Ichiya Sano

Short-term results of microhook ab interno trabeculotomy, a novel minimally invasive glaucoma surgery in Japanese eyes: initial case series.

To report the first early postoperative results and safety profile after microhook ab interno trabeculotomy (μLOT).

Microhook ab interno trabeculotomy, a novel minimally invasive glaucoma surgery, in eyes with open-angle glaucoma with scleral thinning

Editor, A 63-year-old woman with steroidinduced glaucoma presented to our hospital with high intra-ocular pressure (IOP) in both eyes (OU). She had been treated with systemic prednisolone and topical betamethasone for 2 years for scleritis OU that associated with relapsing polychondritis. At referral, the best-corrected visual acuity (BCVA) was 0.5 in the right eye (OD) and 1.2 in the left eye (OS); the respective IOP values were 36 and 32 mmHg with topical 2% carteolol. No signs of active scleritis or intraocular inflammation were observed; however, patchy scleral thinning (Fig. 1A,B, white arrows) due to previous nodular scleritis and secondary cataract was observed OU. Because of the scleral thinning and the possibility of recurrent scleritis, the glaucoma surgeries that require creation of a scleral flap were unsuitable for this case, and therefore, trabeculotomy with an ab interno technique in combination with cataract surgery was performed OU (Video S1). Before trabeculotomy, phacoemulsification/aspiration and intra-ocular lens implantation were performed through a 2.4-mm-wide clear corneal incision. The anterior chamber was filled with a viscoelastic material to stabilize the chamber depth. Under visualization using a Swan–Jacob gonioprism lens (Ocular Instruments, Bellevue, WA, USA), a small goniotomy was created in the temporal angle using a 20-gauge microvitreoretinal (MVR) knife (Mani, Utsunomiya, Japan) inserted through the opposite side corneal side-port; the tip of a straight Sinskey microhook (Inami, Tokyo, Japan) then was inserted into Schlemm’s canal at the goniotomy site (Fig. 1C, black arrow) and moved circumferentially towards both the superior (Fig. 1D) and inferior sides to incise the inner wall of Schlemm’s canal and trabecular meshwork over 3 clock hours. The same trabeculotomy procedure was repeated in the nasal angle over 3 clock hours. No complications other than early postsurgical hyphema (Fig. 1E,F) developed perioperatively. The postoperative IOPs ranged between 7 and 10 mmHg OD and 8 and 14 mmHg OS. At the final visit 4 months postoperatively, the BCVA was 1.0 OU and the IOP was 8 mmHg OU with 2%

4-Hydroxyhexenal- and 4-Hydroxynonenal-Modified Proteins in Pterygia

Oxidative stress has been suspected of contributing to the pathogenesis of pterygia. We evaluated the immunohistochemical localization of the markers of oxidative stress, that is, the proteins modified by 4-hydroxyhexenal (4-HHE) and 4-hydroxynonenal (4-HNE), which are reactive aldehydes derived from nonenzymatic oxidation of n-3 and n-6 polyunsaturated fatty acids, respectively. In the pterygial head, labeling of 4-HHE- and 4-HNE-modified proteins was prominent in the nuclei and cytosol of the epithelium. In the pterygial body, strong labeling was observed in the nuclei and cytosol of the epithelium and proliferating subepithelial connective tissue. In normal conjunctival specimens, only trace immunoreactivity of both proteins was observed in the epithelial and stromal layers. Exposures of ultraviolet (330 nm, 48.32 ± 0.55 J/cm2) or blue light (400 nm, 293.0 ± 2.0 J/cm2) to rat eyes enhanced labeling of 4-HHE- and 4-HNE-modified proteins in the nuclei of conjunctival epithelium. Protein modifications by biologically active aldehydes are a molecular event involved in the development of pterygia.

Assessment of Filtration Bleb and Endplate Positioning Using Magnetic Resonance Imaging in Eyes Implanted with Long-Tube Glaucoma Drainage Devices.

