Utility of Collagen Matrix Insertion during Ahmed Valve Implantation with Adjunctive Mitomycin-C: Outcomes at One-year

Purpose@#To compare the surgical outcomes of adjunctive mitomycin-C (MMC) Ahmed valve implantation with and without collagen matrix insertion. @*Methods@#We retrospectively reviewed 108 eyes of 108 patients who underwent Ahmed valve implant surgery with adjunctive MMC. Collagen matrix insertion/Ahmed valve implant surgery (CM-AGV) was performed on 55 eyes, while conventional Ahmed valve implant surgery (AGV) was performed on 53 eyes. We defined surgical failure as an intraocular pressure (IOP) > 18 mmHg or <5 mmHg on two or more consecutive visits, regardless of medication status. @*Results@#After surgery, the IOP and number of topical medications required fell significantly (compared with the preoperative period) in both groups (both p < 0.001); these findings did not significantly differ between groups. The cumulative surgical success rates at 1 year did not significantly differ between groups (78.2% vs. 79.2%, p = 0.54). The only risk factor significantly associated with surgical failure was a postoperative hypertensive phase. Anterior chamber (compared with sulcus) tube placement was significantly associated with visual acuity loss at 1 year postoperatively, but this did not significantly differ between groups. @*Conclusions@#At the 1-year follow-up after Ahmed implant surgery with adjunctive MMC, the success rates of surgery with and without collagen matrix insertion were similar.

Visual Field Changes after Internal Limiting Membrane Peeling in Glaucoma Patients with Epiretinal Membrane

PURPOSE: To report visual field changes after internal limiting membrane (ILM) peeling for macular epiretinal membrane (ERM) according to the severity of glaucoma. METHODS: A retrospective review of 37 eyes from 37 patients who underwent ILM peeling to treat ERM. Standard automated perimetry (Humphrey visual field 24-2 program) was performed preoperatively and postoperatively. Based on the Advanced Glaucoma Intervention Study (AGIS) scoring system of preoperative visual field, patients were classified into the early glaucoma (AGIS ≤ 1) group or the advanced glaucoma (AGIS ≥ 2) group. Postoperative visual field sensitivity at each point was compared with the preoperative value. RESULTS: Out of 37 eyes, 15 eyes had early glaucoma and 22 had advanced glaucoma. Eyes from both groups had poor postoperative visual field parameters. For eyes with advanced glaucoma, the visual field index was significantly reduced and the visual field damage was larger and wider compared to those with early glaucoma. In both groups, visual field impairment was greater on the nasal side than on the temporal side, and visual acuity was not significantly different. Postoperatively, the macular ganglion cell-inner plexiform layer thickness was decreased, especially on the temporal side of advanced glaucoma. CONCLUSIONS: Visual field impairment was greater and wider in eyes with advanced glaucoma than in those with early glaucoma after ILM peeling in patients with ERM.

Transscleral Cyclopexy Using Partial-Thickness Scleral Flap for Repairing Cyclodialysis Cleft: a Case Report

PURPOSE: To report a case of a cyclodialysis cleft that was successfully managed with gonioscopically guided transscleral cyclopexy using partial-thickness scleral flap. CASE SUMMARY: A 44-year-old man complaining of blurred vision in the left eye after blunt trauma was referred to our hospital. The intraocular pressure (IOP) was 4 mmHg and the visual acuity was counting finger. Gonioscopy examination revealed cyclodialysis cleft from 3 to 6 o'clock and fundus examination revealed macular folds. After the failure of conservative medical therapy and laser photocoagulation, gonioscopically guided transscleral cyclopexy using partial-thickness scleral flap was performed. Four months later, the IOP was 18 mmHg, the visual acuity was 0.8, and fundus examination showed the disappearance of the macular folds. CONCLUSIONS: Transscleral cyclopexy using partial-thickness scleral flap is a safe and effective method to treat hypotony maculopathy due to cyclodialysis and to minimize pupil distortion.

