Koichi Wakimasu

Short-term changes in tear volume after blepharoptosis repair.

Purpose: The aim was to evaluate tear volume change by using videomeniscometry before and after blepharoptosis surgery. Methods: Fifty-nine eyes of 36 patients with blepharoptosis without lacrimal duct obstruction or other eyelid diseases were examined. All the patients underwent levator advancement, and the tear volume was evaluated preoperatively and 1.5 months postoperatively. The margin reflex distance-1 was determined from photographs, and the tear volume was determined by the measurement of tear meniscus radius using videomeniscometry. Results: The mean margin reflex distance-1 was significantly increased after performing a blepharoptosis surgery (0.13 ± 1.13 mm preoperatively vs. 3.18 ± 0.85 mm postoperatively, P < 0.001). The average tear meniscus radius was significantly decreased (0.31 ± 0.16 mm preoperatively vs. 0.23 ± 0.08 mm postoperatively, P < 0.001). A postoperative reduction in the tear meniscus radius was noted in 46 eyes (78%) of 31 patients, and no reduction was noted in 13 eyes (22%) of 12 patients. Preoperative higher tear meniscus radius values were more likely to be decreased (P < 0.01). Conclusions: The tear volume was decreased after the blepharoptosis surgery was performed, especially for an initially high tear volume.

Long-term Tear Volume Changes After Blepharoptosis Surgery and Blepharoplasty

PURPOSE To evaluate long-term changes in tear volume by using video meniscometry following blepharoptosis surgery and upper blepharoplasty. METHODS Forty-three eyes of 27 patients with blepharoptosis and 29 eyes of 18 patients with dermatochalasis without lacrimal duct obstruction or other eyelid diseases underwent anterior approach levator advancement or blepharoplasty. Tear volume was evaluated by measurement of tear meniscus radius (R), using video meniscometry preoperatively and at 1.5, 3, and 6 months postoperatively. Margin reflex distance-1 (MRD-1) was measured before and after surgery by using photographs. RESULTS After blepharoptosis surgery, the mean MRD-1 was significantly increased: 0.45 mm preoperatively, 3.64 mm at 1.5 months, 3.56 mm at 3 months, and 3.57 at 6 months postoperatively (P < 0.001), and the average R value was significantly decreased: 0.29 mm preoperatively, 0.22 mm at 1.5 months, 0.23 mm at 3months, and 0.24 mm at 6 months postoperatively (P < 0.05). Preoperative R was significantly correlated to the reduction rate of R (ΔR). A higher preoperative R was more likely to be decreased (P < 0.01). Postoperative MRD-1 and change in MRD-1 were not correlated to ΔR. After blepharoplasty, the preoperative mean MRD-1 (3.11 mm) was significantly decreased at 1.5 months (2.47 mm; P < 0.01) and 3 months (2.71 mm; P < 0.05) but recovered at 6 months (3.14 mm). However, the average R was not changed: 0.31 mm preoperatively, 0.34 mm at 1.5 months, 0.31 mm at 3 months, and 0.33 mm at 6 months postoperatively. CONCLUSIONS Long-term tear volume was not changed after blepharoplasty but was decreased after blepharoptosis surgery, and even more so in cases with an initial high tear volume.

Predictive clinical factors of cystoid macular edema in patients with Descemet’s stripping automated endothelial keratoplasty

The purpose of this present study was to investigate predictive clinical factors associated with cystoid macular edema (CME) post Descemet’s stripping automated endothelial keratoplasty (DSAEK) in a large case series. Of 393 consecutive patients who underwent DSAEK at Baptist Eye Institute, Kyoto, Japan between July 2011 and November 2016, 241 patients without CME at the pre- or early-postoperative periods were enrolled. The occurrence of anatomic CME was prospectively examined via optical coherence tomography (OCT). Possible predictive clinical factors for CME were analyzed by multivariate logistic regression analysis. At 1-month post DSAEK, CME occurred in 27 (11.2%) of the 241 patients. Multivariate analysis revealed that primary angle closure glaucoma (PACG) was significantly associated with postoperative CME (odds ratio = 6.4, P = 0.04). The findings of this study revealed that DSAEK in patients with PACG showed a high incidence of CME, thus indicating that they should undergo a careful postoperative observation of the macula via OCT.

