Results of visual acuity and foveal thickness in diabetic macular edema after vitrectomy.

PURPOSE: To report results of an investigation of visual acuity (VA) and foveal thickness in diabetic macular edema (DME) patients after vitrectomy. METHODS: A 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. RESULTS: Twenty-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). CONCLUSIONS: PPV 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.

Evaluating adjunctive surgical procedures during vitrectomy for diabetic macular edema.

PURPOSE: To evaluate the long-term outcomes of adjunctive surgical procedures during pars plana vitrectomy (PPV) for the treatment of diabetic macular edema (DME). METHODS: In this nonrandomized study, we retrospectively analyzed 57 eyes of 54 patients who had DME and had undergone PPV. We performed PPV using three different surgical procedures: conventional PPV (group PVD; 13 eyes), triamcinolone acetonide (TA)-assisted PPV (group TA; 22 eyes), and TA-assisted PPV combined with internal limiting membrane (ILM) peeling (group ILM; 22 eyes). We also evaluated the preoperative and postoperative best-corrected visual acuity (BCVA) results. RESULTS: The overall mean preoperative BCVA was 0.86 logarithm of the minimal angle of resolution unit. In groups PVD, TA, and ILM, BCVAs were 0.99, 0.90, and 0.74 (P = 0.310), respectively. The mean postoperative BCVA for all patients improved to 0.68 (P = 0.005). The postoperative BCVA improved in 47% of the treated eyes, it remained unchanged in 37% of the treated eyes, and it deteriorated in 16% of the treated eyes. However, we observed no significant difference in the mean postoperative BCVAs between the three groups. Furthermore, we found that there was no significant difference in postoperative BCVA improvements between any of the groups (P = 0.450). CONCLUSION: The present study suggests that these 3 PPV approaches do not significantly affect postoperative BCVAs after 18 months of DME treatment.

[Effects of implementing clinical pathways for the care of patients undergoing ophthalmic surgery for cataract, glaucoma, and vitreoretinal disorder].

PURPOSE: To evaluate the actual use of clinical pathways and variances, and compare the length of hospital stay for surgery of cataract, glaucoma, and vitreoretinal disorder. METHODS: We designed eight types of clinical pathways for the treatment of cataract, glaucoma, and retinal-vitreous disease. We performed 102 phacoemulsifications and intraocular lens (IOL) implantations, 19 glaucoma or combined trabeculotomy and phacoemulsification/IOL, and 69 retinal-vitreous surgeries during a 1-year period from February 2002. We compared the length of the hospital stay before and after clinical pathway implementation. RESULTS: We applied the clinical pathways to 102 eyes (100%) of 67 patients undergoing phacoemulsification/IOL, to 17 eyes (89.5%) of those undergoing glaucoma surgery, and to 69 eyes (100%) of those undergoing retinal-vitreous surgery. The vaiances occurred in 20 eyes (29.9%) of 67 phacoemulsification/IOLs, 6 eyes (31.6%) of glaucoma, and 24 eyes (34.2%) of retinal-vitreous surgery. The length of hospital stay was shortened in phacomulsification/IOL after clinical pathway implemenation: 7.8 +/- 3.3 to 6.7 +/- 2.5 (mean +/- standard deviation) days. Glaucoma patients had a significantly shorter stay, from 16.4 +/- 5.0 to 12.6 +/- 3.3 days Mann-Whitney U test ; p = 0.032), and the hospital tay for retinal-vitreous surgery was shortened rom 22.8 +/- 11.1 to 17.9 +/- 6.2 days (p = 0.001). CONCLUSIONS: The application of clinical pathways resulted in substantially reduced hospital stay.

The prevalence of pseudoexfoliation syndrome in a Japanese population: the Hisayama study.

