Kazuhisa Sugiyama

Clinical Significance of Owl Eye Morphologic Features by In Vivo Laser Confocal Microscopy in Patients With Cytomegalovirus Corneal Endotheliitis

OBJECTIVEnTo demonstrate the clinical significance of owl eye morphologic features observed by in vivo laser confocal microscopy in patients with cytomegalovirus (CMV) corneal endotheliitis.nnnDESIGNnObservational case series.nnnMETHODSnparticipants: Six eyes of 6 patients (6 men; mean age, 73.3 years) with cytomegalovirus corneal endotheliitis diagnosed by clinical manifestations together with polymerase chain reaction from aqueous humor samples. intervention: All patients were examined by slit-lamp biomicroscopy and in vivo laser confocal microscopy. main outcome measures: Clinical manifestations were summarized by reviewing medical records. Selected confocal images of corneal layers were evaluated qualitatively for shape and degree of light reflection of abnormal cells and deposits.nnnRESULTSnAll patients had long histories of anterior uveitis with intraocular pressure elevation, corneal edema with keratic precipitates, and decrease of endothelial cell densities. Coin-shaped lesions were observed by slit lamp only in 1 patient at the first visit and in 2 additional patients at subsequent follow-up. In all patients, confocal microscopy demonstrated reduced subepithelial nerves, subepithelial opacity, increased reflectivity of keratocytes, highly reflective dots, and needle-shaped bodies. Owl eye morphologic features were observed consistently in all patients at the initial visit, and highly reflective round bodies were detected in 5 patients; most notably, these confocal features were reversible after resolution of endotheliitis.nnnCONCLUSIONSnOwl eye morphologic features and highly reflective round bodies observed by confocal microscopy may be useful as an adjunct for the noninvasive diagnosis of cytomegalovirus corneal endotheliitis. Reversibility of these features after resolution of endotheliitis may be useful for monitoring the therapeutic effects without multiple anterior chamber tap.

Subfoveal Choroidal Thickness Change Following Segmental Scleral Buckling for Rhegmatogenous Retinal Detachment

PURPOSEnTo report the morphologic changes of the subfoveal choroidal thickness using spectral-domain optical coherence tomography following segmental scleral buckling.nnnDESIGNnRetrospective, observational case series.nnnMETHODSnThe study included 21 eyes of 20 patients who underwent segmental scleral buckling for the treatment of rhegmatogenous retinal detachment. All patients underwent the measurements of the subfoveal choroidal thickness preoperatively and 1 week, 1 month, and 3 months after the surgery. The changes in choroidal thickness, 4 mm from the fovea, before and 1 week after surgery were analyzed in the buckled and unbuckled side.nnnRESULTSnThe preoperative mean subfoveal choroidal thickness of operated eyes was 239.2 ± 91.0 μm. The postoperative mean subfoveal choroidal thicknesses of operated eyes at 1 week, 1 month, and 3 months were 267.6 ± 96.8 μm, 250.6 ± 95.8 μm, and 239.4 ± 95.6 μm, respectively. There were significant differences between preoperative subfoveal choroidal thickness and 1-week-postoperative and 1-month-postoperative subfoveal choroidal thicknesses (P < .01, P = .03, ANOVA), and there was no significant difference between subfoveal choroidal thicknesses preoperatively and 3 months postoperatively (P > .99, ANOVA). The changes in choroidal thickness of the buckled and unbuckled side preoperatively and 1 week postoperatively were not significantly different (n = 8, P = .589, 2-way ANOVA).nnnCONCLUSIONnThe subfoveal choroidal thickness may change temporarily following segmental scleral buckling surgery. This may be the result of reversible subclinical microcirculatory dysfunction of the choroid.

In vivo confocal microscopy and ultrasound biomicroscopy study of filtering blebs after trabeculectomy: limbus-based versus fornix-based conjunctival flaps.

PurposeTo evaluate morphological features of filtering blebs after trabeculectomy with limbus-based versus fornix-based conjunctival flaps (LBCF and FBCF, respectively) using in vivo confocal microscopy (IVCM) and ultrasound biomicroscopy (UBM). Patients and MethodsSeventy-five eyes of 62 patients with glaucoma were recruited. Thirty-eight eyes of 31 patients received trabeculectomy with LBCF and 37 eyes of 34 patients received trabeculectomy with FBCF. Successful bleb was defined as postoperative intraocular pressure (IOP) ⩽15 mm Hg and IOP reduction ≥20% without antiglaucoma medication. Microcyst number, density of subepithelial connective tissue, and vascularity of subepithelial tissue were evaluated by IVCM. Bleb reflectivity, the route under the scleral flap, bleb height, and height of fluid-filled space were examined by UBM. ResultsOn the basis of IOP criteria, 79% (30 of 38 blebs) of the LBCF group and 70% (26 of 37 blebs) of the FBCF group were defined as successful blebs (P=0.28). Compared with the successful FBCF group, the successful LBCF group had a larger microcyst number (P<0.001), lower density of subepithelial connective tissue (P=0.046), greater avascularity of subepithelial tissue (P=0.024), and higher height of fluid-filled space (P=0.017). No morphological differences between LBCF and FBCF groups were found in failed blebs. ConclusionsMorphological features of successful blebs in IVCM and UBM were different between blebs with LBCF and FBCF. Type of conjunctival flaps should be considered when estimating the bleb function based on bleb morphology examined with these imaging devices.

