Yoshitake Kato

Changes in choroidal thickness after cataract surgery

Purpose To evaluate changes in choroidal thickness before and after cataract surgery and factors affecting the changes. Setting Tsukazaki Hospital, Himeji, Japan. Design Prospective interventional study. Methods Patients having cataract surgery without other eye pathology were studied. The corrected distance visual acuity (CDVA), intraocular pressure (IOP), axial length (AL), and enhanced‐depth‐imaging optical coherence tomography (OCT) were measured preoperatively. The choroidal thickness was measured at 5 points (subfoveal and 1.5 mm nasal, temporal, superior, and inferior to the fovea) using the OCT device’s software. Enhanced‐depth‐imaging OCT and IOP measurements were obtained 3 days, 1 and 3 weeks, and 3 and 6 months postoperatively and compared with the baseline values. Stepwise analysis determined which factors (ie, age, CDVA, preoperative IOP, AL, operative time, changes in IOP) were associated with changes in choroidal thickness. Results One hundred eyes were analyzed. The postoperative IOP significantly decreased at 3 weeks, 3 months, and 6 months. The postoperative choroidal thickness significantly increased at the foveal and inferior regions throughout the follow‐up; at the nasal region at 3 days, 1 week, and 6 months; at the temporal region at 1 week; and at the superior region at 6 months. These changes negatively correlated with those in IOP early after surgery. The changes in choroidal thickness later negatively correlated with the AL in all regions. Conclusion Cataract surgery caused changes in choroidal thickness. The AL and changes in the IOP are critical for evaluating the changes in choroidal thickness. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Effectiveness of Ureteroscopy-Assisted Retrograde Nephrostomy (UARN) for Percutaneous Nephrolithotomy (PCNL)

Objective To determine the impact of ureteroscopy-assisted retrograde nephrostomy (UARN) during percutaneous nephrolithotomy (PCNL). Materials and Methods From April 2009 to September 2011, a total of 50 patients underwent PCNL for large renal stones (stone burden >2 cm). We performed UARN in the Galdakao-modified Valdivia position for 27 patients (UARN PCNL) and ultrasonography-assisted percutaneous nephrostomy in the prone position for 23 patients (prone PCNL). Results UARN PCNL significantly improved the stone-free rate (81.5% vs 52.2%) and the rate of residual stones (<4 mm, 92.6% vs 65.2%, P<0.05). The median length of the operation was significantly shorter for UARN PCNL, at 160 min, compared to 299 min for prone PCNL (P<0.001). There was one intraoperative complication in prone PCNL, namely a hemorrhage that resulted in stopping the initial treatment, but it was cured conservatively. The postoperative complications included a high grade fever that persisted for three days in two UARN PCNL patients (7.4%) and six prone PCNL patients (26.1%). The Clavien grading scores showed significantly lower postoperative complications for UARN PCNL compared to prone PCNL. Conclusion UARN is associated with a higher stone-free rate, shorter operation time, and fewer complications during PCNL than prone PCNL.

Case of cytomegalovirus retinitis aggravated by sub-Tenon injection of triamcinolone acetonide with subsequent metastatic liver cancer

We report a case of cytomegalovirus (CMV) retinitis in an immunocompetent patient who was resistant to antiviral treatment, and in whom fatal metastatic liver cancer was later detected. A 74-year-old Japanese man visited our ophthalmology clinic in May 2011. He had a history of well controlled type 2 diabetes and colon cancer, and underwent successful surgical treatment in 2008. In April 2011, he was diagnosed with uveitis affecting his left eye and received posterior sub-Tenon injection of triamcinolone acetonide. He was referred to us because of aggravation of the retinal lesion. Funduscopic examination of the left eye revealed arcuate, whitish, necrotizing retinitis with hemorrhage along the temporal arcade of the retina. Polymerase chain reaction of the aqueous fluid was positive for CMV DNA. Because of diagnosis of CMV retinitis in his left eye, he was referred to an internist and investigated for systemic CMV infection or any serious disease which could cause immunocompromise, but neither was detected. Despite an intensive course of intravitreous ganciclovir and oral valganciclovir, the retinitis did not resolve. In June 2012, 14 months after the initial ocular symptoms, metastatic liver cancer was found and the patient passed away. When CMV retinitis is resistant to antiviral treatment or recurs in an immunocompetent patient, it is important that ophthalmologists undertake systemic investigation for occult malignancy.

Amplatz Sheath for Cystolithotripsy Using Ho: YAG Laser in Female Patients

OBJECTIVE To evaluate the effectiveness of cystoscopic lithotripsy, we performed Amplatz sheath technique using Ho: YAG laser. Maheshwari first reported the use of an Amplatz sheath in the female urethra in 1998, and Okeke et al reported the use of an Amplatz sheath for male patients during cystolithotripsy in 2004. The usefulness of the holmium (Ho): yttrium aluminum garnet (YAG) laser lithotripsy is widely accepted, even for large bladder calculi. Since then, there have been no more reports of using the sheath with an Ho: YAG laser. TECHNICAL CONSIDERATIONS We inserted the Amplatz sheath conversely. Because of the clear visualization, we used higher laser settings with 2.5 J × 15 to 20 Hz. RESULTS We experienced 3 female patients that were successfully treated with the Amplatz sheath technique using Ho: YAG laser lithotripsy. In these 3 patients, whose stone burdens were 4.5, 3.8, and 4.3 cm, they were able to successfully become stone-free with surgeries of 74 minutes, 67 minutes, and 58 minutes, respectively, with no complications. CONCLUSION We experienced 3 female patients that were successfully treated with the Amplatz sheath technique using Ho: YAG laser lithotripsy.

