Treatment of Failure of Macular Hole Closure due to Post-Vitrectomy Macular Edema Using Sub-Tenon Triamcinolone Acetonide Injection: A Case Report.

Introduction: Post-vitrectomy cystoid macular edema (CME) can lead to failure of macular hole (MH) closure. We report 2 cases of failure of MH closure due to post-vitrectomy CME, which were successfully treated using sub-Tenon triamcinolone acetonide (STTA) injection. Case Presentations: Case 1 involved a 72-year-old male patient with a Gass Stage 3 MH in the right eye. He underwent pars plana vitrectomy (PPV), internal limiting membrane translocation, and sulfur hexafluoride (SF6) gas injection with cataract surgery in his right eye. The MH did not close postoperatively; further, CME developed at the edge of the MH. Accordingly, the patient underwent an STTA injection. Approximately 2 weeks after the STTA injection, the CME disappeared and the MH closed, which has remained closed 1 year after PPV. Case 2 involved a 78-year-old female patient with Gass Stage 3 MH in the left eye. The patient underwent the same surgical procedure as that performed in case 1. Further, she presented with failure of MH closure caused by CME; therefore, an STTA injection was performed. Approximately 6 weeks after STTA injection, the CME disappeared and the MH closed; further, there was maintained improvement of best-corrected visual acuity for 6 months. Conclusions: STTA injection could be considered before reoperation in cases involving failure of MH closure due to postoperative CME.

Exacerbation of Diabetic Retinopathy following Hypoxia-Inducible Factor-Prolyl Hydroxylase Inhibitor Administration: A Case Report.

Introduction: Hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, used in the treatment of renal anemia, hold the potential to increase the production of vascular endothelial growth factors. Therefore, HIF-PH inhibitors may exacerbate retinal hemorrhage in diseases such as diabetic retinopathy. Here, we present a case involving the administration of an HIF-PH inhibitor, resulting in the exacerbation of retinal hemorrhage in a patient with diabetic retinopathy. Case Presentation: A 32-year-old man with diabetes mellitus and renal anemia caused by diabetic nephropathy was referred to our department for ophthalmic examination, revealing diabetic retinopathy with scattered retinal hemorrhages, exudates, and diabetic maculopathy in both eyes. Darbepoetin alfa was initially administered and switched to the HIF-PH inhibitor roxadustat on day 74. By day 88, fresh retinal hemorrhage was observed in the right eye. On day 132, the retinal hemorrhage had further worsened, with new preretinal hemorrhage in both eyes. Roxadustat was discontinued, replaced with darbepoetin alfa, resulting in retinal hemorrhage improvement by day 181 (49 days post-roxadustat cessation). On day 201, fundus hemorrhage further improved, optical coherence tomography showed no macular edema or subretinal fluid, and the retina was thinning. Fluorescein angiography showed neovascular vessels, active fluorescein leakage, and extensive avascular areas in both eyes, prompting pan-retinal photocoagulation. Visual acuity remained stable throughout treatment. Conclusion: Patients with advanced diabetic retinopathy taking HIF-PH inhibitors should be aware of retinal hemorrhage exacerbations. If observed, the treatment plan, including discontinuation of the HIF-PH inhibitor or switching to another agent, should be discussed with a diabetologist, nephrologist, and ophthalmologist.

Evaluation of microaneurysms as predictors of therapeutic response to anti-VEGF therapy in patients with DME.

Administration of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy is the first-line therapy for diabetic macular oedema (DME). However, some patients show no or insufficient response to repeated anti-VEGF injections. Therefore, it is necessary to identify factors that can predict this resistance against anti-VEGF treatment. Presence of microaneurysms (MAs) is a predictor of the development and progression of DME, but its relationship with the treatment response to the anti-VEGF agents is not well known. Therefore, we aimed to elucidate the relationship between the distribution of MAs and the response to anti-VEGF therapy in patients with DME. The number of MAs was measured before anti-VEGF therapy in each region using fluorescein angiography, indocyanine green angiography (IA), and optical coherence tomography angiography. Patients with DME were divided into the responder and non-responder groups after three loading phases. Differences in the distribution of MAs between the groups were investigated. Pre-treatment IA revealed more MAs in the nasal area in the non-responder group than in the responder group (10.7 ± 10.7 and 5.7 ± 5.7, respectively, in the nasal macula) (1.4 ± 2.1 and 0.4 ± 0.7, respectively, in the nasal fovea). Whereas, pre-treatment FA and OCTA could not reveal significantly difference between the groups. Detection of MAs in the nasal macula using pre-treatment IA may indicate resistance to anti-VEGF therapy. We recommend the clinicians confirm the presence of MAs in the nasal macula, as shown by IA, as a predictor of therapeutic response to anti-VEGF therapy in patients with treatment naive DME.

