[EDAS (encephalo-duro-arterio-synangiosis) for occlusive/stenotic cerebrovascular disease].

The efficacy of encephalo-duro-arterio-synangiosis (EDAS) using superficial temporal artery was evaluated for the treatment of the occlusive/stenotic cerebrovascular disease. Nine patients with the occlusive/stenotic cerebrovascular disease underwent EDAS in our hospital. The mean follow-up period was 6.6 months. Postoperative angiography showed no collateral formation via EDAS in any of the nine patients. We analyzed the following points: 1) operative procedure, 2) follow up period after surgery, 3) preoperative cerebral blood flow, and 4) age of the patients. Results showed that EDAS as a treatment of occlusive/stenotic cerebrovascular disease was not effective. This study failed to reinforce the suggestion that indirect extracranial/intracranial bypass surgery is effective as the treatment of occlusive/stenotic cerebrovascular disease.

Immunohistochemical and immunogenetic analyses of ocular adnexal lymphoid proliferation.

PURPOSE: To compare polymerase chain reaction (PCR) results with histological, immunohistochemical, and clinical findings to understand the nature of ocular adnexal lymphoid proliferation. METHODS: We examined 20 cases (21 specimens) of ocular adnexal lymphoid proliferation, using histological, immunohistochemical, and molecular genetic methods. The latter two types of experiments were performed to examine the light chain restriction of immunoglobulin using the peroxidase-antiperoxidase method, and the clonality of immunoglobulin heavy chains using the PCR method. RESULTS: Although in 8 cases it could not be determined morphologically whether the tumors were neoplastic or not, clonality was revealed in 1 case by immunohistochemistry and in 4 cases by PCR. Two cases showed disparate results between immunohistochemistry and PCR, probably due to somatic mutation of the framework region of the immunoglobulin heavy chain gene. CONCLUSION: Examination using these methods contributes to a better understanding of the nature of the ocular adnexal lymphoid proliferation. Furthermore, the immunoglobulin gene PCR method is very useful in practice for examination of specimens, as it can be used with formalin-fixed and paraffin-embedded specimens.

[Moyamoya disease with intraventricular hemorrhage due to rupture of lateral posterior choroidal artery aneurysm: case report].

Intracranial aneurysms associated with moyamoya disease are often reviewed. Aneurysms not around the circle of Willis but on the collateral vessels are rare. A 71-year-old woman presented with sudden onset of severe headache and vomiting. CT scan showed an intraventricular hemorrhage from bilateral lateral ventricle to fourth ventricle. Cerebral angiography showed the occlusion of the terminal portion of the bilateral internal carotid artery with moyamoya vessels and three aneurysms at the distal portion of the left lateral posterior choroidal artery. Clinical symptoms improved day by day, but 17 days later, due to rebleeding of the aneurysms the patient fell into coma. The day after rebleeding, endovascular embolization was performed using liquid particle, and the left lateral posterior choroidal artery and the aneurysm were occluded. Brain infarction with massive brain edema of the left cerebral hemisphere resulted in the patient's death. The management of the aneurysms in the basal ganglia and on the collateral vessels associated with moyamoya disease is controversial. We suggest positive intervention during the acute stage for the peripheral artery aneurysms taking endovascular embolization into consideration to prevent rupture or rebleeding.

Binocular depth-from-motion in infantile and late-onset esotropia patients with poor stereopsis.

PURPOSE: There are at least two possible ways to detect motion-in-depth binocular without monocular cues: the binocular disparities at different times and a mechanism that detects interocular velocity differences. The perception of interocular velocity differences (Binocular depth-from-motion [BDFM]) depends on the relative velocity of the images on the retina of the left and right eyes, and this information can be experienced by normal and some strabismic patients. The purpose of this study was to determine the characteristics of esotropic patients who have BDFM but have poor stereopsis. METHODS: Forty-one infantile and 28 late-onset esotropia patients with poor stereopsis were studied. Dynamic stereopsis and BDFM were tested with computer-generated random dot stereograms and kinematograms. The correlations between BDFM and other binocular functional tests were determined. RESULTS: A total of 31 (44.9%) patients, 15 (36.5%) of the infantile and 16 (57.1%) of the late-onset esotropia group, passed the BDFM test. None of these patients passed the random dot stereo test under static or dynamic conditions. Fusion of the Worth four dot test at near 0.3 m was correlated with the presence of BDFM. Three of the 15 infantile and 10 of the 16 late-onset esotropic patients with positive BDFM showed gross stereopsis as measured by the Titmus Fly. The angle of strabismus was significantly smaller in the patients with positive BDFM for the infantile and the late-onset esotropia groups. CONCLUSIONS: BDFM was present in about half of the esotropic patients who do not have fine stereopsis. Ocular alignment within 10 to 15 prism diopters is an important factor in obtaining BDFM. Strabismus surgery still provides some binocular benefit for infantile esotropia patients who were bypassed for early surgery. Separate mechanisms may underlie static stereopsis and BDFM.

