Naoko Takada

Ulcerative keratitis in patients with rheumatoid arthritis in the modern biologic era: a series of eight cases and literature review

To assess the prevalence, clinical characteristics, treatment, and outcomes of patients who developed ulcerative keratitis (UK) during the course of rheumatoid arthritis (RA) in the modern biologic era.

OCT-Based Quantification and Classification of Optic Disc Structure in Glaucoma Patients.

Purpose To objectively classify the optic discs of open-angle glaucoma (OAG) patients into Nicolelas four disc types, i.e., focal ischemic (FI), myopic (MY), senile sclerotic (SS), and generalized enlargement (GE), with swept-source optical coherence tomography (SS-OCT). Methods This study enrolled 113 eyes of 113 OAG patients (mean age: 62.5 ± 12.6; Humphrey field analyzer-measured mean deviation: -9.4 ± 7.3 dB). Newly developed software was used to quantify a total of 20 optic disc parameters in SS-OCT (DRI OCT-1, TOPCON) images of the optic disc. The most suitable reference plane (RP) above the plane of Bruch’s membrane opening was determined by comparing, at various RP heights, the SS-OCT-measured rim parameters and spectral-domain OCT-measured circumpapillary retinal nerve fiber layer thickness (cpRNFLT), with Pearsons correlation analysis. To obtain a discriminant formula for disc type classification, a training group of 72 eyes of 72 OAG patients and a validation group of 60 eyes of 60 OAG patients were set up. Results Correlation with cpRNFLT differed with disc type and RP height, but overall, a height of 120 μm minimized the influence of disc type. Six parameters were most significant for disc type discrimination: disc angle (horizontal), average cup depth, cup/disc ratio, rim-decentering ratio, average rim/disc ratio (upper and lower nasal). Classifying the validation group with these parameters returned an identification rate of 80.0% and a Cohen’s Kappa of 0.73. Conclusion Our new, objective SS-OCT-based method enabled us to classify glaucomatous optic discs with high reproducibility and accuracy.

Classification of optic disc shape in glaucoma using machine learning based on quantified ocular parameters

Purpose This study aimed to develop a machine learning-based algorithm for objective classification of the optic disc in patients with open-angle glaucoma (OAG), using quantitative parameters obtained from ophthalmic examination instruments. Methods This study enrolled 163 eyes of 105 OAG patients (age: 62.3 ± 12.6, mean deviation of Humphrey field analyzer: -8.9 ± 7.5 dB). The eyes were classified into Nicolela’s 4 optic disc types by 3 glaucoma specialists. Randomly, 114 eyes were selected for training data and 49 for test data. A neural network (NN) was trained with the training data and evaluated with the test data. We used 91 types of quantitative data, including 7 patient background characteristics, 48 quantified OCT (swept-source OCT; DRI OCT Atlantis, Topcon) values, including optic disc topography and circumpapillary retinal nerve fiber layer thickness (cpRNFLT), and 36 blood flow parameters from laser speckle flowgraphy, to build the machine learning classification model. To extract the important features among 91 parameters, minimum redundancy maximum relevance and a genetic feature selection were used. Results The validated accuracy against test data for the NN was 87.8% (Cohen’s Kappa = 0.83). The important features in the NN were horizontal disc angle, spherical equivalent, cup area, age, 6-sector superotemporal cpRNFLT, average cup depth, average nasal rim disc ratio, maximum cup depth, and superior-quadrant cpRNFLT. Conclusion The proposed machine learning system has proved to be good identifiers for different disc types with high accuracy. Additionally, the calculated confidence levels reported here should be very helpful for OAG care.

The Effect of Systemic Hyperoxia on Optic Nerve Head Blood Flow in Primary Open-Angle Glaucoma Patients

Purpose To assess the optic nerve head blood flow (ONH BF) response to hyperoxia in glaucoma patients using laser speckle flowgraphy (LSFG), and determine factors influencing vasoreactivity within the ONH. Methods We performed oxygen provocation testing in 15 eyes of 15 primary open-angle glaucoma (POAG) patients and 15 eyes of 15 age-matched control subjects. During the test, LSFG-derived tissue mean blur rate (MBRT) and clinical variables, including blood pressure, were recorded. We evaluated differences in MBRT alteration during systemic hyperoxia between the groups. Additionally, we calculated the mean % change in MBRT against baseline and determined contributing factors. Results Despite similar clinical variables during systemic hyperoxia in both groups, the mean % change in MBRT against baseline was significantly lower in the POAG than control subjects (P < 0.0001). Multiple regression analysis revealed that baseline MBRT and systolic blood pressure (SBP) were contributing factors to mean % change in MBRT (β = 0.44, β = -0.32, respectively). Additionally, baseline MBRT and SBP were strongly correlated to mean % change in MBRT only in the POAG group (r = 0.83, P < 0.0001; r = -0.60, P = 0.02, respectively). Conclusions POAG patients had a weaker vasoreactive response to hyperoxia than controls, and this impaired response was associated with lower basal ONH BF and higher SBP. These findings suggest that pre-existing vasoconstriction in the ONH of eyes with glaucoma might reduce the capacity of the vasoconstrictive response to hyperoxia. Alternatively, the pathways that mediate hyperoxia-induced vasoconstriction could be altered in POAG.

