Kazuki Matsuura

Efficacy and safety of prophylactic intracameral moxifloxacin injection in Japan

Purpose To report endophthalmitis rates after cataract surgery and the incidence of complications after intracameral moxifloxacin injection. Setting Nineteen clinics in Japanese institutions. Design Retrospective survey cohort study. Methods The number of surgeries and endophthalmitis cases in the past 4 years before and after the introduction of intracameral moxifloxacin was evaluated. The survey was performed by mail or interview in February 2013. Results All institutions used total‐replacement administration rather than small‐volume injection. At 3 institutions, 50 to 100 &mgr;g/mL moxifloxacin; at 9 institutions, 100 to 300 &mgr;g/mL moxifloxacin; and at 7 institutions, 500 &mgr;g/mL moxifloxacin was administered. The highest concentration (500 &mgr;g/mL) was administered in 14 124 cases. Endophthalmitis cases occurred 1 month or sooner postoperatively in 8 of 15 958 cases (ie, 1 in 1955) without intracameral moxifloxacin administration and in 3 of 18 794 cases (ie, 1 in 6265) with intracameral moxifloxacin administration. Conclusions Intracameral moxifloxacin (50 to 500 &mgr;g/mL) administration decreased the risk for endophthalmitis by 3‐fold. In more than 18 000 cases, moxifloxacin administration of 500 &mgr;g/mL or less did not result in severe complications, such as toxic anterior segment syndrome or corneal endothelial cell loss. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Measures for preventing recurrence after pterygium surgery.

Purpose. To introduce an improved technique of pterygium surgery and to compare postoperative results between this technique and previous techniques. Methods. In a retrospective survey, the records of 216 consecutive eyes with primary pterygium that underwent surgery by three different techniques were reviewed. The new technique (mini-flap technique) involves making a small excision of the pterygium body, removing the pterygium head by scraping with forceps, applying mitomycin C (MMC), and performing a small conjunctival transposition flap. The previous technique (large-flap technique II) involved making a large excision in the pterygium body, removing the pterygium head with a knife, applying MMC, and performing a large transposition flap. Large-flap technique I is the same as large-flap technique II except for the use of intraoperative MMC. The recurrence rate of each technique was estimated by the Kaplan–Meier life table analysis. Results. The recurrence rates estimated at 1 year after surgery were 15.5% in large-flap technique I, 4.2% in large-flap technique II, and 0% in the mini-flap technique. Large-flap technique II or the mini-flap technique had significantly lower recurrence rates compared with large-flap technique I (p = 0.02 and p < 0.01, respectively). The mini-flap technique had a significantly lower incidence of conjunctival scarring or granuloma compared with large-flap technique I and large-flap technique II (p = 0.05 and p = 0.03, respectively.) Conclusions. The mini-flap technique was useful for preventing recurrence and was technically easier and induced fewer postoperative complications than large-flap techniques I and II.

Management of posterior capsule rupture during phacoemulsification using the dry technique

&NA; To manage posterior capsule rupture during phacoemulsification, we use a dry technique in which all procedures are performed without an irrigation/aspiration system. The dry technique is characterized by (1) continuous viscoelastic injection instead of fluid irrigation to maintain anterior chamber depth with the posterior capsule and vitreous located posteriorly and (2) static removal of most residual lens material by viscoexpression and/or manual small incision extracapsular cataract extraction without aspiration and dynamic water flow. In 16 cases of posterior capsule rupture managed using the dry technique, the residual nucleus and cortex were readily removed with minimum extension of the ruptured area and new vitreous loss. Although large amounts of viscoelastic material (mean 5.8 mL) were required, rapid and stable visual recovery was comparable to that in patients having uneventful surgery. The dry system is a safe and reliable technique for managing posterior capsule rupture during phacoemulsification.