[Efficacy of three dimensional CT angiography (3D-CTA) for a first diagnosis of occlusive cerebrovascular disorders].

Patients with cerebrovascular disorders generally undergo computerized tomography (CT), even though magnetic resonance imaging (MRI) is available. We investigated the efficacy of three dimensional CT angiography (3D-CTA) for a first diagnosis of occlusive cerebrovascular disorders. Sixty-two patients, who were suspected of occlusive cerebrovascular disorder on the basis of neurological findings or initial plain CT findings, were reviewed. 3D-CTA was performed at the first medical examination. As a result, two patients were diagnosed with ICA (internal carotid artery) occlusion, nine with MCA (middle cerebral artery) occlusion, and one with BA (basilar artery) occlusion. All twelve patients underwent cerebral angiography immediately after those 3D-CTA in every case. Angiographical findings were the same as 3D-CTA. Interventional superselective thrombolytic therapy was performed in ten of the twelve patients, and recanalization resulted in four of them. 3D-CTA may also be able to determine whether the occlusive vessel is the chief cerebral artery or the perforating artery.

[Cerebral blood flow (CBF) before and after cranioplasty performed during the chronic stage after decompressive craniectomy evaluated by xenon-enhanced computerized tomography (Xe-CT) CBF scanning].

Patients who undergo decompressive craniectomy for the purpose of prevention of cerebral herniation sometimes improve neurologically or increase activity of daily life after cranioplasty during the chronic stage. We studied the effect which cranioplasty at the chronic stage had on intracranial environment by means of xenon-enhanced computerized tomography (Xe-CT) CBF scanning. Eight patients underwent decompressive craniectomy at the acute stage and cranioplasty at the chronic stage was reviewed. Xe-CT CBF scanning was performed before and after cranioplasty. On the slice of the basal ganglia. CBF of the symptomatic hemisphere increased in five patients and CBF of the other hemisphere increased in three patients after cranioplasty. On the slice 20 mm above the basal ganglia, CBF of the symptomatic hemisphere increased in five patients and CBF of the other hemisphere increased in four patients after cranioplasty. Cranioplasty after decompressive craniectomy may increase CBF of not only the symptomatic hemisphere but also the other hemisphere.

Studies on the function of the checkerboard pattern stimulator: analysis of ocular positions during stimulation.

PURPOSE: To analyze the effectiveness of the checkerboard pattern stimulator (CPS) in facilitating stereopsis in patients with acquired esotropia. METHODS: Fourteen patients were treated with checkerboard pattern stimulation following surgical correction of the ocular alignment. In order to determine the cause of the difference in the effectiveness of CPS on exotropes and esotropes, a separate study was carried out on 15 subjects: 5 orthophores, 5 exophores, and 5 esophores. RESULTS: Eight of the 14 patients achieved stereopsis; the remaining 6 cases did not show marked improvement in stereoacuity. The CPS was more effective on exotropes, as reported previously, than on esotropes (P = 0.047, chi2 test). By recording the ocular positions of the 15 subjects in the separate study, we found a tendency toward exodeviation in the orthophoric and exophoric subjects but not in esophoric subjects. CONCLUSIONS: Our results suggest that CPS develops sensory fusion by providing an identical pattern simultaneously to the foveas of both eyes and has no effect on convergence training and motor fusion.

Motion perception tested with reversing grating in Duane's syndrome.

