Preganglionic Parasympathetic Denervation Rabbit Model for Innervation Studies.

PURPOSE: Tear secretion from the main lacrimal gland (LG) is mainly regulated by parasympathetic nerves. We performed several innervation studies to investigate lacrimation. METHODS: In male rabbits, we performed a retrograde dye-tracing study of LG innervation, evaluated preganglionic parasympathetic denervation, and administered glial cell-derived neurotrophic factor (GDNF) in the surgical area after parasympathetic denervation. RESULTS: Accumulation of fluorescent dye was observed in the pterygopalatine ganglion cells on the same side as the dye injection into the main LG. Fewer stained cells were observed in the cervical and trigeminal ganglia. After parasympathetic denervation surgery, tear secretion was decreased, and fluorescein and rose bengal staining scores were increased at day 1 after surgery and remained increased for 3 months on the denervated side only. Most of the effects in rabbits with parasympathetic denervation were not recovered by administration of GDNF. CONCLUSIONS: The main LG is primarily innervated by parasympathetic nerves to stimulate tear secretion. After preganglionic parasympathetic denervation, lacrimation was decreased, resulting in dry eyes, and this was maintained for at least 3 months. Administration of GDNF only minimally altered the effects of denervation.

Short-Term Results of Intravitreal Triamcinolone Acetonide Combined with Cataract Surgery for Diabetic Macular Edema in Japan: In the Era of Anti-Vascular Endothelial Growth Factor Therapy.

PURPOSE: To evaluate the effectiveness of an intravitreal triamcinolone acetonide injection (IVTA) combined with cataract surgery for diabetic macular edema (DME) resistant to anti-vascular endothelial growth factor (anti-VEGF) therapy. PROCEDURE: IVTA combined with cataract surgery was performed on 29 eyes of patients with DME (aged 70.5 ± 6.2 years) who were refractive to anti-VEGF treatments. The visual acuity, central retinal thickness (CRT), and the central retinal sensitivity were assessed at 1, 4, 12, and 24 weeks after the treatment. RESULTS: The visual acuity improved significantly from 0.49 ± 0.30 logMAR units to 0.35 ± 0.33 logMAR units at 24 weeks after the treatment (p < 0.05; repeated ANOVA). The CRT decreased significantly from 435.1 ± 112.3 µm to 350.8 ± 123.3 µm at 12 weeks after the treatment (p < 0.05). The retinal sensitivity threshold also improved significantly from 18.2 ± 4.3 dB to 20.4 ± 3.8 dB at 4 weeks after the treatment (p < 0.05). CONCLUSIONS: IVTA combined with cataract surgery is effective for successful treatment of eyes with DME refractive to anti-VEGF therapy.

Diabetes diagnostic thresholds of the glycated hemoglobin A1c and fasting plasma glucose levels considering the 5-year incidence of retinopathy.

AIMS: As retinopathy is used as a defining threshold of diabetes, we assessed the glycated hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) values associated with an increased risk of 5-year incidence of retinopathy. METHODS: We studied HbA1c, FPG, and optic fundus findings of 2605 individuals without previously diagnosed diabetes annually during a 5-year period. Retinopathy was examined using non-mydriatic, 45° digital fundus photography. Baseline levels were stratified as <5.3 [34], 5.3-5.6 [34-38], 5.7-6.0 [39-42], 6.1-6.4 [43-47], and ⩾6.5% [48mmol/mol] for HbA1c and <5.0, 5.0-5.5, 5.6-6.0, 6.1-6.9, and ⩾7.0mmol/L for FPG. Cox proportional hazard models were used to analyze hazard ratios (HRs) associated with HbA1c or FPG for incident retinopathy. RESULTS: During a total of 11845 person-years, we identified 50 (1.9%) cases of incident retinopathy. The adjusted HRs for incident retinopathy associated with a one-standard deviation increase in HbA1c and FPG were 1.2 (95% confidence intervals: 1.1-1.4) and 1.2 (1.1-1.4), respectively. These HRs were significantly higher for a HbA1c level ⩾6.5% (48mmol/mol) (3.4 [1.1-10.2]) or FPG level ⩾7.0mmol/L (3.6 [1.1-11.6]) than for a HbA1c level <5.3% (34mmol/mol) or FPG level <5.0mmol/L. CONCLUSIONS: A HbA1c value of 6.5% (48mmol/mol) and FPG value of 7.0mmol/L might be proper as diabetes diagnostic thresholds that indicate a high risk of future retinopathy.

