Tetsuya Mutoh

A retrospective study of nine cases of Acanthamoeba keratitis.

Purpose To evaluate the clinical features of Acanthamoeba keratitis in nine patients diagnosed at Dokkyo Medical University Koshigaya Hospital, Saitama, Japan. Methods In nine eyes of nine patients, Acanthamoeba keratitis was diagnosed by direct light microscopy of corneal scrapings stained by the Parker ink-potassium hydroxide method between September 2006 and September 2009. Their clinical features and course were studied retrospectively. Antifungal eye drops, systemic antifungal therapy, and surgical debridement of the corneal lesions were performed in all patients. Results At presentation, the clinical stage was initial in six cases, transient in one case, and complete in two cases. The patients were all contact lens wearers who had washed their lens storage cases with tap water. After treatment, final visual acuity was improved in six cases, unchanged in one case, and worse in two cases. The patient with the worst final vision (hand motion) had rheumatoid arthritis and was taking oral prednisolone, which led to corneal perforation and prevented adequate debridement from being done. Conclusion Acanthamoeba keratitis is closely related to wearing contact lenses and washing the lens storage case with tap water. Although final visual acuity improved after treatment in most patients, insufficient surgical debridement resulted in a poor visual prognosis.

Cataract surgery in patients older than 90 years of age.

OBJECTIVE The aim of this study was to examine whether differences exist after cataract surgery is performed in patients over and under 90 years of age. STUDY DESIGN Retrospective, nonrandomized study. PARTICIPANTS Cataract surgery was performed in 21 patients (31 eyes) who were older than 90 years of age and in 45 patients (70 eyes) who were younger than 90 years of age. METHODS The medical records of all patients who underwent cataract surgery between January 2005 and September 2010 at Dokkyo Medical University Koshigaya Hospital were reviewed. Factors evaluated included systemic disease, changes in systemic condition, surgical time, preoperative and postoperative visual acuity, corneal endothelial cell density, and intraoperative complications. RESULTS The group of patients older than 90 years of age experienced greater occurrences of systemic disease (p < 0.05; χ(2) test) and intraoperative changes in systemic conditions (p < 0.001; χ(2) test). These patients also had significantly lower preoperative visual acuity (p < 0.001; Student t test). No differences were noted between the 2 age groups in surgical time, postoperative visual acuity, preoperative corneal endothelial cell density, or intraoperative complications. CONCLUSIONS Poorer cataract surgery outcome results were noted in patients older than 90 years due to systemic disease and intraoperative changes in systemic condition. Factors that need to be taken into consideration prior to performing cataract surgery in older patients include age, systemic disease, and the likelihood of intraoperative changes in systemic condition.

Four cases of endophthalmitis after 25-gauge pars plana vitrectomy

We report our recent experience with four cases of endophthalmitis (one male, three females) after 25-gauge pars plana vitrectomy (PPV). One was a case of persistent cystoid macular edema caused by branch retinal vein occlusion, whereas the remaining three were cases of epiretinal membrane. Preoperative antibiotics before the first PPV procedure were not administered in three of the four cases. Endophthalmitis occurred 2–4 days after the first procedure in all cases, for which ceftazidime 2.0 mg/0.1 mL and vancomycin 1.0 mg/0.1 mL were injected into the vitreous cavity. This was followed by emergent 20-gauge PPV and intraocular lens removal using an infusion fluid containing ceftazidime and vancomycin. After the second PPV procedure, progress was good in three cases while retinal detachment occurred in the remaining case one month after surgery; this case required a third PPV procedure. Final best-corrected visual acuity ranged from 20/100 to 20/25 for the four cases. Bacterial cultures were negative after the second PPV procedure in all cases. In conclusion, postoperative endophthalmitis occurred in four of 502 cases (0.80%) that underwent 25-gauge PPV at our hospital. It is important to minimize the incidence of endophthalmitis after 25-gauge PPV.