Many papers have reported that motion perception asymmetry (MPA) is replaced by motion perception symmetry (MPS) by the 4th to 5th month after birth, when stereopsis starts to occur in normal infants. Duane's syndrome is a congenital motor abnormality, it does, however, reportedly show good stereopsis. We confirmed the stereopsis in Duane's syndrome and checked the motion perception (MP) by using the Reversing Grating Test to investigate if the congenital motor abnormality affects the MP in patients whose binocular sensory system is well developed. Thirty-eight Duane's syndrome patients aged 3 to 45 years were included in the present study. They were divided into 24 cases of Duane I, 9 cases of Duane II, 5 cases of Duane III. The Titmus Stereo Tests, Lang Stereotest, and TV-Random Dot Stereo Test were used to examine the stereopsis. Thirty-four patients had good stereopsis, and 4 had poor stereopsis. None of them showed MPA in any spatial frequencies (1/ 4, 1/2, 1 cycles/degree) examined. The Reversing Grating Test is useful for examining MPA in strabismus patients with eye movement limitations.

Long-term observation of infants with macular hemorrhage in the neonatal period.

Ten infants with macular hemorrhage in the neonatal period were tested to assess visual acuity, stereopsis, and ocular position. Contrast sensitivity was examined in three of them. The duration of hemorrhages was 1 month in four patients, 1.5 months in one patient, 2 months in two patients, 3 months in one patient, 4 months in one patient (corrected gestational 3 months), and 5 months in one patient (corrected gestational 2.5 months). None of the patients developed deprivation amblyopia or visual loss due to abnormality of macula. The results suggest that there is essentially no risk of visual deprivation for 3 months after birth. If there is any poor visual acuity, abnormal ocular position, abnormal eye movement, or poor stereopsis in the infant with neonatal macular hemorrhage, we have to elucidate the cause of the symptoms.

Comparison of muscle volume between congenital and acquired superior oblique palsies by magnetic resonance imaging.

Magnetic resonance imaging (MRI) studies of superior oblique (SO) muscles have revealed a high incidence of SO muscle atrophy/hypoplasia in congenital SO palsy patients. It has also been reported that long-standing acquired SO palsy patients show atrophic SO muscles in the affected eye. The purpose of this study was to compare the incidence of SO muscle atrophy/hypoplasia in congenital and acquired SO palsy by utilizing MRI. Coronal MRI image planes were taken from 29 cases of unilateral congenital SO palsy and 9 cases of acquired unilateral SO palsy patients. The SO muscle bellies were traced and their sizes were measured from each image plane. The total volume of the affected superior oblique muscle was compared with that of the normal fellow eye. The mean volume of the affected superior oblique muscle to that of the normal muscle was 45.3% (SD = 30.1) in the congenital group and 65.8% (SD = 22.7) in the acquired group. The volume reduction of the SO muscle in congenital SO palsy patients appears to be mainly a congenital abnormality rather than a secondary change, as seen in acquired SO palsy patients.

Treatment of fungal corneal ulcers with amphotericin B ointment.

PURPOSE: To report two patients with severe fungal corneal ulcers who were treated successfully with topical amphotericin B ointment. METHODS: Two eyes of two patients developed corneal ulcers and hypopyon after corneal foreign body removal. Aspergillus fumigatus and Fusarium solani were isolated in Patients 1 and 2, respectively. By antifungal susceptibility testing, amphotericin B was shown to have the lowest minimal inhibitory concentration. RESULT: Topical administration of amphotericin B ointment resulted in dramatic improvement in fungal corneal ulcers. CONCLUSIONS: Antifungal susceptibility tests may aid with selection of antifungal agents. Amphotericin B ointment is one of the promising therapies for keratomycosis caused by antimycotic-resistant fungi.

[Evaluation of the clinical usefulness of the New Aniseikonia Tests].

PURPOSE: We performed the following experiments to evaluate the clinical usefulness of the New Aniseikonia Tests (NAT). METHODS: 1. Aniseikonia was induced artificially by wearing a spectacle lens on the right eye and a contact lens on the left eye in myopic but otherwise normal subjects. The amount of aniseikonia detected was compared between the NAT and the Phase Difference Haploscope (PDH). Three different conditions were used with the PDH in order to study whether the fusional background affects the amount of the aniseikonia. 2. The size of aniseikonia was measured by the NAT in normal subjects. We presented the NAT in two ways in order to study if the method of presentation affects the result. One was the regular NAT which consists of 6 pairs of half-moons on each page, and the other one was one pair of half-moons on each page. RESULTS: The degree of aniseikonia measured was 1.4% smaller in the NAT than with the PDH. Backgrounds did not affect the amount of aniseikonia. Normal subjects showed essentially no aniseikonia regardless of the presentation technique of half-moons. CONCLUSIONS: NAT may underestimate the degree of aniseikonia, but the difference is too small to contraindicate clinical usage.

