Kazuyuki Emi

Two-year follow-up study comparing primary vitrectomy with scleral buckling for macula-off rhegmatogenous retinal detachment.

PURPOSE To compare the anatomic and visual outcomes achieved by scleral buckling and primary vitrectomy for the repair of macula-off rhegmatogenous retinal detachment. METHODS The records were reviewed for a consecutive series of 167 patients (167 eyes) who were initially treated with scleral buckling or pars plana vitrectomy for primary macula-off retinal detachment. Patients were treated between January 1993 and December 1996. After adjustments for preoperative characteristics, data from 102 cases (55 scleral buckle cases and 47 primary vitrectomy cases) were used for the final comparison. There had been a minimum follow-up period of 24 months. RESULTS No significant differences in single-procedure reattachment incidence (91%), final success incidence (100%) and incidence of postoperative proliferative vitreoretinopathy development (4%) were observed between the two treatment groups. Preoperative visual acuity, preoperative intraocular pressure, and duration of macular detachment were the three best predictors of postoperative visual recovery in both groups. Favorable overall visual recovery was obtained postoperatively, with no significant differences between the two groups throughout the follow-up period. However, in the eyes with poor preoperative visual acuity (<0.1), ocular hypotony (intraocular pressure <7 mm Hg), or prolonged macular detachment (more than 7 days), visual recovery in the primary vitrectomy group was significantly better (P <.05) than in the scleral buckle group from the first postoperative month. CONCLUSION Both procedures achieved favorable anatomic and visual outcomes in the majority of patients with primary macula-off retinal detachment. Primary vitrectomy may be more effective than scleral buckling for achieving early visual rehabilitation in cases complicated by poor preoperative vision, ocular hypotony, and prolonged macular detachment.

Comparative Study of Intraocular Lens Implantation Through 3.2- and 5.5-mm Incisions

PURPOSE To prospectively and comprehensively compare the clinical results of two small-incision cataract surgery procedures, silicone intraocular lens (refractive index of 1.46) implantation through a 3.2-mm incision and polymethylmethacrylate intraocular lens implantation through a 5.5-mm incision. METHODS Two hundred eyes with cataract randomly were assigned to either procedure. Except for incision size, identical surgical methods were used in every case. Data on uncorrected and corrected visual acuity, keratometry, corneal topography, flare-cell measurement, fluorophotometry, specular microscopy, glare disability measurement, and photographic examination of intraocular lens decentration were analyzed up to 6 months after surgery. RESULTS Eyes in the 3.2-mm incision group displayed significantly better uncorrected and corrected visual acuity in the early postoperative period, lower aqueous flare intensity and cell counts immediately after surgery, less operatively induced astigmatism throughout the study period, and less corneal topographic changes taken 3 months after surgery. No significant between-group differences were noted for other parameters. Complications in the two groups were few and comparable. CONCLUSION Both procedures of small-incision cataract surgery offered satisfactory clinical results, but 3.2-mm incision cataract surgery allowed significantly earlier recovery of visual function and better preservation of corneal shape.

Quantitative assessment of macular thickness in normal subjects and patients with diabetic retinopathy by scanning retinal thickness analyser

AIMS To evaluate the scanning retinal thickness analyser (RTA), a novel non-invasive imaging instrument, in diagnosing and quantitatively characterising diabetic macular oedema, and to investigate the relation between central macula thickness measured by RTA and other clinical examinations. METHODS Central macular thickness was measured using the RTA in 40 normal subjects and 60 patients with diabetic retinopathy. The reproducibility of the retinal thickness measurements was evaluated by calculating the mean of the inter- and intrasession variations. Central macular thickness was correlated with the results of visual acuity measurements, biomicroscopy, and fluorescein angiography. RESULTS Intra- and intersession reproducibility of the RTA in normal subjects was plus or minus 5.2% (16 μm) and plus or minus 6.1% (19 μm), respectively. The mean central macular thickness was 182 (SD 16) μm in normal subjects, 283 (116) μm in diabetic eyes without clinically significant macular oedema (CSMO), and 564 (168) μm in diabetic eyes with CSMO. Central macular thickness was significantly greater (p<0.001) in eyes with diabetic retinopathy than in normal subjects, even when macular thickening did not meet the standard for CSMO (p=0.019) measured by biomicroscopy. Although greater fluorescein leakage at the macula results in greater central macular thickness, only eyes with diffuse leakage had statistically significant macular thickening compared with normal subjects (p=0.022). Central macular thickness measured with the RTA was significantly correlated with the logarithmic converted visual acuity (r2 = 0.76) in diabetic eyes. CONCLUSION Scanning RTA, which has good reproducibility, might be useful to quantitatively detect and monitor macular thickening in diabetic retinopathy. Central macular thickness was highly correlated with logarithmic converted visual acuity in diabetic macular oedema.