Effect of Retinol Palmitate on Corneal and Conjunctival Mucin Gene Expression in a Rat Dry Eye Model After Injury.

PURPOSE: We examined the wound-healing effect of retinol palmitate (VApal) on mucin gene and protein expressions in a rat dry eye model based on lacrimal gland (LG) resection after injury. METHODS: The rat dry eye model was prepared by surgical resection of the main LG in male Long-Evans rats. After alkaline injury of the central part of the lower palpebral conjunctiva bilaterally, VApal eye drops at 1,500 IU/mL in one eye and a vehicle in the fellow eye were both administered 6 times a day for 7 days. The expression of mucin gene and protein was analyzed by real-time polymerase chain reaction or enzyme-linked immunosorbent assay in the cornea and conjunctiva of MUC1, MUC4, MUC16, and MUC5AC after 1, 3, (5), and 7 days of treatment with VApal. RESULTS: Significant decreases in fluorescein-stained areas and rose bengal scores were observed in VApal-treated dry eyes compared with vehicle-treated dry eyes at both 3 (P < 0.05) and 7 days (P < 0.01). Significant increases in corneal rMuc4 and conjunctival rMuc5AC after 1 day (P < 0.01) and conjunctival rMuc16 gene expression after 3 days were observed with VApal treatment (P < 0.05). Furthermore, conjunctival MUC16 expression significantly increased after 3 days of VApal treatment (P < 0.05). CONCLUSIONS: VApal promoted corneal rMuc4, conjunctival rMuc5AC, and conjunctival rMuc16 gene expression in a rat dry eye model after injury. VApal also promoted conjunctival MUC16 expression. These results indicate that VApal has efficacy in improving keratoconjunctival epithelial damage associated with decreased tear production.

Comparison of 2 optical biometers and evaluation of the Camellin-Calossi intraocular lens formula for normal cataractous eyes.

PURPOSE: To compare the measurements and intraocular lens (IOL) power calculations obtained with an optical biometer (AL-Scan) and partial coherence interferometry (PCI) device (IOLMaster 500), and to evaluate the accuracy of the Camellin-Calossi IOL formula in virgin eyes. SETTING: Saiseikai Kurihashi Hospital, Saitama, Japan. DESIGN: Prospective comparative study. METHODS: Measurements were compared from 262 patients (450 eyes) scheduled for cataract surgery. Axial length (AL), keratometry (K), anterior chamber depth (ACD), and number of eyes that were successfully measured were compared. Comparisons were performed of the residual postoperative refractive error with the SRK/T, Haigis, and Camellin-Calossi IOL formulas with optical biometer data. The IOL constant was optimized for 81 eyes that had iSertMicro 251 IOL implantation. RESULTS: The mean difference in AL between biometers was -0.012 mm ± 0.031 (SD) (P < .0001). Correlation coefficients (r) for AL, keratometry, and ACD were 0.9997, 0.9836, and 0.9571, respectively. The calculated IOL constant for the Camellin-Calossi formula was 119.3. The optimized IOL constant for the SRK/T was 118.8, the same as that of the User Group for Laser Interference Biometry for the PCI device. For the Haigis formula, only a0 was optimized, and it was 1.390. After optimizing the A-constant for the Camellin-Calossi formula, the residual postoperative refractive error of the Camellin-Calossi formula was not statistically significantly different in comparison to those obtainied with the Haigis and SRK/T formulas. CONCLUSION: Ocular biometry measurements were equivalent for both devices, indicating that the AL-Scan can be used for routine preoperative cataract assessment. The predictive accuracy of the Camellin-Calossi formula included in the optical biometer was equivalent to common IOL formulas for virgin eyes. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Association between Ophthalmological Changes and Cardiovascular Diseases in Patients with Chronic Kidney Disease Undergoing Hemodialysis.

