Masayoshi Iwaki

Long-term follow-up of vitrectomy for diffuse nontractional diabetic macular edema.

Purpose: To report the long-term results of pars plana vitrectomy for diffuse nontractional diabetic macular edema. Design: Interventional, retrospective, consecutive case series. Methods: Clinical records of 332 consecutive patients (496 eyes) with diabetic macular edema without a thickened and taut posterior hyaloid on contact lens examination were reviewed. Four hundred eighty-six eyes of 326 consecutive patients were included in this study. All patients underwent pars plana vitrectomy with the creation of a posterior vitreous detachment by one surgeon. Simultaneous phacoemulsification with intraocular lens implantation was performed on 456 phakic eyes. Internal limiting membrane peeling was performed on 178 (36.6%) of 486 eyes. The main outcome measured was best-corrected visual acuity results during follow-up periods. Results: Postoperative follow-up ranged from 12 to 170 months (mean, 74.0 months). Five year follow-up data were available for 356 (71.8%) of 496 eyes. Mean preoperative best-corrected visual acuity significantly increased from 0.19 (20/105) to 0.32 (20/63) at 1 year after surgery (P < 0.0001), and 0.30 (20/67) at the final visit (P < 0.0001). The final best-corrected visual acuity improved in 256 (52.7%) of the 486 eyes, remained unchanged in 152 eyes (31.3%), and worsened in 78 eyes (16.0%). Postoperative major complications included neovascular glaucoma in 19 eyes (3.9%), recurrent vitreous hemorrhage in 10 eyes (2.1%), hard exudate deposits in the center of the macula in 21 eyes (4.2%), and glaucoma in 22 eyes (4.5%). Conclusions: Pars plana vitrectomy with and without internal limiting membrane peeling appears to be beneficial in eyes with diffuse nontractional diabetic macular edema, and its effectiveness is maintained long term.

The levator aponeurosis consists of two layers that include smooth muscle.

Purpose: To investigate the two-fold structure of the levator aponeurosis, which is partly composed of independent smooth muscles. Materials and Methods: Fifteen upper eyelids of 12 Asian postmortems, with age at death ranging from 72 to 91 years, were examined. In 9 eyelids, posterior lamella tissue of the upper eyelid was removed to observe the stratified structures of the levator aponeurosis. Six full-thickness eyelids were used to observe the attachment site or the continuity between the levator aponeurosis and its surrounding tissues. The eyelids were incised perpendicularly in the center of the eyelid; samples were stained with Masson trichrome and antismooth muscle actin antibody and examined microscopically. Results: Masson trichrome staining demonstrated the two-layered nature of the levator aponeurosis. The anterior layer was characterized by thick, robust fibrous tissue, and the posterior by thinner fibrous tissue. Although both layers contained muscle structures, the posterior layer contained more than the anterior. Immunostaining with antismooth muscle actin antibody revealed that the muscle in both layers was smooth muscle. The anterior layer continued to the orbital septum and the submuscular fibroadipose tissue; the posterior layers, located in front of Müller muscle and its tendon, attached to the anterior inferior one-third of the tarsus. Part of the anterior layer went through the orbicularis oculi muscle and attached to the subcuticular tissue. Conclusions: The levator aponeurosis is stratified, consisting of two layers than contain smooth muscle components in their proximal portions. It pulls mainly the preaponeurotic fat and anterior eyelid lamella. This partially regulates the tension of the eyelid and contributes to the ordered movement of the upper eyelid.

Transient Expression of PG-M/Versican, a Large Chondroitin Sulfate Proteoglycan in Developing Chicken Retina

Abstract: We previously showed the expression of PG‐M/versican in embryonic chicken retina. In this study, we characterized the alternatively spliced forms of PG‐M/versican and their developmental regulation to investigate the implication of PG‐M/versican in neurite outgrowth from retinal cells during development. On day 5, the immunolocalization of PG‐M was first observed at the inner surface of neural retina. On day 7, the pronounced staining was observed in the nerve fiber layer and inner plexiform layer where neural networks of ganglion cells were being formed. As the development proceeded, more intensive staining was observed in these layers. The staining peaked on day 14 and then decreased. Northern analysis and western blotting revealed the presence of a single‐sized transcript (13 kb) and the PG‐M/versican core protein (550 kDa) on day 14, but the absence of any transcripts or protein bands on day 20, indicating a transient expression of PG‐M+ (VO), the alternatively spliced form with the most abundant sites for the chondroitin sulfate attachment. Taken together, it is likely that PG‐M/versican is involved in neurite outgrowth from ganglion cells during retinal development, and antiadhesion activity of its chondroitin sulfate chains may be important for regulation.