Survey of surgical indications and results of primary pars plana vitrectomy for rhegmatogenous retinal detachments

BACKGROUND Several surgical techniques to repair rhegmatogenous retinal detachment have been developed. Recently, both the method of reattaching the retina and of obtaining an early visual recovery are considered important factors when determining which surgical techniques to perform to treat retinal detachment. CASES The surgical outcome in a series of 63 consecutive patients, who were treated at Osaka Rosai Hospital between 1993 and 1996, was reviewed retrospectively to evaluate the efficacy of primary vitrectomy to treat uncomplicated rhegmatogenous retinal detachment associated with posterior hyaloid separation. The criteria for vitrectomy included the presence of not only posterior retinal breaks, but also of multiple peripheral retinal breaks. OBSERVATIONS The reattachment rate after the first surgery was 92.1% (58 eyes), and by the final examination it increased to 100%. Of the 46 eyes with macular detachment, good visual rehabilitation and a visual acuity improvement of 5 or more lines was obtained in 33 eyes (71.7%) by 1 month postoperatively. No statistically significant difference in the reattachment rate was found when eyes that underwent an encircling procedure were compared with those that did not. In eyes with lens opacity, cataract surgery was also performed and intraocular lenses were implanted uneventfully in all but one case with myopia. There was a high incidence (53.8%) of cataract progression in phakic eyes. However, no other serious complications, such as proliferative vitreoretinopathy, were found throughout the follow-up period. CONCLUSIONS The results indicate that vitrectomy performed to alleviate peripheral vitreoretinal traction is an effective surgical technique to treat primary rhegmatogenous retinal detachment. Vitrectomy combined with cataract surgery may also be a valuable surgical option in selected cases to maintain long-standing visual rehabilitation.

Severe Intraocular Inflammation after Intravitreal Injection of Bevacizumab

PURPOSE To report 5 cases of severe intraocular inflammation that developed after an intravitreal injection of the same lot of bevacizumab. DESIGN Retrospective case series. PARTICIPANTS Patients treated with an intravitreal injection of bevacizumab (lot B3003B01). METHODS The clinical charts of 35 eyes of 35 consecutive patients who were treated with intravitreal injection of lot B3003B01 bevacizumab from December 18, 2008, through January 20, 2009, were reviewed. MAIN OUTCOME MEASURES Incidence of intraocular inflammation, results of bacterial cultures, best-corrected visual acuity (BCVA), and endothelial cell density. RESULTS Five (14.3%) of the 35 cases had severe intraocular inflammation, and the inflammation had some characteristics of toxic anterior segment syndrome (TASS). Five of the 5 cases had a predominantly anterior chamber reaction, and 4 of the 5 cases were accompanied by hypopyon. Undiluted samples collected from both the aqueous and vitreous of the 5 cases were culture negative. The BCVA was 0.66+/-0.29 (mean+/-standard deviations) logarithm of the minimum angle resolution (logMAR) units, and the endothelial cell density was 2683.6+/-97.3/mm(2) before the intravitreal bevacizumab. At the final visit, the BCVA was 0.44+/-0.36 logMAR units, and the cell density was 2679.0+/-217.5/mm(2). These differences were not significant (P = 0.171 and 0.964). CONCLUSIONS These observations indicate that an intravitreal injection of bevacizumab can induce sterile endophthalmitis that has characteristics of TASS.

Three year prospective, randomized evaluation of intraocular lens implantation through 3.2 and 5.5 mm incisions

Purpose: To compare the long‐term clinical results of two small incision cataract surgery procedures. Setting: Seven centers in Japan. Methods: Two hundred eyes were randomly assigned to receive a silicone intraocular lens (IOL) through a 3.2 mm incision or a poly(methyl methacrylate) (PMMA) IOL through a 5.5 mm incision. Except for incision size and implantation technique, the surgical methods were identical. Uncorrected and corrected visual acuity, keratometry, flare‐cell intensity, specular microscopy, and neodymium:YAG (Nd:YAG) laser posterior capsulotomy rate were analyzed up to 3 years after surgery. Results: Eyes in the 3.2 mm incision group had significantly better uncorrected and corrected visual acuity in the early postoperative period and lower aqueous flare intensity immediately after surgery, but these differences disappeared after the first postoperative month. However, surgically induced astigmatism was significantly less in the 3.2 mm incision group than in the 5.5 incision group throughout the study. The Nd:YAG laser capsulotomy rate was higher in the silicone IOL group (23.5% at 3 years postoperatively) than in the PMMA IOL group (18.4%), but the difference was not statistically significant. Conclusion: Smaller incision cataract surgery led to earlier recovery of visual function in the short term and less induced astigmatism in the long term.