AIMS: Patients with chronic kidney disease (CKD) undergoing hemodialysis (HD) have a high prevalence of cardiovascular diseases (CVD). Arterial sclerosis plays an important role in the pathogenesis of CVD. However, to date, there have been no reports of assessment of the association between retinal arterial sclerosis and CVD in patients with CKD on HD. The aim of this study was to assess retinal arterial sclerosis and to investigate the relationship between retinal arterial changes in patients with CKD on HD and arterial stiffness/past history of CVD. METHODS: We examined the data of 44 patients (21 female, 23 male) with CKD receiving HD treatment at Saiseikai Kurihashi Hospital. The relationship between ophthalmological changes and arterial stiffness [pulse wave velocity (PWV)] or past history of CVD was evaluated. All medications being taken were recorded, and biochemical parameters were analyzed. RESULTS: Significant correlations were found between the presence of arteriosclerotic retinopathy [Scheie classification S grade (grade 0: 7 patients, grade 1: 18 patients, grade 2: 14 patients, grade 3: 4 patients, and grade 4: 1 patient)] and results of the evaluation of arterial stiffness (PWV) and past history of CVD (p=0.001, p=0.045). Other ophthalmological findings were not associated with a history of CVD or arterial stiffness. CONCLUSION: We showed that the classification (Scheie S grade) of retinopathy on ophthalmoscopic examination may be a useful tool for predicting arterial stiffness and its association with CVD.

Survey of Japanese ophthalmic surgeons regarding perioperative disinfection and antibiotic prophylaxis in cataract surgery.

PURPOSE: To elucidate Japanese trends for perioperative disinfection and antibiotic selection during cataract surgeries. METHODS: Perioperative iodine use and antibiotic prophylaxis for cataract surgery were surveyed in eight regions in Japan by mail or through interviews from February 1 to March 1, 2014. RESULTS: We surveyed 572 surgeons, of whom 386 (67%) responded. Most of the surgeons (94%) used iodine compounds before surgery for periocular skin disinfection (povidone-iodine [PI]: 79%; polyvinyl alcohol-iodine [PAI]: 15%) or conjunctival disinfection (85%; PI: 36%; PAI: 49%). Preoperative conjunctival iodine was primarily used as an eye wash (irrigation: 95%) and less often as an eye drop (5%). It was determined that 31% of surgeons waited 30 seconds or more between periocular disinfection and conjunctival disinfection. During surgery, 14% of surgeons used iodine several times, including immediately before intraocular lens insertion, and 7% used the Shimada technique (repeated iodine irrigation). Preoperative antibiotic eye drops were used by 99% of surgeons, and antibiotics were added to the irrigation bottle by 22%. The surgeons reported use of subconjunctival antibiotic injections (23%), antibiotic ointments (79%), and intracameral antibiotics (7%: 22 moxifloxacin; 6 levofloxacin). All surgeons prescribed postoperative eye drops, with 10% initiating the drops on the day of surgery. CONCLUSION: Iodine compounds are commonly used preoperatively, but few institutions use iodine compounds intraoperatively, particularly with repeated application. The selection of antibiotic administration and disinfection technique has to be at the surgeon's discretion. However, intracameral antibiotic and intraoperative iodine compound use are techniques that should be widely recognized.

Safety of intracameral injection of moxifloxacin using total replacement technique (bag and chamber flushing).

PURPOSE: To assess the safety of intracameral injection of moxifloxacin (MFLX) using the total replacement technique [bag and chamber (BC) flushing]. METHODS: The anterior chamber including the area behind the intraocular lens was irrigated and replaced using BC flushing. In Group A, 36 patients received balanced salt solution irrigation in the right eye and intracameral MFLX (150 µg/mL: 33-fold dilution of 0.5% eye drops) in the left eye. In Group B, 33 patients received intracameral MFLX in the right (500 µg/mL: 10-fold dilution) and left eyes (150 µg/mL: 33-fold dilution). Visual acuity, intraocular pressure, corneal endothelial cell density, corneal thickness, and foveal thickness were recorded before and up to 3 months after surgery. RESULTS: In either group, there were no statistically significant differences between the right and left eyes with respect to visual acuity, intraocular pressure, corneal endothelial cell count, and foveal thickness before and at 3 months after surgery. There was no difference in corneal thickness before and at 3 months after surgery. In patients who received 500 µg/mL MFLX during surgery, central corneal thickness at 1 week after surgery was significantly reduced. CONCLUSIONS: In the present study, there was no adverse effect associated with intracameral injection of 150-500 µg/mL MFLX. Moreover, our results supported the safety of BC flushing. Thus, BC flushing, which can irrigate the inside of the capsular bag and attain stable antibiotic concentrations, appears to be a favorable technique for intracameral injection of MFLX.

