Hiroshi Shimojyo

Efficacy of intravitreal injection of bevacizumab for severe retinopathy of prematurity: a pilot study

Aim: The aim of the study was to evaluate the short-term efficacy of intravitreal injections of bevacizumab for severe retinopathy of prematurity (ROP). Methods: A retrospective chart review was conducted of 23 consecutive eyes (stage 3, three eyes; 4A, 18 eyes; 4B, two eyes) of 14 patients with vascularly active ROP considered at high risk for progression or development of tractional retinal detachment despite conventional laser ablation therapy. Patients received an intravitreal injection of bevacizumab (0.5 mg), either as the initial treatment (15 eyes) or at the end of vitrectomy (eight eyes). Results: After injection of bevacizumab as the initial treatment, reduced neovascular activity was seen on fluorescein angiography in 14 of 15 eyes. In three eyes, a tractional retinal detachment developed or progressed after bevacizumab injection. No other ocular or systemic adverse effects were identified. Vitrectomy was performed in 20 eyes and the retina was reattached after one surgery in 18 eyes. Multiple surgeries were necessary in two eyes, resulting in retinal reattachment. Conclusion: There results suggest that intravitreal injection of bevacizumab seems to be associated with reduced neovascularisation without apparent ocular or systemic adverse effects, and is thus beneficial for treating severe ROP that is refractory to conventional laser therapy.

Evaluation of residual retinal function by pupillary constrictions and phosphenes using transcorneal electrical stimulation in patients with retinal degeneration

BackgroundTo evaluate inner-retinal function by pupillary constrictions and phosphenes evoked by transcorneal electrical stimulation (TES) in patients with hereditary retinal degeneration.MethodsConsecutive 20 eyes of 20 patients (16 with retinitis pigmentosa (RP); and four with cone-rod dystrophy (CRD)) whose visual acuity was equal to or worse than 20/2000 at Osaka University Hospital and eight eyes of eight healthy subjects were enrolled. TES was performed on with a contact lens stimulating electrode. The electrically evoked pupillary response (EEPR) was recorded by a pupillometer, and the phosphenes by the subjective responses. Three electrical current thresholds were determined: T1, threshold current for initial phosphene; T2, threshold for eliciting a phosphene extending into the central field; and P, threshold for a relative pupillary constriction ≥3%.The EEPR and phosphene thresholds were compared with the visual acuity or the visual field.ResultsAll T1, T2 and P were significantly higher in patients than in normals (Mann-Whitney, P<0.001). Both T1 and T2 were not correlated with visual acuity but depended on the area and location of the residual visual field. T1 and T2 in RP eyes with a EEPR was significantly lower than that in RP eyes without an EEPR. During TES, all subjects and patients had no pain, and no complications except for a slight corneal superficial punctuate keratopathy.ConclusionsThe safety and the efficacy of TES to estimate the residual inner-retinal function in patients with retinal degeneration indicate that TES can be used as one of the most important test to select candidates for retinal prostheses.

Effect of simultaneous oblique muscle surgery in foveal translocation by 360° retinotomy

Abstract.Purpose: To assess the effect of simultaneous oblique muscle surgery during foveal translocation surgery with 360° retinotomy in patients with neovascular maculopathy. Methods: Foveal translocation with 360° retinotomy was performed on 31 eyes of 31 patients with neovascular maculopathy (21 with age-related macular degeneration 9 with myopic neovascular maculopathy, and 1 with idiopathic neovascular maculopathy). All eyes had simultaneous torsional muscle surgery with recession of the superior oblique muscle and tucking of the inferior oblique muscle. Visual acuity, binocular vision, and degree of cyclotorsion were assessed pre- and postoperatively. The angles of retinal and global rotation, distance of foveal shift, and surgical complications were also investigated. Results: With a mean postoperative follow-up of 10.0 months, vision improved (>0.2 log MAR units) in 13 eyes, was unchanged in 9 eyes, and worsened (>0.2 log MAR units) in 9 eyes. Ten of 31 eyes (32%) had a final visual acuity of 20/50 or better. Eleven patients had binocular fusion, 13 patients showed suppression, and 7 patients developed diplopia that was managed by spectacles with prisms or by secondary muscle surgery. The mean retinal and global rotations were 30.3° and 23.7°, respectively. The average size of the choroidal neovascular membrane was 1.3 disc diameters (DD), while the average shift of the fovea was 1.5 DD. After the primary surgery, six eyes developed retinal detachment, two eyes macular hole, and three eyes proliferative vitreoretinopathy. These complications were successfully managed by additional surgery. Conclusion: Foveal translocation with 360° retinotomy is effective in restoring vision in 40% of patients with neovascular maculopathy. Simultaneous oblique muscle surgery was effective in rotating the globe by about 20°, corresponding to to a foveal shift of 1.5 DD. While the development of torsional diplopia is generally prevented by simultaneous oblique muscle surgery, the relatively high incidence of surgical complications with this procedure should be taken into account.

