Toshio Okanouchi

Autologous Transplantation of the Internal Limiting Membrane for Refractory Macular Holes

PURPOSE To determine the effectiveness of autologous transplantation of the internal limiting membrane (ILM) for refractory macular holes. DESIGN Prospective, interventional case series. PATIENT AND METHODS Ten eyes of 10 consecutive patients who underwent autologous transplantation of the ILM for the treatment of refractory macular holes were studied. The primary diseases in these patients were large idiopathic macular holes that had existed for more than 1 year (4 eyes), a traumatic macular hole (1 eye), myopic foveoschisis (2 eyes), foveoschisis resulting from pit-macular syndrome (2 eyes), and proliferative diabetic retinopathy (1 eye). Apart from the 5 eyes with idiopathic or traumatic macular holes, macular holes developed in the other 5 eyes after initial vitrectomies with ILM removal. In all eyes, regular macular hole surgery failed to achieve closure. The main outcome measures used in this study were macular hole closure and best-corrected visual acuity (BCVA). RESULTS Macular holes were closed successfully in 9 eyes (90%) after autologous transplantation of the ILM. The postoperative BCVAs were significantly better than the preoperative BCVAs (P = .007, paired t test). Postoperative BCVAs improved by more than 0.2 logarithm of the minimal angle of resolution units in 8 eyes (80%) and were unchanged in 2 eyes (20%). CONCLUSIONS Although this is a pilot study, the results suggest that autologous transplantation of the ILM may contribute to improved anatomic and visual outcomes in the treatment of refractory macular holes and may warrant further investigation.

Clinical and Angiographic Characteristics of Retinal Manifestations in Cat Scratch Disease

PURPOSE To elucidate clinical and angiographic features of retinal manifestations in cat scratch disease. METHODS Clinical characteristics as well as fluorescein and indocyanine green (ICG) angiographic features were reviewed in 4 consecutive patients with retinal manifestations caused by serologically confirmed cat scratch disease. RESULTS A subretinal to intraretinal granuloma at the upper margin of the optic disc was found in 3 patients, while 1 patient developed subretinal to intraretinal granuloma in the midperiphery with serous retinal detachment. Fluorescein angiography revealed the abnormal vascular network of the peripapillary granuloma in the early phase followed by its dye leakage toward the late phase. Indocyanine green angiography demonstrated more clearly the abnormal vascular network with its minimal dye leakage than did fluorescein angiography. In contrast, only the late dye leakage was noted from granuloma of the midperipheral fundus by fluorescein angiography in one patient. Indocyanine green angiography detected no choroidal lesions other than the retinal lesions delineated by fluorescein angiography. The granulomas disappeared in response to a 4-week course of sulfamethoxazole-trimethoprim combined with steroids. CONCLUSIONS Granuloma with abnormal vascular network as revealed by fluorescein and ICG angiography is characteristic of retinal manifestations in cat scratch disease.

Scleral Infolding Combined with Vitrectomy and Gas Tamponade for Retinal Detachment with Macular Holes in Highly Myopic Eyes

PURPOSE To describe the effectiveness of a surgical procedure, scleral infolding combined with vitrectomy and gas tamponade, for retinal detachment caused by macular holes in highly myopic eyes. METHODS In a pilot study, scleral infolding was performed in 5 patients with macular holes, who were selected from 10 consecutive highly myopic patients with retinal detachment caused by macular holes (8 patients) or extramacular posterior-pole holes (2 patients), treated during 1 year at Okayama University Hospital. The patients were all women, 48-77 years of age (mean = 63.4 years), who had been followed-up for 1-2 years. Selection criteria for scleral infolding were either second surgeries for reopening of macular holes (2 patients) or residual retinal detachment around macular holes after complete fluid-air exchange with drainage of subretinal fluid at the initial surgery (3 patients). Following vitrectomy and complete epiretinal membrane removal in the posterior pole, the sclera was shortened by infolding on the temporal side. Three mattress sutures with 5-0 Dacron in each quadrant, 6 sutures in total, were placed at a 7-mm anteroposterior interval with posterior sutures located as deep as possible, near vortex veins. Fluid-gas exchange was then done, with or without endophotocoagulation applied around macular holes. RESULTS After scleral infolding, macular holes were closed, and the retina was totally attached in all 5 patients. The final visual acuity ranged from 20/2000 to 20/70. CONCLUSION Scleral infolding is a simple and effective procedure for treating retinal detachment with macular holes in highly myopic eyes and could be used as an optional procedure of reoperation for a failed initial vitrectomy.

Selection for inferior limited macular translocation on the basis of distance from the fovea to the inferior edge of the subfoveal choroidal neovascularization

PURPOSE To assess the visual outcome of inferior limited macular translocation in eyes selected based on the distance from the fovea to the inferior edge of the subfoveal choroidal neovascularization. DESIGN Interventional case series. METHODS We performed inferior limited macular translocation in 12 consecutive eyes (12 patients) with age-related macular degeneration or polypoidal choroidal vasculopathy, in which the choroidal neovascularization did not extend for more than half of one disk diameter inferior to the fovea. RESULTS In all eyes, the choroidal neovascularization was moved to an extrafoveal location. In seven of the 12 eyes, postoperative vision was 20/40 or better. The visual acuity improved by 2 or more lines in 11 eyes. CONCLUSION Selection for inferior limited macular translocation on the basis of distance from the fovea to the inferior edge of the choroidal neovascularization may be associated with a greater likelihood of visual acuity improvement.