Extrafoveal photostress recovery testing with a scanning laser ophthalmoscope.

We used a modified photostress recovery test (PSRT) with microperimetry in a scanning laser ophthalmoscope (SLO) to evaluate the extrafoveal region. After the red-target threshold was determined, the retina was bleached with argon green laser illumination. Test spots were presented every 3 seconds at the testing point and subjects indicated when they saw the spot. We determined the recovery time in 17 normal subjects under the following conditions: bleaching times of 10, 20, and 30 seconds; spot intensities of 0, 2, and 4 dB greater than threshold; Goldmann I, II, and III spots; and spot locations 7.5 degrees temporal to, nasal to, above and below the fovea, and at the fovea. We also measured recovery times inside and outside the detachment in 11 patients with central serous chorioretinopathy. Recovery time was correlated with bleaching time and spot intensity, but not with the location of spot size in normal subjects. In patients with chorioretinopathy, the recovery time was longer inside than outside the detachment. This technique is useful for measurement of photostress recovery time at extrafoveal points, and for comparison of times at various testing points. Results in patients with chorioretinopathy suggest that this technique may be useful for studying the pathophysiology in ocular diseases.

[Immunohistochemical and immunogenetic analysis of ocular adnexal lymphoid proliferations].

We examined 20 cases (21 specimens) of ocular adnexal lymphoid proliferations, using the histological, immunohistochemical and molecular genetic methods. The latter two protocols were performed to detect the light chains restriction of immunoglobulin with peroxidase-antiperoxidase (PAP) methods, and the clonality of immunoglobulin heavy chain gene with the hemi-nested polymerase chain reaction (PCR) method, respectively. Although in 8 cases it could not be morphologically determined whether they were neoplastic or not, clonality was revealed in 1 case with immunohistochemistry and in 4 cases with PCR. Two cases showed discordant results between immunohistochemistry and PCR probably due to somatic mutation of the framework region of the immunoglobulin heavy chain gene. Therefore, we, concluded that examination with these methods contribute to a better understanding of the nature of the ocular adnexal lymphoid proliferations. Furthermore, the immunoglobulin gene PCR method is very useful in practical examination, as it can be used with formalin-fixed paraffin-embedded specimens.

[Studies on ocular positions at close distance with a new system of measuring ocular positions].

The purpose of our study was to develop a new system of measuring ocular positions and to assess its clinical applicability. This system is derived from that of the Hess coordimeter and is used at a distance of 40 cm. Our system enables us to distinguish tropia from phoria by testing the ocular positions both with and without a fusional target which can be seen by both eyes. All devices are installed in one structure and it can be used in a lighted room. The system was checked in 10 normal subjects by plotting the data of the charts onto a graph and deriving a static eye position curve. There was no significant vertical deviation, and there was an exodeviation of 5.32 +/- 3.78 (mean +/- standard deviation) degrees without a fusional target, but no significant deviation occurred when the fusional target was lighted. In 37 of the 38 patients with ocular motor disturbance, the results with this system corresponded well with those obtained by the Hess coordimeter or prism cover test. One particular case with extraocular myositis involving more than two extraocular muscles showed an atypical complicated pattern. We believe that our system is simple and easy for clinical evaluation of ocular movement abnormality in ophthalmic diagnosis.

Activation of non-selective cation conductance by carbachol in freshly isolated bovine ciliary muscle cells.

In smooth muscle cells freshly isolated from the bovine ciliary body, effects of carbachol (CCh) on the membrane potential and current were examined by the whole-cell clamp method. The resting membrane potential of the muscle cells used was -60 +/- 1 mV (n = 111). Extracellular application of CCh (2 microM) depolarized the cells to -15 +/- 5 mV (n = 50) with an apparent increase in membrane conductance. Under voltage-clamp conditions, CCh (2 microM) evoked an inward current which exhibited inward-going rectification and reversed the polarity at about 0 mV. Removal of Na+ from the external solution caused a reduction of the amplitude of the current and a shift of the reversal potential to the negative direction. CCh was able to elicit an inward current even under a condition where Ca2+ was the only cation producing an inwardly directed electrochemical gradient. The current was not affected by verapamil or by tetrodotoxin. The CCh-induced current was inhibited by antimuscarinic agents with the affinity sequence: atropine approximately 4-DAMP > > pirenzepine > AF-DX116, indicating that the response is mediated by a muscarinic cholinoceptor that belongs to the M3-subtype. Unlike the non-selective cation channel current in intestinal smooth muscles, which is activated by elevation of the intracellular Ca2+ concentration ([Ca2+]i), the current of the ciliary muscle was inactivated when the [Ca2+]i was increased. The conductance, which admits Ca2+, may serve as a pathway for Ca2+ entry required for contraction.

