Taku Wakabayashi

Foveal Microstructure and Visual Acuity after Retinal Detachment Repair : Imaging Analysis by Fourier-Domain Optical Coherence Tomography

PURPOSE To evaluate foveal microstructural changes in eyes with anatomically successful repair of rhegmatogenous retinal detachments (RRDs). DESIGN Retrospective, consecutive, observational case series. PARTICIPANTS Fifty-three eyes of 51 consecutive patients with macula-on RRDs (15 eyes) or macula-off RRDs (38 eyes) after anatomically successful surgical repair. METHODS A microscopic fundus examination was conducted followed by Fourier-domain optical coherence tomography (FD-OCT) to assess the postoperative foveal microstructure. The correlation between the postoperative best-corrected visual acuity (BCVA) and microstructural findings at the fovea was evaluated. MAIN OUTCOME MEASURES Images of the foveal microstructure obtained by FD-OCT and the BCVA measured on the same day. RESULTS We obtained FD-OCT images a mean of 10.3+/-7.3 months (range, 1-25) postoperatively. Foveal anatomic abnormalities were detected in 33 eyes (62%); disruption of the junction between the photoreceptor inner and outer segments (IS/OS) in 23 eyes (43%), of which 9 eyes (39%) had a disrupted external limiting membrane (ELM); residual subretinal fluid in 6 eyes (11%), epiretinal membranes in 12 eyes (23%), and cystoid macular edema in 2 eyes (4%). Disruption of the photoreceptor IS/OS junction was observed only in macula-off eyes, whereas other microstructural abnormalities were observed in both macula-on and macula-off eyes. In preoperative macula-off eyes, the postoperative BCVA was significantly correlated with the integrity of the photoreceptor IS/OS and ELM signals detected by FD-OCT postoperatively (r=0.805; P<0.001). Of the 16 eyes followed by FD-OCT, the photoreceptor IS/OS junction was restored in 7 (64%) of the 11 eyes with a disrupted back-reflection line from the IS/OS junction, but without disrupted ELM signals at the initial examination. Of the 5 eyes with disrupted back-reflection lines from both IS/OS junction and ELM at the initial examination, the photoreceptor layer was not restored completely during the follow-up period in any eyes. CONCLUSIONS After anatomically successful RRD repair, FD-OCT is a valuable, noninvasive tool for evaluating foveal microstructural changes. The integrity of the photoreceptor IS/OS junction and ELM signals detected by FD-OCT may account for visual restoration in patients with preoperative macula-off RRDs. Preservation of the ELM postoperatively may predict the subsequent restoration of the photoreceptor layer.

Intravitreal Bevacizumab to Treat Iris Neovascularization and Neovascular Glaucoma Secondary to Ischemic Retinal Diseases in 41 Consecutive Cases

PURPOSE To evaluate the biologic efficacy of intravitreal bevacizumab (IVB) for iris neovascularization (INV) or neovascular glaucoma (NVG) in patients with ischemic retinal disorders. DESIGN Retrospective, consecutive, interventional case series. PARTICIPANTS Thirty patients (41 eyes) with INV or NVG secondary to ischemic retinal disorders. METHODS Patients received IVB (1 mg) as the initial treatment for INV or NVG and were followed up for at least 6 months. Ophthalmic evaluations included measurement of visual acuity and intraocular pressure (IOP), a complete ophthalmic examination, and fluorescein angiography. Patients were divided into 3 subgroups: INV without elevated IOP (INV group), NVG with an open angle (O-NVG group), and NVG with angle closure (C-NVG group) for outcomes analysis. MAIN OUTCOME MEASURES The controllability of IOP by IVB, incidence of recurrence, and requirement for surgery to treat NVG. RESULTS No significant ocular or systemic adverse events developed during follow-up (range, 6-22 months; mean, 13.3 months). The mean IOP levels were 14.7, 31.2, and 44.9 mmHg at baseline in the INV, O-NVG, and C-NVG groups, respectively. In the INV group (9 eyes), the INV regressed or resolved after 1 injection. Iris neovascularization recurred in 4 eyes by 6 months and stabilized after repeated injections without IOP elevation. In the O-NVG group (17 eyes), rapid neovascular regression with successful IOP normalization (<or=21 mmHg) occurred in 12 eyes (71%) within 1 week after 1 injection. Five (29%) of the 17 eyes required surgery by 6 months despite repeated IVB injections, and a total of 7 eyes (41%) underwent surgery during follow-up. In the C-NVG group (15 eyes), IVB caused INV resolution but failed to lower the IOP. Fourteen (93%) of 15 eyes required surgery by 2 months after initial IVB and achieved IOP stabilization. The mean interval between IVB and surgery was significantly shorter in the C-NVG group than in the O-NVG group (P<0.001). CONCLUSIONS Intravitreal bevacizumab is well tolerated, effectively stabilized INV activity, and controlled IOP in patients with INV alone and early-stage NVG without angle closure. In advanced NVG, IVB cannot control IOP but may be used adjunctively to improve subsequent surgical results. Further evaluation in controlled randomized studies is warranted.

