Yuka Shimonagano

Intraocular Pressure Elevation after Injection of Triamcinolone Acetonide : A Multicenter Retrospective Case-Control Study

PURPOSE To determine the risk factors for intraocular pressure (IOP) elevation after the injection of triamcinolone acetonide (TA). DESIGN Retrospective interventional case-control study. METHODS SETTING Multicenter. PATIENT POPULATION Four hundred and twenty-seven patients. OBSERVATION PROCEDURES Intraocular pressure levels after TA treatment by the sub-Tenon capsule injection (STI; 12 mg, 20 mg, or 40 mg), intravitreal injection (IVI; 4 mg or 8 mg), or the combination of STI (20 mg) and IVI (4 mg), and IOP levels after two TA treatments. MAIN OUTCOME MEASURE Risk factors for IOP levels of 24 mm Hg or higher. RESULTS Younger age (hazards ratio [HR], 0.96/year; P < .0001), IVI (HR, 1.89/year; P < .0001), and higher baseline IOP (HR, 1.15/mm Hg; P = .003) were identified as risk factors. Dose dependency was shown in STI-treated eyes (HR, 1.07/mg; P = .0006), as well as after IVI (HR, 1.64/mg; P = .013). The combination of STI and IVI was a significant risk factor (HR, 2.27; P = .003) compared with STI alone. In eyes receiving two TA treatments, IVI (HR, 2.60; P = .010), higher IOP elevation after the first injection (HR, 1.18/mm Hg; P = .011), and increased dosage of STI (HR, 1.07/mm Hg; P = .033) were risk factors. CONCLUSIONS Younger age, higher baseline IOP, IVI, and increased TA dosage were associated with TA-induced IOP elevation. IOP elevation after repeated TA injection was frequently associated with eyes treated with IVI, high IOP elevation after the first injection, and high doses of STI.

Results of Visual Acuity and Foveal Thickness in Diabetic Macular Edema after Vitrectomy

PurposeTo report results of an investigation of visual acuity (VA) and foveal thickness in diabetic macular edema (DME) patients after vitrectomy.MethodsA retrospective study was performed of the records of 47 patients (61 eyes) who received pars plana vitrectomy (PPV) for DME. All eyes were followed up for over 6 months (mean, 24.8 months; range, 6–60 months). VA and foveal thickness evaluated by optical coherence tomography were reviewed preoperatively and postoperatively.ResultsTwenty-four-month follow-up data were available for 46 of the 61 eyes (75%). VA at the final examination had improved by 0.2 log units or more in 34 of the 61 eyes (56%), remained unchanged in 21 eyes (34%), and worsened in six eyes (10%). Mean foveal thickness decreased by more than 20% of the preoperative value in 50 of the 61 eyes (82%), remained unchanged in ten eyes (16%), and increased by more than 20% in one eye (2%) at the final examination. Postoperative best-corrected visual acuity (BCVA) at both 12 and 24 months was significantly better than preoperative BCVA (P < 0.0001). Foveal thickness at 3 months or later significantly decreased from the preoperative value (P < 0.0001), but remained unchanged in comparison with postoperative 12 months and 24 months values (P = 0.19). Preoperative VA and presence of cystoid macular edema (CME) were independently associated with final visual acuity (P = 0.001).ConclusionsPPV for DME effectively improved VA and reduced foveal thickness for a longer postoperative period. Better preoperative VA was associated with better final postoperative VA. The eyes without CME tended to have better final postoperative VA. Jpn J Ophthalmol 2007;51:204–209

Recurrence of Diabetic Macular Edema After Intravitreous Injection of Triamcinolone Following Vitrectomy