A case of radial keratoneuritis in non-Acanthamoeba keratitis

A case of non-Acanthamoeba keratitis with radial keratoneuritis, which is thought to be pathognomonic for Acanthamoeba keratitis, is reported. A healthy 32-year-old woman with a history of frequent replacement of her contact lenses due to wear was examined at Dokkyo Medical University Koshigaya Hospital (Saitama, Japan) and found to have a slight corneal opacity that was accompanied by radial keratoneuritis. Based on both the patient’s clinical findings and past history, the presence of Acanthamoeba keratitis was highly suspected. However, direct light microscopy of corneal scrapings stained by the Parker ink–potassium hydroxide method only found Acanthamoeba-type material in the specimen collected at her initial visit. In all other specimens collected from the patient, no Acanthamoeba was found either when using the same method or when performing cultures of the surgical debridement of the corneal lesion. In addition, topical antifungal eye drops, systemic antifungal drugs, and surgical debridement were also not effective in this case. Since a precise diagnosis could not be made, the patient was treated with topical 0.1% betamethasone sodium, which ultimately resulted in a dramatic improvement of her corneal inflammation. At 23 days after initiation of topical administration of 0.1% betamethasone sodium, visual acuity was 20/250, with a slight corneal opacity noted at the original site of infection. The outcome of the current case suggests that radial keratoneuritis is not always pathognomonic for Acanthamoeba keratitis.

Scleral fixation of foldable acrylic intraocular lenses in aphakic post-vitrectomy eyes

Purpose To evaluate the outcome for scleral fixation of a foldable acrylic intraocular lens (IOL) in aphakic post-pars plana vitrectomy eyes for vitreoretinal disease. Methods The medical records of 15 patients were reviewed. We evaluated such factors as the underlying vitreoretinal disease, preoperative expected refraction and postoperative actual refraction, best corrected visual acuity (BCVA), corneal endothelial cell density, and intraoperative and postoperative complications. Results The most common cause of underlying vitreoretinal disease was retinal detachment, which was found in 8 cases. The mean refractive error was −0.10 diopters (D). The mean minimum angle of resolution (logMAR) values of BCVA were 0.27 preoperatively and 0.14 postoperatively. The mean corneal endothelial cell density was 2400 cells/mm2 preoperatively and 2187 cells/mm2 postoperatively. No significant differences were observed in either the logMAR values of BCVA or the corneal endothelial cell density before and after surgery. No intraoperative complications occurred in any of the patients. Postoperative complications occurred in a total of 7 eyes, and the most severe complications comprised 4 cases of transient ocular hypertension. Conclusion The results for the scleral fixation of foldable acrylic IOLs were good in aphakic post-vitrectomy eyes.

Correlation between the matrix metalloproteinase-9 activity and chondroitin sulfate concentrations in tear fluid after laser in situ keratomileusis.

Aims: The aim of the present study was to evaluate the correlation between matrix metalloproteinase-9 (MMP-9) and chondroitin sulfate (CS) concentrations in human tear fluid following laser in situ keratomileusis (LASIK). Methods: Twelve eyes from six patients who had no ocular complaints except for refractive errors, and who had undergone LASIK, were enrolled in this study. We measured the concentrations of chondroitin 4 sulfate (C4S), chondroitin 6 sulfate (C6S), and MMP-9 activity with an enzyme-linked immunosorbent assay and an enzyme immunocapture activity assay preoperatively and postoperatively on days 1 and 4, week 1, and at 1 and 3 months. Results: Although the preoperative MMP-9 activity and the C4S concentration were highly correlated (r = 0.900; P < 0.001), they were not postoperatively correlated at month 1. Although the preoperative MMP-9 activity and the C6S concentration were highly correlated (r = 0.885; P < 0.001), they were not postoperatively correlated at either week 1 or months 1 and 3. Conclusions: The correlation appeared to be collapsed by LASIK, and it did not recover to the preoperative score at 3 months post-surgery. Our study indicates that the corneal wound healing was not terminated at 3 months following LASIK.

Four cases of traumatic hypotony maculopathy treated by various methods.

