Parameters of a basic ophthalmic examination that can ensure proper timing of corneal crosslinking in patients with keratoconus.

BACKGROUND: By the time patients with keratoconus are referred to specialists for treatment, the disease-related thinning of their corneas has already made them ineligible (< 400 µm) for corneal crosslinking (CXL). PURPOSE: To find basic ophthalmic examination parameters that can ensure proper timing of referral for CXL. METHODS: We reviewed cases referred to Toyama University Hospital for the treatment of keratoconus from August 2011 to May 2021 to identify the frequency of contraindication due to minimal corneal thickness (MCT) < 400 µm at first visit. We performed a receiver operator characteristic (ROC) analysis of basic exam parameters (uncorrected distance visual acuity, corrected distance visual acuity, corrected distance visual acuity with hard contact lens, sphericity, cylindricity, and/or corneal astigmatism) potentially predicting eligibility for CXL. For those with an area under the curve (AUC) > 0.8, we determined cut-off values and calculated sensitivity and specificity. RESULTS: Analyses included 66 eyes of 38 Japanese patients aged 25.0 ± 7.1 yrs (range 12-38 yrs) (56 male eyes and 10 female eyes). Thirty percent of the patients had an MCT < 400 µm. The AUC for uncorrected distance visual acuity (UCDVA) was 0.85. A cut-off value of 1.22 (converted to decimal visual acuity: ≥ 0.06) yielded 87% sensitivity and 75% specificity. The AUC for corrected distance visual acuity (CDVA) was 0.90. A cut-off of 0.52 (converted to decimal visual acuity: ≥ 0.3) yielded 89% sensitivity and 75% specificity. CONCLUSIONS: It is advisable to refer patients with keratoconus to a specialized facility for CXL when either of the following conditions is present: (i) UCDVA (decimal visual acuity) ≥ 0.06 or (ii) CDVA (decimal visual acuity) ≥ 0.3.

Association between tear meniscus dimensions and higher-order aberrations in patients with surgically treated lacrimal passage obstruction.

PURPOSE: To analyze the relationship between tear meniscus dimensions and higher-order aberrations (HOAs) in patients with lacrimal passage obstruction using anterior segment optical coherence tomography (AS-OCT). METHODS: This study was a retrospective observational study of 71 eyes of 49 patients with lacrimal passage obstruction. These patients received sheath-guided dacryoendoscopic probing and bicanalicular intubation (SG-BCI) at Toyama University Hospital between August 2020 and October 2021. Using AS-OCT, tear meniscus height (TMH), tear meniscus area (TMA), and total corneal HOAs values were measured before and after surgery. RESULTS: Surgical success was achieved in 69 eyes (97.1%). At the final observation, 62 eyes showed lacrimal patency (89.8%). The preoperative TMH, TMA, and HOAs values were 1.55 ± 0.96 mm, 0.11 ± 0.14 mm2, and 0.37 ± 0.27 µm, respectively, and the final postoperative TMH, TMA, and HOAs values were 0.97 ± 0.74 mm (p < 0.0001), 0.06 ± 0.11 mm2 (p = 0.02), and 0.29 ± 0.16 µm (p = 0.001), respectively. The results showed a significant improvement. The changes in HOAs before and after surgery were positively correlated with the changes in TMH (r = 0.3476, p = 0.0241) and TMA (r = 0.3653, p = 0.0174). CONCLUSION: SG-BCI for lacrimal passage obstruction resulted in a significant decrease in measured HOAs. The decrease in HOAs was correlated with decreases in tear meniscus dimensions.

Switching to brolucizumab from aflibercept in age-related macular degeneration with type 1 macular neovascularization and polypoidal choroidal vasculopathy: an 18-month follow-up study.