Foveal Microstructure and Visual Acuity in Surgically Closed Macular Holes: Spectral-Domain Optical Coherence Tomographic Analysis

PURPOSE To evaluate reconstructive changes in foveal microstructures and identify a correlation with visual outcomes in eyes with surgically closed macular holes (MHs). DESIGN Retrospective, consecutive, observational case series. PARTICIPANTS Forty eyes (40 patients) with surgically closed MHs. METHODS Spectral-domain optical coherence tomography (SD-OCT) was performed to assess the foveal microstructural changes 3 and 12 months postoperatively. The correlation between the postoperative best-corrected visual acuity (BCVA) and the integrity of the foveal photoreceptor layer was evaluated. MAIN OUTCOME MEASURES The integrity of the back-reflection lines from the photoreceptor inner segment (IS) and outer segment (OS) junction and the external limiting membrane (ELM) on SD-OCT images and the BCVA measured on the same day. RESULTS The integrity of the foveal photoreceptor layer was the only postoperative SD-OCT finding significantly associated with the 3-month BCVA (r=0.483; P=0.002). The eyes were categorized into 3 groups according to restoration of the IS/OS junction and ELM signals: 6 eyes (15%) in group A with complete restoration of the IS/OS junction and the ELM; 26 eyes (65%) in group B with a disrupted IS/OS junction and intact ELM; and 8 eyes (20%) in group C with disruption or loss of the IS/OS junction and the ELM. Although the baseline BCVA did not differ significantly (P=0.137) among groups, the mean 3-month BCVA values in groups A and B, both with reconstructed ELM with or without a restored photoreceptor IS/OS, were significantly better than in group C (P<0.05); the difference between groups A and B was not significant (P>0.05). Groups A (P=0.029) and B (P<0.001) had significant visual improvement at 12 months; group C did not have marked visual recovery. Fourteen eyes (54%) in group B had subsequent realignment of the foveal photoreceptor IS/OS; no eyes in group C had a restored IS/OS at 12 months. The presence of the ELM at 3 months is a critical structural feature significantly correlated with the BCVA at 12 months (r=0.832, P<0.001). CONCLUSIONS Reconstruction of the foveal ELM in the early postoperative period helps predict subsequent restoration of the foveal photoreceptor layer and the potential for better visual outcomes.

A 27–Gauge Instrument System for Transconjunctival Sutureless Microincision Vitrectomy Surgery

OBJECTIVES To evaluate the efficiency, preliminary safety, and feasibility of a 27-gauge instrument system for transconjunctival microincision vitrectomy surgery (MIVS) in a variety of vitreoretinal diseases. DESIGN Experimental, interventional case series. PARTICIPANTS Thirty-one eyes (31 patients) underwent a variety of vitreoretinal procedures using the 27-gauge transconjunctival MIVS system to treat epiretinal membrane (n = 10), idiopathic macular holes (n = 7), diabetic vitreous hemorrhage (n = 5), vitreous opacity with suspicion of intraocular lymphoma (n = 4), focal diabetic traction retinal detachment (n = 3), macular traction syndrome (n = 1), and macular edema secondary to central retinal vein occlusion (n = 1). METHODS We developed a 27-gauge instrument system that includes an infusion line, a high-speed vitreous cutter, an illumination system, and a variety of vitreoretinal instruments, such as membrane forceps and sharp-tipped endophotocoagulation probes. The duty cycle of the 27- and 25-gauge cutters was measured for several cut rates using a high-speed imaging camera. Infusion and aspiration rates were measured using balanced saline solution (BSS) and porcine vitreous with different aspiration levels. Surgical outcomes, including anatomic success, visual outcomes, operating times, and intraoperative and postoperative complications, were evaluated. MAIN OUTCOME MEASURES Duty cycle of cutters, infusion and aspiration rates, and surgical results of 27-gauge vitrectomy. RESULTS Although the infusion and aspiration rates of the 27-gauge system measured in BSS were reduced to an average of 62% and 80%, respectively, compared with those of the 25-gauge system, the duty cycle of the 27-gauge cutter, 61% at 1000 cpm and 38% at 1500 cpm, was equal to or better than those of the 25-gauge cutter (62% and 28%, respectively). Analysis of the fluid dynamics showed that vented gas-forced infusion can be set to range from 20 to 30 mmHg to control intraocular pressure (IOP) during 27-gauge vitrectomy. Anatomic success was achieved in all study eyes (100%); 20 eyes (65%) had visual improvement of 3 lines or more. No eyes required conversion to larger gauge instrument. All sclerotomies self-sealed without hypotony (IOP < or = 7 mmHg) from 1 day postoperatively. CONCLUSIONS Although the fluid dynamics and cutting efficiency of 27-gauge instruments are lower compared with 25-gauge MIVS, the 27-gauge system is feasible and may reduce concerns about wound sealing-related complications in selected cases. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Microincision Vitrectomy Surgery and Intravitreal Bevacizumab as a Surgical Adjunct to Treat Diabetic Traction Retinal Detachment