PurposeTo evaluate the effects of intravitreous triamcinolone acetonide (TA) after pars plana vitrectomy (PPV) for diabetic macular edema (DME).MethodsWe studied a prospective interventional case series. TA was injected intravitreously after PPV in 28 eyes (PPV+TA group). Eyes with DME that met the same criteria and had been treated with PPV alone (29 eyes) were used as controls. The best-corrected visual acuity (VA) and foveal thickness determined by optical coherence tomography were followed up for over 12 months in both groups. Chronological changes of VA and foveal thickness between the groups were evaluated.ResultsIn the PPV+TA group, VA had improved at 1 month, but worsened after 3 months. Improvement of foveal thickness was found until 3 months, but not after 6 months. In controls, both VA and foveal thickness continued to improve. The VA of the PPV+TA group was significantly better than that of the controls at 1 and 3 months (P = 0.007 and 0.015, respectively). The foveal thickness of the PPV+TA group was significantly less than that of controls at 1 month (P = 0.0004). These differences became insignificant thereafter, and foveal thickness became significantly worse in the PPV+TA group than in the controls at 12 months (P = 0.0002).ConclusionAlthough adjunctive use of TA after PPV for DME improved VA and foveal thickness, the effect was transient and foveal thickness increased significantly compared with the PPV alone group at 12 months postoperatively. Jpn J Ophthalmol 2007;51:278–284 @ Japanese Ophthalmological Society 2007

Conjunctival nodules associated with Vogt-Koyanagi-Harada disease

BackgroundTo report on conjunctival nodules as an unusual manifestation of Vogt-Koyanagi-Harada disease.MethodsA 24-year-old woman presented with a two-month history of bilateral conjunctival injection and gradually decreased vision. Ophthalmological examinations revealed bilateral granulomatous uveitis and bulbar conjunctival nodules, and a biopsy of the conjunctival nodules was performed.ResultsThe biopsy specimens showed noncaseating granulomas. The major components of the infiltrating lymphocytes were CD8-positive T cells. Topical corticosteroid therapy reduced the anterior segment inflammation, and the conjunctival nodules disappeared within a week. Afterwards, the patient demonstrated bilateral retinal detachments, sunset glow fundus and alopecia, and, therefore, was diagnosed to have Vogt-Koyanagi-Harada disease four months after the first symptoms.ConclusionsConjunctival nodules may represent the primary manifestation of Vogt-Koyanagi-Harada disease.

Iris involvement in natural killer/T-cell lymphoma.

Natural killer (NK)/T-cell lymphoma is a rare clinicopathologic entity of non-Hodgkin’s lymphoma, which was originally recognized to involve the nasal region. Pathologically confi rmed ocular cases are rare, although orbital infi ltration, anterior uveitis, vitritis, and retinal complications have been reported. We report a patient in whom the ocular and nasal signs of NK/T-cell lymphoma initially appeared in the iris.

Reply to comment by S. Kase and N. Rao regarding our publication “Conjunctival nodules associated with Vogt-Koyanagi-Harada disease”

Dear Editor We thank Drs Kase and Rao for their comments on our publication. We reported a case of Vogt-Koyanagi-Harada disease (VKH) with conjunctival nodules at the initial presentation [1]. The histological examination of the conjunctival nodules showed noncaseating granulomas. Pathologically VKH is a type of granulomatous panuveitis, but clinically, granulomatous ocular manifestations are more commonly observed in the convalescent or recurrent phase than in the acute phase. We therefore stated in the Discussion “commonly, granulomatous ocular manifestations of VKH, such as Dalen-Fuchs nodules and Koeppe nodules, are seen in either the convalescent phase or the recurrent phase”. In the study by Inomata and Rao [2], five eyes from patients with VKH were subjected to histopathologic examinations. Two of five eyes had Dalen-Fuchs nodules; one eye enucleated at 5 months after onset had Dalen-Fuchs nodules consisting of a mound of proliferated retinal pigment epithelial cells admixed with lymphocytes and macrophages, and another eye enucleated at 3 years after onset had a few Dalen-Fuchs nodules consisting mainly of proliferated retinal pigment epithelial cells containing dense, purple-stained homogenous acellular materials. From these results, Drs Kase and Rao suggested that Dalen-Fuchs nodules display a granulomatous process in the acute phase of VKH and not granulomatous components in the convalescent phase and the recurrent phase. However, the eye with typical Dalen-Fuchs nodules displaying granulomatous process was enucleated not in the acute phase but in the chronic phase with no treatment for 5 months, and another eye with Dalen-Fuchs nodules displaying non-granulomatous process was enucleated in the cicatricial stage 2.5 years after a complete remission rather than in the convalescent phase. Although no clear-cut definition is available, the convalescent phase is thought to follow after several weeks or months of the uveitic phase [3, 4]. There have been more histopathological studies of sympathetic ophthalmia (SO) considered to be pathologically identical to VKH. Small Dalen-Fuchs nodules in size from 130 up to 160 μm have been observed in the periphery of an eye enucleated in the acute phase of SO [5]. In an enucleated eye because of recrudescent SO, despite 2.5 months of treatment with systemic prednisone and cyclosporine, the Dalen-Fuchs nodules, which tend to be more numerous in the periphery, were mostly composed of histiocytes and epithelioid cells [6]. In a histological study of 50 cases of SO, the presence of at least one welldefined Dalen-Fuchs nodule was confirmed in 18 cases [7]. Three types of lesions at the level of the retinal pigment epithelium were recognized. One type was found to consist of focal hyperplasia and aggregation of retinal pigment epithelial cells. A second type, classically referred to as Dalen-Fuchs nodules, consisted of epithelioid cells and lymphocytes covered by an intact dome of retinal pigment epithelium. The third type of lesion was characterised by Graefes Arch Clin Exp Ophthalmol (2008) 246:325–326 DOI 10.1007/s00417-007-0700-8