PURPOSE: To assess the effect of switching to brolucizumab from aflibercept on eyes with type 1 macular neovascularization (MNV) and polypoidal choroidal vasculopathy (PCV) at 18 months. METHODS: This study was a retrospective, observational case series that included 19 eyes of 19 patients with type 1MNV and 23 eyes of 22 patients with PCV. We compared the injection intervals, visual acuity, total lesion size, and the number of polypoidal lesions between baseline and 18 months. The correlations between the data including treatment interval, total lesion size, and the number of polyps were also assessed. RESULTS: Treatment intervals were significantly extended; from 7.4 ± 1.4 weeks to 11.6 ± 2.6 weeks for type 1 MNV, p < 0.001; from 6.9 ± 1.3 to 11.7 ± 3.1 weeks for PCV, p < 0.001. In type 1 MNV eyes, strong correlation was found between total lesion size and brolucizumab injection intervals (r = - 0.81; p = 0.0002) and moderate correlation was found between treatment frequency with aflibercept and that with brolucizumab (r = 0.76; p = 0.040). In PCV eyes, we found strong correlation between the number of polyps and brolucizumab treatment frequency (r = - 0.81; p = 0.0016) and moderate correlation between total lesion size and brolucizumab treatment interval (r = - 0.48; p = 0.034). Intraocular inflammation occurred in 2 of 19 eyes (10.3%) with type 1 MNV and 5 of 23 eyes (21.7%) with PCV. CONCLUSION: The properties to extend brolucizumab injection intervals might be the smaller lesion size and lower aflibercept frequency for type 1 MNV and the smaller number of polyps and the smaller size of lesion for PCV.

Efficacy and Safety of Cryotherapy for Residual Tarsus and Free Tarsal Graft Implantation After Excision of Malignant Eyelid Tumor.

PURPOSE: To examine the usefulness and safety of cryotherapy for residual tarsus and free tarsal graft implantation for eyelid reconstruction after excision of malignant eyelid tumor. METHODS: Fifteen patients with 17 eyelid malignancies (10 sebaceous gland carcinomas and 7 basal cell carcinomas) who underwent eyelid reconstruction between June 2017 and February 2021 were included in the study. In these patients, the tumors were resected in the entire eyelid layer including the safety margin. Only sebaceous gland carcinomas patients underwent cryotherapy at the residual tarsus margin. Then, a free tarsal graft taken from the ipsilateral or contralateral upper eyelid was transplanted into the eyelid plate defect, and anterior lamella reconstruction was performed with an orbicularis oculi myocutaneous advance flap. RESULTS: In both the non-cryotherapy and cryotherapy groups, there were no serious complications such as dropout or necrosis of the free tarsal graft. There were no differences in the occurrence of complications such as eyelid retraction or trichiasis between the 2 groups, but 1 patient who underwent cryotherapy required revision surgery to correct eyelid retraction. In addition, there were no complications on the donor side associated with free tarsal graft collection. CONCLUSIONS: The use of a free tarsal graft in the reconstruction of eyelid malignancies is relatively effective and safe, and if vascular support of the anterior lamella is obtained, cryotherapy is less likely to affect the viability of the free tarsal graft and may contribute to a decrease in local recurrence.

Long-term changes of choroidal blood flow velocity in Vogt-Koyanagi-Harada disease.

PURPOSE: To evaluate changes in choroidal blood flow in patients with Vogt-Koyanagi-Harada (VKH) disease after initiation of corticosteroid treatment. METHODS: Fourteen patients (10 men and 4 women) with acute VKH disease followed for 2 years were retrospectively reviewed; only right eyes were included in the analysis. Mean blur rate (MBR) in the macula was measured by laser speckle flowgraphy (LSFG) and central choroidal thickness (CCT) was measured by optical coherence tomography (OCT), both prior to treatment and over 2 years after initiation of corticosteroid treatment. RESULTS: Of 14 patients included in this study, 13 received initial treatment consisting of intravenous corticosteroid pulse therapy and one patient was treated using bilateral sub-Tenon injections of triamcinolone acetonide. Mean percentage change in MBR was significantly increased after initiation of treatment compared to pretreatment values (P < 0.001). Mean CCTs were significantly decreased after initiation of treatment, compared to pretreatment thicknesses (P < 0.001). There was no significant change in either MBR change or CCT at 1 month after initiation of treatment through 2 years of follow-up. The mean MBR percentage change was significantly higher in eyes with sunset glow fundus (SGF) compared to eyes without SGF at 1 year. CONCLUSION: With initiation of corticosteroid treatment in VKH disease patients, choroidal blood flow improved and was maintained for 2 years. However, the presence of SGF should be taken into consideration when interpreting MBR results in VKH disease patients.