Treatment of Recurred Iris Cyst with Laser Photocoagulation and Cystotomy

PURPOSE: To report a case of recurred iris cyst 11 years after treatment with endodiathermy, which was treated with laser photocoagulation and cystotomy followed by intraocular pressure elevation and underwent anterior chamber irrigation. CASE SUMMARY: A 46-year-old female presented to our department with decreased vision in her left eye that had persisted for several months. The patient had a history of surgical removal of an iris cyst with endodiathermy 11 years ago. Slit lamp examination showed an iris cyst adjacent to the nasal corneal limbus. The cyst was filled with turbid fluid. It distorted the pupil and threatened visual axis. Iris cystotomy (diameter larger than 500 microm) was done with diode laser photocoagulation and a neodymiumdoped yttrium aluminium garnet laser. At the same day, the patient's intraocular pressure elevated to 50 mm Hg in spite of maximal conservative treatment and went through anterior chamber irrigation. After six months, the iris cyst was adhered to corneal endothelium and disappeared. Visual acuity and intraocular pressure was within normal range. CONCLUSIONS: An iris cyst can recur after treatment with endodiathermy. Recurred iris cyst can be successfully treated with laser photocoagulation and cystotomy. However, turbid fluid inside the cyst may outflow to the anterior chamber and cause secondary ocular hypertension after treatment, so careful observation is needed.

Synchronous multicentric small hepatocellular carcinomas: defining the capsule on high-frequency intraoperative ultrasonography with pathologic correlation

PURPOSE: The aim of this study was to define the capsules of synchronous multicentric small hepatocellular carcinomas (HCCs) with use of high-frequency intraoperative ultrasonography (IOUS). METHODS: Among the 131 consecutive patients undergoing hepatic resection and high-frequency IOUS for HCC, 16 synchronous multicentric small HCCs in 13 patients were histologically diagnosed in the resected specimens. High-frequency IOUS and pathologic findings of these lesions were compared, with particular focus on the presence and appearance of the capsule in or around each lesion. RESULTS: Synchronous multicentric small HCCs were pathologically classified into distinctly nodular (n=12) or vaguely nodular (n=4) types. All 12 distinctly nodular HCCs including six subcentimeter lesions showed detectable capsules on high-frequency IOUS and pathology. The capsules appeared as a hypoechoic rim containing hyperechoic foci (n=6), hypoechoic rim (n=5), or hyperechoic rim (n=1) with varying degrees of coverage around each lesion. Histologically, the capsules were composed of a combination of one to four layers consisting of a fibrous capsule, peritumoral fibrosis, prominent small vessels, and entrapped hepatic parenchyma. CONCLUSION: Synchronous multicentric small HCCs with distinctly nodular type, even at subcentimeter size, can show capsules with varying coverage and diverse echogenicity on high-frequency IOUS.

Surgical Treatment for Tube Erosion after Ahmed Valve Implantation

PURPOSE: To report serial cases of patients who received surgical treatment for tube erosion after Ahmed valve implantation. METHODS: In this retrospective and longitudinal study, surgical outcomes of reconstruction for tube erosion after Ahmed valve implantation were evaluated. Tube erosion occurred in 7 of 125 eyes (121 patients) at 60.5 ± 67.5 months (2 to 196 months). To prevent recurrence of tube erosion, the tube was repositioned backward in 4 eyes. Scleral allograft was used in all cases. Partial thickness scleral flap, collagen matrix implant, or bovine pericardium was used to cover the exposed tube in selected cases. In eyes with large conjunctival defects or severe adhesions between surrounding conjunctiva and episclera, rotational conjunctival flap, conjunctival autograft, or amniotic membrane graft was used to reconstruct the ocular surface. RESULTS: Three of 7 eyes (42.9%) with tube erosion were successfully repaired by the first surgical treatment. No recurrence of tube erosion was found after the second and the fourth surgical procedure in 3 and 1 eyes, respectively. There was no case of explantation of the Ahmed valve in our series. Tube erosion recurred in 1 of the 4 eyes in which tube-repositioning was required and in 3 of the 5 eyes in which a partial thickness scleral flap was made to cover a tube. One eye experienced recurrent tube erosion in a relatively short-term interval and was repaired successfully using both collagen matrix implantation and amniotic membrane transplantation. CONCLUSIONS: Tube erosion after Ahmed valve implantation was successfully treated by various methods including tube repositioning, partial thickness scleral flap combined with scleral allograft, biodegradable collagen implant, pericardial graft, and/or amniotic membrane transplantation.

