1 (very dissatisfied) to 5 (very satisfied) (Wilcoxon signed-rank test, P<.001). CONCLUSIONS Multifocal IOL explantation was required in some patients undergoing multifocal IOL implantation. IOL exchange surgery appears to be a feasible surgical option for dissatisfied patients with persistent visual symptoms after multifocal IOL implantation.

In vitro behavior of ophthalmic viscosurgical devices during phacoemulsification

PURPOSE: To evaluate the behavior and aspiration of several ophthalmic viscosurgical devices (OVDs) during phacoemulsification. SETTING: Department of Ophthalmology, Tokyo Dental College Suidobashi Hospital, Tokyo, Japan. METHODS: Cohesive OVDs (sodium hyaluronate 1.0% [Healon and Provisc]), dispersive OVDs (sodium hyaluronate 3.0%–chondroitin sulfate 4.0% [Viscoat]), and new‐generation OVDs such as viscoadaptive (sodium hyaluronate 2.3% [Healon5]) and viscodispersive (hyaluronic acid 1.65%–chondroitin sulfate 4.0% [DisCoVisc]) OVDs, were stained with fluorescein sodium. The movement of the OVDs during simulated cataract surgery was recorded in porcine eyes under an operating microscope and with a side‐view video camera. The initial and complete aspiration times of each OVD during phacoemulsification using 20 and 40 mL/min flow rates and sleeves and the removal times using the irrigation and aspiration (I/A) tip at the end of surgery were evaluated from the recorded videos. RESULTS: The complete aspiration time of the cohesive OVDs was less than 3 seconds but up to 20 seconds with a low flow rate of 20 mL/min with a smaller sleeve. Other OVDs remained in the anterior chamber during phacoemulsification with both flow rates. The removal time for cohesive OVDs was less than 4 seconds and for new‐generation OVDs, 10 to 15 seconds. The dispersive OVD required a significantly (P<.05) longer removal time than other OVDs. CONCLUSIONS: Cohesive OVDs are removed easily during phacoemulsification; however, the aspiration rate can be affected by fluidics. New‐generation OVDs, such as Healon5 and DisCoVisc, remained in the anterior chamber during phacoemulsification and were removed easily by I/A at the end of surgery. The behavior of these OVDs is preferable during phacoemulsification.

Experimental observation of intraocular pressure changes during microkeratome suctioning in laser in situ keratomileusis

Purpose: To observe changes in intraocular pressure (IOP), the manner in which the eye is suctioned, and the effect of the number of suction ports. Setting: Department of Ophthalmology, Tokyo Dental College, Suidobashi Hospital, Tokyo, Japan. Methods: Suction rings with single or dual ports were made of transparent acrylic acid resin to facilitate observation with a digital video camera. The IOP and the duration of the IOP increase (time to reach 90% of the maximum IOP) were measured in 6 porcine eyes with an intra‐vein pressure‐sensor catheter in the vitreous cavity. The IOP changes were recorded using a personal computer. Results: Suctioning with single‐ and dual‐port suction rings was similar. The IOP increases with single‐ and dual‐port suction rings were similar (99.1 mm Hg ± 6.1 [SD] and 99.0 ± 6.5 mm Hg, respectively) (P = .987). The duration of the IOP increase was also similar (4.21 ± 0.24 seconds and 4.12 ± 0.33 seconds, respectively) (P = .190). Conclusions: The number of ports did not affect suctioning and changes in IOP. This technique is useful in developing the ideal shape and setting of the suction ring.

