Kazuno Negishi

The Efficacy, Sensitivity, and Specificity of In Vivo Laser Confocal Microscopy in the Diagnosis of Meibomian Gland Dysfunction

PURPOSE To evaluate the efficacy, sensitivity and specificity of confocal microscopy (CM) parameters: meibomian gland (MG) acinar longest diameter (MGALD), MG acinar shortest diameter (MGASD), inflammatory cell density (ICD), and MG acinar unit density (MGAUD) in the diagnosis of MG dysfunction (MGD). DESIGN Prospective, controlled, single-center study. PARTICIPANTS Twenty MGD patients (9 males, 11 females; mean age, 63.5+/-16.5 years) and 26 age- and gender-matched control subjects (13 males, 13 females; mean age, 53.2+/-15.7 years) were recruited. METHODS All subjects underwent slit-lamp examinations, tear film break-up time (BUT) measurements, assessment of tear evaporation rate from the ocular surface (TEROS), vital stainings, Schirmer test, meibography, MG expressibility, and CM of the MG. Data were compared between the 2 groups using the Mann-Whitney and chi-square tests. MAIN OUTCOME MEASURES The correlation between the clinical findings of tear functions, vital staining scores, and the 4 CM parameters were tested by Spearmans correlation coefficient by rank test. Receiver operating characteristic curve technique was used to evaluate the sensitivity, specificity, and cutoff values of CM parameters. RESULTS The mean tear film BUT, vital staining scores, TEROS values, MG expressibility, and MG dropout grades by meibography were significantly worse in MGD patients compared with controls (P<0.001). The mean values of the MGALD, MGASD, ICD, and MGAUD in MGD patients were significantly worse than those observed in the controls with CM. All CM parameters showed a strong, significant correlation with tear functions, ocular surface vital stainings, MG expressibility, and MG dropout grades. The cutoff values for MGALD, MGASD, ICD, and MGAUD in the diagnosis of MGD were 65 microm, 25 microm, 300 cells/mm2, and 70 glands/mm2, respectively. The sensitivity and specificity values of these parameters under these cutoff values were 90% and 81% for MGALD, 86% and 96% for MGASD, 100% and 100% for ICD, 81% and 81% for MGAUD. CONCLUSIONS Confocal microscopy has the potential to diagnose the simple MGD with high sensitivity and specificity. The CM-based diagnostic parameters correlated significantly and strongly with the status of the ocular surface disease. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

The evaluation of the treatment response in obstructive meibomian gland disease by in vivo laser confocal microscopy

PurposeTo evaluate the status of periglandular inflammation, ocular surface and tear function alterations in patients with obstructive meibomian gland disease (OMGD) by in vivo confocal microscopy before and after anti-inflammatory treatment, and to compare the results with patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops without anti-inflammatory agents.MethodsThirty-two eyes of 16 OMGD patients receiving anti-inflammatory treatment (treatment group) and 22 eyes of 11 OMGD patients receiving only topical non-preserved artificial tears and sodium hyaluronate eye drops (control group) were recruited in this prospective study. All subjects underwent slit-lamp examinations, tear film break-up time (BUT) measurements, fluorescein and Rose-Bengal stainings, Schirmer test І without anesthesia, transillumination of the lids (meibography), and in vivo laser confocal microscopy of the lids (HRTII-RCM).ResultsThe mean BUT, fluorescein staining scores, and inflammatory cell densities observed by in vivo confocal microscopy improved significantly in the group receiving anti-inflammatory treatment (p < 0.05), whereas no significant alterations of these parameters were observed in the group not receiving anti-inflammatory agents (p > 0.05).ConclusionsIn vivo confocal microscopy was able to effectively demonstrate the treatment responses in patients with OMGD. Inflammatory cell density calculation seems to be a promising new parameter of in vivo confocal microscopy in the evaluation of treatment responses.

The Contribution of the Posterior Surface to the Corneal Aberrations in Eyes after Keratoplasty

PURPOSE To investigate the contribution of posterior corneal surfaces to higher-order aberrations (HOAs) of the cornea, optical quality, and visual acuity after keratoplasty. METHODS Corneal topography of anterior and posterior surfaces and pachymetry were conducted using anterior segment optical coherence tomography (AS-OCT) in 40 eyes (10 eyes after penetrating keratoplasty [PK], 10 eyes after deep anterior lamellar keratoplasty [DALK], 10 eyes after Descemets stripping automated endothelial keratoplasty [DSAEK], and 10 normal eyes). Anterior, posterior, and total corneal HOAs were calculated using ray-tracing and decomposition into Zernike polynomials and were evaluated as root mean square values. Modulation transfer functions (MTFs) were also evaluated. RESULTS Topography maps of the anterior and posterior surfaces showed reverse patterns in the normal, PK, and DALK eyes, but not in DSAEK eyes. In the normal, PK, and DALK eyes, the total corneal HOAs were significantly smaller (~10%) than were the HOAs of the anterior surface (P < 0.01), whereas there was no significant difference between total and anterior HOAs in the DSAEK eyes (P = 0.483). In the normal, PK, and DALK eyes, the MTFs of the total cornea were slightly better than those of the anterior surface. In the DSAEK eyes, the MTFs of the total cornea were lower than those of the anterior surface. Visual acuity was significantly correlated with total and anterior surface HOAs (P < 0.05). CONCLUSIONS Posterior surfaces compensate for anterior aberrations in normal, PK, and DALK eyes. In DSAEK eyes, the posterior surface increased total corneal HOAs and had a negative influence on MTFs.