Ahmed Valve Implant Surgery with Adjunctive Mitomycin C and Selective 5-Fluorouracil Injection

PURPOSE: To evaluate the surgical results of Ahmed valve implant surgery with adjunctive mitomycin C and selective postoperative 5-fluorouracil (5-FU) subconjunctival injection with a needling procedure. METHODS: In this retrospective study, 40 eyes of 40 patients who had undergone Ahmed valve implant surgery with adjunctive mitomycin C were observed for at least 1 year. The Ahmed valve was implanted after 5-minute application of 0.04% mitomycin C. Selective 5-FU injection with a needling procedure was performed during the follow- up period based on intraocular pressure (IOP). Hypertensive phase was defined as IOP higher than 21 mm Hg within 3 months after operation. IOP higher than 18 mm Hg regardless of IOP-lowering medications at 2 consecutive visits was considered to be a surgical failure. RESULTS: The mean follow-up period was 35.5 ± 12.4 months. Preoperative intraocular pressure was 32.8 ± 7.5 mm Hg, which decreased to 14.0 ± 4.2 mm Hg post-operatively. The number of glaucoma medications decreased significantly from 3.8 ± 0.5 to 2.0 ± 1.0. Eleven of 40 eyes (27.5%) experienced hypertensive phase at 6.0 ± 3.1 weeks after surgery. Kaplan-Meier survival analysis showed cumulative probability of surgical success rates of 82.5%, 79.6%, 72.7%, and 58.8% at 1, 2, 3, and 4 postoperative years respectively. There were no risk factors that affecting surgical failure except age (hazard ratio = 0.17, p = 0.02). CONCLUSIONS: Ahmed valve implant surgery with adjunctive mitomycin C and selective 5-FU injection with a needling procedure showed good success in refractory glaucoma.

CT Findings of Foreign Body Reaction to a Retained Endoloop Ligature Plastic Tube Mimicking Acute Appendicitis: A Case Report

Many hospitals experience one or more retained surgical instrument events with risk of patient morbidity and medicolegal problems. Identification of retained surgical instrument is important. The radiologists should be familiar with imaging finding of retained surgical instrument. In a 62-year-old female with a retained plastic tube, localized peritoneal infiltration around air-containing tubular structure mimicked acute appendicitis on abdomen computed tomography (CT), one year after laparoscopic cholecystectomy. We reported CT findings of foreign body reaction related to retained Endoloop ligature plastic tube mimicking acute appendicitis.

Ultrasonography for nerve compression syndromes of the upper extremity

Nerve compression syndromes commonly involve the nerves in the upper extremity. High-resolution ultrasonography (US) can satisfactorily assess these nerves and may detect the morphological changes of the nerves. US can also reveal the causes of nerve compression when structural abnormalities or space-occupying lesions are present. The most common US finding of compression neuropathy is nerve swelling proximal to the compression site. This article reviews the normal anatomic location and US appearances of the median, ulnar, and radial nerves. Common nerve compression syndromes in the upper extremity and their US findings are also reviewed.

Comparison of Ocular Pulse Amplitude Measured Using Dynamic Contour Tonometry and Ocular Blood Flow Analyzer

PURPOSE: To compare ocular pulse amplitude (OPA) measured using dynamic contour tonometry (DCT) and ocular blood flow analyzer (BFA). METHODS: Thirty-five eyes of 35 patients were enrolled in this cross-sectional and retrospective study. OPA was measured using DCT. Pulse amplitude (PA) and pulsatile ocular blood flow were measured using BFA. RESULTS: OPA measured using DCT (2.79 +/- 0.89 mm Hg) was not significantly different from PA measured with BFA (3.02 +/- 0.90 mm Hg; p = 0.082) and both were significantly correlated (r = 0.663, p < 0.001). Mean difference +/- limit of agreement was -0.22 +/- 1.44 mm Hg between OPA and PA. OPA correlated significantly with intraocular pressure (IOP) measured using Goldmann applanation tonometry (r = 0.330, p = 0.047) but not PA (r = 0.057, p = 0.745). Both PA and OPA did not show significant correlation with the spherical equivalent of refractive error and central corneal thickness. CONCLUSIONS: Although both OPA and PA measure IOP fluctuation and are not significantly different, they showed different relationships with IOP.