Novel Technique for Subretinal Injection Using Local Removal of the Internal Limiting Membrane.

Novel Technique for Subretinal Injection Using Local Removal of the Internal Limiting Membrane Surgical procedures for subretinal injections have been used to treat a variety of retinal conditions, such as the displacement of subretinal hemorrhages, in gene therapy for retinal degeneration, in macular translocation in age-related macular degeneration, in the removal of hard foveal exudates, and in planned foveal detachments to resolve diffuse diabetic macular edema. Currently, these procedures use 38to 41gauge flexible cannulas to inject fluid into the subretinal space. However, the retina is resistant to puncture, making subretinal injections difficult to administer smoothly. Using excessive pressure to puncture the retina can damage it, as well as the retinal pigment epithelium (RPE) and the choroid, and damage to these tissues can lead to retinal and/or subretinal hemorrhage, tears in the RPE, or choroidal neovascularization. One approach to achieving a smooth injection technique is to create a sharp point on the cannula by cutting its tip obliquely so that the retina can be punctured more easily. However, it is still difficult to avoid trauma to the RPE and choroid, which are close to the injection site. We considered the possibility that the major resistance to subretinal injection is due to the internal limiting membrane (ILM) and that removing this at the site where the injection is to be performed might enable a smoother and safer insertion. In this report, we describe this novel technique for subretinal injection with local ILM removal.

Evaluation of the Dynamics of Choroidal Circulation in Experimental Acute Hypertension Using Indocyanine Green-stained Leukocytes

PURPOSE To evaluate the dynamics of choroidal circulation in experimental acute hypertension, using the indocyanine green leukocyte angiography (ILA) method, which the authors have developed for the evaluation of leukocyte dynamics in choroidal circulation. METHODS Japan White rabbits were used in the present study. Leukocytes were collected by centrifugal separation of the autologous blood, and were stained with indocyanine green (ICG) dye. The ICG-stained leukocyte fluid was injected into an ear vein, and fundus images were obtained by infrared laser and a scanning laser ophthalmoscope. Experimental acute hypertension was induced by the intravenous drip injection of angiotensin II (AII). RESULTS The fluorescent dots rapidly moved in choroidal arteries at a decreasing velocity, passed very slowly through choroidal capillaries and drained into choroidal veins. Under normal blood pressure, the mean leukocyte velocities in arteries, capillaries and veins were 8.63+/-1.68, 0.52+/-0.07, and 6.96+/-2.20 mm/s, respectively. On the other hand, the respective mean velocities in acute hypertension induced by AII were 13.50+/-1.82, 0.81+/-0.09, and 10.54+/-3.91 mm/s. Besides flow velocity, no change in leukocyte dynamics was observed. CONCLUSIONS Under the condition of acute hypertension induced by AII, leukocytes moved faster in the total choroidal circulation (from arteries to veins) compared to their velocity under the condition of normal blood pressure. Blood velocities might increase in the total choroidal circulation at an early stage in acute hypertension induced by AII, resulting in increased choroidal blood flow. ILA makes it possible to evaluate the changes in choroidal circulation under various pathologic conditions.

Assessment of Lamellar Macular Hole and Macular Pseudohole With a Combination of En Face and Radial B-scan Optical Coherence Tomography Imaging

PURPOSE To investigate lamellar macular hole (LMH) and macular pseudohole (MPH) using a combination of en face and radial B-scan OCT. DESIGN Retrospective observational case series. METHODS Setting: Institutional study. PATIENT POPULATION En face and radial B-scan OCT images of 63 eyes of 60 patients diagnosed with LMH or MPH based on an international classification were reviewed. OBSERVATION PROCEDURES Cases were classified using en face images based on the presence/absence of epiretinal membrane (ERM), retinal folds, parafoveal epicenter of contractile ERM (PEC-ERM), and retinal cleavage. We compared the en face imaging-based classification system with the international classification system using radial B-scan images. We quantitatively evaluated visual function and macular morphology. MAIN OUTCOME MEASURES Characterization of multimodal OCT-based subtypes of LMH and MPH. RESULTS All cases showed ERM and were classified into 4 groups. In the first group, which lacked retinal folds and showed significantly lower visual acuity than the other groups, 81% of eyes had degenerative LMH. In the second group, which lacked PEC-ERM and retinal cleavage and showed significantly lower retinal fold depth, all eyes had MPH. The third group, in which 95% of eyes had symmetric tractional LMH, included eyes with retinal cleavage but without PEC-ERM, and this group showed higher circularity of the foveal aperture and cleavage area than the group with both these features, in which all eyes had asymmetric tractional LMH. CONCLUSIONS Multimodal OCT enables classification of LMH and MPH based on pathologic conditions. Retinal traction in particular may be useful for determining treatment methods.