Age-related changes of phoria myopia in patients with intermittent exotropia

PurposeTo investigate the age-related changes in a myopic shift under binocular conditions (phoria myopia) in patients with intermittent exotropia (IXT).MethodsForty-five patients with IXT were studied: 21 were ≤9 years old (children), 11 were between 10 and 19 years (adolescents), and 13 were between 20 and 43 years (adults). The angle of strabismus was determined by the alternating prism cover test. The spherical refractive error was measured at 1 m using infrared video retinoscopy under monocular and binocular viewing conditions.ResultsThe change in the spherical refractive error (ΔR) between binocular and monocular conditions was significantly larger in adults (ΔR = −1.11 ± 1.01 diopters (D), average ± standard deviation) than in children (ΔR = −0.34 ± 0.34 D; P < 0.05, analysis of variance). ΔR was significantly correlated with the angle of exotropia only in adults (r = 0.55, P = 0.04). After strabismus surgery, ΔR decreased in adults (n = 3).ConclusionsBecause a significant myopic shift under binocular conditions was detected in IXT patients older than 20 years, phoria myopia can occur after age 20 even if functional disturbances are not observed in children or adolescent IXT patients, a fact that specialists need to bear in mind when treating younger patients.

Development of anisometropia in patients after surgery for esotropia.

PurposeAnisometropia is reported to increase with age; however, the relationship between the development of anisometropia and binocular vision has not been determined. The purpose of this study was to determine the relationship between anisometropia and binocular vision after esotropia (ET) surgery.MethodsThe medical records of 51 consecutive patients with ET who had undergone ET surgery were studied. Patients with amblyopia or anisometropia ≥2 diopters (D) before surgery were excluded. The average age of the patients at the time of surgery was 4.5 ± 3.7 years, and the average postoperative period was 5.0 ± 2.2 years. The refractive errors (spherical equivalent) in both eyes were measured preoperatively and postoperatively. Binocular visual function was evaluated with a modified Worth-4 dot test.ResultsAt the final visit, average anisometropia was 0.98 ± 1.30 D, which was significantly greater than the preoperative value of 0.36 ± 0.46 D (P < 0.001). Anisometropia ≥2 D was observed in ten patients (23%) postoperatively. One patient was able to fuse a target of ≥2° (10%) in the anisometropia ≥2 D group, significantly fewer than the 13 patients (32%) in the anisometropia <2.0 D group (P = 0.02).ConclusionsAnisometropia may develop in patients with poor sensory fusion after surgery for esotropia.

Pupilloplasty for congenital pupillary‐iris‐lens membrane with 25‐gauge vitreous cutter

Editor, I n 1986, Cibis and coworkers reported congenital pupillary-irislens membrane with goniodysgenesis (CPILMG) as a new clinical entity characterized by anomalies of the chamber angle and iris-lens membrane (Cibis et al. 1986). CPILMG is a rare, congenital, unilateral and sporadic disease with distinctive features of a white pupillary membrane that can be progressive and adheres to the anterior iris surface. Because the membrane often causes an ectopic pupil or pupillary block glaucoma, surgical intervention is sometimes required (Cibis et al. 1994; Robb 2001; Cibis & Walton 2004; Demidenko et al. 2009). We present a case of CPILMG in which a white membrane on the iris of the right eye triggered pupillary displacement and caused pupillary block. A 2-month-old full-term boy delivered uneventfully was noted by his paediatrician to have a white opacity in the right pupil. The patient was referred to our department for evaluation. White membranes on the surface of the lens and iris were observed biomicroscopically. Virtually no pupil dilation was observed after application of mydriatic eyedrops, most likely because of strong adhesion of the membrane to the iris and lens surface. The anterior segment of the left eye was normal. Because the centre of the pupil was open, the patient was followed bimonthly. At 4 months of age, although the centre of the pupil remained open, the pupil diameter was smaller than it had been 2 months previously. At 6 months of age, he was examined because the mother noticed a corneal opacity accompanied by conjunctival redness in the right eye. Slit-lamp examination showed severe corneal oedema, ciliary injection and a shallow peripheral anterior chamber. The pupil was a pinpoint and had shifted to the inferior-nasal quadrant (Fig. 1A). The intraocular pressure (IOP) of the right eye was 60 mmHg. Although the fundus could not be visualized, B-scan ultrasonography showed a grossly normal eye. Ultrasound biomicroscopy under general anaesthesia showed that the pupillary margin adhered completely to the lens surface because of the white membrane, resulting in iris bombe (Fig. 1B). Surgical excision of the iris at the visual axis was performed to normalize the IOP by releasing the pupillary block and create a new pupil centrally. An excision was performed using a 25-gauge vitreous cutter inserted from the limbus under BSS plus irrigation into the anterior chamber. Caution was exercised to avoid damaging the anterior lens surface (Fig. 2A); thus, the white membrane that adhered to the lens surface was not removed. After surgery, the depth of the anterior chamber and the IOP became normal. The left eye was patched part-time. The newly created pupil has remained open and at the central position during the 30-month postoperative follow-up (Fig. 2B). Although the patient could fixate and follow with patching of his left eye, visual acuity measurement was impossible because of delayed mental development. In previous reports, a relatively large percentage of patients with CPILMG developed pupillary closure with iris bombe and angle-closure glaucoma (Cibis & Walton 2004). This patient required surgery for pupillary block glaucoma with closure of the visual axis. Forceps and scissors may be used to perform the surgery (Robb 2001), but a 25-gauge vitreous cutter that can be inserted into the anterior chamber with smaller wounds allows easier and more controlled surgical manoeuvres, resulting in safer and less invasive surgery. Especially in the small eyes of infants who have a thin