Hydroxychloroquine's Early Impact on Cone Density.

PURPOSE: To evaluate early effects of hydroxychloroquine (HCQ) on the retina using adaptive optics (AO). METHODS: This was a prospective observational single-center study of 29 eyes of 29 patients who had been treated with HCQ for the first time and followed with AO for a minimum of two years. Cone counting was performed in 4 quadrants, nasal, temporal, superior, and inferior, at 0.75 mm from the foveal center. The changes of cone density on AO, visual acuity, and foveal thickness within two years of use were analyzed. The changes of mean cone density of patients whose cumulative dose was over 200 g in 2 years were also assessed. We evaluated the correlation between cone density and cumulative dose of HCQ. RESULTS: There was no significant decrease in cone density in the first 2 years of HCQ use. VA and foveal thickness did not show obvious change, either. Among 9 patients whose cumulative dose was over 200 g in 2 years, the mean cone density showed no significant change at 6, 12, 18, and 24 months compared with baseline (P=0.381, P=0.380, P=0.281, and P=0.534, respectively). There was no correlation between cone density and cumulative dose of HCQ at two years (Spearman's correlation coefficient, r = -0.0553, P=0.780; n = 29). CONCLUSION: AO showed no change in cone density in the first two years of HCQ use.

Using optical coherence tomography angiography to guide myopic choroidal neovascularization treatment: a 3-year follow-up study.

PURPOSE: To report the long-term changes of the size of myopic choroidal neovascularization (mCNV) using optical coherence tomography angiography (OCTA). METHODS: This was a retrospective, observational case study of eleven eyes in eleven patients with mCNV followed with OCTA for a minimum of 3 years. The flow area of mCNV on OCTA, the size of chorioretinal atrophy (CRA) and central choroidal thickness were analyzed. The relationship between the changes of mCNV size and recurrences treated with anti-vascular endothelial growth factor (VEGF) agents was also assessed. RESULTS: Three eyes out of eleven eyes showed enlargement of the mCNV over 3 years. In two of the three eyes, the mCNV recurrences had not been treated immediately (the examination intervals were 4 months and 5 months, respectively), and we found obvious enlargement of the mCNV. In three eyes, the mCNV size decreased in 1 year and was stable thereafter without recurrences. In five eyes, mCNV size did not show remarkable changes for 3 years. In three of the five eyes, no recurrences were detected and two of the five eyes underwent prompt treatments against recurrences. CONCLUSION: Regular examination and prompt treatments against recurrences are critical to prevent enlargement of mCNV.

Glaucoma Filtering Bleb Analysis Before and After Aponeurotic Blepharoptosis Surgery.