Survey of Japanese ophthalmic surgeons regarding perioperative disinfection and antibiotic prophylaxis in cataract surgery

Purpose To elucidate Japanese trends for perioperative disinfection and antibiotic selection during cataract surgeries. Methods Perioperative iodine use and antibiotic prophylaxis for cataract surgery were surveyed in eight regions in Japan by mail or through interviews from February 1 to March 1, 2014. Results We surveyed 572 surgeons, of whom 386 (67%) responded. Most of the surgeons (94%) used iodine compounds before surgery for periocular skin disinfection (povidone–iodine [PI]: 79%; polyvinyl alcohol-iodine [PAI]: 15%) or conjunctival disinfection (85%; PI: 36%; PAI: 49%). Preoperative conjunctival iodine was primarily used as an eye wash (irrigation: 95%) and less often as an eye drop (5%). It was determined that 31% of surgeons waited 30 seconds or more between periocular disinfection and conjunctival disinfection. During surgery, 14% of surgeons used iodine several times, including immediately before intraocular lens insertion, and 7% used the Shimada technique (repeated iodine irrigation). Preoperative antibiotic eye drops were used by 99% of surgeons, and antibiotics were added to the irrigation bottle by 22%. The surgeons reported use of subconjunctival antibiotic injections (23%), antibiotic ointments (79%), and intracameral antibiotics (7%: 22 moxifloxacin; 6 levofloxacin). All surgeons prescribed postoperative eye drops, with 10% initiating the drops on the day of surgery. Conclusion Iodine compounds are commonly used preoperatively, but few institutions use iodine compounds intraoperatively, particularly with repeated application. The selection of antibiotic administration and disinfection technique has to be at the surgeon’s discretion. However, intracameral antibiotic and intraoperative iodine compound use are techniques that should be widely recognized.

Recovery of binocular responses by cortical neurons after early monocular lesions

A small lesion of the retina in one eye deprives normally binocular neurons in a sector of primary visual cortex of activating inputs from the lesioned eye, but not from the other, intact eye. Here we demonstrate that after monocular lesions early in life followed by years of recovery, deprived cortical neurons become robustly responsive to stimulation via new receptive fields in a zone of preserved retina around the retinal lesion, while maintaining receptive fields for the intact eye. These neurons respond similarly to comparable stimuli in two different locations, possibly producing a local diplopia or blur.

Manual sutureless cataract surgery using a claw vectis

&NA; Two‐handed sandwich methods of extracapsular cataract extraction using a self‐sealing incision have proved difficult for many inexperienced surgeons. We developed a simpler 1‐handed technique using a claw vectis—a vectis with a claw placed on its tip. When the nucleus is pulled through the scleral tunnel, it is fixed by the claw and is smoothly removed from a wound of a size comparable to that in the sandwich method. During nucleus removal, viscoelastic material is constantly injected through the irrigation vectis to maintain the anterior chamber depth, resulting in a low incidence of complications. We have performed 620 cases using the technique and found it safe and easy for both novice and experienced surgeons.

Clinical application of full-arc, depth-dependent, astigmatic keratotomy.

Purpose. To report a case series of the first clinical application of a new method of astigmatic keratotomy termed full-arc, depth-dependent astigmatic keratotomy (FDAK). Methods. The type of astigmatism was analyzed by corneal topography. If the astigmatism was regular, paired arcuate incisions of 90° length were used. Incision depth varied between 40% and 75% of local corneal thickness for controlling the level of astigmatic correction. Results. All 13 cases had regular astigmatism, and paired arcuate incisions of 90° length were used. Four cases with incisions at 40% depth, five cases at 50% depth, three cases at 60% depth, and one case at 75% depth induced vector astigmatic change of 0.93 ± 0.33 D, 1.92 ± 0.24 D, 3.17 ± 0.26 D, and 4.44 D, respectively, 3 months after surgery. From 3 months to 1 year or 3 years, the postoperative astigmatism was stable, and no cases showed astigmatic regression of 0.50 D or more. Every topographic difference map indicated effective flattening and steepening occurring with a 1:1 coupling ratio. All postoperative color maps showed a marked improvement in corneal sphericity. Conclusions. In FDAK using paired 90° incisions at 40–75% depth, an almost linear relationship between the incision depth and degree of astigmatic change was observed. FDAK may be an effective and safe method of astigmatic keratotomy that accurately controls the level of astigmatic correction. More clinical applications are necessary for drawing final conclusions and making a nomogram.