Background To evaluate ocular fluid filtration and endplate positioning in glaucomatous eyes with long-tube glaucoma drainage devices (GDDs) using magnetic resonance imaging (MRI) and the effects of various factors on postoperative intraocular pressure (IOP). Methods This observational case series included 27 consecutive glaucomatous eyes (18 men, 7 women; mean age ± standard error, 63.0±2.0 years) who underwent GDD implantation (n = 8 Ahmed Glaucoma Valves [AGV] and n = 19 Baerveldt Glaucoma Implants [BGI]). Tubes were inserted into the pars plana in 23 eyes and anterior chamber in 4 eyes. Six months postoperatively, high-resolution orbital images were obtained using 3-Tesla MRI with head-array coils, and the filtering bleb volume, bleb height, and distances between the anterior endplate edge and corneal center or limbus or between the endplate and orbital wall were measured. Results In MR images obtained by three-dimensional fast imaging employing steady-state acquisition (3D-FIESTA) sequences, the shunt endplate was identified as low-intensity signal, and the filtering bleb was identified as high-intensity signals above and below the endplate in all eyes. The 6-month-postoperative IOP level was correlated negatively with bleb volume (r = -0.4510, P = 0.0182) and bleb height (r = -0.3954, P = 0.0412). The postoperative IOP was significantly (P = 0.0026) lower in BGI-implanted eyes (12.2±0.7 mmHg) than AGV-implanted eyes (16.7±1.2 mmHg); bleb volume was significantly (P = 0.0093) larger in BGI-implanted eyes (478.8±84.2 mm3) than AGV-implanted eyes (161.1±52.3 mm3). Other parameters did not differ. Conclusions The presence of intraorbital/periocular accumulation of ocular fluid affects postoperative IOP levels in eyes implanted with long-tube GDDs. Larger filtering blebs after BGI than AGI implantations explain lower postoperative IOP levels achieved with BGI than AGV. The findings will contribute to better understanding of IOP reducing mechanism of long-tube GDDs.

Possible bidirectional flow of aqueous fluid after Baerveldt glaucoma implant surgery

parameter with increasing refractive error. But, regarding the influence of refractive error on the diagnostic ability, the coefficient representing the SE refractive error in the ROC regression model was not statistically significant for all diagnostic parameters. All pairwise comparisons, with the exception of temporal pRNFL thickness, between the two AROCs for each diagnostic parameter at levels of SE refractive error chosen arbitrarily did not show any statistically significant differences. In conclusion, although a trend towards decreasing diagnostic ability of diagnostic parameters with increasing myopic SE refractive error was observed, results of the current study indicated that both pRNFL and mGCIPL thickness measurements showed a good and comparable overall diagnostic ability for detecting mild-tomoderate glaucoma using ROC logistic regression analysis. Therefore, pRNFL and mGCIPL thickness measurements should both be considered valuable glaucoma diagnostic parameters, regardless of the presence of myopia.

Intraoperative floppy-iris syndrome associated with use of antipsychotic drugs

OBJECTIVE We report 3 cases of intraoperative floppy-iris syndrome (IFIS) during cataract surgery in patients without a history of selective α1-blocker use but with a long-term history of antipsychotic drug use. We reviewed previously reported cases of antipsychotic drug-associated IFIS cases. DESIGN Observational case series. RESULTS In case 1, bilateral IFIS developed in a 39-year-old man with chronic angle-closure glaucoma. He had used several classes of antipsychotic drugs to treat schizophrenia, including the first-generation antipsychotic drugs haloperidol and chlorpromazine, the dopamine system stabilizer aripiprazole, the dopamine serotonin antagonists olanzapine and quetiapine, and the serotonin dopamine antagonists risperidone and blonanserin for 7 years. In case 2, a 63-year-old woman with schizophrenia had used aripiprazole, quetiapine, and risperidone for more than 10 years. In case 3, a 65-year-old woman with an organic mental disorder had used haloperidol for more than 10 years. At least 5 cases of antipsychotic drug-induced IFIS have been reported in the literature. CONCLUSIONS Any class of antipsychotic drugs can cause IFIS. Although antipsychotic drug-induced IFIS can be mild, surgeons should be alert to the possibility of IFIS when they treat patients with current and past use of antipsychotic drugs.

Periarteriolar-Sparing Retinal Edema in Acute Central Retinal Artery Occlusion.