Positional Change of Intraocular Pressure and Its Relationship to Ocular Pulse Amplitude

PURPOSE: To investigate the postural change of intraocular pressure (IOP) from sitting to supine position and determine the relationship to other ocular parameters including ocular pulse amplitude (OPA) in glaucoma suspect and open angle glaucoma patients. METHODS: The present study included 46 eyes of 46 patients. First, we measured IOP and OPA using Goldmann applanation tonometer (GAT), Pascal dynamic contour tonometer and TonoPen(R). Using TonoPen(R), the IOP was measured immediately after the subjects were placed in a supine position and 10 minutes and 30 minutes thereafter. We also investigated the correlation between positional change of IOP and axial length (AL), refractive error (RE), and OPA. RESULTS: IOPs of patients in a sitting position measured with GAT and TonoPen(R) were 15.3 +/- 3.3 mm Hg and 16.6 +/- 2.9 mm Hg, respectively, and OPA was 2.57 +/- 0.89 mm Hg. IOPs measured with TonoPen(R) were 17.6 +/- 2.9 mm Hg immediately after position change, 18.2 +/- 3.7 mm Hg after 10 minutes and 17.5 +/- 2.7 mm Hg after 30 minutes. Each IOP change was statistically significant and the largest change was after 10 minutes. Changes of IOP after 10 minutes were positively correlated with OPA (R = 0.340) and RE (R = 0.330) and negatively correlated with AL (R = -0.410). CONCLUSIONS: When placed in a supine position, the IOP of patients increased and then decreased over time. Positional IOP change was influenced by AL and OPA and variable hemodynamic factors and apparently influenced OPA and ocular perfusion pressure.

Comparison of Dorzolamide-Timolol Fixed Combination and Latanoprost, Effects on Intraocular Pressure and Ocular Pulse Amplitude

PURPOSE: To compare dorzolamide-timolol fixed combination (DTFC) and latanoprost with regard to their effects on intraocular pressure (IOP) and ocular pulse amplitude (OPA). METHODS: Sixty eyes of 60 patients with open angle glaucoma or glaucoma suspect were included in the present study. Patients were divided into 2 groups, DTFC-treated (n = 30) and latanoprost-treated (n = 30). IOP and OPA were measured with dynamic contour tonometer (DCT) and Goldmann applanation tonometer (GAT), before and at least 1 month after treatment. RESULTS: GAT IOP, DCT IOP and OPA decreased by 2.25 +/- 2.23 mm Hg, 1.97 +/- 2.06 mm Hg, and 0.14 +/- 0.88 mm Hg, respectively in the DTFC-treated group. In the latanoprost-treated group, GAT IOP, DCT IOP and OPA was reduced by 2.74 +/- 2.96 mm Hg, 2.06 +/- 3.50 mm Hg, and 0.69 +/- 1.07 mm Hg, respectively. There was no significant difference (p = 0.311) in the decline of IOP between the 2 groups, but OPA of the DTFC-treated group decreased less than the latanoprost-treated group (p = 0.032). CONCLUSIONS: No significant differences were observed in the short-term decline of IOP between the 2 medications. However, the influence of DTFC on OPA appeared negligible in the latanoprost-treated group.

Ectopic Insertion of the Pectoralis Minor Tendon: Inter-Reader Agreement and Findings in the Rotator Interval on MRI

OBJECTIVE: To evaluate magnetic resonance imaging (MRI) observer variability to detect ectopic insertion of the pectoralis minor tendon (EIPMT) and to investigate changes in the rotator interval in patients with EIPMT using MRI. MATERIALS AND METHODS: A total of 507 shoulder MRIs (male:female = 259:248; mean age, 55.4 years) were classified into 1) normal type insertion of the pectoralis minor tendon, 2) complete type EIPMT, and 3) partial type EIPMT independently by two radiologists. Inter-observer agreement was calculated using the kappa coefficient. Thickness of the fibrotic scar tissue in the subcoracoid triangle and humeral side axillary recess was measured. MRIs were reviewed by consensus with regard to the grade of fibrotic scar tissue proliferation in the rotator interval. Comparisons were made between normal and EIPMT and between partial and complete type EIPMT. RESULTS: The incidence of EIPMT was 13.4% (complete type, 7.7%; partial type, 5.7%). Inter-observer agreement was substantial (kappa = 0.775). Fibrotic scar tissue in the subcoracoid triangle was thicker, and the grade of fibrotic scar tissue proliferation in the rotator interval was higher in the EIPMT group than those in the control group. No significant difference was observed in the thickness of humeral side axillary recess. The thicknesses of fibrotic scar tissue in the subcoracoid triangle and humeral side axillary recess as well as the grade of fibrotic scar tissue in the rotator interval were not significantly different between complete and partial type EIPMT. CONCLUSION: MRI enabled detection of EIPMT with substantial observer agreement. Patients with EIPMT show a high tendency for fibrotic scar tissue proliferation in the rotator interval.