PURPOSE: To examine the prevalence and systemic associations of pseudoexfoliation syndrome (PXS) in a Japanese population. METHODS: In 1998, a cross-sectional population-based survey was conducted among residents of Hisayama. Of a total of 3054 residents living in Hisayama, Japan, aged 50 years or older, 1844 consented to participate in the study. Each participant underwent a comprehensive examination that included an ophthalmic examination. The presence of any pseudoexfoliation material on the iris or lens capsule was determined by slit-lamp examination. The participants were classified as having pseudoexfoliation syndrome if any pseudoexfoliation material was present in either eye. Using these cross-sectional data, logistic regression analyses were performed to determine the systemic associations of pseudoexfoliation syndrome. The following eight possible correlates were considered: age, sex, hypertension, diabetes, hyperlipidemia, current smoker, alcohol intake, and body mass index. RESULTS: Among the subjects, 50 (3.4%) had pseudoexfoliation syndrome. The prevalence of pseudoexfoliation syndrome increased significantly with age. Multiple logistic regression analysis showed that age and hypertension were significantly associated with pseudoexfoliation syndrome. CONCLUSION: The prevalence of pseudoexfoliation syndrome in a Japanese population was 3.4%, and increased with age. This study suggests that hypertension strongly correlates with pseudoexfoliation syndrome in our population-based sample of Japanese subjects aged 50 years or older.

The 5-year incidence and risk factors for age-related maculopathy in a general Japanese population: the Hisayama study.

PURPOSE: To estimate the 5-year incidence and risk factors for age-related maculopathy (ARM) in a representative older Japanese population. METHODS: A population-based cohort study was conducted in 1998 on 1482 Hisayama residents aged 50 years or older, and 961 of these subjects attended the 5-year follow-up examinations in 2003. At both time points, the characteristics of ARM were determined by grading color fundus photographs according to the Wisconsin Age-Related Maculopathy Grading System. Using these cohort data, logistic regression analyses were performed to determine the risk factors for ARM. Nine possible risk factors were examined: age, sex, hypertension, diabetes, hyperlipidemia, smoking, alcohol intake, body mass index, and white blood cell count. RESULTS: The 5-year incidence of early ARM was 8.5%, and that of late ARM was 0.8%. Men were found to have a significantly higher incidence of late ARM than did women. The incidence of both early and late ARM increased significantly with age. Multiple logistic regression analysis showed that age and smoking were significantly associated with early and late ARM. CONCLUSIONS: The results suggest that the overall 5-year incidence of early ARM is 8.0% and that of late ARM is 0.8% in the general Japanese population and that higher age and smoking are relevant risk factors for early and late ARM in the Japanese.

Fibrous proliferation of the pre-papillary canal in proliferative diabetic retinopathy: Cloquet's canal as a scaffold for proliferative diabetic retinopathy.

BACKGROUND: The structure of the vitreous body is known to play an important role in the pathogenesis of proliferative diabetic retinopathy (PDR). The purpose of this study was to ascertain the pattern of fibrous membrane proliferation in PDR focusing on pre-optic disc canal-like fibrous proliferation. METHODS: The investigation comprised two parts. The first, prospective study involved examining ten eyes of ten patients with PDR who underwent triamcinolone acetonide-assisted pars plana vitrectomy (TA-PPV). The presence of canal-like intravitreous structures was determined during TA-PPV. The second, retrospective study included analysis of photographs and clinical records of 235 eyes examined in 207 patients with PDR. The clinical and surgical records of the 235 eyes treated with PPV were reviewed and were categorized into four groups based upon the pattern of fibrous proliferation (optic disc type, pre-cortical pocket type, mixed type, or other). Each clinical feature was studied. The clinical features of the four groups of PDR were compared. RESULTS: A pre-optic disc canal-like structure was observed in seven of the ten eyes. In the retrospective study, 25 eyes (10.7%) were classified as optic disc type, 16 eyes (6.9%) as pre-cortical pocket type, 68 eyes (29.1%) as mixed type, and 126 eyes (53.4%) as other types. The patients with the optic disc type were significantly younger than the other three groups (P = 0.02). Other clinical features and post-operative outcome were not significantly different between the groups. CONCLUSIONS: A pre-optic disc canal-like structure, probably Cloquet's canal and the area of Martegiani, was present in PDR eyes. The PDR patients with fibrous proliferation of this structure were younger than those with other patterns of fibrous proliferation.

Effects of volcanic ash on ocular symptoms: results of a 10-year survey on schoolchildren.

