Yoshitsugu Inoue

Clinical features and management of cytomegalovirus corneal endotheliitis: analysis of 106 cases from the Japan corneal endotheliitis study

Aims The purpose of this study is to elucidate the clinical manifestations and the current treatment status of cytomegalovirus (CMV) endotheliitis via a large case series obtained from a national survey conducted in Japan. Methods The Japan Corneal Endotheliitis Study Group proposed diagnostic criteria for CMV endotheliitis based on a viral examination by PCR of aqueous humour, in combination with clinical manifestations. A national survey was then retrospectively conducted among 1160 members of the Japan Cornea Society. The study reviewed the patient profiles, clinical manifestations, and treatment modalities of individuals who met the diagnostic criteria for CMV endotheliitis. Results The study included 109 eyes of 106 patients. Mean patient age was 66.9±10.9u2005years (85 males (80.2%), 21 females (19.8%)). Patients were commonly diagnosed with anterior uveitis and ocular hypertension prior to confirmation of CMV endotheliitis. Coin-shaped lesions were observed in 70.6%, and linear keratic precipitates in 8.3% of the patients, respectively. 95% of cases were treated with anti-CMV drugs. Conclusions CMV endotheliitis is most common in middle-aged and elderly men. CMV endotheliitis should be suspected when patients present with corneal endotheliitis involving coin-shaped lesions accompanied by anterior uveitis and ocular hypertension.

Relationship between the number of cytomegalovirus in anterior chamber and severity of anterior segment inflammation

PurposeTo characterize the cytomegalovirus-associated anterior segment inflammation and to determine whether the number of cytomegalovirus is significantly correlated with the disease characteristics.MethodsRetrospective consecutive case series. Seventy-three patients with refractory anterior segment inflammation due to iridocyclitis, corneal endotheliitis and keratouveitis were studied. All the patients were suspected to have cytomegalovirus infection and had undergone real-time PCR of the aqueous humor to determine the amount of cytomegalovirus DNA.ResultsCytomegalovirus DNA was detected in 24 of the 73 cases. The cytomegalovirus copy number was significantly correlated with the number of recurrent episodes and glaucoma treatment levels, but was not significantly correlated with the disease type. A high cytomegalovirus copy number was a significant risk factor for IOP elevation [Odds ratio (OR) per logarithm CMV amount: 2.5 (95xa0% confidence interval (CI) 1.1–5.4), presence of coin-shaped lesions (2.3 (1.3–4.0)), recurrent inflammation (2.1 (1.3–3.5)), and reduction of endothelial cell densities (1.7 (1.2–2.5))]. An IOP elevation [OR 18.2 (95xa0% CI 2.2–153.0)], reduction of endothelial cell densities [13.2 (2.9–60.0)], and recurrent inflammations [11.9 (2.5–56.6)], but not the disease type, were significant predictors of the presence of >103xa0copies/ml cytomegalovirus in the aqueous.ConclusionsMeasurements of the cytomegalovirus DNA amount is useful for evaluating the severity of the anterior segment inflammation.

Survey of Japanese ophthalmic surgeons regarding perioperative disinfection and antibiotic prophylaxis in cataract surgery

Purpose To elucidate Japanese trends for perioperative disinfection and antibiotic selection during cataract surgeries. Methods Perioperative iodine use and antibiotic prophylaxis for cataract surgery were surveyed in eight regions in Japan by mail or through interviews from February 1 to March 1, 2014. Results We surveyed 572 surgeons, of whom 386 (67%) responded. Most of the surgeons (94%) used iodine compounds before surgery for periocular skin disinfection (povidone–iodine [PI]: 79%; polyvinyl alcohol-iodine [PAI]: 15%) or conjunctival disinfection (85%; PI: 36%; PAI: 49%). Preoperative conjunctival iodine was primarily used as an eye wash (irrigation: 95%) and less often as an eye drop (5%). It was determined that 31% of surgeons waited 30 seconds or more between periocular disinfection and conjunctival disinfection. During surgery, 14% of surgeons used iodine several times, including immediately before intraocular lens insertion, and 7% used the Shimada technique (repeated iodine irrigation). Preoperative antibiotic eye drops were used by 99% of surgeons, and antibiotics were added to the irrigation bottle by 22%. The surgeons reported use of subconjunctival antibiotic injections (23%), antibiotic ointments (79%), and intracameral antibiotics (7%: 22 moxifloxacin; 6 levofloxacin). All surgeons prescribed postoperative eye drops, with 10% initiating the drops on the day of surgery. Conclusion Iodine compounds are commonly used preoperatively, but few institutions use iodine compounds intraoperatively, particularly with repeated application. The selection of antibiotic administration and disinfection technique has to be at the surgeon’s discretion. However, intracameral antibiotic and intraoperative iodine compound use are techniques that should be widely recognized.