Evaluation of corneal hysteresis after pars plana vitrectomy combined phacoemulsification and intraocular lens implantation.

We evaluated the early effects of pars plana vitrectomy (PPV) on corneal biomechanics by comparing corneal hysteresis (CH) after cataract surgery (phacoemulsification and aspiration with intraocular lens implantation; PEA + IOL) alone and PPV combined with cataract surgery. This study included 20 eyes (18 patients), who underwent cataract surgery alone (PEA + IOL group), and 28 eyes (27 patients) who underwent PPV combined with cataract surgery (PPV triple group). The CH was 11.1 ± 1.1, 10.4 ± 1.1, and 11.0 ± 1.0 mmHg in the PEA + IOL group and 11.0 ± 1.4, 9.8 ± 1.4, and 10.6 ± 1.6 mmHg in the PPV triple group, preoperatively, at 2 weeks, and 3 months after surgery, respectively. The CH was not significantly different after surgery in the PEA + IOL group, but decreased significantly in the PPV triple group 2 weeks following surgery (p < 0.01). Intraocular pressure (IOP) and central corneal thickness (CCT) did not change significantly after surgery in either group. Preoperatively, there was a positive correlation between CH and CCT in the PPV triple group, but the correlation disappeared postoperatively. In PPV combined with cataract surgery, CH temporarily decreased postoperatively, independent of IOP and CCT. Removal of the vitreous may reduce the elasticity and rigidity of the entire eye.

Simultaneous Vitreoretinal Surgery and Sclerokeratoplasty for Keratoglobus with Intraocular Hemorrhage and Extensive Corneal Rupture.

We reported a case of simultaneous vitrectomy and sclerokeratoplasty (SKP) performed for keratoglobus with extensive corneal rupture and intraocular hemorrhage caused by trauma. A 73-year-old woman was treated for keratoglobus and glaucoma. She was punched in both eyes, her right eye showed corneal rupture and the left eye showed prolapse of the ocular contents due to eyeball rupture. She immediately underwent corneal sutures in the right eye and resection of the prolapsed ocular contents in the left eye at a nearby ophthalmological clinic. Three days after the injury, the patient was referred to our clinic for vision recovery. The best corrected visual acuity of the right eye was measured by counting fingers. Her right eye presented severe corneal edema with a sutured corneal wound in the upper periphery, which was positive in the Seidel test. B-mode ultrasound revealed choroidal detachment and subchoroidal hemorrhage. Fourteen days after injury, simultaneous corneal suture and posterior sclerotomy were performed in the right eye, but corneal fragility and corneal opacity were prominent, and B-mode examination revealed prolonged vitreous hemorrhage and retinal detachment. Twenty-one days after injury, we performed simultaneous SKP and 25-G pars plana vitrectomy (PPV). In this procedure, we initially performed SKP followed by 25-G PPV without a keratoprosthesis or endoscope. The visibility of the fundus through the corneoscleral graft was good during vitrectomy. Three months after surgery, her corrected visual acuity improved to 10/1,000. Although there was mild corneal stromal edema and khodadoust line, there were no obvious fundus complications. Simultaneous SKP and PPV for keratoglobus with extensive corneal rupture and vitreous diseases may be a good option.

3D imaging through a highly heterogeneous double-composite random medium by common-path phase-shift digital holography.

A method is proposed for 3D imaging through a highly heterogeneous double-composite random medium made of a thick mildly inhomogeneous medium followed by a thin strongly scattering layer. To realize the immunity to the heterogeneous random medium, a system of common-path phase-shift digital holography is designed in such a manner that the wavefront distortion caused by the first inhomogeneous medium is canceled out by the common-path geometry, and the influence of the random phase introduced by the second scattering layer is removed by the intensity-based recording of the digital hologram on the thin scattering layer. The validity of the method was confirmed by experiments.

Background Factors Affecting Visual Acuity at Initial Visit in Eyes with Central Retinal Vein Occlusion: Multicenter Study in Japan.

