Shima Fukuoka

Proposed Diagnostic Criteria for Obstructive Meibomian Gland Dysfunction

PURPOSE To compare clinical findings between patients with obstructive meibomian gland dysfunction (MGD) and normal controls and to propose diagnostic criteria for obstructive MGD. DESIGN Cross-sectional, observational case series. PARTICIPANTS Fifty-three eyes of 53 patients (18 men, 35 women; age [mean +/- standard deviation] 71.4 +/- 10.0 years) who were diagnosed with obstructive MGD and 60 eyes of 60 healthy volunteers (22 men, 38 women; 71.0 +/- 9.3 years) as a control group. METHODS Ocular symptoms were scored from 0 to 14 according to the number of existing symptoms. Lid margin abnormality was scored from 0 to 4 depending on the number of existing abnormalities. Meibomian gland changes were scored from 0 to 6 based on noncontact meibography (meibo-score). Superficial punctuate keratopathy (SPK) was scored from 0 to 3. Meibum was graded from 0 to 3 depending on the volume and quality. Tear film production was evaluated by Schirmers test. Receiver operating characteristic curves with calculations of area under the curve (AUC) were used to describe the accuracy of each parameter to differentiate obstructive MGD from normal eyes. MAIN OUTCOME MEASURES Ocular symptom score, lid margin abnormality score, meibo-score, meibum score, SPK score, tear film breakup time (BUT), and the Schirmer value. RESULTS Ocular symptom score, lid margin abnormality score, meibo-score, meibum score, and SPK score were significantly higher in the obstructive MGD group than in the control group (P<0.0001 for all scores). The BUT was significantly shorter in the obstructive MGD group than in the control group (P<0.0001). The AUC values indicated that the ocular symptom score had the highest diagnostic power as a single parameter, followed by the lid margin abnormality score, meibo-score, and BUT. CONCLUSIONS Based on these findings, we recommend that physicians use the ocular symptom score, lid margin abnormality score, and meibo-score to diagnose MGD. Obstructive MGD should be suspected when any 2 of the 3 scores are abnormal. Obstructive MGD is very likely when all 3 scores are abnormal.

Intraocular pressure in an ophthalmologically normal Japanese population

Purpose:  To investigate the distribution of intraocular pressure (IOP) measured by Goldmann applanation tonometry (GAT) and factors correlating with IOP, with special attention to age, in a large sample of ophthalmologically normal Japanese subjects.

Extended long-term results of penetrating keratoplasty for keratoconus.

Purpose: To investigate the extended long-term results of penetrating keratoplasty (PK) for keratoconus. Methods: The subjects were all patients with clinical keratoconus who underwent initial PK at University of Tokyo from 1971 to 1990 and whose medical records were available. Data were retrieved from the medical records. Kaplan-Meier survival analysis was performed to estimate the cumulative probability of immune reaction-free grafts and graft survival. Results: One hundred twenty-five eyes in 125 patients met the entry criteria. The average age at the time of PK was 25.0 ± 8.9 years. With an average follow-up period of 15.3 ± 9.7 years, 12 eyes (9.6%) experienced rejection and 5 eyes (4.0%) experienced graft failure. Average best-corrected visual acuity in logarithm of the minimum angle of resolution at preoperation, 10, 20, and 25 years after surgery was 1.54 ± 0.68, 0.06 ± 0.22, 0.03 ± 0.17, and 0.14 ± 0.42, respectively. The cumulative probability of graft survival at 10, 20, and 25 years after PK was 98.8%, 97.0%, and 93.2%, respectively. Conclusions: Recovery of visual acuity was good after PK for keratoconus in an extended follow-up. The graft survival rate, however, gradually decreased 20 years after PK.