PURPOSE: To evaluate the effectiveness and safety of aponeurotic blepharoptosis surgery and the morphology of filtering bleb in patients with filtrating bleb. METHODS: This retrospective case series included 7 consecutive patients (9 eyes) with filtering bleb after trabeculectomy. They underwent transcutaneous levator aponeurotic advancement from May 2018 to April 2019. The authors evaluated margin reflex distance-1 and intraocular pressure and analyzed filtering bleb morphology, such as filtering bleb volume, filtering bleb height, and filtering bleb wall thickness, using anterior segment optical coherence tomography before and after aponeurotic advancement. The authors also evaluated intra and postoperative complications. RESULTS: The mean age was 75.6 ± 7.8 years; the mean duration from glaucoma surgery to blepharoptosis surgery was 36.9 ± 26.8 months; the mean follow-up after blepharoptosis surgery was 6.1 ± 2.9 months. The mean margin reflex distance-1 value changed significantly from 0.7 ± 0.8 mm before surgery to 3.3 ± 0.4 mm after surgery (p < 0.0001). The mean intraocular pressure showed no significant change from 12.9 ± 2.6 mm Hg before surgery to 12.7 ± 3.3 after surgery. In the filtering bleb analysis using anterior segment optical coherence tomography no significant differences were found, such as in bleb volume, height and wall thickness, before and after blepharoptosis surgery. There were no intraoperative complications in any of the cases. A postoperative corneal disorder was seen in 1 eye, but there was no infection of or damage to filtering bleb in any of the cases during the postoperative follow-up period. CONCLUSIONS: In patients with glaucoma filtering bleb, transcutaneous levator aponeurotic ptosis surgery is considered to be safe and unlikely to affect the morphology of the filtering bleb or intraocular pressure in the short term.In patients with glaucoma filtering bleb, transcutaneous levator aponeurotic ptosis surgery is considered to be highly safe and unlikely to affect the morphology of the filtering bleb or intraocular pressure in the short term.

Posterior microphthalmos with good visual acuity: A case report.

PURPOSE: We report the case of an 11-year-old boy with posterior microphthalmos who exhibited normal and age appropriate development of visual acuity. OBSERVATIONS: At the initial diagnosis, when he was 3 years old, the best-corrected visual acuity (BCVA) was 20/125 in the right eye (OD) and 20/200 in the left eye (OS) with high hyperopia (cycloplegic refraction +15.75 D sphere OD and +16.25 D sphere OS). Eight years after he began wearing hyperopic glasses, BCVA was 20/16 OD and 20/20 OS. Optical coherence tomography did not reveal a foveal pit in either eye throughout the observation period. However, elongation of the outer segment and widening of the outer nuclear layers were observed. CONCLUSION AND IMPORTANCE: Many cases of posterior microphthalmos demonstrate subnormal BCVA due to an abnormal foveal structure (papillomacular retinal folds, absence of the foveal pit and avascular zone) and high hyperopia. However, if foveal maturity progresses, even if the foveal structure is abnormal, early aggressive amblyopia treatment can result in normal and age appropriate development of visual acuity.

The association between cone density and visual function in the macula of patients with retinitis pigmentosa.

PURPOSE: We observed cone photoreceptors by using adaptive optics (AO) fundus camera and optical coherence tomography (OCT) in patients with retinitis pigmentosa (RP) and examined the correlations between cone photoreceptors and visual function over 2 years. METHODS: Six patients with RP were studied. All patients underwent measurement using best-corrected decimal visual acuity, OCT, a Humphrey Field Analyzer with the 10-2 test grid pattern, and AO. AO images of the foveal center were obtained using an rtx1™ AO fundus camera, and cone counting was performed at 0.5 mm from the foveal center. RESULTS: AO detected a decrease of cone density over 2 years in RP patients. However, visual acuity, foveal sensitivity, and photoreceptor thickness were not changed over the 2 years. CONCLUSIONS: AO images showed a decrease in the number of foveal cone densities over 2 years in patients with RP. AO may shorten the period required to predict the RP progression rate.

Long-term changes of retinal pigment epithelium in the eyes with Vogt-Koyanagi-Harada disease observed by adaptive optics imaging.