OBJECTIVE: To study the effects of volcanic ash on the ocular symptoms of schoolchildren ages 6 to 15 residing near Mt. Sakurajima, an active volcano. DESIGN: Retrospective, cross-sectional study. PARTICIPANTS: A total of 10,380 children ages 6 to 15, 1175 in a high-exposure area and 9205 in a low-exposure area, were studied. METHODS: High- and low-exposure areas for volcanic ash were selected. All subjects in both areas were examined annually each September in the decade from 1994 to 2003. MAIN OUTCOME MEASURES: The frequency of positive ocular symptoms in years with and without active volcanic eruptions was compared. The association of ocular symptoms with volcanic ash dispersal was assessed with the Mantel-Haenszel test or chi-square test. RESULTS: Subjects in the high-exposure area showed ocular symptoms more often than those in the low-exposure area (P<0.0001). Years of active volcanic eruptions (volcanic ash of 5000 g/m2/year or more) were closely related to years with a high frequency of ocular symptoms in subjects in the high-exposure area (P<0.05) but related conversely in subjects in the low-exposure area (P<0.01). Major ocular symptoms were redness, discharge, foreign body sensation, and itching, all treated effectively with eyedrops. CONCLUSIONS: Ocular symptoms in subjects were strongly influenced by volcanic eruptions in the Mt. Sakurajima area, but direct influence was limited to those living in areas very near the volcano (i.e., 4 km from the volcano's crater).

[Incidence of endogenous uveitis at Kyushu University Hospital].

PURPOSE: We performed a clinical statistical study on recent patients with endogenous uveitis at the clinic of the Department of Ophthalmology, Kyushu University Hospital. SUBJECTS: We studied 616 patients with endogenous uveitis who first visited the clinic of the Department of Ophthalmology, Kyushu University Hospital, between January 1996 and December 2001. RESULTS AND CONCLUSION: The most frequent clinical entity was sarcoidosis (8.6%), followed by Behçet's disease (8.4%), Vogt-Koyanagi-Harada syndrome (6.5%), human T-lymphotropic virus type I (HTLV-1) uveitis (3.9%), and toxoplasmosis (2.6%). Unclassified uveitis comprised 58.1% in our study. Next we classified the subjects into four age groups; adolescent (0-19 years old), young (20-39 years old), middle-aged (40-59 years old), and elderly (60-years old). We also classified the disease into four groups: uveitis pan, anterior, intermediate, and posterior uveitis, according to the site of inflammation. The most frequent clinical entity was Behçet's disease in the young group, and sarcoidosis in the elderly group. The frequency of unclassified uveitis was high in the adolescent and the elderly groups. As to the anatomic diagnosis of uveitis, panuveitis was most frequent, followed by anterior, posterior, and intermediate uveitis. Finally we investigated the frequency of secondary glaucoma. The frequency in all 616 patients was 19.7%. Secondary glaucoma was more frequent in male patients and more frequent in the middle-aged and the elderly groups.

Epidemiology of cutaneous tuberculosis in Japan: a retrospective study from 1906 to 2002.

BACKGROUND: Interest in tuberculosis has recently been revived, especially in association with the onset of acquired immunodeficiency syndrome (AIDS). In Japan, the incidence of tuberculosis has declined since the 1950s, but has shown a tendency to increase in the past 10 years. METHODS: To determine the patterns of prevalence of cutaneous tuberculosis in Japan, data for cutaneous tuberculosis cases recorded between 1906 and 2002 were obtained from the dermatologic clinic of Kyushu University Hospital. The population of tuberculosis-infected patients was stratified into groups encompassing 10-year periods. Each patient group was then classified as having true tuberculosis or tuberculid, as well as being classified by gender. The total number of patients with cutaneous tuberculosis analyzed was 1324. RESULTS: The incidence of cutaneous tuberculosis, both true tuberculosis and tuberculid, decreased between 1906 and 1935, increased between 1936 and 1955, and decreased again from 1955. The incidence of true tuberculosis was higher than that of tuberculid between 1906 and 1925. The incidence rates of true tuberculosis and tuberculid were equal from 1926 to 1945, and since 1946 the incidence of tuberculid has been higher than that of true tuberculosis. The incidence of tuberculid decreased between 1986 and 1995, but showed a dramatic increase between 1996 and 2000. The frequency of cutaneous tuberculosis was highest in the 10-49 year age group before 1980, but since 1981 has been highest in groups over 40 years of age. CONCLUSIONS: The incidence of cutaneous tuberculosis in Japan is decreasing and shows a shift towards older generations. However, there is an increase in the incidence of tuberculid, especially in elderly female patients.

Residual vitreous cortex after surgical posterior vitreous separation visualized by intravitreous triamcinolone acetonide.