Experimental study using pig eyes for realizing ideal astigmatic keratotomy.

Purpose. The effects of varying the incision length and depth were analyzed using pig eyes to acquire information for realizing an ideal method of astigmatic keratotomy (AK). Methods. Single and paired arcuate incisions were made on pig corneas using a diamond knife. Incisions with varying lengths of 40°, 60°, and 90° were made with the incision depth fixed at 90% of corneal thickness. Next, paired incisions with varying incision depth from 20% to 95% of corneal thickness were made with the incision length fixed at 90°. The changes in corneal shape were analyzed using corneal topography and the degrees of astigmatic change were measured using a surgical keratometer. Results. For short single and paired incisions (40° or 60° in length), narrow areas of flattenings occurred, and steepenings were observed on both sides adjacent to the flattened areas. For long paired incisions of 90° length, wide areas of flattenings and steepenings were observed with an approximately 1:1 coupling ratio, and a positive linear relationship between the incision depth and degree of astigmatic change was observed in the range of incision depth between 40% and 80% of corneal thickness. Conclusion. This experimental study suggests that for achieving ideal corneal sphericity after AK, long incisions covering the entire steep areas (paired 90° incisions for regular astigmatism) should be used and the degree of astigmatic correction may be controlled by varying the incision depth.

Quarters extraction technique for manual phacofragmentation

&NA; In the quarters extraction technique, the nucleus is manually split and the fragments then removed. A 5.5 to 6.5 mm sclerocorneal single‐plane incision is made. After capsulorhexis, hydrodissection, hydrodelineation, and surface cortex aspiration, the edge of the nucleus is prolapsed into the anterior chamber. The front quarter of the nucleus is cut and removed with a nucleus puncher. A corner of the remaining three quarters of nucleus is wedged into the wound and rotated out with a claw vectis. Among the initial 120 cases, there were no posterior capsule ruptures, and the mean endothelial cell loss at 3 months was 8.7% ± 6.5% (SD). Because there is no need to deeply insert instruments at the time of nuclear fragmentation, this technique can be performed safely and easily in most cases except in eyes with very large nuclei.

Subtenon triamcinolone injection for postoperative cystoid macular edema associated with tafluprost

Purpose We report the successful treatment of a case of cystoid macular edema (CME) associated with topical tafluprost, which was accompanied by serous retinal detachment (SRD). Case A 78-year-old woman underwent intraocular lens suture surgery, including anterior vitreous cutting, for crystalline lens dislocation in the right eye. Tafluprost was initiated 12 weeks after surgery. Intraocular pressure (IOP) was controlled at 10–14 mmHg. Visual acuity remained at 20/40–30/40. However, the patient complained of blurred vision (20/200) 9 months after surgery. CME accompanied by SRD was identified by optical coherence tomography (OCT) and treated with subtenon triamcinolone injection. Visual acuity rapidly increased to 20/50, and the volume of SRD decreased in a few days. Discontinuation of tafluprost and initiation of diclofenac eye drops improved visual acuity to 20/40 and resulted in improved OCT findings within a few weeks. Three months after injection, tafluprost was resumed along with diclofenac. No recurrence of CME occurred over the following 3 months, and IOP was controlled at 10–15 mmHg. Conclusion SRD is considered to be a symptom of treatment-resistant CME, which may lead to poor visual acuity after recovery. In such cases, subtenon triamcinolone injection should be strongly considered at an early stage.