A case of fungal keratitis and endophthalmitis post penetrating keratoplasty resulting from fungal contamination of the donor cornea

Purpose Fungal infections post keratoplasty due to contamination of the donor corneal graft have become important issues that need to be addressed. Here we report a case of fungal keratitis and endophthalmitis post penetrating keratoplasty (PKP) due to fungal contamination of the donor corneal graft. Observations We present a 52-year-old male who underwent PKP with a donor corneal graft that was later found to be contaminated with fungus. At 4-weeks postoperative, infectious infiltrates suddenly appeared at the border between the host and donor corneal graft, and endophthalmitis concomitantly occurred. A culture of the remnant donor corneoscleral rims and the vitreous fluid obtained during vitreous surgery was found to be positive for Candida albicans. At 6-months post vitreous surgery and intensive anti-fungal medical treatment, both corneal infiltrates and vitreous opacity completely disappeared, and the patients best-corrected visual acuity recovered to 20/40, with a transparent cornea. Conclusions and importance The findings of this case show that prompt intensive medical treatment and surgical intervention effectively saved the vision in a patient with fungal keratitis and endophthalmitis due to contamination of the donor corneal graft.

Effect of Trabeculotomy on Corneal Endothelial Cell Loss in Cases of Postpenetrating-Keratoplasty Glaucoma.

PURPOSE The aim of this study was to evaluate the effect of trabeculotomy (TLO) on glaucoma and endothelial cell loss after penetrating keratoplasty (PK). METHODS A retrospective study was conducted on consecutive patients who underwent PK and in whom more than 24 months of follow-up was available. Patients were categorized into the PK+TLO group [ie, TLO for post-PK glaucoma (n = 10)] and the PK group [PK alone (n = 73)]. Intraocular pressure (IOP) was evaluated during each follow-up examination. Central corneal endothelium images were obtained and analyzed to determine corneal endothelial cell (CEC) density. RESULTS The mean duration period from original PK to TLO for secondary glaucoma was 25.5 ± 34.9 months in the PK+TLO group. Mean preoperative IOP in the PK+TLO group was 35.8 mm Hg, and decreased to 17.5 mm Hg at 24 months postoperative (P < 0.01). CEC density decreased in the same manner in both groups. In the PK+TLO group, mean CEC density was 1838 cells per square millimeter before TLO and decreased to 1195 cells per square millimeter at 24 months after TLO. In the PK group, mean CEC density decreased from 1870 to 1209 cells per square millimeter at each corresponding time point. CONCLUSIONS TLO for post-PK glaucoma appeared to safely lower IOP, although repeated surgeries were required in some patients, and did not accelerate CEC loss.PURPOSE The aim of this study was to evaluate the effect of trabeculotomy (TLO) on glaucoma and endothelial cell loss after penetrating keratoplasty (PK). METHODS A retrospective study was conducted on consecutive patients who underwent PK and in whom more than 24 months of follow-up was available. Patients were categorized into the PK+TLO group [ie, TLO for post-PK glaucoma (n = 10)] and the PK group [PK alone (n = 73)]. Intraocular pressure (IOP) was evaluated during each follow-up examination. Central corneal endothelium images were obtained and analyzed to determine corneal endothelial cell (CEC) density. RESULTS The mean duration period from original PK to TLO for secondary glaucoma was 25.5 ± 34.9 months in the PK+TLO group. Mean preoperative IOP in the PK+TLO group was 35.8 mm Hg, and decreased to 17.5 mm Hg at 24 months postoperative (P < 0.01). CEC density decreased in the same manner in both groups. In the PK+TLO group, mean CEC density was 1838 cells per square millimeter before TLO and decreased to 1195 cells per square millimeter at 24 months after TLO. In the PK group, mean CEC density decreased from 1870 to 1209 cells per square millimeter at each corresponding time point. CONCLUSIONS TLO for post-PK glaucoma appeared to safely lower IOP, although repeated surgeries were required in some patients, and did not accelerate CEC loss.