PURPOSE: To determine the baseline characteristics of patients with central retinal vein occlusion (CRVO) that were significantly associated with the best-corrected visual acuity (BCVA) at the initial examination. METHODS: This was a retrospective multicenter study using the medical records registered in 17 ophthalmological institutions in Japan. Patients with untreated CRVO (≥20-years-of-age) who were initially examined between January 2013 and December 2017 were studied. The patients' baseline factors that were significantly associated with the BCVA at the initial examination were determined by univariate and multivariate linear regression analyses. RESULTS: Data from 517 eyes of 517 patients were analyzed. Univariate analyses showed that an older age (r = 0.194, p < 0.001) and the right eye (r = -0.103, p < 0.019) were significantly associated with poorer BCVA at the initial visit. Multivariate analyses also showed that an older age (ß = 0.191, p < 0.001) and the right eye (ß = -0.089, p = 0.041) were significantly associated with poorer BCVA at the initial visit. CONCLUSIONS: The results indicate that an older age, a known strong factor, and the right eye were significantly associated with poorer BCVA at the initial visit to the hospital. These results suggest that functional and/or anatomical differences between the right and left eyes may be involved in these results.

Influence of extended depth of focus intraocular lenses on visual field sensitivity.

PURPOSE: To investigate the influence of EDOF IOLs, TECNIS Symfony® (Johnson & Johnson Surgical Vision, Inc.), on visual field sensitivity and to compare the IOLs with other kinds of IOLs. METHODS: The subjects included the normal fellow eyes of patients who underwent the Humphrey Field Analyzer (HFA) 30-2 with Swedish Interactive Threshold Algorithm Fast within 6 months after cataract due to glaucoma or suspected glaucoma. Each parameter of HFA was compared among eyes implanted with TENIS Symfony® (EDOF group), diffractive bifocal IOLs (bifocal group), and monofocal IOLs (monofocal group). RESULTS: The total of 76 eyes, including 24 eyes in the EDOF group, 26 eyes in the bifocal group, and 26 eyes in the monofocal group, were included in this study. Mean deviation (MD) of HFA was -0.24±0.58 dB in the EDOF group, -1.38±0.58 dB in the bifocal group, and 0.02±0.44 dB in the monofocal group. Foveal threshold (FT) of HFA was 35.8±1.6 dB in the EDOF group, 33.6±1.7 dB in the bifocal group, and 36.6±1.4 dB in the monofocal group. In both MD and FT, there was significant difference between the bifocal group and the others (p<0.001). There was no difference between the EDOF group and the monofocal group. Moreover, there was no significant difference between the three groups about pattern standard deviation (PSD) of HFA. CONCLUSION: TECNIS Symfony® may have little influence on visual field sensitivity, whereas diffractive bifocal IOLs decrease visual field sensitivity.

Three-dimensional microscopic imaging through scattering media based on in-line phase-shift digital holography.

Microscopic three-dimensional imaging and phase quantification for objects hidden behind a scattering medium by using in-line phase-shift digital holography are proposed. A spatial resolution of 1.81 µm and highly accurate quantitative phase imaging are demonstrated for objects behind a scatter plate. Three-dimensional imaging was confirmed using objects with a depth difference of 1.32 mm. Further, imaging was performed using rat skin as a demonstration for imaging through a complex multilayer scattering medium, where a spatial resolution close to the theoretically predicted value was achieved by experiment.

Recovery of the Corneal Stroma Associated With Rapid Reepithelialization Induced by the Fibronectin-Derived Peptide PHSRN in 2 Cases of Corneal Perforation Due to a Persistent Epithelial Defect.

PURPOSE: To report 2 cases of corneal perforation associated with a persistent epithelial defect (PED), which were treated with eye drops containing the fibronectin-derived peptide PHSRN (Pro-His-Ser-Arg-Asn). METHODS: A 67-year-old man and a 58-year-old man presented with corneal perforation associated with a PED caused by lagophthalmos. PHSRN eye drops were administered 4 times a day to both patients. RESULTS: Both patients experienced healing of the epithelial defect and closure of corneal perforation within 3 or 4 days after the onset of PHSRN treatment. Anterior segment optical coherence tomography also revealed recovery of corneal stromal thickness at the lesion site. CONCLUSIONS: PHSRN eye drops were effective for the treatment of corneal perforation due to the PED, with rapid reepithelialization being followed by full restoration of stromal thickness.

Sperm motility-initiating activity in the egg jelly of the externally-fertilizing urodele amphibian, Hynobius lichenatus.