OBJECTIVE: To visualize the residual vitreous cortex (VC) on the retinal surface after surgical posterior vitreous separation (PVS) during a pars plana vitrectomy (PPV), especially in patients with diabetic retinopathy. DESIGN: Case-control study. PARTICIPANTS: Patients with proliferative diabetic retinopathy (PDR), diabetic macular edema (DME), branch retinal vein occlusion (BRVO), and rhegmatogenous retinal detachment (RRD). METHODS: A triamcinolone acetonide (TA)-assisted vitrectomy was performed on patients with the following diseases: PDR (40 eyes), DME (26 eyes), BRVO (11 eyes), and RRD (17 eyes). Eyes with no apparent preoperative posterior vitreous detachment were enrolled in this study. After performance of surgical PVS, the residual VC was visualized as a white gel highlighted by TA. Based on this finding, the residual VC pattern was then divided into 3 groups: (1) diffuse type (VC was diffusely present in the temporal vascular arcade), (2) focal type (a small island of VC was left), and (3) no residual VC. A multivariate analysis using analysis of variance was performed regarding the residual VC pattern, disease type, age, and the 3 different surgeons. MAIN OUTCOME MEASURES: Each surgeon determined the type of residual VC during the operation, and the results were confirmed by a postoperative review of the videotape records judged by the other 2 surgeons. RESULTS: Eighty percent of the PDR eyes demonstrated the diffuse type; 10%, the focal type; and 10%, no residual VC. Fifty-eight percent of the eyes with DME demonstrated the diffuse type; 19%, the focal type; and 23%, no residual VC. Eighteen percent of the BRVO eyes showed the diffuse type; 24%, the focal type; and 59%, no residual VC. Thirty percent of the RRD eyes showed the diffuse type; 30%, the focal type; and 40%, no residual VC. A multivariate logistic regression analysis showed that PDR was a predictor of the diffuse type of residual VC in comparison to RRD (odds ratio = 8.42, 95% confidence interval = 2.07-34.3). Neither age nor the surgeon was a significant factor for a specific type of residual VC. CONCLUSIONS: Diabetic eyes more often demonstrated the diffuse type of residual VC, even after surgical PVS. This information may be valuable for surgeons performing a PPV on patients with diabetic retinopathy.

Prevalence and risk factors for epiretinal membranes in a Japanese population: the Hisayama study.

PURPOSE: To examine the prevalence and risk factors for epiretinal membranes (ERMs) in a sample Japanese population. METHODS: In 1998 a cross-sectional community survey was conducted among residents of Hisayama. A total of 688 men and 1087 women living in Hisayama, Japan, aged 40 years or older consented to participate in the study. Each participant underwent a comprehensive physical examination that included an ophthalmic examination. The presence of ERMs was judged from grading based on fundus examination using indirect ophthalmoscopy, slit lamp examination, and color fundus photographs. This study used non-stereoscopic 45 degrees fundus photographs to grade ERMs, whereas the other population-based studies used 30 degrees stereoscopic fundus photographs, which might explain some differences in prevalence of ERMs. Multiple logistic regression analysis was performed on the cross-sectional data to determine the risk factors for ERMs. The following ten possible risk factors were used: age; gender; hypertension; diabetes; serum cholesterol; serum HDL cholesterol; serum triglycerides; smoking habits; alcohol intake; and body mass index. RESULTS: The prevalence of ERMs was 4.0%, and increased with age. The ERMs were more prevalent in women (4.3%) than in men (3.5%). Multiple logistic regression analysis showed that age and serum cholesterol significantly associated with ERMs. CONCLUSIONS: This study suggests that ERMs are less common in the Japanese population than in similar populations in Western countries, and that hypercholesterolemia is a relevant risk factor for ERMs.

Recovery of corneal sensation after myopic correction by laser in situ keratomileusis with a nasal or superior hinge.

PURPOSE: To measure corneal sensitivity after laser in situ keratomileusis (LASIK) to determine the time required for recovery of this parameter. SETTING: Ohshima Hospital of Ophthalmology, Fukuoka, Japan. METHODS: Corneal sensation was measured with a Cochet-Bonnet-type esthesiometer in 75 patients before and 1, 3, 6, and 12 months after correction of myopia by photorefractive keratectomy (n = 21) or LASIK (n = 54). RESULTS: Photorefractive keratectomy did not affect corneal sensation. In the LASIK group, a large and significant decrease in corneal sensitivity was apparent at 1 month (P<.05). Although corneal sensitivity appeared to have recovered slightly at 3 months, it remained significantly decreased (P<.05). By 6 or 12 months, the corneal sensitivity in LASIK patients was not statistically different from the preoperative values in the study patients. A significantly greater decrease in corneal sensitivity was apparent in the LASIK patients with a nasal hinge than in those with a superior hinge (F = 7.54, P<.01). Corneal sensitivity was in the normal range in 31.5% of LASIK patients at 3 months and in 57.4% and 82.1% at 6 and 12 months, respectively. CONCLUSION: Recovery of corneal sensation had begun 3 months after LASIK and appeared complete after 12 months.