Infectious keratitis outbreak after laser in situ keratomileusis at a single laser center in Japan

PURPOSE: To evaluate an outbreak of infectious keratitis after laser in situ keratomileusis (LASIK) at a single laser center in Japan. SETTING: Tokyo Dental College, Chiba, Japan. DESIGN: Case series. METHODS: Relevant demographic and clinical data were obtained from case records using a standardized multicenter questionnaire at 12 major hospitals. The clinical manifestations, management, and outcomes were analyzed. RESULTS: Thirty‐nine eyes of 30 patients developed infectious keratitis after LASIK at the specified clinic. Cases of infection continued to appear over a 5‐month period. The most common interval between LASIK and the onset of infection was within 2 weeks (36 eyes, 92.3%). Slitlamp manifestation included granular opacity beneath flap (71.8%), multiple infiltration (66.7%), and epithelial defect (30.8%). Mycobacterium was identified as the causative organism in 9 eyes (23.1%). In most cases, topical amikacin, arbekacin, and erythromycin in addition to fourth‐generation fluoroquinolones were effective. Flap amputation was necessary in 10 eyes (25.6%) of 10 patients. Decimal visual acuity at initial presentation was worse than 0.10 in 14 eyes (35.9%), 0.15 to 0.50 in 8 eyes (20.5%), and 0.60 to 0.90 in 7 eyes (17.9%) and was better than 1.00 in 10 eyes (25.6%). Final decimal visual acuity was worse than 0.10 in 2 eyes (5.1%), 0.15 to 0.50 in 5 eyes (12.8%), and 0.60 to 0.90 in 11 eyes (28.2%) and was better than 1.00 in 21 eyes (53.8%). CONCLUSIONS: Mycobacterium was identified as the causative organism of this outbreak. This study shows the possibility of an epidemic of post‐LASIK infectious keratitis. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Pupil sizes in different Japanese age groups and the implications for intraocular lens choice

PURPOSE: To observe pupil sizes with near and distance vision under different lighting conditions in different Japanese age groups. SETTING: Department of Ophthalmology, Tokyo Dental College Suidobashi Hospital, Tokyo, Japan. METHODS: Using an open view–type infrared video pupillometer, the horizontal and vertical pupil sizes were measured prospectively with subjects gazing at 30 cm or 3 m targets under photopic (illumination 500 lux) and mesopic (illumination 5 lux) conditions. The results were analyzed by age, and the benefits with various multifocal IOLs were evaluated. RESULTS: The study comprised 140 eyes (70 subjects; 14 to 94 years). The mean ± standard deviations of photopic vertical pupil sizes when gazing far/near decreased from 3.77 ± 0.23/3.50 ± 0.33 mm (<20 years) to 2.20 ± 0.30/1.95 ± 0.20 mm (over 80 years), with pupil sizes stabilizing after 60 years. The mesopic vertical pupil sizes when gazing far/near decreased from 6.35 ± 0.11/6.27 ± 0.14 mm (<20 years) to 3.42 ± 0.30/3.21 ± 0.28 mm (over 80 years). The pupil sizes decreased with age until 60 years and stabilized (1‐way analysis of variance, P<.05). Fewer than 50% of subjects over 60 years of age had pupil sizes conducive to the near zone of refractive multifocal intraocular lenses. CONCLUSION: Photopic and scotopic pupil sizes decreased with age up to 60 years. The pupil was smaller when gazing at a near target than previously reported.

Clinical comparison of Healon5 and Healon in phacoemulsification and intraocular lens implantation: Randomized multicenter study☆