Selection of the antifungal agent decides prognosis of invasive aspergillosis: case report of a successful outcome with voriconazole.

Invasive aspergillosis is a rare disease and is often misdiagnosed. The clinical course is quite aggressive and it is a potentially fatal disease. We report a case of invasive aspergillosis involving the dura mater and optic nerves which was successfully treated with voriconazole, even though the patient had residual monocular blindness. An 86-year-old Japanese man complained of developing loss of vision in his left eye while taking oral fluconazole prescribed by an otolaryngologist for mycosis of the left maxillary sinus. He was referred to our hospital. At the first visit, he already had no light perception in the left eye, with decreased ocular motility in all directions and orbital apex syndrome. His corrected distance visual acuity (CDVA) in the right eye was 20/25 with enlargement of Mariotte's blind spot. Magnetic resonance imaging revealed inflammation around both optic nerves that also involved the dura mater. His antifungal therapy was changed to intravenous voriconazole. Although his right CDVA temporarily declined to 20/50, it improved to 20/16 by 10 months after the initiation of treatment. Maxillary sinus biopsy detected Aspergillus. Invasive aspergillosis progresses rapidly and aggressively. The present case highlights the importance of early diagnosis and selection of an appropriate antifungal agent.

Effect of subconjunctival lacrimal gland transplantation in a rabbit dry eye model.

PURPOSE: The main and accessory lacrimal glands are involved in reflex and basal secretion of tears, respectively, with the glandular tissue anatomy being similar for both glands. We transplanted part of the main lacrimal gland under the palpebral conjunctiva in a rabbit dry eye model and assessed the therapeutic effect of this procedure. METHODS: In New Zealand White rabbits, the greater superficial petrosal nerve was cut unilaterally under a microscope. The other eye served as a normal control. For transplantation, approximately 0.07 g of the main lacrimal gland was harvested from the normal side, labeled with octadecylindocarbocyanine, and transplanted under the palpebral conjunctivae of both eyes. At 1 week and 1 month after the transplantation, the eyes were observed, and the Schirmer tear test and histological examination of the palpebral conjunctiva were performed. RESULTS: On the denervated side, tear flow, measured by the Schirmer tear test, recovered at 1 month after the transplantation of the main lacrimal gland compared with that before transplantation. The contralateral control side showed no changes. On the denervated side, the fluorescein score significantly improved at 1 month after transplantation compared with that before transplantation (P < 0.005), whereas the rose bengal score showed no difference. Histological examination revealed that octadecylindocarbocyanine-labeled transplanted main lacrimal gland tissue was present under the palpebral conjunctiva. CONCLUSIONS: These results suggest that the partial transplantation of the main lacrimal gland may be effective for treatment of dry eyes.

Efficacy and safety of prophylactic intracameral moxifloxacin injection in Japan.

PURPOSE: To report endophthalmitis rates after cataract surgery and the incidence of complications after intracameral moxifloxacin injection. SETTING: Nineteen clinics in Japanese institutions. DESIGN: Retrospective survey cohort study. METHODS: The number of surgeries and endophthalmitis cases in the past 4 years before and after the introduction of intracameral moxifloxacin was evaluated. The survey was performed by mail or interview in February 2013. RESULTS: All institutions used total-replacement administration rather than small-volume injection. At 3 institutions, 50 to 100 µg/mL moxifloxacin; at 9 institutions, 100 to 300 µg/mL moxifloxacin; and at 7 institutions, 500 µg/mL moxifloxacin was administered. The highest concentration (500 µg/mL) was administered in 14,124 cases. Endophthalmitis cases occurred 1 month or sooner postoperatively in 8 of 15,958 cases (ie, 1 in 1955) without intracameral moxifloxacin administration and in 3 of 18,794 cases (ie, 1 in 6265) with intracameral moxifloxacin administration. CONCLUSIONS: Intracameral moxifloxacin (50 to 500 µg/mL) administration decreased the risk for endophthalmitis by 3-fold. In more than 18,000 cases, moxifloxacin administration of 500 µg/mL or less did not result in severe complications, such as toxic anterior segment syndrome or corneal endothelial cell loss.