Possible benefits of triamcinolone-assisted pars plana vitrectomy for retinal diseases.

PURPOSE: To study the advantages and complications of triamcinolone acetonide (TA)-assisted pars plana vitrectomy (PPV) for various retinal diseases. METHODS: This report is an interventional case series and nonrandomized study. One hundred seventy-seven eyes from 158 patients underwent PPV with or without TA. Group TA(+) consisted of 94 eyes and group TA(-) consisted of 83 eyes. The improvement in vision and postoperative complications were prospectively studied. RESULTS: Sixty-two percent of the eyes in group TA(+) and 49% of the eyes in group TA(-) had improved vision after surgery (P = 0.34). Twelve eyes in group TA(+) and 12 eyes in group TA(-) had an intraocular pressure higher than 21 mmHg after the operation, with no statistically significant difference (P = 0.63). Four eyes with proliferative diabetic retinopathy in group TA(+) and five eyes with proliferative diabetic retinopathy in group TA(-) needed an additional filtering surgery. Group TA(+) (five eyes) had a lower incidence (P = 0.041) of reoperation caused by preretinal fibrous membrane formation than group TA(-) (13 eyes). No apparent corneal disorder or infectious signs were found in any eyes. CONCLUSIONS: Triamcinolone acetonide-assisted PPV appears to be potentially useful to reduce the incidence of reoperation owing to preretinal fibrosis with no serious complications.

Triamcinolone-assisted pars plana vitrectomy improves the surgical procedures and decreases the postoperative blood-ocular barrier breakdown.

PURPOSE: To determine the effect of a triamcinolone-assisted pars plana vitrectomy (PPV) on the visibility of hyaloid during surgery and the postoperative clinical outcome. METHODS: Thirty-one patients with proliferative retinal disease [8 with diabetic macular edema (DME), 10 with proliferative diabetic retinopathy (PDR), 13 with proliferative vitreoretinopathy (PVR)] underwent PPV, where the vitreous body was visualized by the intravitreal injection of triamcinolone solution during the operation. The visual acuity, intraocular pressure (IOP), tamponade, corneal pathology, after-cataract, vitreous hemorrhage, and necessity of reoperation, were thereafter examined for at least 3 months after surgery. The anterior chamber laser flare cell meter was used on postoperative day 8 in DME eyes with triamcinolone-assisted PPV and with routine PPV to evaluate the breakdown of the blood-ocular barrier. RESULTS: The vitreous body was clearly seen by means of triamcinolone during surgery, which greatly helped us to perform a posterior hyaloid resection safely and thoroughly. Six of 8 DME eyes, 8 of 10 PDR eyes, and 5 of 13 PVR eyes showed an improvement in their vision postoperatively. No eye except one experienced IOP elevation above 21 mmHg for 7 days. Six eyes had vitreous hemorrhage. The DME eyes which received triamcinolone-assisted PPV showed significantly less breakdown of the blood-ocular barrier than those with routine PPV (Mann-Whitney U-test, P<0.01). CONCLUSION: Triamcinolone improved the visibility of the hyaloid and the safety of the surgical procedures during PPV and also inhibited the postoperative breakdown of the blood-ocular barrier. Although the long-term effects are still unknown, this method appears potentially useful as an improved treatment for proliferative retinal diseases.

A simple method for calculating the financial balance of a hospital, based on proportional dividing.

It is necessary to estimate financial status to determine hospital management policy. The costs and revenues (financial balance) of each hospital division are one good index. However, it is difficult to calculate the financial balance for each division, since clinics and central services are intricately involved with each other There are no reports on a pragmatic method for calculating the financial balance. We devised a simple method based on proportional dividing. Consequently, one individual was able to complete the calculation for our hospital, which consists of 1300 beds and 23 clinics, without using the central hospital computer system.