Toru Yasuhara

The CD4/CD8 Ratio in Vitreous Fluid Is of High Diagnostic Value in Sarcoidosis

PURPOSE Sarcoidosis is an idiopathic inflammatory disorder involving multiple organs, and ocular manifestation (represented by granulomatous uveitis) is one of the common features. A well-known immunologic feature in sarcoidosis is an increased CD4+ helper T-cell type 1 lymphocyte subset in bronchoalveolar lavage (BAL) fluid. The current study investigated the vitreous lymphocyte subsets of ocular sarcoidosis to elucidate the immunologic features of this disorder in the eye. DESIGN Case-control study. PARTICIPANTS AND CONTROLS Fifty-one eyes of 38 patients with ocular sarcoidosis, confirmed by international diagnostic criteria, were enrolled in this study. Twenty-seven eyes of 26 patients with other causes of uveitis were enrolled as nonsarcoid controls. METHODS Evaluation of diagnostic tests for cell profiles of ocular sarcoidosis. Lymphocytes in the vitreous samples were analyzed by cytology, polymerase chain reaction, and flow cytometry. Peripheral blood was also obtained from each patient and analyzed in comparison with the vitreous samples. MAIN OUTCOME MEASURES CD4/CD8 ratios of vitreal and peripheral T lymphocytes. RESULTS CD4/CD8 ratios of the vitreous T lymphocytes were significantly higher in ocular sarcoidosis than in nonsarcoidosis vitreous samples. In the patients with ocular sarcoidosis, the CD4/CD8 ratios of vitreal T lymphocytes were significantly higher than the CD4/CD8 ratios of peripheral T lymphocytes. No significant differences were found between the CD4/CD8 ratios of vitreal and peripheral T lymphocytes in the patients without sarcoidosis. Moreover, the CD4/CD8 ratios of peripheral T lymphocytes in the patients with ocular sarcoidosis were significantly higher than in patients without sarcoidosis. The sensitivity and specificity of the vitreal CD4/CD8 ratio were 100% and 96.3%, respectively, for the diagnosis of ocular sarcoidosis. CONCLUSIONS Our findings suggest that the CD4/CD8 ratio of vitreous-infiltrating lymphocytes has high diagnostic value in ocular sarcoidosis, comparable to that of the CD4/CD8 ratio in BAL fluid lymphocytosis for pulmonary sarcoidosis. Furthermore, a high CD4/CD8 ratio of peripheral blood T lymphocytes should be one of the laboratory findings for ocular sarcoidosis. Diagnostic vitrectomy using flow cytometric analysis may be a useful adjunct for the diagnosis of ocular sarcoidosis, particularly in complex cases.

Vitrectomy for rhegmatogenous or tractional retinal detachment with familial exudative vitreoretinopathy

OBJECTIVE To examine the anatomic features and surgical indications of familial exudative vitreoretinopathy (FEVR) complicated with rhegmatogenous or tractional retinal detachment. DESIGN Retrospective noncomparative case series. PARTICIPANTS Twenty-eight eyes of 25 patients who had either clinically suspected or fully diagnosed FEVR. Of these, 25 had rhegmatogenous retinal detachment, 2 had tractional retinal detachment, and 1 had tractional retinal detachment plus vitreous hemorrhage. INTERVENTIONS The authors carefully observed the vitreoretinal interface during surgery, studied the clinical and anatomic features of FEVR, and then evaluated the surgical results. RESULTS The vitreoretinal adhesions were so strong in the peripheral avascular area that iatrogenic retinal breaks easily occurred in 22 of 28 eyes. In all cases, the bimanual technique with vitreous scissors and forceps was required to dissect the posterior vitreous membrane from the retinal surface. The retina was reattached in 24 of 28 cases (85.7%), and visual acuity improved in 20 eyes (71.4%). CONCLUSION Dissection of the vitreous in the peripheral avascular area is very difficult in FEVR, and those patients for whom this procedure was not successfully performed may have a poorer prognosis.