Closure of pancreatoduodenal fistula using vascular occluding coil embolization and fibrin glue injection: a case study

The conventional management of pancreatoenteric fistulas and pancreatic abscess with aggressive surgery or percutaneous drainage catheter placement are associated with increased surgery-related morbidity and mortality, and a longer hospitalization. We report here a case of successful closing pancreatoduodenal fistula, which remained open after the percutaneous catheter drainage of pancreatic abscess, by using vascular coil embolization and fibrin glue injection. This procedure is a less invasive, more effective and better tolerated strategy for the management of pancreatoenteric fistula in a selected group of high risk patients and needs further investigation.

The Ability of Disc-to-Fovea Distance to Disc-Diameter Ratio to Estimate Optic Disc Size

PURPOSE: To investigate the usefulness of the measurement of disc-to-fovea distance to disc-diameter ratio (DF/DD ratio) in detecting large and small discs. METHODS: A total of 300 randomly selected subjects were included in the present study. All patients underwent stereoscopic disc photography and DF/DD ratio, which is the shortest distance between disc margin and fovea divided by mean disc diameter was determined by planimetry. The diagnostic accuracy of DF/DD ratio was evaluated using areas under the receiver operating characteristics curves (AUCs), sensitivity, and specificity. RESULTS: No significant differences in disc-to-fovea distance were observed among small and large disc groups. The DF/DD ratio was significantly lower in subjects with large discs (1.74 +/- 0.27) compared with subjects with small discs (2.70 +/- 0.15). AUCs of the DF/DD ratio were 0.942 and 0.947 in detecting large and small discs, respectively. In detecting disc size by a fixed DF/DD ratio of 2.0, sensitivity was 100% for both large and small discs, and specificity was 70.1% and 40.9% for the large and small discs, respectively. CONCLUSIONS: The DF/DD ratio may be a simple and useful clinical aid in detecting large and small discs. The 2.0 fixed DF/DD ratio, showed 100% sensitivity in detecting both large and small discs, although medium discs may be misdiagnosed as small discs more often than as large discs.

Colon Cancer After Acute Diverticulitis Treatment

Diverticulitis is the most common clinical complication of diverticular disease, affecting 10-25% of the patients with diverticula. The prevalences of diverticulitis and colon cancer tend to increase with age and are higher in industrialized countries. Consequently, diverticulitis and colon cancer have been reported to have similar epidemiological characteristics. However, the relationship between these diseases remains controversial, as is the performance of routine colonoscopy after an episode of diverticulitis to exclude colon cancer. Recently, we experienced three cases of colon cancer after treating acute diverticulitis, based on which we suggest the importance of follow-up colonoscopy after acute diverticulitis.

A Case of a Mucinous Adenocarcinoma Arising from a Rectal Diverticulum

The occurrence of an adenocarcinoma arising from a rectal diverticulum that causes mechanical ileus is very rare. Recently, we diagnosed a case of a mucinous adenocarcinoma in a rectal diverticulum after an emergent abdominal perineal resection and permanent colostomy by laparotomy. Here, we present a case report and a review of the literature.