Two presentations of upper lid migration of rigid gas-permeable contact lenses.

Objective: To report two differing forms of upper lid migration of rigid gas-permeable contact lens and review the literature on embedded contact lenses. Methods: Two case reports and review of the literature. Results: Case 1 was a 36-year-old woman, who presented with a 1-year history of a left upper lid mass. Eversion of the upper lid revealed a tarsoconjunctival mass with an overlying scar. Excision revealed a migrated contact lens within a cyst of conjunctival epithelium. She recalled she had lost the lens 1 year before noticing the mass. Case 2 was a 42-year-old woman, who had a 10-month history of mucopurulent discharge from the right eye. Double eversion of the upper lid revealed an embedded contact lens with pus. Excision demonstrated a lens surrounded by inflamed granulation tissue. She recalled having lost the lens after sleeping overnight with the lens in place approximately 1 year before the development of the mucopurulent discharge. Conclusions: These cases highlight the importance of acquiring a detailed history of contact lens loss in patients presenting with upper eyelid masses. Furthermore, the history of lens loss may be remote from commencement of symptoms, which may vary significantly between patients.

Involvement of anterior and posterior corneal surface area imbalance in the pathological change of keratoconus

Keratoconus (KC) is an ectatic disorder with a high prevalence rate. However, the exact cause of the disease and possible underlying mechanisms of development remain unclear. In this present study, we aimed to investigate the anterior and the posterior corneal surface area in normal, forme fruste keratoconus (FFKC), and keratoconic eyes (as a reference group) using anterior segment optical coherence tomography (AS-OCT) in order to assess the pathological change of KC. The surface areas of the anterior or posterior cornea, and the anterior-posterior (As/Ps) ratio of corneal surface area, were measured at the central 5.0 mm-, 6.0 mm-, and 7.0 mm-diameter areas via AS-OCT, and a comparison between the normal eyes and FFKC eyes was then performed using the Mann-Whitney U test. The posterior surface area at the central 5.0 mm areas in the FFKC eyes (20.430 mm2) and KC eyes (20.917 mm2) seemed to become larger than that of normal eyes (20.389 mm2) (normal vs FFKC; P = 0.06). Moreover, the As/Ps of the corneal surface area in the FFKC eyes (0.986) and the KC eyes (0.976) was significantly smaller than that of the normal eyes (0.988) (normal vs FFKC; P < 0.01). Anterior and posterior corneal surface area imbalance may reflect keratoconic eyes at the early stage of the disease.

Topical ganciclovir treatment post-Descemet’s stripping automated endothelial keratoplasty for patients with bullous keratopathy induced by cytomegalovirus

Background/aims To investigate the efficacy of topical ganciclovir (GCV) for preventing disease recurrence and improving the surgical outcome post-Descemet’s stripping automated endothelial keratoplasty (DSAEK) in patients with cytomegalovirus (CMV) endotheliitis. Methods This prospective, non-comparative case series study involved six eyes of six patients with endothelial decompensation due to CMV endotheliitis who underwent DSAEK, followed by a continuous, four to six times daily, topical administration of 0.5% GCV. Patient demographics, clinical history, and preoperative and postoperative examination (including any recurrence of CMV endotheliitis post-DSAEK), best corrected visual acuity (BCVA), intraocular pressure (IOP), graft survival rate and endothelial cell density (ECD) were examined. Results No recurrence of CMV endotheliitis was detected post-DSAEK. The mean follow-up period was 40 months (range, 12–60 months). The mean preoperative BCVA was 1.52±0.68 LogMAR (range, 0.52–2.40 LogMAR), yet it had significantly improved to 0.15±0.16 LogMAR (range: −0.08 to 0.30 LogMAR) by 1 year postoperative (P<0.01). In all patients, IOP was well controlled (10–20 mm Hg) postsurgery. The mean preoperative donor ECD was 2692±177 cells/mm2, and the mean postoperative ECD was 1974, 1771 and 1174 cells/mm2 for the ECD loss of 26%, 33% and 54% at 6, 12 and 36 months, respectively. No adverse effects were observed associated with the long-term topical administration of GCV. Conclusion The continuous topical application of 0.5% GCV was found to be effective for preventing the recurrence of CMV endotheliitis, and it provided the optimal mid-term clinical outcomes post-DSAEK in patients with CMV endotheliitis. Trial registration number UMIN000026746