In Vivo Confocal Microscopy of Hereditary Sensory and Autonomic Neuropathy

Purpose: To observe the morphology of the corneal cells and corneal nerve fibers in patients with type IV or V hereditary sensory and autonomic neuropathy (HSAN) by in vivo confocal microscopy and elucidate the mechanism leading to the loss of corneal sensation in this disease. Methods: In vivo confocal microscopy was performed on the central cornea of the right eye in 3 patients with HSAN (ages 17, 20, and 32 years), and their corneal morphology was compared with that of 3 healthy subjects (ages 28, 30, and 36 years). Corneal sensation was tested with a Cochet-Bonnet esthesiometer. Results: The superficial epithelial cell density was lower in the HSAN patients compared with the healthy subjects (1525, 1225, and 1250/mm2 vs. 2225, 1750, and 2500/mm2), but the basal epithelial cell density of the patients was similar to that of the healthy subjects. Nerve bundles were clearly observed in the sub-basal nerve plexus layer of the cornea in the healthy subjects, but were undetectable at the central cornea in the patients with HSAN. The corneal sensation of the patients with HSAN was much weaker than that of the healthy subjects (2.79, 40.30, and 132.50 g/mm2 vs. 1.47, 1.47, and 1.47 g/mm2). Conclusions: Superficial keratopathy accompanied with neurotrophic keratopathy and tear film instability observed clinically agrees with the large keratinized cells in the superficial corneal epithelium by in vivo confocal microscopy in these patients. Our findings suggest that the loss of corneal nerves contributes to impairment of corneal sensation in patients with type IV or V HSAN.

Conjunctivochalasis and Contact Lenses

PURPOSE To assess the relationship between age and the incidence and severity of conjunctivochalasis in contact lens (CL) wearers by grading of conjunctivochalasis, and to compare the severity of conjunctivochalasis between CL wearers and nonwearers. DESIGN Prospective, nonrandomized consecutive case study. METHODS A total of 600 CL wearers (94 hard CLs [HCL] and 506 soft CLs [SCL]) aged 11 to 60 years and 579 nonwearers aged 10 to 60 years were enrolled. The age, gender, medical history, ocular history, and the grade and other parameters of conjunctivochalasis at 3 locations (nasal, middle, and temporal areas) were determined in all subjects. RESULTS The prevalence of conjunctivochalasis increased dramatically with age in all groups. The mean grade of conjunctivochalasis was higher in CL wearers than in nonwearers (nasal area, P < .00001; temporal area, P < .00001) and was higher in HCL wearers than in SCL wearers (nasal area, P < .00001; temporal area, P = .00003). Parameters such as the downward gaze-dependent or digital pressure-dependent changes of conjunctivochalasis and the presence of superficial punctate keratitis all increased with age in both CL wearers and nonwearers. The gaze-dependent and pressure-dependent changes of conjunctivochalasis showed an increase with age and the duration of CL wear in both SCL and HCL wearers. CONCLUSIONS This was the first assessment of the severity of conjunctivochalasis in a large series of consecutive CL wearers. Our results strongly suggest that wearing CLs is an important risk factor for conjunctivochalasis.

Subconjunctival Hemorrhage and Conjunctivochalasis

OBJECTIVE Subconjunctival hemorrhage (SCH) is a relatively common disease, but there have been no reports concerning the relationship between SCH and conjunctivochalasis (CCh). We compared the grade of CCh between patients with SCH and control patients. DESIGN Prospective, nonrandomized study. PARTICIPANTS A total of 104 patients with SCH aged 41 to 94 years and 120 age- and gender-matched controls aged 41 to 94 years were enrolled. METHODS The conjunctiva was divided into the following 8 equal areas: superior, superior/nasal, nasal, inferior/nasal, inferior, inferior/temporal, temporal, and superior/temporal. The age, gender, medical history, ocular history, site of hemorrhage, grade of CCh at 3 locations (nasal, middle, and temporal), and other parameters of CCh were determined in all subjects. MAIN OUTCOME MEASURES Grade of each CCh parameter and location of SCH. RESULTS The mean grade of CCh was higher in patients with SCH than in control patients at the nasal (P<0.00001), middle (P<0.00001), and temporal areas (P<0.00001). The downward gaze- or digital pressure-dependent changes of CCh and the frequency of superficial punctate keratitis were all increased in SCH patients compared with control patients (P<0.00001, P<0.00001, and P = 0.00106, respectively). The number of areas involved by SCH and the presence of SCH in each area were positively correlated with the grade of each CCh-related parameter (P<0.05). CONCLUSIONS This was the first assessment of the grade of CCh in a large series of consecutive patients with SCH. Our results strongly suggest that CCh may have an important role in the pathogenesis of SCH.