Fluid Collection in the Right Lateral Portion of the Superior Aortic Recess Mimicking a Right Mediastinal Mass: Assessment with Chest Posterior Anterior and MDCT

OBJECTIVE: We observed patients in whom the fluid collection in the right lateral portion of the superior aortic recess on computed tomography (CT) scans mimicked a right anterior mediastinal mass on chest PA radiographs. The purpose of this study was to assess chest PA and CT features of these patients. MATERIALS AND METHODS: All chest PA radiographs and CT scans in 9 patients were reviewed by two radiologists on a consensus basis; for the presence of pleural effusion, pulmonary edema and heart size on chest PA radiographs. For the portion of the fluid collection in the superior aortic recess (SAR), a connection between the right lateral portion of the SAR (rSAR) and posterior portion of the SAR (pSAR) on CT scans, and the distance between the right lateral margin of the rSAR and the right lateral margin of the superior vena cava. RESULTS: Fluid collection in the rSAR on CT scans caused a right anterior mediastinal mass or a bulging contour on chest PA radiographs in all women patients. All patients showed cardiomegaly, five patients had pleural effusion, and two patients had mild pulmonary edema. Further, eight patients showed a connection between the rSAR and the pSAR. CONCLUSION: The characteristic features of these patients are the right anterior mediastinal mass-like opacity due to fluid collection in the rSAR, are bulging contour with a smooth margin and cardiomegaly regardless of pulmonary edema on the chest PA radiographs, and fluid connection between the rSAR and the pSAR on CT scans.

The Effect of Cataract Surgery on Ocular Pulse Amplitude

PURPOSE: To investigate the change of intraocular pressure (IOP) and ocular pulse amplitude (OPA) measured by dynamic contour tonometry (DCT) after cataract surgery and to identify the influencing factors related with OPA change after cataract extraction. METHODS: The present study included 32 patients who underwent unilateral cataract surgery and the non-operated fellow eyes were used as control. IOP was measured by Goldman applanation tonometry (GAT) and Pascal DCT preoperatively, and 3 months postoperatively. Additionally, OPA was measured by Pascal DCT preoperatively, and 3 months postoperatively. Axial length (AL), anterior chamber depth (ACD), and central corneal thickness (CCT) were measured preoperatively. RESULTS: After cataract surgery, IOP by GAT, IOP by DCT, and OPA decreased significantly with a mean decrement of 1.3 mm Hg, 1.6 mm Hg, and 0.5 mm Hg, respectively (p 0.05) postoperatively. The most important factor influencing the decrement of IOP by GAT, IOP by DCT, and OPA after cataract surgery was the preoperative level of their measurements (r = 0.382, p < 0.05 in GAT, r = 0.807, p < 0.001 in DCT, r = 0.627, p < 0.001 in OPA). In addition, the OPA decrement after cataract surgery was significantly correlated with age (r = -0.370, p = 0.037), and was not correlated with AL, ACD, and CCT. CONCLUSIONS: Both IOP and OPA decreased after cataract surgery, which appears to influence the relationship between IOP and OPA. The correlation between OPA decrement and age may be related to increased ocular rigidity with aging.

The Effect of Cataract Surgery on Ocular Pulse Amplitude

PURPOSE: To investigate the change of intraocular pressure (IOP) and ocular pulse amplitude (OPA) measured by dynamic contour tonometry (DCT) after cataract surgery and to identify the influencing factors related with OPA change after cataract extraction. METHODS: The present study included 32 patients who underwent unilateral cataract surgery and the non-operated fellow eyes were used as control. IOP was measured by Goldman applanation tonometry (GAT) and Pascal DCT preoperatively, and 3 months postoperatively. Additionally, OPA was measured by Pascal DCT preoperatively, and 3 months postoperatively. Axial length (AL), anterior chamber depth (ACD), and central corneal thickness (CCT) were measured preoperatively. RESULTS: After cataract surgery, IOP by GAT, IOP by DCT, and OPA decreased significantly with a mean decrement of 1.3 mm Hg, 1.6 mm Hg, and 0.5 mm Hg, respectively (p 0.05) postoperatively. The most important factor influencing the decrement of IOP by GAT, IOP by DCT, and OPA after cataract surgery was the preoperative level of their measurements (r = 0.382, p < 0.05 in GAT, r = 0.807, p < 0.001 in DCT, r = 0.627, p < 0.001 in OPA). In addition, the OPA decrement after cataract surgery was significantly correlated with age (r = -0.370, p = 0.037), and was not correlated with AL, ACD, and CCT. CONCLUSIONS: Both IOP and OPA decreased after cataract surgery, which appears to influence the relationship between IOP and OPA. The correlation between OPA decrement and age may be related to increased ocular rigidity with aging.