Low osmolality initiates sperm motility during the external fertilization of aquatic anuran amphibians. It is thought that this process occurs also in urodeles, but this has not been fully examined in these species. We report here that fertilization was achieved in the externally fertilizing hynobiid, Hynobius lichenatus, by direct insemination onto the egg jelly surface without initial exposure of the sperm to a hypoosmotic solution. To identify the factors in addition to low osmolality that initiate sperm motility in Hynobius, we suspended the sperm of this amphibian in egg jelly extract (JE), and about 90% began to move within 1 min. This indicated the presence of a substance in JE that promotes motility initiation, as is also the case in the newt, Cynops pyrrhogaster. To examine whether this JE factor is homologous to the sperm motility-initiating substance (SMIS) in the newt, we tested for possible inter-species cross-reactivity of the JE. The percentage of moving Cynops sperm was increased to 67% in Hynobius JE at 5 min, and 65% of the Hynobius sperm began to move in Cynops JE within 1 min, indicating that JE is indeed cross-reactive between these species of salamander and newt. Concomitantly, pretreatment of Hynobius JE with Fab fragments of a Cynops SMIS monoclonal antibody resulted in a decreased number of moving Hynobius sperm. Immunoblotting further suggested that the substance in Hynobius JE responsible for motility initiation has an 18 kDa molecular mass, with an isoelectric point at 7.5.

Identification of the sperm motility-initiating substance in the newt, Cynops pyrrhogaster, and its possible relationship with the acrosome reaction during internal fertilization.

Motility initiation is a key event during internal fertilization of female-stored sperm, although the underlying mechanisms remain unclear. In internally fertilizing urodeles, quiescent sperm initiate motility on the surface of the egg-jelly, a thick extracellular matrix that accumulates around the egg in oviduct. By immunizing mice with egg-jelly extracts, we successfully generated an alpha34 monoclonal antibody (mAb) which neutralized sperm motility-initiating activity in the egg-jelly of the newt, Cynops pyrrhogaster, in a dose-dependent manner. The alpha34 mAb recognized an unglycosylated 34 kDa protein in the outermost of the six layers that comprise egg-jelly. Under nonreducing conditions, immunoblotting with alpha34 mAb produced many bands in addition to the 34 kDa protein, suggesting that the 34 kDa protein associates not only with the jelly matrix itself, but also with additional substances present in the matrix. Our current results are compatible with the supposed features of sperm motility-initiating substance (SMIS), indicating that the 34 kDa protein itself, or a complex consisting of the 34 kDa protein and some other molecules, is the SMIS in C. pyrrhogaster. Immunofluorescence staining further indicated that SMIS was distributed in a dot-like pattern in the outermost jelly layer and was fully covered with acrosome reaction-inducing substance (ARIS). Immunocytochemical and scanning electron microscopic examinations of the outermost jelly layer strongly suggests that the 34 kDa protein localized in granules (2 microm) and that ARIS was distributed covering the granules and in the sheet-like structure above the granules. These data suggest that the initiation of sperm motility is mediated by the acrosome reaction.

Identification of egg-jelly substances triggering sperm acrosome reaction in the newt, Cynops pyrrhogaster.

Our previous studies have shown that the acrosome reaction (AR) occurs in egg-jelly of the Japanese newt, Cynops pyrrhogaster. This is analogous to the substances of echinoderms but distinct from those of many other vertebrates derived from the egg envelope or its derivative, the zona pellucida. To identify the AR-inducing substances in newt egg jelly, a monoclonal antibody (mAb) was generated against the jelly by screening the culture supernatants to find the one that best neutralized the AR-inducing activity of the jelly substance. The mAb specifically reacted to protein bands in the jelly. These proteins, with apparent molecular weights of 122 and 90 kDa, exhibited AR-inducing activity, indicating that they are definitely AR-inducing substances. Western blotting using the mAb indicated that the 122 and 90 kDa proteins are present only in the egg jelly's outermost layer, where AR-inducing activity is known to occur. Both proteins were recognized with wheat germ agglutinin (WGA), a lectin that inhibits AR-induction in egg jelly extract. Taken together, these findings indicate that the 122 and 90 kDa proteins are the AR-inducing substances in the egg jelly of C. pyrrhogaster. The WGA recognition of the proteins was lost by N-glycosidase digestion, suggesting that N-linked carbohydrate moieties in these proteins may be responsible for the AR-inducing activity.