Acute angle-closure glaucoma following cerebral angiography in moyamoya disease.

A 13-year-old girl was referred to our hospital complaining of ocular pain and visual disturbance in her right eye, which had occurred immediately after cerebral angiography. When she was 7 years old, she presented transient paralysis in her right leg and moyamoya disease was diagnosed. She received a right brain encephalo-duro-arteriosynangiosis (EDAS) and a left EDAS. She did not have any remarkable ocular history or family history. Cerebral angiography had shown delay of flow, retrograde flow of internal carotid artery, carotid-cavernous sinus fistula (CCSF), and strong congestion of the right orbit in the late arterial phase (Fig. 1A). On examination 2.5h after angiography, her right eyelid was swollen. Engorgement of episcleral vessels and chemosis were noticed. The right pupil was mid-dilated and fixed. Shallowing of the anterior chamber with closed angle and corneal edema were present in her right eye (Fig. 1B). The left eye had an anterior chamber with normal depth. In her right eye, visual acuity was counting fingers at 30cm and intraocular pressure (IOP) was 64mmHg. Fundus examination showed marked macular edema, associated with dilated and tortuous retinal veins. Computed tomography disclosed a forward shift of the iris–lens diaphragm of her right eye (Fig. 1C). She received 2% pilocarpine eye drops and intravenous mannitol. Next day, visual acuity was (0.1 2.5D) OD and (1.5 2.0D) OS. Right IOP was 30mmHg, and left IOP was 19mmHg. Shallowing of the anterior chamber still remained, and gonioscopy disclosed the angle to be closed 360° in the right eye. Therefore, she underwent laser iridotomy. Soon after laser treatment, IOP decreased to 18mmHg and corneal edema resolved. The depth of the anterior chamber was reduced below normal (Fig. 1D). After 4 days, her visual acuity improved to 1.0OD and macular edema resolved. When we examined her 5 years later, her visual acuity was 1.0OD and IOP was 15mmHg. On observation, her left eye did not show any remarkable change, with good visual acuity and normal IOP.

Propofol in a patient at risk for malignant hyperthermia : report of a case

Malignant hyperthermia (MH) is a syndrome triggered by volatile inhalation anesthetics and/or succinylcholine. The symptoms are the result of hypermetabolism in skeletal muscle. Although the mortality rate has now dropped to less than 5%, MH is still one of the most serious complications of general anesthesia [1]. Although several reports have suggested that propofol is safe to use in patients who have a history of MH [2,3] or who are considered to be susceptible to MH [4-6] , there have been no studies of changes in serum creatine kinase (CK), serum myoglobin (Mb), and urine Mb during and after propofol anesthesia. We report a case of the successful use of propofol in a patient with a history of MH.