Microscopic anatomy of Asian lower eyelids.

Purpose: To elucidate the microscopic anatomy of the Asian lower eyelid. Methods: Specimens (full-thickness sections of lower eyelids from 19 postmortem lower eyelids) from 11 Asians aged 73 to 96 years at death were fixed in 10% buffered formalin and microscopically examined. After pretreatment, sagittal sliced sections of the central part were stained with Masson trichrome. Results: The distinct junction of the orbital septum to the capsulopalpebral fascia (CPF) was confirmed in 7 eyelids in which orbital septum was clearly stained, with an average distance from the tarsus to the junction of 2.38 mm. The other 12 eyelids did not show a distinct junction, and the orbital septum was poorly defined anteriorly and indistinct posteriorly. There was a distinct layer between the orbicularis oculi muscle and the orbital septum. The inferior and the posterior attachments of the CPF to the tarsus were seen in all eyelids. Seventeen of the 19 eyelids had attachment of the CPF on the anterior aspect of the tarsus, from which an extension of the CPF through the pretarsal orbicularis oculi muscle was observed. All eyelids had anterior extension of the CPF through the preseptal orbicularis oculi muscle, which was overridden on the pretarsal orbicularis oculi muscle. Conclusions: The microscopic findings of Asian lower eyelids, especially fascial components, were mostly similar to those of non-Asian eyelids, but differences existed in higher or indistinct septum fusion, anterior and superior orbital fat projection, and the overriding of the preseptal orbicularis oculi muscle.

Direct insertion of the medial rectus capsulopalpebral fascia to the tarsus.

Purpose: To clarify the insertion of the medial rectus capsulopalpebral fascia to the tarsus in Asians. Methods: Specimens from 19 (11 right, 8 left) postmortem medial eyelids and orbits of 11 Asians (aged 45–96 years at death) were used. Samples had been fixed in 10% buffered formalin before their removal and microscopic examination. The tarsi were incised at 2 different heights in the upper and lower eyelids, as it was not disclosed which parts had the insertion of the medial rectus capsulopalpebral fascia. The first and second sections, parallel to the eyelid margin, were obtained, respectively, at 1 mm and 5 mm from the upper eyelid margin, and at 1 mm and 3 mm from the lower eyelid margin. Sections were stained with Masson trichrome. Results: Both upper and lower eyelids demonstrated similar findings. The first sections, which showed the medial rectus capsulopalpebral fascia and included many smooth muscle fibers, did not insert in the tarsi. However, the deep part of Horner muscle directly inserted, whereas the superficial part went in the dense fibrous tissue closely attaching on the tarsi. Then, some of the muscle branched out in the tarsi. The second sections showed that the medial rectus capsulopalpebral fascia had a direct insertion to the tarsi. Conclusions: The tarsi are supported medially by the medial rectus capsulopalpebral fascia and Horner muscle. The “medial eyelid retractors, ” comprising the medial rectus capsulopalpebral fascia and smooth muscles, were clearly defined, highlighting the relationship of the eyelid to the medial rectus muscle and offering a new pathogenesis and treatment for lateral tarsal shifts and lower medial ectropion.

Versican and Fibrillin-1 Form a Major Hyaluronan-Binding Complex in the Ciliary Body

PURPOSE In this study, biochemistry, molecular biology, immunohistochemistry, and electron microscopy techniques were used to examine whether versican, which is known to bind fibrillin-1, interacts with fibrillin-1 in the ciliary body and vitreous, and whether the versican in this complex binds to hyaluronan. METHODS The new polyclonal antibodies against the amino and carboxyl termini of versican were raised and characterized. The mRNA expression levels of versican and fibrillin-1 were analyzed by RT-PCR and real-time PCR, and their protein levels were evaluated by Western blot analysis and immunohistochemistry. Isolation of versican bound to fibrillin-1-containing microfibrils from ciliary bodies was performed by extraction studies. Slot-blot analyses and rotary shadowing electron microscopy were applied to identify versican associated with fibrillin-1-containing microfibrils after gel filtration chromatography and density gradient centrifugation. RESULTS The newly prepared polyclonal antibodies recognized amino and carboxyl termini of chicken versican. Versican, principally V0 and V1, was found to be securely bound to fibrillin-1-containing microfibrils, forming a major hyaluronan-binding structure in the ciliary nonpigmented epithelium. In addition, Western blot analysis revealed two cleaved complexes, the carboxyl-terminal end of versican bound to fibrillin microfibrils and the amino terminal end of versican bound to hyaluronan in the vitreous body. CONCLUSIONS Fibrillin-1, versican, and hyaluronan form a unique complex in the ciliary nonpigmented epithelium, and two cleavage products of this complex were shown to exist in the vitreous body. This newly clarified fibrillin-versican-hyaluronan (FiVerHy) complex and its cleavage products may be indispensable for the physiological properties important to the ciliary body and vitreous.