Regional susceptibility of the optic disc to retinal nerve fiber layer thinning in different optic disc types of eyes with normal tension glaucoma

1. Thomas R, Lawlor M. Ophthalmic support in developing countries. Clin Experiment Ophthalmol 2014; 42: 397–8. 2. Available from: http://www.who.int/blindness/ AP2014_19_English.pdf?ua=1 3. Available from: http://www.ranzco.edu/index.php/ about/our-organisation/strategic-plan 4. Available from: http://www.ranzco.edu/index.php/ international-development 5. Available from: http://www.acfid.asn.au/about-acfid/ what-is-acfid 6. Available from: http://www.iapb.org

Regional correlation of macular areas and visual acuity in patients with open-angle glaucoma.

a case of post-intravitreal injection endophthalmitis (P = 0.503). In the multivariate analysis, no potentially modifiable risk factors were identified to increase postintravitreal injection endophthalmitis. This survey sought to establish some of the practices of Victorian ophthalmologists who perform intravitreal injections to treat neovascular AMD, mainly in their private rooms. Although no potentially modifiable risk factors are identified for post-intravitreal injection endophthalmitis, some trends are shown. Of particular interest are the trends for those who see more patients and those who do not use a drape, and while these two factors are not linked, it is not possible to hypothesize whether ‘time’ is a factor. Major limitations of this study include the potential low number of responses, volunteer bias with an underparticipation of those who may have had endophthalmitis and the retrospective design. The authors are pleased to report that current practices in Victoria are consistent with current evidence. We thank all those who participated and believe that the information from this survey explores and helps ophthalmologists to keep thinking about potentially modifiable risk factors for optimal management in the prevention of post-intravitreal injection endophthalmitis.

Regional structural vulnerability of the macula in patients with normal tension glaucoma

Spectral domain-optical coherence tomography enables the segmentation and quantification of macular layer thickness in glaucoma patients. Major spectral domain-optical coherence tomography parameters helpful in diagnosing early glaucoma include circumpapillary retinal nerve fiber layer thickness (cpRNFLT), macular retinal nerve fiber layer (mRNFL) thickness and ganglion cell layer plus inner plexiform layer (mGCL + IPL) thickness. Clinically, cpRNFLT and other macular parameters are routinely used as diagnostic instruments in glaucoma detection and follow-up. Recent studies of these parameters in glaucoma patients have revealed that macular lesions are common in this disease, and that specific regions of the retina are more susceptible to glaucomatous damage than others, in particular the 7 o’clock and 11 o’clock sectors of the circumpapillary retinal nerve fiber layer. Additionally, regional susceptibility has been reported in the area below the fixation in the optical coherence tomography (OCT) macular map in open-angle glaucoma (OAG) patients. However, regional susceptibility in the macular of normal tension glaucoma (NTG) is not yet well understood. A greater understanding of regional damage in NTG, measured with OCT macular parameters, would therefore be of significant clinical value. Thus, the purpose of this investigation was to determine the regional vulnerability of the macular area in patients with NTG. This was a retrospective and cross-sectional study including 106 eyes of 106 patients with mild or moderate NTG (Humphrey Field Analyser mean deviation > −12.0 dB). The inclusion criteria were: NTG with untreated intraocular pressure (IOP) less than 22 mmHg, spherical equivalent refractive error of >−8.00 diopters (i.e. excluding patients with high myopia) and a glaucomatous visual field according to the Anderson-Patella classification. The exclusion criteria were: decimal visual acuity < 0.3, the presence of ocular disease other than OAG, systemic disease affecting the visual field and cataract progression. Topographical macular maps of the mRNFL, mGCL + IPL and circumpapillary retinal nerve fiber layer were made with three-dimensional OCT-2000 software (ver. 8.00, Topcon Corporation, Tokyo, Japan). The maps, based on macular cube scans of a 6 × 6 mm area of the retina centered on the fovea (corresponding to the central 20 degrees of the macula), were divided into 100 points in a 10 × 10 grid. Scans with image quality less than 70 or with inaccurate segmentation were excluded. For each grid point, we counted the number of patients with ganglion cell plus inner plexiform layers (GCL + IPL) thickness <1% (red) or <5% (yellow) less than an intergenerational normative database. Our statistical analysis used the Wilcoxon signed-rank test to analyse these differences in the superior and inferior hemifields, and Fisher’s exact test in the grid points. The demographic and average data from this study were as follows: male : female, 42:64; average age, 60.0 ± 14.7 years; spherical equivalent, −2.9 ± 2.5 D; Humphrey Field Analyzer (HFA) 24–2 mean deviation, −4.5 ± 3.2 dB; intraocular pressure, 13.5 ± 3.0 mmHg; and cpRNFLT, 88.6 ± 12.8 μm. Figure 1 shows the number of patients with abnormal mGCL + IPL thickness in each grid. Damaged grid points were widely distributed throughout the macular map. Eighty eyes (75%) had damage in the most commonly damaged grid point (located in the 1st column/5th row), and five eyes (5%) had damage in the least commonly damaged point (located in the 10th column/10th row). The average number of eyes in all grid points was 41.9 (39.5%). The inferior hemifield of the macular map was more susceptible than the superior hemifield (P < 0.001). The most significant damage was in an arcuate region containing 2 temporal grid points in the superior hemifield and 23 grid points in the inferior hemifield (Fig. 2a). The inferior arcuate region was more damaged distally than proximally (Fig. 2b). Competing/conflicts of interest: No stated conflict of interest.