Effect of anterior and posterior corneal surface irregularity on vision after Descemet-stripping endothelial keratoplasty

PURPOSE: To evaluate irregularity of the anterior and posterior cornea before and after Descemet‐stripping endothelial keratoplasty (DSEK) and its effect on visual acuity. SETTING: Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan. METHODS: Corneal data were acquired using a rotating Scheimpflug camera before and 1 month and 3 months after DSEK. Anterior and posterior corneal elevation data were decomposed into a set of Zernike polynomials up to the 8th order within a 4.0 mm diameter region. Total higher‐order root mean square (HO‐RMS) and RMS from the 3rd to 8th order were calculated. The effects of anterior and posterior surface irregularity on visual acuity were evaluated. RESULTS: This clinical study comprised 13 consecutive eyes of 12 bullous keratopathy patients. The mean best corrected visual acuity (BCVA) was 1.11 logMAR ± 0.5 (SD) preoperatively, 0.49 ± 0.49 logMAR 1 month postoperatively, and 0.27 ± 0.32 logMAR at 3 months. The HO‐RMS of the anterior surface 1 month (P = .040) and 3 months (P = .048) postoperatively was significantly lower than preoperatively. There were no significant differences in posterior surface HO‐RMS between preoperatively and 1 month (P = .45) and 3 months (P = .054). The postoperative BCVA was significantly correlated with HO‐RMS (P<.001), but not with posterior surface HO‐RMS, at 3 months (P = .354). CONCLUSION: Postoperative BCVA correlated with irregularity of the anterior surface but not the posterior surface. In addition to corneal transparency, regularity of the anterior surface is an important factor in visual acuity after DSEK.

Comparison of anterior and posterior corneal surface irregularity in Descemet stripping automated endothelial keratoplasty and penetrating keratoplasty.

Purpose: To evaluate the irregularity of the anterior and posterior cornea after Descemet stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK). Methods: This clinical study comprised 39 eyes: 13 consecutive eyes after DSAEK, 13 consecutive eyes after PK, and 13 age-matched normal eyes. Corneal elevation data were acquired using a rotating Scheimpflug camera 1 and 3 months after DSAEK and PK. Anterior and posterior corneal elevation data were decomposed into a set of Zernike polynomials up to eighth order. Total higher-order root mean square (RMS) and RMS from third to eighth order were calculated. The astigmatism and irregularity of the anterior and posterior surfaces were compared between DSAEK and PK. Results: The regular astigmatism and tilt components of the anterior surface were significantly lower after DSAEK than after PK at 1 and 3 months (P < 0.001), whereas there was no difference in astigmatism of the posterior surface between the groups (P = 0.07, 0.22). The higher-order RMS and RMSs of third- to eighth-order components of the anterior surface were significantly larger after PK than those after DSAEK at 1 and 3 months (P < 0.01), whereas there were no significant differences between DSAEK and PK in higher-order aberration RMS and RMSs of third- to eighth-order components of the posterior surface. Conclusions: Postoperative corneal irregularity of the anterior surface was greater after PK than after DSAEK, whereas there was no significant difference in posterior surface irregularity. DSAEK is superior to PK in terms of the higher-order irregularity of the anterior surface.

The role of oxidative stress and inflammation in conjunctivochalasis

Purpose. To investigate the status of oxidative stress and histopathologic alterations in patients with conjunctivochalasis and compare the findings with those in healthy control subjects. Methods. Eleven patients (n = 20 eyes) with Yokoi grade 3 conjunctivochalasis and 11 health control subjects (n = 22 eyes) were prospectively recruited. ELISA for tear hexanoyl-lysine (HEL) and inflammatory cytokines, tear film break-up time tests, Schirmer test measurements, and fluorescein and rose bengal vital staining were performed. Conjunctival specimens obtained during surgery for conjunctivochalasis and cataract underwent immunohistochemical staining for HEL+8-OHdG, MMP-3, and MMP-9, and positively stained cells were counted. Transmission electron microscopy was also performed, with staining for elastic fibers in the conjunctival stroma. Results. The mean tear stability and vital staining scores were significantly worse in the conjunctivochalasis patients than in the control subjects. The tear HEL and tear cytokine levels showed significantly higher values in eyes with conjunctivochalasis. IL-1beta and IL-6 levels showed a significant correlation with corneal epithelial damage. IL-1beta and TNFalpha showed a significant correlation with 8-OHdG-stained cell counts. Specimens from patients with conjunctivochalasis revealed a significantly higher number of cells positively stained for HEL, 8-OHdG, MMP-3, and MMP-9 than did specimens from age- and sex-matched control subjects. Transmission electron microscopy showed decreased intercellular cohesiveness, with the conjunctival stroma showing an accumulation of elastic fibers. Conclusions. Lipid and DNA oxidative stress were present in the conjunctiva. Increased tear inflammation seemed to coexist with loss of conjunctival epithelial cohesiveness and increased collagenolytic activity, which may explain the conjunctival laxity observed in patients with conjunctivochalasis.