Ophthalmic artery blood flow in patients with internal carotid artery occlusion

Aim: To evaluate the risk factors for rubeosis iridis by colour Doppler imaging (CDI) in patients with complete internal carotid artery occlusion (ICAO). Methods: 34 eyes of 32 consecutive patients with complete ICAO were enrolled. Using CDI, blood flow direction (forward, reverse, undetectable) in the ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary artery (SPCA) were determined. Arterial mean blood velocity (Vmean) and resistive index (RI) were calculated and correlations between the rubeosis iridis incidence and CDI parameters analysed. Results: The eyes were classified into four types according to blood flow direction: forward flow in OA, CRA, and SPCA (type 1; n = 11); reverse OA and forward CRA and SPCA flow (type 2a; n = 12); reverse OA and undetectable CRA and SPCA flow (type 2b; n = 8); undetectable flow in all three arteries (type 3; n = 3). Rubeosis iridis was seen only in type 2b and 3 eyes. Type 2b showed significantly (p<0.01) higher Vmean and lower RI values in the OA, indicating more rapid reverse flow than in type 2a eyes. Although in type 1 and 2a eyes OA flow was in opposite directions, they manifested no rubeosis iridis and no difference in the Vmean and RI values of the CRA and SPCA. Conclusions: The classification of eyes from patients with ICAO into four types by CDI may facilitate the identification of the eyes at high risk for rubeosis iridis. Markedly diminished flow in both the CRA and SPCA may result in rubeosis iridis, regardless of OA flow direction.

Vitrectomy for proliferative diabetic retinopathy with asteroid hyalosis.

Purpose: To characterize the clinical features of proliferative diabetic retinopathy (PDR) with asteroid hyalosis treated by pars plana vitrectomy. Methods: Vitrectomy was performed in 26 eyes with PDR accompanied by asteroid hyalosis (7 eyes with vitreous hemorrhage, 6 eyes with tractional retinal detachment with vitreous hemorrhage, and 13 eyes with tractional retinal detachment without vitreous hemorrhage). We observed the occurrence of posterior vitreous detachment intraoperatively and evaluated the clinical characteristics retrospectively. Results: In 24 eyes, posterior vitreous detachment was slight, necessitating artificial detachment. Of the 26 eyes, 20 experienced iatrogenic retinal breaks and 6 (23%) experienced postoperative retinal detachment due to iatrogenic breaks. Three cases worsened to anterior proliferative vitreoretinopathy and retinal reattachment could not be achieved. Conclusions: In vitrectomy for PDR with asteroid hyalosis, and in cases of simple vitreous hemorrhage, surgery should be performed with full understanding of the anatomic characteristics. Notably, if posterior vitreous detachment is not present, the occurrence of iatrogenic retinal breaks is more likely.

A Case of Bacterial Endophthalmitis Following Perforating Injury Caused by a Cat Claw

A case of bacterial endophthalmitis following a perforating ocular injury caused by a cat claw is reported. The scleral wound was sutured immediately following the injury and systemic antibiotics were administered. Despite this treatment, endophthalmitis occurred 3 days after the injury. The endophthalmitis was resolved by pars plana vitrectomy, however preretinal reproliferation and retinal detachment subsequently occurred. After reoperation the retina was reattached and the corrected visual acuity improved from 10 cm/HM to 20/200. Pseudomonas aeruginosa was detected in cultured vitreous humor that was collected during surgery. This case illustrates the possibility of endophthalmitis being caused by gram negative bacillus in cases of perforating injuries caused by animal claws. Perforating ocular injuries caused by animal claws are relatively rare. Here we report a case of endophthalmitis due to Pseudomonas aeruginosa that occurred after a perforating injury caused by a cat claw. The eye was treated by pars plana vitrectomy.