Comparison between intracameral moxifloxacin administration methods by assessing intraocular concentrations and drug kinetics.

BACKGROUND: Studies have indicated that intracameral administration of moxifloxacin (MFLX), a fourth-generation fluoroquinolone, is safe and effective. However, administration methods vary between studies, and no definite protocol exists. A prospective study clarifying the incidence of endophthalmitis and complication rates associated with each administration method would require an extremely large sample size because endophthalmitis has a low incidence rate. Therefore, we investigated appropriate intracameral MFLX administration methods by assessing intraocular concentrations following simple injection and flushing, and by measuring drug kinetics (half-life). METHODS: Experiment 1: (human eyes). Irrigation (flushing) with 33.33 µg/ml MFLX (150-fold dilution) and simple injection with 0.1 ml of 500 µg/ml MFLX (10-fold dilution) were assessed after cataract surgery. Experiment 2: (rabbits: kinetics study). Flushing with 30-fold or 150-fold dilutions of MFLX was assessed. Aqueous humor samples (0.1 ml) obtained immediately after irrigation and 1, 3, and 5 h after irrigation were analyzed using high-performance liquid chromatography. RESULTS: Experiment 1: MFLX (500 µg/ml) administered using simple injection in humans underwent a 3.3-fold dilution (152.33 µg/ml). Total anterior chamber displacement after flushing with 33.33 µg/ml MFLX resulted in a concentration of 29.54 µg/ml (90% displacement). Experiment 2: Concentrations at baseline were 52% at 1 and 15% at 3 h respectively, suggesting that the half-life of intracameral MFLX was >1 h. CONCLUSIONS: Considering that the half-life of MFLX was >1 h, a final concentration of 150 µg/ml results in a 2 h concentration of 38 µg/ml, which was beyond the minimum inhibitory concentration required to inhibit the growth of 90% of bacteria (MIC90) for most resistant pathogens. We postulate that a final concentration of 150 µg/ml is considerably effective and safe. However, more resistant bacteria will evolve in the future, and the standard MIC90 may change accordingly. Therefore, even if a suitable concentration is determined, it may not necessarily remain constant. This effective concentration should be continually revised on the basis of safety and effectiveness assessments.

Bag and chamber flushing: a new method of using intracameral moxifloxacin to irrigate the anterior chamber and the area behind the intraocular lens.

BACKGROUND: Intracameral moxifloxacin is currently administered by injecting small doses (0.05-0.2 mL) of either undiluted or diluted solutions. It is difficult to ensure delivery of small amounts of antibiotic into the area behind the intraocular lens (IOL). Moreover, the anterior chamber pressure decreases as the tip of irrigation is removed, often leading to contaminated fluid flowing into the chamber. Conventional intracameral injection administers the diluted antibiotic without irrigating the recontaminated anterior chamber. Therefore, we developed a method of intracameral moxifloxacin delivery which flushes both the anterior chamber and the area behind the IOL immediately after surgery. METHODS: Surgical technique (bag and chamber flushing = BC flushing): After removing the viscosurgical device, 1.5-1.8 mL diluted moxifloxacin was injected. Both the anterior chamber and the area behind the IOL were irrigated by lifting the IOL edge so that a stream of solution could circulate behind the IOL. Experiment 1 (pig): The anterior chamber was filled with condensed milk, and irrigated with 150-fold diluted moxifloxacin (33.3 µg/mL) in six eyes (BC flushing) to observe the irrigating effect. The anterior aqueous humor was sampled. Experiment 2 (human): A conventional intracameral injection (500 µg/mL) or BC flushing (33.3 µg/mL) was followed by sampling 0.1 mL of the anterior aqueous humor in six eyes each. High-performance liquid chromatography was performed to determine antibiotic levels. RESULTS: Experiment 1: The antibiotic concentration in the anterior chamber was 33.0 µg/mL (99.0 % was displaced). The area behind the IOL was not effectively irrigated without inserting the cannula tip. Experiment 2: The final antibiotic concentration was 152.3 µg/mL using the conventional method and 29.4 µg/mL using the BC flushing (88.3 % was displaced). CONCLUSION: BC flushing technique enables surgeons to completely displace the anterior chamber including the posterior IOL surface, resulting in effective irrigation and a stable antibiotic concentration in virtually all cases.