Clinical Evaluation of a New Donor Graft Inserter for Descemet’s Stripping Automated Endothelial Keratoplasty

BACKGROUND AND OBJECTIVEnTo present clinical outcomes of Descemets stripping automated endothelial keratoplasty (DSAEK) using a newly developed donor graft inserter, the Tan EndoGlide (AngioTech, Reading, PA/Network Medical Products, North Yorkshire, UK).nnnPATIENTS AND METHODSnSix eyes of six patients with bullous keratopathy were treated with DSAEK using the Tan EndoGlide. Intraoperative and postoperative complications, postoperative donor endothelial cell densities (ECDs), and best-corrected visual acuity were recorded.nnnRESULTSnFive cases had no difficulties during donor graft loading into the Tan EndoGlide; however, the donor graft was folded inside-out into the Tan EndoGlide in one case, resulting in severe endothelial cell loss. All patients achieved a visual acuity of 20/63 or better at 12 months, with four patients reaching better than 20/32. Excluding the case with the graft folded inside-out, postoperative ECDs were 2,041 cells/mm(2) (mean loss: 22.9%) at 6 months and 1,973 cells/mm(2) (mean loss: 24.6%) at 12 months.nnnCONCLUSIONnIn this small preliminary series, the clinical outcome with the Tan EndoGlide was comparable to or better than that achieved with the conventional technique. Additional studies using a larger number of patients are required to fully evaluate the usefulness and potential advantages of this new donor graft inserter.

Clinical evaluation of non-Descemet stripping automated endothelial keratoplasty (nDSAEK)

PurposeTo report the clinical outcomes of non-Descemet stripping automated endothelial keratoplasty (nDSAEK) as a treatment for endothelial dysfunction.MethodsNineteen eyes of 19 patients (mean age 74.2xa0years) with non-Fuchs-type bullous keratopathy suitable for endothelial keratoplasty were enrolled in this study. All participants underwent endothelial keratoplasty without Descemet stripping. Best corrected visual acuity (BCVA) and donor central endothelial cell density (ECD) were recorded preoperatively and postoperatively.ResultsAll 19 cases had a clear graft at 1xa0year postoperatively. Mean BCVA improved from 0.80 logarithm of the minimum angle of resolution (logMAR) preoperatively to 0.20 logMAR after 3xa0months, 0.13 logMAR after 6xa0months, and 0.08 logMAR after 1xa0year. The average and standard deviations of ECD (cells/mm2) after 3xa0months were 2324xa0±xa0493 (representing a 20.0% mean cell loss from preoperative donor cell measurements), 2268xa0±xa0525 (22.0% decrease) after 6xa0months, and 2064xa0±xa0665 (29.0% decrease) after 1xa0year. No intraoperative complications were noted. One case of transient pupillary air block was observed postoperatively.ConclusionsThis modified endothelial keratoplasty technique for the treatment of non-Fuchs-type endothelial dysfunction produced excellent clinical outcomes such as reduced endothelial cell loss and good visual acuity.

Clinical features of single and repeated globe rupture after penetrating keratoplasty.

Background In this paper, we report our experience of the clinical features of single and repeated globe rupture after penetrating keratoplasty. Methods We undertook a retrospective analysis of single and repeated globe ruptures following keratoplasty in eight eyes from seven consecutive patients referred to Kanazawa University Hospital over a 10-year period from January 2002 to March 2012. We analyzed their ophthalmic and demographic data, including age at time of globe rupture, incidence, time interval between keratoplasty and globe rupture, cause of rupture, complicated ocular damage, and visual outcome after surgical repair. Results Five patients (71.4%) experienced a single globe rupture and two patients (28.6%) experienced repeated globe ruptures. Patient age at the time of globe rupture was 75.4 ± 6.8 (range 67–83) years. Four of the patients were men and three were women. During the 10-year study period, the incidence of globe rupture following penetrating keratoplasty was 2.8%. The time interval between penetrating keratoplasty and globe rupture was 101 ± 92 months (range 7 months to 23 years). The most common cause of globe rupture in older patients was a fall (n = 5, 79.8 ± 3.7 years, all older than 67 years). Final best-corrected visual acuity was >20/200 in three eyes (37.5%). In all except one eye, globe rupture involved the graft-host junction; in the remaining eye, the rupture occurred after disruption of the extracapsular cataract extraction wound by blunt trauma. Conclusion Preventative measures should be taken to avoid single and repeated ocular trauma following penetrating keratoplasty.