Associations of inflammatory cytokines with choroidal neovascularization in highly myopic eyes.

Purpose: To determine the relationships between the levels of intraocular inflammatory cytokines and the clinical characteristics of myopic choroidal neovascularization (mCNV) in eyes with myopic maculopathy. Methods: One hundred eyes of 100 cases, including 51 mCNV eyes, 14 highly myopic eyes without choroidal neovascularization, and 35 normal subjects, were studied. The intraocular levels of choroidal neovascularization-related cytokines, like vascular endothelial growth factor, MCP-1, IL-8, IL-10, and IL-23, were determined. Results: The levels of vascular endothelial growth factor and IL-8 were significantly higher in eyes with mCNV than in high myopia eyes without mCNV with significant odds ratio of 2.00 and 2.25 per quartile, respectively (P < 0.05). When myopic lesions of patients with mCNV were classified into 3 categories based on the severity, IL-8 and MCP-1 were significantly elevated depending on the presence of maculopathy (P < 0.05). Vascular endothelial growth factor was significantly elevated in eyes of Category 2. An advancement of the maculopathy category was significantly associated with the need for multiple treatment of intravitreal bevacizumab (P < 0.05). In 12 eyes that required multiple intravitreal bevacizumab, the MCP-1 level was significantly elevated. Conclusion: The significant associations of mCNV in highly myopic eyes with elevated levels of vascular endothelial growth factor or inflammatory cytokines and maculopathy lesions strongly suggest an involvement of inflammation in the etiology of mCNVs.

The effect of topical application of 0.15% ganciclovir gel on cytomegalovirus corneal endotheliitis

Background/aims The aim of this study was to evaluate the therapeutic efficacy and drug transfer of topical application of 0.15% ganciclovir (GCV) gel on cytomegalovirus (CMV) corneal endotheliitis. Methods This study is a multicentre, prospective, interventional case series. Seven eyes of seven immunocompetent patients diagnosed with CMV corneal endotheliitis, based on clinical manifestations and qualitative PCR, were enrolled in this study. The patients were treated with topical applications of 0.15% GCV gel six times daily for 12u2005weeks without concomitant systemic GCV. Clinical evaluations and quantitative PCR of CMV were performed, and GCV concentrations in aqueous humour were measured by liquid chromatography/tandem mass spectrometry. Results Clinical improvement of coin-shaped lesions, other types of keratic precipitates, corneal oedema, and anterior chamber inflammation was confirmed at the 4-week visit in all seven eyes. The GCV treatment significantly decreased the CMV copy numbers (p<0.0001). After 12u2005weeks of treatment, six eyes recovered clear corneas with good vision, and endothelial function was well maintained. Detectable levels of GCV were confirmed in the aqueous humour of all the eyes. The mean GCV concentration in the anterior chamber was 162.0±202.4u2005ng/mL. The re-emergence of CMV without symptoms was observed in one eye with lower drug transfer. No side effects were observed. Conclusions Clinical improvement and reduced CMV copy numbers in the aqueous humour were confirmed in the CMV corneal endotheliitis cases. Although the case numbers are limited and long-term follow-up is necessary, the topical application of 0.15% GCV gel appears to be a useful treatment option for CMV endotheliitis. Trial registration number UMIN000012435.

Clinical utility of antimicrobial susceptibility measurement plate covering formulated concentrations of various ophthalmic antimicrobial drugs.