Relationship between frequent swimming pool use and lacrimal duct obstruction

Editor, I n our clinical practice, we often encounter frequent swimming pool users and swimming instructors to be among patients with acquired lacrimal duct obstruction (LDO). Only one previous report of 45 patients with primary acquired nasolacrimal duct obstruction has noted that history of swimming pool exposure may be associated with the development of LDO (Ohtomo et al. 2013). To examine whether or not frequent swimming pool use is associated with LDO, we conducted a questionnaire survey of patients who underwent treatment for LDO and compared the results with an ageand gender-matched control group. The questionnaire survey was conducted in 332 patients who visited the Department of Ophthalmology at Kyoto Prefectural University of Medicine, Kyoto, Japan, and underwent surgical treatment (dacryocystorhinostomy or silicone tube insertion) for LDO between April 2003 and March 2009. LDO was defined as the complete obstruction of the nasolacrimal duct, canaliculus or both by syringing and probing during surgery. A questionnaire survey on the frequency of swimming pool use was given to 332 LDO patients, of whom 227 completed the questionnaire (adopted LDO group; 68.4%, 45 males and 182 females, mean age: 65.4 12.8 years), and a control group of 625 patients without LDO (159 males and 466 females, mean age: 63.3 15.3 years), recruited from the outpatient clinic and matched for age and gender. Statistical analysis was performed on the correlation between LDO and frequency of swimming pool use and the frequency between the two groups. Frequent swimming pool use was defined as the use of the pool one or more times per month for a period of at least 6 months. Individuals who had onset of symptoms prior to commencing swimming pool use were not defined as frequent users. Individuals unable to use swimming pools for medical reasons were excluded from the study. The percentage of frequent swimming pool use differed significantly and statistically between the LDO group (35 of 227 patients, 15.4%) and the control group (20 of 625 subjects, 3.2%). In the LDO group, the average age of patients with frequent swimming pool use (60.1 years old) significantly differed from the patients without frequent use (66.4) (Table 1). In the LDO group, patient-age-related percentages of frequent swimming pool use were 100% (2/2, ages 10–19), 20% (1/5, ages 20–29), 0% (0/4, ages 30–39), 40% (4/10, ages 40–49), 18.9% (7/37, ages 50–59), 18.4% (14/76, ages 60–69), 7% (5/71, ages 70–79) and 9% (2/22, ages 80–89). Previous studies have reported epidemiological evidence that bathing or swimming in polluted waters is a potential health risk (Seyfried et al. 1985). In most swimming pools, microbiological control is performed by disinfection via the addition of chlorine. The disinfection properties of free chlorine are linked to its oxidant capacity, and chlorination of swimming pool water leads to the formation of disinfection by-products, including combined chlorine or trihalomethanes, which are associated with some types of illness (Florentin et al. 2011). The phenomenon of a swimming-induced rhinitis in elite swimmers in chlorinated pools has been reported (Alves et al. 2010), and allergic rhinitis may have a role in primary acquired LDO (Eriman et al. 2012). Thus, it is possible that combined chlorine in water is one of the factors potentially involved in LDO among swimming pool users, and our results suggest that frequent swimming pool use may be a risk factor for LDO. Further investigation is needed to provide a more detailed analysis of the relationship between LDO and the quality of swimming pool water.