Purpose: To observe long-term changes of the retinal pigment epithelium (RPE) in the eyes of patients with Vogt-Koyanagi-Harada (VKH) disease using an adaptive optics (AO) fundus camera, and their correlation with the findings of spectral-domain optical coherence tomography (SD-OCT), fundus autofluorescence (AF) imaging. Patients and methods: Three eyes of two patients with new-onset acute VKH disease were retrospectively studied. After the serous retinal detachment was resolved by high-dose corticosteroid treatment, the patients were examined with SD-OCT, blue-wavelength AF, near-infrared (NIR) AF, and an AO fundus camera. AO images of the macula were obtained using the rtx1TM AO fundus camera. The area around the foveal center of the hyper-reflective lesion in AO imaging was measured manually. The time at which the serous retinal detachment resolved was set as the baseline, and AO and other images were obtained every 3 to 6 months from the baseline. Results: In all three eyes, lesions with elevation or thickening of the RPE layer were observed with OCT imaging in the macula after the serous retinal detachment resolved. These lesions showed hyper-autofluorescence in NIR-AF image and hyper-reflective lesions with clear boundaries in AO image. The area of the hyper-reflective lesions of AO images in each eye showed an approximately 40% decrease at 6 months from baseline. However, the hyper-reflective lesion remained to some extent after 18 months in case 1 and 36 months in case 2. Conclusions: By using OCT, fundus autofluorescence and AO images, it was possible to observe temporal changes of RPE layer in VKH eyes noninvasively. High-resolution AO images also allow us to observe for improvements in the elevation or thickening of the RPE layer quantitatively.

Recovery of macular cone photoreceptors in Vogt-Koyanagi-Harada disease.

PURPOSE: Our purpose was to study changes in macular cone photoreceptors in Vogt-Koyanagi-Harada (VKH) disease patients after high-dose corticosteroid treatment using an adaptive optics (AO) fundus camera. METHODS: We retrospectively analyzed 16 eyes of eight patients with new-onset acute VKH disease that were studied retrospectively. After serous retinal detachment (SRD) had resolved, AO images were obtained using the rtx1™ AO fundus camera over a 12-month course. Cone counting was performed in the nasal, temporal, superior and inferior areas of the macula 0.75 mm from the foveal center. A control group of 30 eyes of 30 healthy subjects was established for comparison. RESULTS: In the eyes with VKH disease, the mean cone densities 0.75 mm from the foveal center were 11,847 at baseline (resolution of SRD), and 15,218, 16,684 and 17,686 cones/mm2, at 3, 6, and 12 months later, respectively. The mean cone densities at 3, 6, and 12 months were significantly increased compared to those of baseline (p = 0.007, p < 0.001, and p < 0.001, respectively); however, they were significantly lower than that of the healthy control eyes (p < 0.001). The mean cone densities at areas with a previous presence of cystoid spaces were significantly lower than those without cystoid spaces at the baseline, and at 3, 6, and 12 months (p < 0.001, p = 0.007, p < 0.001, and p = 0.008, respectively). CONCLUSIONS: Cone densities were gradually increased after the resolution of SRD in the eyes of VKH disease patients. The presence of cystoid spaces might be a marker of severe damage to cone photoreceptors.

Correlation between outer retinal layer thickness and cone density in patients with resolved central serous chorioretinopathy.