Management of a small paracentral corneal perforation using iatrogenic iris incarceration and tissue adhesive.

Background: Surgical intervention for corneal perforation is indicated when the anterior chamber does not reform within a short period of time. Herein, we report the successful management of a small paracentral corneal perforation using autologous iris incarceration and tissue adhesive. Case: A 41-year-old man developed a small paracentral corneal perforation (0.5 mm in size) in the right eye, while the treating physician attempted to remove the residual rust ring after removal of a piece of metallic foreign body. Observations: The eye was initially managed with a bandage soft contact lens to ameliorate the aqueous leakage; however, without success. Iatrogenic iris incarceration of the wound was first induced, followed by application of cyanoacrylate tissue adhesive to the perforated site. As a result, the anterior chamber was immediately reformed and maintained. Complete corneal epithelialization of the perforation was achieved in 2 months without visual compromises. Conclusions: Cyanoacrylate tissue adhesive with iatrogenic incarceration of the autologous iris was effective in treating this type of small corneal perforation. This technique is simple and potentially useful for small paracentral corneal perforations outside the visual axis and without good apposition.

Ex vivo laser confocal microscopy findings of cultured Acanthamoeba trophozoites

Purpose The purpose of the current study was to investigate ex vivo laser confocal microscopic findings of cultured Acanthamoeba trophozoites obtained from Acanthamoeba keratitis patients. Methods Eight cultured samples of Acanthamoeba trophozoites from eight eyes of seven patients (mean age, 26.9 years; age range, 18–52 years) were used. Seven samples were from corneal scrapings of Acanthamoeba keratitis patients and one sample was from the solution in a soft contact lens case. Ex vivo laser confocal microscopy was performed to qualitatively evaluate the shape and degree of light reflection of the living Acanthamoeba trophozoites. Results Ex vivo laser confocal microscopy demonstrated highly reflective, high-contrast Acanthamoeba trophozoites with no walls (mean size, 25.4 μm; range, 17.1–58.5 μm). The shapes of the trophozoites were highly pleomorphic, and some showed characteristic acanthopodia by laser confocal microscopy. Conclusion Ex vivo laser confocal microscopy was effective in demonstrating cultured Acanthamoeba trophozoites of various shapes and sizes. The observations of the current study may be helpful when similar structures are identified under in vivo conditions.

Rationale for performing penetrating keratoplasty rather than DSAEK in patients with bullous keratopathy in Japan.

BACKGROUND AND OBJECTIVEnTo analyze the rationale for performing penetrating keratoplasty (PK) rather than Descemets stripping automated endothelial keratoplasty (DSAEK) in patients with bullous keratopathy (BK) in Japan.nnnPATIENTS AND METHODSnA total of 136 eyes of 130 patients with consecutive BK were enrolled. Patients treated by DSAEK were categorized as the DSAEK group. The remaining patients were considered unsuitable for DSAEK due to the presence of risk factors, and were treated by PK (PK group). In both groups, the number of the patients and the causes of BK were analyzed. Also, specifically in the PK group, the reasons for not performing DSAEK were analyzed.nnnRESULTSnThe causes of BK differed significantly between the two groups (P < .001). Risk factors considered unsuitable for DSAEK include significant stromal scarring, iris abnormalities, and lens abnormalities.nnnCONCLUSIONnFor successful DSAEK, risk factors and contraindications should be carefully evaluated before surgery.

Descemet stripping automated endothelial keratoplasty for microcornea

PurposeOur aim was to evaluate the surgical technique and postoperative results of Descemet stripping automated endothelial keratoplasty (DSAEK) for bullous keratopathy in eyes with microcornea.MethodsTwo patients with microcornea (8.8xa0mm in case 1 and 9.3xa0mm in case 2) and bullous keratopathy after cataract surgery or after laser iridotomy were treated by DSAEK. A donor lamella with a smaller diameter (7.5xa0mm) was inserted into the anterior chamber using the double-glide donor insertion technique (Busin glide with intraocular lens sheet glide).ResultsNo intraoperative or postoperative complications occurred. Corrected visual acuity improved from counting fingers to 0.222 logMAR in case 1 and from 1.000 to 0.155 logMAR in case 2 over 6xa0months. Corneal endothelial cell loss was 6.5xa0% in case 1 and 1.9xa0% in case 2.ConclusionsDSAEK was useful for bullous keratopathy in patients with microcornea. However, surgery should be done with meticulous care, and modification of the diameter of the donor lamella and of the donor insertion technique may be required.