PURPOSE To investigate the feasibility and efficacy of microincision vitrectomy surgery (MIVS) combined with intravitreal bevacizumab (IVB) as a surgical adjunct for treating traction retinal detachment (TRD) secondary to severe proliferative diabetic retinopathy (PDR). DESIGN Retrospective, comparative, consecutive, interventional case series. PARTICIPANTS Seventy-one eyes of 59 consecutive patients who underwent primary vitrectomy for diabetic TRD and were followed up for more than 6 months after surgery. METHODS Eyes that received IVB (1 mg) as a preoperative adjunct followed by MIVS (IVB/MIVS group) from November 2005 through December 2007 were compared with eyes that underwent conventional 20-gauge pars plana vitrectomy (20-g PPV group) from September 2003 through October 2005. MAIN OUTCOME MEASURES Primary and ultimate anatomic success, intraoperative and postoperative complications, and final visual success with at least 6 months of follow-up. RESULTS This series included 38 eyes (33 patients) in the IVB/MIVS group and 33 eyes (26 patients) in the 20-g PPV group. The primary and ultimate anatomic success rates (95% vs. 91% and 100% in both groups, respectively) and the mean visual acuity changes did not differ significantly between groups; the surgical time and intraoperative bleeding in the IVB/MIVS group decreased significantly compared with the 20-g PPV group (P<0.001). The rate of visual improvement of 3 lines or more at the 6-month follow-up was 68% in the IVB/MIVS group and 49% in the 20-g PPV group, respectively. Progression of the preexisting TRD after IVB occurred in 7 eyes (18%). Absence of previous laser photocoagulation (P = 0.025) and the presence of a ring-shaped fibrovascular membrane (P = 0.013) were relevant findings in eyes with these IVB-induced complications. CONCLUSIONS Intravitreal bevacizumab plus MIVS offers comparable anatomic success compared with conventional 20-gauge PPV in patients with TRD resulting from severe PDR. This technique shortens the surgical time with fewer intraoperative complications and favorable visual recovery. However, caution should be taken because of rapid progression of the preexisting TRD after IVB in some patients. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Morphologic Changes in Acute Central Serous Chorioretinopathy Evaluated by Fourier-Domain Optical Coherence Tomography

OBJECTIVE To investigate morphologic alterations around fluorescein leakage sites using Fourier-domain optical coherence tomography (FD OCT) in acute central serous chorioretinopathy (CSC). DESIGN Observational case series. PARTICIPANTS Twenty-one eyes with acute CSC with subjective symptoms for under 3 months. METHODS Patients underwent measurement of visual acuity, fundus observations, and FD OCT examinations at every visit with the intervals of 2 to 4 weeks until subretinal fluid (SRF) resolved. Fluorescein angiography was performed at baseline to confirm dye leakage sites. Horizontal and vertical OCT scans (B-scans and consecutive raster scans) of the fovea and fluorescein leakage sites were obtained. MAIN OUTCOME MEASURES Morphologic changes in the retinal pigment epithelium (RPE), detached retina, and subretinal space around the leakage sites were evaluated repeatedly during follow-up. RESULTS The mean period between baseline and the final examination was 108 days (mean no. of examinations, 3.9). Among 23 leakage sites in 21 eyes, FD OCT showed RPE abnormalities in 22 (96%) sites (14 sites [61%] with a pigment epithelial detachment [PED] and 8 [35%] with a protruding or irregular RPE layer). Fibrinous exudates in the subretinal space and sagging/dipping of the posterior layer of the neurosensory retina above the leakage sites were seen at 12 (52%) and 10 (43%) leakage points, respectively. An RPE defect at the edge of or within the PED was observed in 5 leakage sites (22%); in 2 of these, a defect was detectable after the SRF decreased. The posterior surface of the detached retina was smooth in 17 eyes (81%) and granulated in 4 eyes (19%) (mean duration of subjective symptoms, 10 days and 42 days, respectively). The smooth posterior detached retina became granulated in the presence of residual SRF. A PED remained at the 5 leakage sites in 5 eyes (22%) despite SRF resolution. CONCLUSIONS Fourier-domain OCT examinations showed detailed morphologic changes in eyes with acute CSC including an RPE defect within the PED at a leakage site through which fluid might pass from the sub-RPE to the subretinal area. Fourier-domain OCT findings may offer new information to facilitate understanding of the mechanisms of acute CSC.