Purpose: To compare the overall clinical performance during phacoemulsification and intraocular lens (IOL) implantation, the effect on intraocular pressure (IOP), and the effect on corneal endothelium of Healon®5 (sodium hyaluronate 2.3%) and Healon® (sodium hyaluronate 1.0%) ophthalmic viscosurgical devices (OVDs). Setting: Multicenter study. Methods: In this randomized prospective clinical study, the performance of Healon5 (viscoadaptive; dispersive and cohesive) and Healon (cohesive) during cataract surgery was evaluated in 157 patients, 79 with Healon5 and 78 with Healon. Surgeons evaluated the following on a 5‐point scale: retention during phacoemulsification (primary endpoint), ease of injection, anterior chamber maintenance during continuous curvilinear capsulorhexis (CCC), facilitation of IOL implantation, and ease of removal from the eye. Masked examiners other than the surgeon performed the following measurements: IOP preoperatively and 5 and 24 hours, 7 days, and 3 months postoperatively; corneal thickness before and 24 hours, 7 days, and 3 months postoperatively; and corneal endothelial cell count preoperatively and 3 months postoperatively. Results: Intraocular retention during phacoemulsification was assessed as good or very good in 77% in the Healon5 group and 8% in the Healon group; the difference was statistically significant (P<.0001, Wilcoxon rank sum test). The Healon5 group had significantly better scores for anterior chamber maintenance during CCC (P<.0001) and facilitation of IOL implantation (P = .032), and the Healon group had significantly better scores for ease of injection (P<.0001) and ease of removal (P<.0001). There were no statistically significant between‐group differences in IOP, corneal endothelial cell count, or corneal thickness. Conclusions: Surgeons rated Healon5 better than Healon in retention during phacoemulsification, anterior chamber maintenance during CCC, and facilitation of IOL implantation. They assessed Healon as easier to inject and remove. There was no difference in safety‐related parameters between the 2 OVDs. These findings indicate that Healon5 is effective in cataract surgery.

Limbal relaxing incisions using a reference point and corneal topography for intraoperative identification of the steepest meridian.

PURPOSE To examine the efficacy and safety of topography-based limbal relaxing incision (LRI) surgery. METHODS Forty-four eyes of 36 consecutive patients who underwent cataract surgery more than 1 month previously, had refractive against-the-rule astigmatism of ≥2.00 diopters (D), and were scheduled to undergo LRI surgery were enrolled in the study. Patients were randomized into two groups-a topography-based LRI group (19 eyes of 14 patients) and a conventional LRI group (25 eyes of 22 patients). The topography-based LRI procedure comprised 3 steps: placing a mark on the cornea and conjunctiva, identifying this mark in the topographic image, and performing LRI based on the location of the mark. In the conventional LRI group, the horizontal meridian was marked under a slit lamp and LRIs were made based on the position of the horizontal mark. RESULTS Corneal astigmatism in the topography-based LRI group before and 1 month after surgery was 2.03±0.92 D and 1.33±0.69 D, respectively (P=.014). Corneal astigmatism in the conventional LRI group before and 1 month after surgery was 2.36±0.77 D and 0.93±0.70 D, respectively (P<.0001). Fourier harmonic analysis of the topography data demonstrated that regular astigmatism was significantly decreased in the two groups. The mean regular astigmatism was not significantly different before and after LRI between groups, whereas the variances (mean of the deviation squared from its mean) of regular astigmatism were significantly different between groups 1 month after LRI. CONCLUSIONS Compared with conventional LRI surgery, a topography-based procedure may reduce the deviation of the effect of LRIs.

Wavy horizontal artifacts on optical coherence tomography line-scanning images caused by diffractive multifocal intraocular lenses

PURPOSE: To report wavy horizontal artifacts on optical coherence tomography (OCT) monitor images. SETTING: Tokyo Dental College Suidobashi Hospital, Department of Ophthalmology, Tokyo, Japan. METHODS: The line‐scanning ophthalmoscopy images from an OCT device of eyes that had uneventful cataract extraction with implantation of a diffractive multifocal intraocular lens (IOL) were evaluated. The images were compared with those of eyes that had cataract surgery with implantation of a monofocal IOL. RESULTS: The study evaluated 38 eyes of 19 patients with a diffractive multifocal IOL and 29 eyes of 18 patients with a monofocal IOL. Wavy horizontal artifacts were seen in all eyes with a multifocal IOL but not in any image of eyes with a monofocal IOL (P<.0001, Fisher exact probability test). The OCT images, fundoscopic photographs, and scanning‐laser ophthalmoscopy images were unaffected by the multifocal IOLs. CONCLUSION: The aberrations in the images from line‐scanning ophthalmoscopy may have been caused by the optical design of the diffractive multifocal IOLs.