Effect of trabeculectomy on ocular and corneal higher order aberrations

PurposeTo examine the effect of trabeculectomy on ocular and corneal higher order wavefront aberrations.MethodsTrabeculectomy with a limbal-based conjunctival flap was performed in 13 patients (13 eyes). Ocular and corneal higher order aberrations were measured using a wavefront analyzer before and after surgery. The higher order aberrations for a 4-mm pupil diameter were expanded into Zernike’s polynomials. Coma aberration, spherical aberration, and total higher order aberrations were evaluated as root mean square values.ResultsMean intraocular pressure was significantly reduced from 15.5 ± 3.1 mmHg preoperatively to 7.5 ± 3.5 and 7.2 ± 4.4 mmHg at 1 and 3 months after surgery, respectively. The mean spherical equivalent refractive error was not changed by the surgery. Mean vector powers for surgically induced refractive changes at 1 and 3 months postoperatively were 1.29 ± 0.69 and 1.30 ± 0.89 diopters, respectively. Corneal coma-like, spherical-like, and total higher order aberrations were not significantly changed by surgery. Trabeculectomy significantly increased ocular coma-like (P = 0.0021) and total (P = 0.0019) higher-order aberrations at 1 month, but not at 3 months postoperatively.ConclusionOcular coma-like and total aberrations were significantly increased at 1 month after trabeculectomy with a limbal-based conjunctival flap, but they had returned to normal levels by 3 months.

Location and extent of subconjunctival hemorrhage.

Purpose: Subconjunctival hemorrhage (SCH) is a relatively frequent disease; however, there have been no reports about its location and extent. We examined its location and extent. Methods: A total of 151 patients with SCH aged 2–94 years were studied. The conjunctiva was divided into 8 equal areas. The age, gender, medical history, ocular history and site of hemorrhage were determined for all subjects. Results: The number of areas involved by SCH showed an age-related increase. Traumatic SCH had a smaller extent compared with SCH related to hypertension, diabetes and hyperlipidemia, or idiopathic SCH. Overall, SCH was significantly more common in the inferior areas than the superior areas (55.3% vs. 25.0%, p < 0.000001). In patients with SCH secondary to trauma or diabetes, however, the temporal areas were affected more often than the nasal areas (61.5% vs. 30.8% and 73.3% vs. 20.0%, respectively). Conclusion: SCH showed an age-related increase in extent and was predominant in the inferior areas. However, traumatic SCH was usually detected as localized hemorrhage in the temporal areas.

Tear Interferometric Patterns Reflect Clinical Tear Dynamics in Dry Eye Patients

PURPOSE We investigated whether the tear interferometric pattern was able to identify differences in tear film kinetics among clinical subtypes of dry eye. METHODS A total of 138 eyes of 76 subjects (38 men and 38 women; mean age ± SD, 61.6 ± 16.2 years) with or without dry eye who visited Itoh Clinic from May to August 2015 were enrolled in a cross-sectional study. Clinical diagnosis of dry eye subtype was based on tear film parameters. The pattern of tear film kinetics determined by interferometry was classified as 0 (monotonous gray or multicolor interferometric fringe with a noninvasive breakup time [NIBUT] of ≥5 seconds), 1 (multicolor interferometric fringe with a NIBUT of <5 seconds), or 2 (grayish amorphous interferometric fringe with a NIBUT of <5 seconds), and reliability of classification was evaluated. Lipid layer thickness (LLT) for the tear film was also determined by interferometry. RESULTS Interrater κ values for evaluation of interferometric patterns ranged from 0.57 to 0.94 for both physicians and nonphysicians with reference to a dry eye expert, the latter of whom showed an intrarater reliability of 0.90. The distribution of eyes among interferometric patterns 0, 1, and 2 coincided well with the clinical subgroups of normal tear condition, non-Sjögren syndrome aqueous-deficient dry eye, and meibomian gland dysfunction, respectively. A multicolor interferometric fringe was essentially observed only at an LLT of >70 nm. CONCLUSIONS Tear interferometry was able to reliably distinguish clinical subtypes of dry eye by reflecting the balance between the lipid and aqueous layers of the tear film.

Severe hyperopic shift and irregular astigmatism after radial keratotomy.

Objectives: To report a case of acute high hyperopia occurring after radial keratotomy and evaluate the extent of corneal wavefront aberration with a Hartmann-Shack aberrometer. Methods: A 45-year-old man had undergone bilateral radial keratotomy with four incisions for myopia 15 years earlier. The patient developed significant hyperopia and irregular corneal astigmatism in the left eye after the operation, reducing his best-corrected visual acuity. Results: The best-corrected visual acuity was 20/20 (with refraction of +0.25–1.50 diopters [D] × 169) in the right eye and 10/20 (with refraction of +9.5D–3.00D × 50) in the left eye. Topography showed marked flattening of the left cornea, and simulated retinal images of Landolt C circles were distorted in the left eye. Conclusions: This is a rare case in which radial keratotomy induced severe hyperopic shift. Wavefront analysis with a Hartmann-Shack aberrometer revealed severe irregular astigmatism with small clear zones.