Several reports have been published on methods for treating hypotony maculopathy. Currently, the preferred choice of treatment depends on the severity of the illness. We experienced four cases of traumatic hypotony maculopathy and treated them by various methods. Cases 1–3 were treated by various surgical treatments. Case 1 was treated by combined cataract surgery and pars plana vitrectomy. The vitreous cavity was replaced with 20% sulfur hexafluoride (SF6). Case 2 did not improve with laser trabeculoplasty, so further encircling was performed. Case 3 did not improve with photocoagulation of the ciliary body and injection of 20% SF6 into the vitreous cavity. Consequently, this case required suturing of the ciliary body to the sclera, cryopexy for the ciliary body, and injection of 100% SF6. Case 4 was treated only with eye drops. Intraocular pressure (IOP) increased in all cases as a result of treatment. Treatment improved hypotony maculopathy in all cases. Pre-treatment visual acuities ranged from 0.03 to 0.4, with IOP ranging from 2 to 10 mmHg. Post-treatment visual acuity ranged from 0.09 to 1.2, with IOP ranging from 14 to 16 mmHg. Only case 2 resulted in poor visual prognosis because of choroidal rupture near the foveola. The difficulty in choosing treatment methods lies in the need for multiple surgical treatments for some cases. Effective and noninvasive treatment methods are expected to be established in the future.

A case of iridoschisis associated with lens displacement into the vitreous cavity

We report the case of a 67-year-old woman with a lens that was displaced into the vitreous cavity in one eye and ipsilateral iridoschisis. She was free from a history of ocular trauma or of heritable ocular disease. Her best-corrected visual acuity was 1.2 bilaterally and right eye showed signs of iridoschisis. The corneal endothelial cell density decreased to 1,263 cells/mm2 in the right eye preoperatively. We speculated that iris tissue flowing in the anterior chamber might have intermittently touched the corneal endothelium. 25-gauge pars plana vitrectomy and lens removal were performed immediately. Free-floating iris tissue was cut during surgery with care not to injure the corneal endothelial cells. The postoperative progress was satisfactory and scleral fixation of an intraocular lens is planned. Iridoschisis is an uncommon cause of lens displacement into the vitreous cavity.

Photorefractive keratectomy: measuring the matrix metalloproteinase activity and chondroitin sulfate concentration in tear fluid

We herein report the case of a 20-year-old man who underwent a photorefractive keratectomy (PRK). We measured matrix metalloproteinase-9 (MMP-9) activity and chondroitin 4 sulfate and chondroitin 6 sulfate concentrations in tear fluid. Tear fluid was collected pre-operatively via microcapillary tube, and was collected postoperatively on the first and fourth days, and after one week, one month, three months, and six months. Samples were formulated by dilution with 200 μL of saline. MMP-9 activity was analyzed by an enzyme immunocapture activity assay, and the concentrations of chondroitin sulfate were analyzed by enzyme-linked immunosorbent assay. No complications were observed after surgery, except for a minimal subepithelial haze. Although MMP-9 activity changed on the fourth postoperative day, the activity changed only minimally at this time. Chondroitin 4 sulfate concentrations in tear fluid increased dramatically from one week to one month, decreased transiently at three months, and increased by six months. The chondroitin 6 sulfate concentration did not normalize within one week, and decreased from one week to three months compared with the preoperative score, and was close to the preoperative score at six months. We conclude that corneal wound healing was still incomplete six months after PRK, and chondroitin 4 sulfate appears to be critical in this process.

Lens dislocation has a possible relationship with laser iridotomy

We report our recent experience of four eyes with spontaneous lens dislocation in four patients with no history of trauma or any systemic disease associated with zonular dialysis. Lens dislocation developed with 0.5 to 6 months following laser iridotomy. All patients were male and two eyes were complicated with acute primary angle closure glaucoma preoperatively. Case 1 showed bilateral lens dislocation, while cases 2 and 3 involved unilateral lens dislocation. Cases 2 and 3 showed lenses completely dislocated into the vitreous cavity. All cases needed lens removal and scleral fixation of intraocular lenses. Final visual acuity was 1.2 in all cases. We suspect that laser iridotomy may induce localized zonular dialysis that results in progressive zonular weakness, leading to lens dislocation.