Ureteroscopy-assisted retrograde nephrostomy (UARN) for an incomplete double ureter

We previously described ureteroscopy (URS)-assisted retrograde nephrostomy (UARN) [4, 5]. In UARN, it is possible to continuously visualize the dilation of the ureter from puncture to insertion of the nephroaccess sheath (NAS). We herein report the first case of UARN for percutaneous nephrolithotomy (PCNL) in a patient with an incomplete double ureter. A 67-year-old male was referred to our department for treatment of left renal calculus with an incomplete double ureter (Fig. 1a, b). In April 2012, the patient was admitted to our department for PCNL to treat the left renal stone. We performed PCNL using the UARN technique. The technique was performed as described in our previous reports [4, 5]. In brief, under general and epidural anesthesia, the patient was placed in a modified Valdivia position (Galdakao-modified Valdivia position) [2]. After inserting a ureteral access sheath, the URS findings showed a bifurcation of his ureter (Fig. 1d). We confirmed the location of the target stone and determined the target calyx to puncture. A Lawson retrograde nephrostomy puncture wire (Cook Urological, Bloomington, IN, USA) was set in URS and approached to the target calyx, which was subsequently punctured (Fig. 1e, f). The renal stones were composed of two stones in the renal pelvis and two stones in the renal calyx next to the punctured calyx (Fig. 1g). Before dilating the nephrostomy, we first reposition the two stones in the renal calyx to avoid the target stone blocking the NAS. After repositioning the target stone, balloon dilation and insertion of the NAS were performed. PCNL was then successfully performed (Fig. 1c). The incidence of a double renal pelvis and ureter ranges from 0.5 to 3.0 % in humans [3, 6]. The anomalous duplication of the ureter and pelvis has been classified as complete and incomplete ureters [3, 6]. An incomplete duplication is three times more common than a complete duplication. In an incomplete duplication, the pelvis and the two ureters join and enter the bladder by one common orifice, and such duplication may be unilateral or bilateral. The patients who have duplication of the ureter have an increased risk of stone formation [1]. PCNL for abnormal kidneys is sometimes difficult, particularly without hydronephrosis. UARN facilitates the continuous visualization from puncture to insertion of the NAS with URS. In this case, URS contributed to the visualization of the detailed anatomy between the punctured calyx and target stone. UARN might represent a new option to perform PCNL in subjects with ureteral duplication. T. Kawahara (&) H. Ito H. Terao Y. Kato J. Matsuzaki Department of Urology, Ohguchi Higashi General Hospital, 2-19-1, Irie, Kanagawa-ku, Yokohama City, Kanagawa, Japan e-mail: takashi_tk2001@yahoo.co.jp

Cataract surgery causes biomechanical alterations to the eye detectable by Corvis ST tonometry

Purpose Modern cataract surgery is generally considered to bring about modest and sustained intraocular pressure (IOP) reduction. However, the pathophysiological mechanism for this remains unclear. Moreover, a change in ocular biomechanical properties after surgery can affect the measurement of IOP. The aim of the study is to investigate ocular biomechanics, before and following cataract surgery, using Corvis ST tonometry (CST). Patients and methods Fifty-nine eyes of 59 patients with cataract were analyzed. IOP with Goldmann applanation tonometry (IOP-G), axial length, corneal curvature and CST parameters were measured before cataract surgery and, up to 3 months, following surgery. Since CST parameters are closely related to IOP-G, linear modeling was carried out to investigate whether there was a change in CST measurements following cataract surgery, adjusted for a change in IOP-G. Results IOP-G significantly decreased after surgery (mean±standard deviation: 11.8±3.1 mmHg) compared to pre-surgery (15.2±4.3 mmHg, P<0.001). Peak distance (the distance between the two surrounding peaks of the cornea at the highest concavity), maximum deformation amplitude (the movement of the corneal apex from the start of deformation to the highest concavity) and A1/A2 velocity (the corneal velocity during inward or outward movement) significantly increased after cataract surgery (P<0.05) while radius (the central curvature radius at the highest concavity) was significantly smaller following cataract surgery (P<0.05). Linear modeling supported many of these findings, suggesting that peak distance, maximum deformation amplitude and A2 velocity were increased, whereas A2 deformation amplitude and highest concavity time were decreased (after adjustment for IOP change), following cataract surgery. Conclusion Corneal biomechanical properties, as measured with CST, were observed to change significantly following cataract surgery. Trial registration Japan Clinical Trials Registry UMIN000014370