Evaluation of retinal nerve fiber layer defect using wide-field en-face swept-source OCT images by applying the inner limiting membrane flattening

Purpose The assessment of retinal nerve fiber layer defects (RNFLDs) is a useful part of glaucoma care. Here, we obtained en-face images of retinal layers below the inner limiting membrane (ILM) with swept source-optical coherence tomography (SS-OCT), and measured RNFLD angle with new software. Methods This study included 105 eyes of 105 normal tension glaucoma (NTG) patients (age, 59.8 ± 13.2). Exclusion criteria were best-corrected visual acuity < 0.5, axial length > 28 mm, non-glaucoma ocular disease, and systemic disease affecting the visual field. We obtained 12 x 9 mm 3D volume scans centered on the macula with SS-OCT (DRI OCT-1, Topcon), and from these scans, created 3 averaged en-face images, each comprising 7 horizontal en-face images (total thickness: 18.2 μm). We labeled these averaged images, according to their depth below the ILM, as en-face images 1 (shallowest), 2 (middle) and 3 (deepest). In each image, a circle was drawn centered on the disc, with a radius of half the distance between the centers of the disc and macula. The investigator marked points where the edge of the RNFLD intersected this circle, and RNFLD angle (RNFLDA) was calculated with new software. Finally, we analyzed the association between RNFLDA, cpRNFLT, weighted RGC count (wrgc) and Humphrey field analyzer (HFA)-measured mean deviation (MD) and hemifield total deviation (TD), both overall and in each hemifield. Results En-face image 2 had the highest interclass reproducibility for measuring RNFLDA (intra-rater intraclass correlation coefficient (ICC): 0.988, inter-rater ICC: 0.962). The correlation coefficients with RNFLDA were: HFA MD, -0.60; superior TD, -0.73; inferior TD, -0.69; overall cpRNFLT, -0.27; superior hemifield cpRNFLT, -0.39; and inferior hemifield cpRNFLT, -0.53 (all p<0.001). Conclusions RNFLDA measured in SS-OCT images had high reproducibility and was correlated to glaucoma severity. Our new method may be a valuable future part of glaucoma care.

Pseudothrombocytosis caused by cryoglobulin crystals in a patient with primary Sjögren's syndrome

because of high titers of platelet-associated immunoglobulin G (212 ng/10 7 cells) and exclusion of other diseases. In rare cases, cryoglobulin-induced laboratory artifacts, such as pseudoleukocytosis and pseudothrombocytosis, impacts laboratory test results, which diff er from clinical symptoms [2 – 4]. Therefore, we rheumatologists should realize that the electrical resistance method, which is the conventional method for counting platelets, is aff ected by the formation of cryoglobulin crystals and that such artifacts may lead to a wrong decision of blood transfusion, potentially resulting in fatal consequences.