Microscopic findings of lateral tarsal fixation in Asians.

Purpose: To identify microscopically lateral tarsal fixation in Asians. Methods: Specimens from 19 postmortem lateral eyelids and orbits of 11 Asians (11 right, 8 left; aged 45–96 years at death) were used. Samples damaged on sectioning and samples without tarsal plates were excluded. The samples were fixed in 10% buffered formalin and examined under a microscope. Two levels of tarsus were observed in the upper and lower eyelids, suggesting the possibility of different means of fixation. The first and second sections, which were incised parallel to the eyelid margin, were obtained at 1 mm and 5 mm from the upper eyelid margin, and at 1 mm and 3 mm from the lower eyelid margin. The sections were stained with Masson trichrome. Results: The first sections of all upper eyelids and those of the lower eyelids except one showed tarsal fixation by both the lateral rectus capsulopalpebral fascia (lr-CPF) and the tendon-ligament complex of the lateral canthal tendon (LCT), which in several cases received the muscle of Riolan. The second sections of all upper eyelids showed fixation by the lr-CPF and the ligamentous part of the LCT. The second sections of the lower eyelids were mostly similar to the second sections of upper eyelids, though some showed only ligamentous fixation. The lr-CPF in all cases included a small amount of smooth muscle fibers. Conclusions: The lateral aspect of the tarsus is supported by the lr-CPF and the LCT, which in some cases includes the muscle of Riolan.

Lateral Canthal Anatomy: A Review

The anatomy of the lateral canthus is analogous to that of the medial canthus, but with a less defined structure. Although the lateral canthal tendon occupies the major part of the lateral canthal anatomy, the lateral rectus capsulopalpebral fascia and other structures also play a significant role. Appropriate comprehension and consideration of the lateral canthal anatomy enable safe and effective performance in the lateral canthal surgeries. In this review, we present the lateral canthal anatomy along with updated topics. We discuss the lateral canthal tendon, lateral orbital thickening, lateral palpebral raphe, lateral canthal muscle, lateral rectus capsulopalpebral fascia, lateral check ligament, lateral retinaculum, and orbitomalar ligament.

Posterior layer advancement of the lower eyelid retractor in involutional entropion repair.

Purpose: To examine effectiveness of posterior layer advancement of the lower eyelid retractor in involutional entropion repair. Methods: Fifty lower eyelids (30 right and 20 left, average patient age 75.5 years) of 43 patients with involutional entropion underwent surgery. All cases were observed for at least 1 year postoperatively. During surgery, after detaching the anterior and posterior surfaces of the lower eyelid retractor, we positively advanced and fixed the posterior layer of the lower eyelid retractor to the tarsus. The anterior layer was used as reinforcement for the posterior layer. When lower eyelid retraction was intraoperatively observed, the suture was changed to fix to a more undercorrected position. Results: Of the 50 patients, only 1, who was the second case operated on, showed recurrent entropion 5 months postoperatively, but following a repeat operation using the same procedure no recurrence was seen in the next 2 years. Three eyelids showed a low degree of ectropion in the early postoperative period, but all improved within 1 month. No postoperative lower eyelid retraction was observed in any patient. Conclusions: Posterior layer advancement of the lower eyelid retractor is useful for entropion repair.

The rate of symptomatic improvement of congenital nasolacrimal duct obstruction in Japanese infants treated with conservative management during the 1st year of age

This study aimed to examine the rate of symptomatic improvement of congenital nasolacrimal duct obstruction (CNLDO) in Japanese infants treated with conservative management within the 1st year of age. Thirty-five lacrimal ducts in 27 patients diagnosed with CNLDO were included in the study. During the observational period, lacrimal ducts were massaged. As well, antibiotic eye drops, to be administered 4 times a day, were sometimes prescribed for obvious conjunctivitis. Two lacrimal ducts in 2 patients were probed before the 1st year of age because of dacryocystitis or severe blepharitis; these patients were included in the unimproved group. Twenty-nine lacrimal ducts in 21 patients resolved during the period (82.9%); with 16 lacrimal ducts resolving before six months of age. Therefore, a comparatively high percentage of resolution for CNLDO (82.9%) following conservative management was shown before the 1st year of age in Japanese infants.