Prevalence of retinopathy and its risk factors in a Japanese population.

AIMS/INTRODUCTION: To determine the prevalence and risk factors of retinopathy and validity of the current diagnostic cut-offs for diabetes by using data of health check-up examinees. MATERIALS AND METHODS: The study comprises 1,864 Japanese who participated in the general health check-up program and did not have a previous history of cardiovascular disease. Non-mydriatic 45° digital fundus photographs were taken twice annually. Multivariate logistic regression model was used to identify risk factors for retinopathy in participants without previously diagnosed diabetes. RESULTS: The overall prevalence of retinopathy in participants with and without previously diagnosed diabetes were 23.3% (28/120) and 4.2% (74/1,744), respectively. Univariate logistic regression analysis identified age, systolic blood pressure (SBP), fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) as risk factors for retinopathy. Multivariate logistic regression analysis showed that FPG or both HbA1c and SBP were significant, positive and independent risk factors for retinopathy. The prevalence of retinopathy increased with deterioration of glucose categories (P < 0.001 for FPG or HbA1c). However, a statistically significant increased risk of retinopathy remained only in participants with FPG ≥ 7.0 mmol/L or HbA1c ≥ 6.5% compared with those with the lowest quartile of glucose in the participants without previously diagnosed diabetes after adjusting for age and SBP. CONCLUSIONS: The prevalence of retinopathy was 4.2%, and FPG or both HbA1c and SBP were positive and independent risk factors for retinopathy in health check-up examinees without previously diagnosed diabetes. The FPG 7.0 mmol/L or HbA1c 6.5% seems to be appropriate to diagnose diabetes in view of its association with retinopathy.

Iris rubeosis and hyphema caused by chemical injury due to household detergent.

We report an unusual case of iris rubeosis and hyphema caused by chemical injury due to household detergent. A 74-year-old man with a 15-year history of diabetes mellitus was refilling a container with household detergent at home. He splashed the detergent in his eyes. Slit-lamp examination revealed extensive epithelial damage to the left eye, leading to a persistent corneal epithelial defect. We used a bandage soft contact lens with levofloxacin eye drops as concomitant therapy in order to promote healing. However, a strain of fluoroquinolone-resistant Corynebacterium colonized the eye, so that the corneal ulcer eventually became severe. Use of the bandage soft contact lens was discontinued. His antimicrobial agent was changed to cefmenoxime, a drug to which fluoroquinolone-resistant Corynebacterium is sensitive, and topical instillation of autologous serum subsequently promoted improvement of the ulcer. On day 38 after injury, iris rubeosis led to hyphema and ghost cell glaucoma. With improvement of his corneal epithelial defect, the iris rubeosis and hyphema regressed and his visual acuity improved to 20/25 on the left eye. To the best of our knowledge, this is the first report of a case resulting in severe complications due to chemical injury by a neutral detergent. Ophthalmologists should be aware that corneal epithelial damage may become prolonged in elderly patients with diabetes, and unexpectedly severe when wearing bandage soft contact lens, with infection of Corynebacterium resistant to fluoroquinolones, even if the chemical agent is a neutral detergent.

Efficacy of retinol palmitate eye drops for dry eye in rabbits with lacrimal gland resection.

PURPOSE: We examined the efficacy of retinol palmitate (VApal) for dry eyes using dry eye model rabbits whose lacrimal glands were resected. MATERIALS AND METHODS: After alkaline injury on keratoconjunctival epithelium, VApal eye drops were administered 6 times a day for 7 days. The efficacy of VApal was also compared with that of 0.1% hyaluronic acid eye drops. RESULTS: The fluorescein staining and rose bengal scores showed a significant decrease compared with the score in the vehicle group at 7 days (P < 0.05) in the 1000 IU/mL VApal group and at both 3 days (P < 0.05) and 7 days (P < 0.01) in the 1500 IU/mL VApal group. Histological examination revealed recovery of the corneal epithelium, and PAS staining disclosed the recovery of mucin-producing lower palpebral conjunctival goblet cells after 7 days in the 1500 IU/mL VApal group compared with the vehicle group. Results from impression cytology showed a significant increase in density of conjunctival goblet cells compared with that in the vehicle group after 7 days in the 1000 IU/mL VApal group and after 3 and 7 days in the 1500 IU/mL VApal group. There were no significant changes in tear flow in either group. Topical application of VApal at 1500 IU/mL showed greater improvement than 0.1% hyaluronic acid in both fluorescein and rose bengal score and in the density of conjunctival goblet cells. CONCLUSION: It is suggested that VApal is effective for the improvement of keratoconjunctival epithelial damage associated with tear abnormalities, such as dry eyes.