Transscleral fixation of acrylic intraocular lenses in the absence of capsular support through 3.5 mm self-sealing incisions

Purpose: To evaluate the safety and efficacy of transscleral ciliary sulcus fixation of acrylic intraocular lenses (IOLs) through small incisions in the management of secondary IOL implantation. Setting: Department of Ophthalmology, Osaka Rosai Hospital, Osaka, Japan. Methods: This retrospective study consisted of 28 patients (30 eyes) who had transscleral fixation of acrylic IOLs through 3.5 mm incisions. All patients were followed for a minimum of 6 months in several different clinical settings. Data on visual acuity, keratometry, and central corneal endothelial cell count were evaluated preoperatively and postoperatively. The refractive error achieved and incidence of postoperative complications were determined. Results: Uncorrected visual acuity (UCVA) improved in all eyes. Of the 18 eyes without pre‐existing pathology, 11 (61.1%) had a UCVA of 20140 or better from 1 week postoperatively. Best corrected visual acuity was unchanged in 24 eyes (80.0%) and improved by 2 Snellen lines or more in 5 eyes (16.7%) at the final examination. Self‐sealing wound adaptation was achieved in 25 eyes (83.3%). The mean scalar shift in keratometric cylinder was 1.25 diopters (D) at 1 day postoperatively, 1,17 D at 1 week, and 1.06 D at 3 months. The rate of central corneal endothelial loss 6 months postoperativelyaveraged 7.84%. No intraoperative complications that were directly associated with acrylic IOL implantation occurred. Postoperative complications that included transient ocular hypertension, slight vitreous hemorrhage, and IOL malposition were found in a small population but resolved spontaneously without further surgical intervention. Conclusions: The good visual outcomes and low incidence of complications achieved in the present study indicate that acrylic IOLs positioned through small incisions might be considered for ciliary sulcus fixation. However, evaluation of this technique in a large population over the long term is required.

Fluid Dynamics in Eyes With Rhegmatogenous Retinal Detachments

Inward and outward permeabilities to sodium fluorescein at the blood-retinal barrier were measured by kinetic vitreous fluorophotometry in ten eyes with rhegmatogenous retinal detachments. Fellow eyes were used as controls. Inward permeability of eyes with detachments was significantly larger than that of controls (P less than .005), suggesting damage to the blood-retinal barrier in eyes with detachments. Outward permeability of eyes with detachment and retinal holes was slightly less than that of controls, but the difference was not statistically significant. However, outward permeability of eyes with detachments and with retinal tears was significantly larger than that of controls (P less than .05). This increased outward permeability may be attributed to the increased fluid flow posteriorly through the break across the retinal pigment epithelium.

Piggyback foldable intraocular lens implantation in patients with microphthalmos

Purpose: To evaluate the clinical results of phacoemulsification and implantation of 2 foldable acrylic intraocular lenses (IOLs) in microphthalmic eyes. Setting: University of Tokyo School of Medicine, Tokyo, Eguchi Eye Hospital, Hakodate, and Osaka Rosai Hospital, Osaka, Japan. Methods: This study comprised 5 eyes of 3 patients whose manifest spherical equivalent was +10.5 to +18.0 diopters (D) and axial length was 15.79 to 16.82 mm. After phacoemulsification, 2 foldable acrylic IOLs with a mean power of +43.0 D ± 9.5 (SD) (range +32.0 to +55.0 D) were implanted in the capsular bag. Results: There were no significant intraoperative complications, and there was significant improvement in uncorrected and best corrected visual acuities after surgery. The spherical equivalent decreased significantly; however, the postoperative refraction was considerably more hyperopic than predicted in all eyes. Except for posterior synechias in 2 eyes and slight interlenticular opacification in 2 eyes, no major postoperative complications occurred during the mean follow‐up of 14.8 months. Conclusion: Implanting 2 piggyback IOLs was beneficial in eyes with an extremely short axial length. However, the current system of lens power calculation markedly underestimates the required lens power, resulting in a hyperopic refractive error after surgery. The benefits of in‐the‐bag placement of 2 foldable lenses are questionable.

Optical cross-sectional observation of resolved diabetic macular edema associated with vitreomacular separation

PURPOSE To describe the resolution of cystoid macular edema associated with vitreomacular separation in a diabetic patient. METHODS Case report. A 58-year-old man who had cataract surgery 3 years earlier developed diabetic macular edema after panretinal laser photocoagulation. For a detailed fundus examination, we performed neodymium: YAG (Nd:YAG) laser capsulotomy in the left eye as the initial management. RESULTS Two days after the laser capsulotomy, fundus biomicroscopy and B-mode ultrasonography disclosed a vitreomacular separation in the left eye that was not detectable preoperatively. Optical coherence tomography through the macula disclosed a dramatic decrease in the size of intraretinal cystoid spaces with an improvement of visual acuity. Scanning retinal thickness analysis also confirmed the decrease of retinal thickness at the macula with the resolution of cystoid macular edema. CONCLUSION Resolution of diabetic macular edema with subsequent visual recovery is potentially associated with the vitreomacular separation in a patient after Nd:YAG laser capsulotomy.