A 56-year-old man was referred to our hospital about 48 h after sudden onset of painless central visual loss in his right eye (OD) on a winter morning. He had a more than 25-year history of systemic hypertension and smoking. Funduscopic observation showed striated retinal whitening in the macular region, faint cotton-wool patches around the optic disc, and segmental narrowing of the retinal arteries near the optic disc edge. Based on the pattern of onset and fundus findings, he was diagnosed with vasospastic acute central retinal artery occlusion OD, and a venous drip injection of prostaglandin E1 was started immediately. Optical coherence tomography showed bands of high and low density in the inner retina arranged alternately in the edematous area; the bands corresponded to edematous and nonedematous areas, respectively, and geographically to venules and arterioles, respectively. The best-corrected visual acuity of 0.03 at referral improved to 0.5, and the striated retinal edema and most cotton-wool patches resolved 1 month after onset. The oxygen pressure gradient in the capillary networks due to differences in the distance from the arterioles may be the mechanism of this unique periarteriolar-sparing retinal edema pattern.

Patch Grafting Using an Ologen Collagen Matrix to Manage Tubal Exposure in Glaucoma Tube Shunt Surgery

Purpose: To report the results using an ologen Collagen Matrix as a patch graft in eyes with tubal exposure after tube shunt surgery. Case Reports: Case 1 was an 82-year-old man with tubal exposure in his right eye 26 months after receiving a Baerveldt glaucoma implant. The tube was covered by surrounding conjunctival tissue combined with subconjunctival placement of an ologen Collagen Matrix as a patch graft. Two years after implantation, the tube was not exposed. Anterior-segment optical coherence tomography (AS-OCT) showed dense conjunctival tissue over the tube. Case 2 was an 82-year-old man with peripheral keratitis, anterior scleritis, and secondary glaucoma in the right eye who underwent tube shunt surgery using an Ahmed glaucoma valve and cataract surgery. Intraoperatively, scleritis-related scleral thinning prevented the tube from being covered fully by an autologous scleral flap. An ologen Collagen Matrix was placed over the scleral flap as a patch graft. Seventeen months after implantation, the tube was not exposed. Case 3 was a 52-year-old man with diabetic maculopathy and steroid-induced glaucoma in the right eye who underwent tube shunt surgery using an Ahmed glaucoma valve. Intraoperatively, a flap defect prevented the tube from being covered fully by an autologous scleral flap. An ologen Collagen Matrix was placed over the scleral flap as a patch graft. Three weeks postoperatively, AS-OCT showed thick subconjunctival tissue over the tube. Three months after implantation, the tube was not exposed. Conclusions: The ologen Collagen Matrix can be used successfully as a patch graft to prevent and treat tubal exposure after tube shunt surgery.

Patch Grafting Using a Cryopreserved Descemet Stripping Automated Endothelial Keratoplasty Flap for Treating Corneal Perforation

A 73-year-old woman with a corneal perforation of undetermined etiology was treated with corneal patch grafting. A residual partial-thickness corneal button obtained during a previous Descemet stripping automated endothelial keratoplasty (DSAEK) surgery and stored at –80°C in Optisol GS for 3 months was used as a patch graft. Five days postoperatively, the anterior chamber was reformed and the perforation was masked by the donor cornea. During the next several weeks, gradual displacement of the anterior edge of the donor cornea in the limbal direction occurred. Seven weeks postoperatively, further displacement of the donor cornea resulted in unmasking of the perforated area. At this time, the corneal defect was closed by stromal scar tissue and corneal epithelium. Five months postoperatively, best corrected visual acuity was 1.0 without marked astigmatism and intraocular pressure was 9 mm Hg in the left eye. From this case, we learned that cryopreserved DSAEK flaps stored longer than reported previously can be used as patch grafts to treat emergency conditions. Scar tissue can fill a corneal stromal defect 1 mm in diameter during temporary patch grafting for less than 2 months.

A Case Report of Preoperative, Intraoperative, and Postoperative Anterior Chamber Shallowing Resulting from Different Mechanisms

A 54-year-old woman with an epiretinal membrane in her left eye accompanied by a shallow anterior chamber due to primary angle closure glaucoma underwent vitrectomy and cataract surgery. During the cataract surgery, immediately after the ultrasonic tip had been removed from the anterior chamber, anterior chamber flattening occurred. An intraoperative fundus examination showed the development of acute intraoperative choroidal effusion. Postoperatively, the anterior chamber remained shallow even after the choroidal detachment had subsided; capsular bag distension seen by ultrasound biomicroscopy suggested the development of early postoperative capsular block syndrome. After neodymium:yttrium-aluminium-garnet laser capsulotomy, the anterior chamber deepened. Depending on the perioperative period, the mechanism of a flat anterior chamber can change, and understanding the underlying mechanisms is required for appropriate treatment.