[Indocyanine green angiography in Stargardt's disease].

We performed indocyanine green angiography (ICG angiography) and fluorescein angiography in order to investigate the choroidal circulation in patients with Stargardt's flavimaculatus. Eight eyes of 4 patients in Groups 2 approximately 3 (Noble classification) were included in this study. In the area with "dark choroid" in fluorescein angiography, ICG angiography revealed large choroidal vessels in all eyes, but some fluorescent choroidal vessels were dark around the atrophic macula and in the peripapillary area, which indicated a greater storage of lipofuscin within the retinal pigment epithelium in those areas. In the atrophic macula area, irregular hypofluorescence was observed in ICG angiography, which might be caused by filling defect and/or block. Many flecks revealed hyperfluorescence in fluorescein angiography and hypofluorescence in ICG angiography, suggesting that focal circulatory disturbances in the choriocapillaries exist beneath the flecks.

[Aging of the blue mechanism studied by measuring the increment threshold on flashed background].

We studied aging of the blue cone mechanism by measuring increment thresholds for detection of a small blue flash of light (439 nm, 1 degree, 50 ms duration) on a second flashed light of identical color, (139 nm, 2 degrees, 500 ms duration) in 30 subjects. Simultaneously, a large yellow adapting field was presented. Subjects, consisting of 17 normal cases, 13 cases with refraction errors under 3 diopters, 11 myopes, and 2 hyperopes, with 1.0 or better corrected visual acuity, were divided into 4 groups by age. The control group consisted of 11 cases under 30 years, group I, 7 cases in their forties, group II, 6 cases in their fifties, and group III, 6 cases over 60 years. Best fitting exponential curves were calculated for this phase of the blue mechanism and averaged threshold curves for each group were evaluated. The averaged threshold curve in group I showed an upper shift, that is, an increase in the threshold alone. Curves in groups II and III demonstrated an upper right shift, with increased thresholds in both the blue flash and the yellow background. Together with decreased function of the blue cone mechanism, the shift of curves in the elderly groups is probably caused largely by yellowing of the crystalline lens.

Fluorescein angiography of peripheral retina and pars plana during vitrectomy for proliferative diabetic retinopathy.

PURPOSE: To evaluate the extreme peripheral retina and pars plana during vitrectomy in patients with proliferative diabetic retinopathy. METHODS: In a prospective study using a modified ophthalmic endoscopic system and an intraocular light source, we performed fluorescein angiography during pars plana vitrectomy in 12 eyes of 10 patients with proliferative diabetic retinopathy. Vitrectomy had been performed previously in two patients, and the subsequent surgery was necessary because of recurrent vitreous hemorrhage in one patient and silicone oil removal in the other. RESULTS: All 12 eyes of 10 patients demonstrated a wide avascular area in the peripheral retina anterior to the previous photocoagulation scar. At the ora serrata in two eyes, a fibrovascular ridge of peripheral retinal vessels with fluorescein leakage that resembled the demarcation line in retinopathy of prematurity was noted; one eye had developed neovascular glaucoma 4 weeks after vitrectomy with maximum augmentation of endolaser photocoagulation, and the other eye had neovascular glaucoma that had been treated with photocoagulation 1 year before vitrectomy. In the two eyes that had undergone previous pars plana vitrectomy, fluorescein leakage was apparent at the fibrous scar of the sclerotomy site. CONCLUSION: Intraoperative fluorescein angiography using an endoscope disclosed unusual findings in the extreme peripheral retina and pars plana of patients with proliferative diabetic retinopathy. Intraoperative fluorescein angiography may aid intraoperative evaluation and treatment of proliferative diabetic retinopathy.