Purpose The purpose of this study was to evaluate the clinical utility of SG17, an ophthalmic antimicrobial susceptibility measurement plate. Design This was a multicenter, retrospective, observational study. Patients and methods Using clinical isolates from patients with ocular infections, drug susceptibility testing using the Clinical Laboratory and Standards Institute standards was routinely conducted at five facilities. The minimum inhibitory concentrations of the isolated strains were determined using SG17 at the Research Foundation for Microbial Diseases of Osaka University. The records of antimicrobial drugs used and the therapeutic course were evaluated for all cases. The susceptibility results from SG17 and routine methods used at each facility were compared. Results A total of 112 bacterial strains were isolated from 92 patients. Of these cases, keratitis was the most common (52.2%), followed by conjunctivitis (21.7%) and others (26.1%). Principal signs and symptoms resolved in all patients, indicating that therapeutic effects had been achieved. With SG17, drug susceptibility was determined in 98.9% of isolates compared with 30.4% of isolates determined using conventional methods. By adapting the Clinical Laboratory and Standards Institute standards to SG17 results, we found that 91.3% of patients were susceptible and 7.6% were resistant. In five patients, drugs with a resistant evaluation were initially administered with no effect, and the patients were then switched to drugs with a susceptible evaluation with final resolution, indicating agreement of clinical results with SG17. Conclusion SG17 can be used to determine drug susceptibility to antimicrobial agents currently used in ophthalmic practice. SG17 is useful for selecting antimicrobial drugs.

Efficacy of herpes virus helicase-primase inhibitor, ASP2151, for treating herpes simplex keratitis in mouse model

Aims To determine the efficacy of a new helicase-primase inhibitor, ASP2151, for treating herpetic keratitis. Methods Murine corneas were infected with herpes simplex virus type 1 (HSV-1). ASP2151 was administered orally or topically, and the severity of epithelial dendritic keratitis was determined. The effectiveness of ASP2151 was compared with that of acyclovir and valacyclovir. The reduction of the amount of HSV in tears, enucleated eyes and trigeminal ganglia was determined by real-time PCR or plaque assay. Results Orally administered ASP2151 reduced the epithelial keratitis score significantly more than that of the vehicle-treated group (p<0.01). It also lowered the HSV-DNA levels in the tears significantly more than that by valacyclovir (p<0.01). ASP2151 ointment resulted in the same reduction of the keratitis score as acyclovir ointment, and lowered the HSV DNA in tears more than acyclovir ointment. Topical instillation of ASP2151 improved the herpetic dendritic keratitis score significantly and reduced the titre of HSV DNA in the tears in a dose-responsive way. Conclusions ASP2151 had significantly better anti-HSV activity against herpes simplex keratitis than valacyclovir and acyclovir after systemic or topical use. These findings indicate that ASP2151 should be considered as an alternative treatment for herpes simplex keratitis.

Effectiveness of timely intraoperative iodine irrigation during cataract surgery

PurposeTo determine the antiseptic efficacy of timely intraoperative iodine irrigation during cataract surgery.MethodsA total of 198 eyes of 99 cataract surgery patients were studied. The eyes were randomly assigned to treatment with or without timely intraoperative iodine irrigation of the surgical field with an iodine compound equivalent to 0.33xa0% povidone-iodine. In eyes in the timely intraoperative iodine irrigation group, the ocular surface was irrigated twice intraoperatively—before the initial incision and before insertion of the intraocular lens (IOL). The efficacy of the antiseptic treatment was evaluated by culture tests using scrapings of the surface of the sclerocornea and conjunctiva to the left of the incision and by broad-range real-time PCR for bacterial 16S ribosomal DNA using scrapings from the right side of the incision.ResultsFollowing intraoperative application of the iodine, bacteria were not detected in cultures of the samples. For the control eyes without timely iodine irrigation, cultures of samples from five and two eyes were positive before the initial incision and before IOL insertion, respectively. The bacterial DNA copy number before the initial incision was 1.7xa0±xa00.5xa0×xa0103, which was significantly lower than that of the control eyes (1.7xa0±xa00.6xa0×xa0104). For both groups of eyes, the bacterial DNA copy number was significantly lower before the IOL insertion depending on the time course. When the antiseptic effect of the iodine irrigation and time course on bacterial DNA copy number was analyzed using generalized mixed linear regression, both were found to be significantly effective. No significant intraoperative epithelial defect was observed. The postoperative corneal endothelial cell count did not differ significantly between the two groups of eyes.ConclusionsTimely iodine irrigation can serve as a simple and useful adjunctive disinfection step in cataract surgery.