Identification and characterization of a resident vascular stem/progenitor cell population in preexisting blood vessels

Vasculogenesis, the in‐situ assembly of angioblast or endothelial progenitor cells (EPCs), may persist into adult life, contributing to new blood vessel formation. However, EPCs are scattered throughout newly developed blood vessels and cannot be solely responsible for vascularization. Here, we identify an endothelial progenitor/stem‐like population located at the inner surface of preexisting blood vessels using the Hoechst method in which stem cell populations are identified as side populations. This population is dormant in the steady state but possesses colony‐forming ability, produces large numbers of endothelial cells (ECs) and when transplanted into ischaemic lesions, restores blood flow completely and reconstitutes de‐novo long‐term surviving blood vessels. Moreover, although surface markers of this population are very similar to conventional ECs, and they reside in the capillary endothelium sub‐population, the gene expression profile is completely different. Our results suggest that this heterogeneity of stem‐like ECs will lead to the identification of new targets for vascular regeneration therapy.

Efficacy of Intravitreal Bevacizumab Combined With Photodynamic Therapy for Polypoidal Choroidal Vasculopathy

PURPOSE To compare the efficacy of photodynamic therapy (PDT) with or without intravitreal bevacizumab injection for polypoidal choroidal vasculopathy. DESIGN Retrospective, comparative, interventional case series. METHODS We included 146 eyes of 146 patients with treatment-naïve polypoidal choroidal vasculopathy including the subfoveal region treated with PDT monotherapy or combined with intravitreal bevacizumab injection. Treatments were chosen according to the time period. For eyes that received combination therapy, bevacizumab (1.25 mg) was administrated 1 day before PDT. All eyes were followed up for at least 12 months. Ophthalmic evaluations, including measurement of the best-corrected visual acuity and optical coherence tomography, were performed at every visit. Indocyanine green angiography and fluorescein angiography were performed every 3 months. RESULTS Sixty-one eyes were treated with PDT combined with bevacizumab and 85 eyes were treated with PDT monotherapy. The mean best-corrected visual acuity was significantly better in the combined treatment group than in the monotherapy group at 3 months (P = .0016), 6 months (P = .028), 9 months (P = .038), and 12 months (P = .048). However, lesions resolved in 78.7% of eyes in the combined group and in 75.3% in the monotherapy group; the recurrence rates were 43.8% and 40.6%, respectively, and did not differ significantly. The rate of development of subretinal hemorrhage within 1 month from the initial treatment was significantly lower in the combined group than in the PDT monotherapy group (4.5% vs 17.7%; P = .023). CONCLUSIONS Photodynamic therapy combined with bevacizumab injection offers significantly better early visual outcomes than PDT alone. Combined treatment did not affect the resolution and recurrence of lesions; however, it decreased the rate of development of PDT-related hemorrhages.

Marked vascular changes of polypoidal choroidal vasculopathy after photodynamic therapy.

Aims: To clarify vascular changes of polypoidal choroidal vasculopathy (PCV) after photodynamic therapy (PDT). Methods: Thirty-one eyes underwent PDT with verteporfin and were followed every 3 months with indocyanine green angiography (ICGA) using confocal scanning ophthalmoscope and optical coherence tomography (OCT) for over 15 months and the findings recorded. Results: The mean follow-up period was 19.2 months. Regression of the polypoidal lesions were confirmed once in 29 eyes (94%) on ICGA and OCT. Some lesions recurred at the initial regions (n = 5 eyes), at different regions connected to the branching vascular network (n = 4 eyes), and at both regions (n = 1 eye) (mean 11.4 (SD 1.9) months) after initial PDT. The branching vascular network remained in all eyes and enlarged in 13 eyes (42%) at the final visit. The vascular features of residual branching vascular networks changed (n = 7 eyes); fibrinous subretinal exudation developed (n = 4 eyes), and the retinal pigment epithelium was elevated similar to vascularised pigment epithelial detachment (n = 3 eyes). Conclusion: Polypoidal lesions of PCV are treatable with PDT; however, they often recur. The branching vascular networks do not regress and allow the recurrence of polypoidal lesions at the network termini. Alterations of the vascular features may occur; careful observation is needed after PDT.

Correlation of fundus autofluorescence with photoreceptor morphology and functional changes in eyes with retinitis pigmentosa

Purpose:  To assess and correlate fundus autofluorescence (FAF) characteristics with photoreceptor morphology and functional features in eyes with retinitis pigmentosa (RP).