Investigation of Corneal Autofluorescence in Diabetic Patients

PURPOSE The investigation of corneal autofluorescence in diabetic patients. OBJECTS AND METHODS Corneal autofluorescence was investigated with a newly-developed fluorophotometer (wave length: excitation, 290-390 nm; emission, 430-630 nm) having, fluorescence characteristics involving those of reduced pyridine nucleotides (PN) and advanced glycation endoproduct (AGE) except pentosidine and pyrraline. Twenty-eight patients with non-insulin-dependent diabetes mellitus and sixty-seven healthy volunteers were studied. RESULTS The corneal autofluorescence was 1.65 times higher than that of controls (p < 0.0001). In non-insulin-dependent diabetes mellitus, the corneal autofluorescence was not correlated significantly with various diabetic parameters in blood (r < 0.4). In controls, the corneal autofluorescence was correlated significantly with age (r = 0.438). CONCLUSION The corneal autofluorescence has some relation with PN and AGE accumulation in the cornea.

Transforming Growth Factor β2 Increases in Subretinal Fluid in Rhegmatogenous Retinal Detachment with Subretinal Strands

Purpose: To compare transforming growth factor (TGF) β2 levels in subretinal fluid of rhegmatogenous retinal detachment with or without subretinal strand formation. Methods: We assessed total and mature TGF-β2 levels in subretinal fluid obtained from 24 eyes with rhegmatogenous retinal detachment using an enzyme-linked immunosorbent assay. Group I comprised 18 specimens from eyes without subretinal strands, while group II comprised 6 specimens from eyes with subretinal strands. Results: Total and mature TGF-β2 levels were higher in group II than in group I (p = 0.01 and p = 0.07, respectively). Conclusion: The concentrations of total and mature TGF-β2 were higher in cases of rhegmatogenous retinal detachment associated with subretinal strand formation compared to those without subretinal strand formation.

Multiple cranial arteriovenous malformations in a child with eventual blindness in the affected eye.

PURPOSE To report a case of multiple cranial arteriovenous malformations involving the orbit and retina. METHOD Case report. We treated a 7-year-old girl who was diagnosed with a left submaxillary, a left retinal, a left orbital, and a middle subdural arteriovenous malformation. RESULTS Enlargement of the arteriovenous malformations, except for the retinal arteriovenous malformation, was observed. After external carotid artery embolizations and radiation therapy for uncontrolled oral cavity bleeding, loss of light perception in the affected eye occurred, but no marked changes occurred in the retinal arteriovenous malformation. CONCLUSION This rare case suggests that the clinical finding of a stable retinal arteriovenous malformation may be associated with enlargement of arteriovenous malformation lesions at other sites.

Vitreous hemorrhage from a ciliary granuloma associated with Wegener granulomatosis

PURPOSE To report a case of vitreous hemorrhage from ciliary granuloma in Wegener granulomatosis. METHODS Interventional case report. An 18-year-old woman with Wegener granulomatosis and episcleral granuloma in her LE had ultrasound biomicroscopy findings of a mass in the pars plana of the ciliary body in the meridian corresponding to the episcleral granuloma. RESULTS The patient underwent vitrectomy in the LE for subsequent vitreous hemorrhage. Intraoperatively, the mass was diagnosed as a ciliary granuloma at the pars plana. Dense blood clotting around the ciliary granuloma and subretinal exudation at the ora serrata were observed, with no other changes causative for the vitreous hemorrhage. CONCLUSIONS We report a case of vitreous hemorrhage associated with a ciliary granuloma that was revealed by ultrasound biomicroscopy. Careful observation is necessary in eyes with persistent inflammation in Wegener granulomatosis.

The use of perfluorocarbon liquids in diabetic vitrectomy.

Three eyes of 3 patients were operated on for severe proliferative diabetic retinopathy with tractional and/or rhegmatogenous retinal detachment using perfluoro-n-octane as temporary tamponade. The perfluorocarbon was removed at the end of the procedure. Intraocular tamponade was provided by a long-acting gas in all eyes. The intraoperative use of perfluorocarbon effectively facilitated retinal flattening and endophotocoagulation. Anatomical success was obtained in all 3 cases, with a minimum follow-up of 10 months. Visual acuity improved in all eyes. The main advantages of perfluorocarbon are that it enables easy flattening of the posterior retinal folds and effective endophotocoagulation with good visual conditions.