PURPOSE: We aimed to observe photoreceptors and outer retinal layer thickness by using an adaptive optics (AO) fundus camera and spectral domain optical coherence tomography (SD-OCT) in patients with central serous chorioretinopathy (CSC). METHODS: Twelve eyes of 12 patients with resolved CSC were studied. After subretinal fluid (SRF) had resolved, AO images of the macula were obtained by using the rtx1TM AO fundus camera (Imagine Eyes, France). Cones in the nasal and temporal areas of the macula, 0.5 mm from the foveal center, were counted. Outer retinal layer thickness was measured as the distance between the outer border of external limiting membrane (ELM) and the inner border of retinal pigment epithelium (RPE) at 0.5 mm from the foveal center. The first measurement was performed after resolution of the subretinal fluid and was defined as the baseline. Then, the second measurement was performed in the same location after 12 months. RESULTS: In the eyes with resolved CSC, the mean logMAR values of visual acuity at baseline and 12 months were 0.16 and 0.01, respectively (p = 0.0023). The mean cone densities at baseline and 12 months were 12,213 and 17,146 cones/mm2, respectively. The mean cone densities at 12 months were significantly increased compared to baseline (p = 0.0014). The mean outer retinal layer thickness at baseline (53.5 µm) was significantly thinner than that at 12 months (60.7 µm) (p = 0.0013). The mean cone densities were significantly correlated with outer retinal layer thickness and logMAR visual acuity. CONCLUSIONS: Adaptive optics imaging revealed a gradual increase in the number of macular cone densities during 12 months in patients with resolved CSC, which was correlated with outer retinal layer thickness and visual acuity in a short term.

Analysis of macular cone photoreceptors in a case of occult macular dystrophy.

PURPOSE: To investigate changes in cone photoreceptors with adaptive optics (AO) fundus imaging and spectral domain optical coherence tomography (SD-OCT) in a case of occult macular dystrophy (OMD). PATIENT AND METHODS: Both eyes of a 42-year-old woman diagnosed with OMD were examined. We used an AO fundus camera to obtain images of cone photoreceptors in the macula of the OMD subject and five healthy control subjects. Correlations between the AO images and the SD-OCT images were examined. Cone photoreceptors in eight areas in the macula of OMD and healthy control subjects were analyzed and compared. RESULTS: SD-OCT showed a loss of the cone outer-segment tips line outside of the fovea in both eyes of the subject with OMD. The left eye with decreased visual acuity showed a discontinuous photoreceptor inner-segment and outer-segment line and cone outer-segment tips line at the fovea in SD-OCT and loss of cone mosaics as a dark spot in the AO image. In panoramic AO images and cone-density maps, less cone density was observed in a ring-like region outside the fovea than in the peripheral retina. In most of the areas examined, the cone densities were lower in the OMD eyes than in the healthy control eyes. CONCLUSIONS: Cone densities in the macula of the OMD patient were greatly decreased. AO images were found to be useful to evaluate morphologic changes in cone photoreceptors in patients with OMD.

Adaptive optics fundus images of cone photoreceptors in the macula of patients with retinitis pigmentosa.

BACKGROUND: The purpose of this study was to examine cone photoreceptors in the macula of patients with retinitis pigmentosa using an adaptive optics fundus camera and to investigate any correlations between cone photoreceptor density and findings on optical coherence tomography and fundus autofluorescence. METHODS: We examined two patients with typical retinitis pigmentosa who underwent ophthalmological examination, including measurement of visual acuity, and gathering of electroretinographic, optical coherence tomographic, fundus autofluorescent, and adaptive optics fundus images. The cone photoreceptors in the adaptive optics images of the two patients with retinitis pigmentosa and five healthy subjects were analyzed. RESULTS: An abnormal parafoveal ring of high-density fundus autofluorescence was observed in the macula in both patients. The border of the ring corresponded to the border of the external limiting membrane and the inner segment and outer segment line in the optical coherence tomographic images. Cone photoreceptors at the abnormal parafoveal ring were blurred and decreased in the adaptive optics images. The blurred area corresponded to the abnormal parafoveal ring in the fundus autofluorescence images. Cone densities were low at the blurred areas and at the nasal and temporal retina along a line from the fovea compared with those of healthy controls. The results for cone spacing and Voronoi domains in the macula corresponded with those for the cone densities. CONCLUSION: Cone densities were heavily decreased in the macula, especially at the parafoveal ring on high-density fundus autofluorescence in both patients with retinitis pigmentosa. Adaptive optics images enabled us to observe in vivo changes in the cone photoreceptors of patients with retinitis pigmentosa, which corresponded to changes in the optical coherence tomographic and fundus autofluorescence images.