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.

Effect of Controlled Adverse Chamber Environment Exposure on Tear Functions in Silicon Hydrogel and Hydrogel Soft Contact Lens Wearers

PURPOSE To prospectively evaluate the effect of controlled adverse chamber environment (CACE) exposure on tear function, including tear osmolarity, in subjects wearing narafilcon A versus those wearing etafilcon A soft contact lens (SCL). METHODS Thirty-one healthy subjects with no history of contact lens wear (13 women, 18 men; average age, 30.5 ± 6.5 years) were randomly divided into age- and sex-matched groups (15 subjects wearing narafilcon A SCL; 16 subjects wearing etafilcon A SCL) and entered a CACE for 20 minutes. All subjects underwent tear osmolarity, tear evaporation rate, strip meniscometry, tear film breakup time, fluorescein vital staining, and functional visual acuity measurement before and after exposure to the controlled adverse chamber. RESULTS The mean blink rate increased with significant deteriorations in the mean symptom VAS scores, mean tear osmolarity, tear evaporation rate, strip meniscometry score, and tear stability with CACE exposure along with a decrease in visual maintenance ratio in functional visual acuity testing in etafilcon A wearers. The mean symptom VAS scores, mean tear evaporation rate, tear stability, blink rates, and visual maintenance ratios did not change significantly in narafilcon A wearers after CACE exposure. CONCLUSIONS This study suggested marked tear instability, higher tear osmolarity, and increased tear evaporation with marked dry eye and visual symptomatology in nonadapted hydrogel SCL wearers, suggesting that silicone hydrogel SCLs may be suitable for persons who live and work in cool, low-humidity, and windy environments, as tested in this study.

Elschnig pearl formation along the posterior capsulotomy margin after neodymium: YAG capsulotomy

Purpose: To determine the incidence of Elschnig pearl formation along the capsulotomy margin (string of pearls) after neodymium:YAG (Nd:YAG) laser posterior capsulotomy and to elucidate its clinical features, predisposing factors, effect on visual function, and association with additional capsulotomy. Setting: Keio University Hospital, Tokyo, Japan. Methods: The records of 418 eyes that had had Nd:YAG posterior capsulotomy after cataract surgery were retrospectively reviewed. Of those, 315 were excluded for short follow‐up (fewer than 12 months) or insufficient clinical examination data. In the remaining 103 eyes, the incidence of string of pearls was calculated, and its clinical features, predisposing factors, effect on visual function, and correlation with additional capsulotomy were evaluated. Results: String of pearls was identified in 49 eyes (47.6%); 37 (75.5%) developed pearls within 1 year after Nd:YAG capsulotomy. The incidence was significantly higher in patients having intraocular lens implantation and continuous curvilinear capsulorhexis (CCC) than in those without (95.9 versus 61.1% and 97.9 versus 55.6%, respectively). No significant differences were found in patient age and sex, total Nd:YAG energy, and the presence of diabetes mellitus or high myopia. String of pearls caused visual disturbances in 17 eyes (34.7%). The rate of repeat capsulotomy was higher in patients with string of pearls than in those without (36.7 and 9.3%, respectively). Conclusions: String of pearls formation was a common and significant complication after Nd:YAG posterior capsulotomy. Intraocular lens implantation and CCC may promote its formation.

Improvements in sleep quality and gait speed after cataract surgery.

BACKGROUND Gait speed and sleep quality are health indices related to longevity and mortality. In the present study, we measured sleep quality, quality of life, gait speed, and visual acuity before and after cataract surgery to evaluate the efficacy of the procedure on systemic health. METHODS The study was conducted on 155 patients (93 women; average age 74.8 years) undergoing cataract surgery with the implantation of a yellow soft acrylic lens. Patients were evaluated using the Pittsburgh Sleep Quality Index (PSQI) and the National Eye Institute Visual Function Questionnaire 25 (VFQ-25; vision-related quality of life) before and then 2 and 7 months after surgery. Four-meter gait speed was also determined. RESULTS Of the 155 patients, 68 (43.9%) were classified as poor sleepers (PSQI>5.5) prior to surgery. Significant improvements were noted in sleep 2 months after surgery (p<0.05, paired t-test), but thereafter the improvements were not significant. Prior to surgery, 117 patients (77.0%) were classified as slow walkers (speed<1.0 meter/s). Gait speed increased significantly in these patients 2 months after surgery (p<0.001, paired t-test). Multiple regression analysis revealed significant correlations between the preoperative VFQ-25 score and both PSQI (p<0.05) and gait speed (p<0.001). Postoperative increases in the VFQ-25 score were positively correlated with decreases in the PSQI (p<0.05). Improvements in visual acuity were correlated with improvements in the VFQ-25 score, but not with either PSQI or gait speed. CONCLUSION Cataract surgery effectively improves sleep quality and slow gait speed.