Comparison of toxicities of moxifloxacin, cefuroxime, and levofloxacin to corneal endothelial cells in vitro

Purpose To evaluate and compare the toxic effects of moxifloxacin, cefuroxime, and levofloxacin on human corneal endothelial cells in vitro and determine the safe intracameral concentrations for them. Setting Tottori University, Tottori, Japan. Design Experimental study. Methods Human corneal endothelial cells in culture were exposed to moxifloxacin, cefuroxime, and levofloxacin at concentrations up to 2000 &mgr;g/mL. Evaluation of membrane damage was determined by ethidium homodimer‐1 uptake and cell viability, by intrinsic esterase activity. The inhibitory effects of the 3 antibiotics on the constitutive secretion of interleukin‐6 (IL‐6) by human corneal endothelial cells were determined by enzyme‐linked immunosorbent assay. Results The acute effects (6 hour) of the 3 antibiotics on membrane damage and cell death were dose‐dependent for moxifloxacin and levofloxacin (≥500 &mgr;g/mL). For cefuroxime, membrane damage was not observed at 6 hours and only slight damage was detected at 24 hours at concentrations higher than 500 &mgr;g/mL. The half maximum inhibitory concentrations on cell viability of moxifloxacin, levofloxacin, and cefuroxime were 487 &mgr;g/mL, 578 &mgr;g/mL, and 1600 &mgr;g/mL, respectively. The inhibitory effects of the 3 antibiotics on the constitutive secretion of IL‐6 were observed at 15.6 &mgr;g/mL or higher, indicating the antibiotics can impair the secretion of the protective cytokine even at low concentrations. Conclusions Moxifloxacin at more than 500 &mgr;g/mL caused damage to the cell membranes of corneal endothelial cells; even higher concentrations decreased cell viability. Considering the lower minimum inhibitory concentration for inhibiting 90% growth by moxifloxacin, intracameral moxifloxacin at 500 &mgr;g/mL or less is recommended for prophylactic use. Financial Disclosure Dr. Inoue is a medical advisor to Alcon Japan Ltd. No author has a financial or proprietary interest in any material or method mentioned.

Pharmacologic Inhibition of IκB Kinase Activates Immediate Hypersensitivity Reactions in Mice

Pharmacologic inhibitors of IκB kinase (IKK), especially IKK-β, have been developed to treat inflammatory diseases. However, their interactions with components of the NF-κB pathways are not fully known in allergic diseases. To examine whether IKK is involved in immediate hypersensitivity reactions and to determine whether counterregulatory mechanisms in the NF-κB activation system were active, we examined the role played by IKK components on mast cell degranulation using a murine ocular immediate hypersensitivity reaction model. Pharmacologic inhibition of IKK in mice caused paradoxical aggravation of the mast cell-mediated immediate hypersensitivity reaction and up-regulation in the expression of inflammatory cytokines. Downstream analyses showed that B-cell deficiency or treatment by IL-1 receptor antagonist corrected the aberrant activation of tissue-resident mast cells, which would indicate contribution by activated B cells. Analyses of co-cultures of tissue-resident mast cells showed the contribution of activated B cells to activation of mast cells and secretion of inflammatory cytokines. Aberrant activation of the NF-κB promoter in isolated B cells was induced exclusively by IKK-β inhibition and was negated by ablating IKK-α. Aggravated mast cell degranulation by pharmacologic IKK inhibition in the murine immediate hypersensitivity reaction was corrected by B-cell-targeted inhibition of IKK-α. Thus, IKK-β limits B-cell-mediated mast cell activation and inflammatory cytokine induction in immediate hypersensitivity by counterbalancing the activity of IKK-α.