Choroidal detachment after uncomplicated small incision cataract surgery.

BACKGROUND AND PURPOSE: Angioedema is a well-recognized side effect of angiotensin-converting enzyme inhibitors, but is rarely associated with angiotensin II receptor blockers (ARB). Here, we report the first case of a patient on ARB therapy (telmisartan) for hypertension who developed serous choroidal detachment localized to the posterior pole after sub-Tenon anesthesia for small incision cataract surgery. METHODS AND RESULTS: An 82-year-old Japanese woman who received oral medications for hypertension underwent cataract surgery with sub-Tenon anesthesia using 2% Xylocaine(®) on her left eye. Her corrected distance visual acuity improved to 20/25 on the first day after the surgery. On the fifth day, however, it decreased to 20/40 and choroidal detachment was detected at the posterior pole. We suspected an increase of choroidal vascular permeability and started oral steroid therapy. After 1 week, the area of detachment was smaller and her acuity improved to 20/20. Subsequently, she underwent cataract surgery without sub-Tenon anesthesia on her right eye, and no choroidal detachment occurred. CONCLUSION: This is the first published case of ARB-induced choroidal detachment after uncomplicated small incision cataract surgery. Sub-Tenon anesthesia may aggravate angioedema associated with ARB therapy, so ophthalmologists should be aware of this rare complication.

Conjunctival sac bacterial flora isolated prior to cataract surgery.

OBJECTIVE: To determine the trends of conjunctival sac bacterial flora isolated from patients prior to cataract surgery. SUBJECTS AND METHODS: The study comprised 579 patients (579 eyes) who underwent cataract surgery. Specimens were collected by lightly rubbing the inferior palpebral conjunctival sac with a sterile cotton swab 2 weeks before surgery, and then cultured for isolation of bacteria and antimicrobial sensitivity testing. The bacterial isolates and percentage of drug-resistant isolates were compared among age groups and according to whether or not patients had diabetes mellitus, hyperlipidemia, dialysis therapy, oral steroid use, dry eye syndrome, or allergic conjunctivitis. RESULTS: The bacterial isolation rate was 39.2%. There were 191 strains of Gram-positive cocci, accounting for the majority of all isolates (67.0%), among which methicillin-sensitive coagulase-negative staphylococci was the most frequent (127 strains, 44.5%), followed by methicillin-resistant coagulase-negative staphylococci (37 strains, 12.7%). All 76 Gram-positive bacillary isolates (26.7%) were from the genus Corynebacterium. Among the 16 Gram-negative bacillary isolates (5.9%), the most frequent was Escherichia coli (1.0%). The bacterial isolation rate was higher in patients >60 years old, and was lower in patients with dry eye syndrome, patients under topical treatment for other ocular disorders, and patients with hyperlipidemia. There was no significant difference in bacterial isolation rate with respect to the presence/absence of diabetes mellitus, steroid therapy, dialysis, or a history of allergic conjunctivitis. Methicillin-resistant coagulase-negative staphylococci showed a significantly higher detection rate in diabetic patients than nondiabetic patients (20.3% versus 7.0%, P < 0.05). The percentage of all isolates resistant to levofloxacin, cefmenoxime, and tobramycin was 14.0%, 15.2%, and 17.9%, respectively, with no significant differences among these drugs. CONCLUSION: The high bacterial isolation rate in patients >60 years old and the high methicillin-resistant coagulase-negative staphylococci isolation rate in patients with diabetes are important to consider for prevention of perioperative infections.

Multipurpose soft contact lens care in Japan.

PURPOSE: To assess the use of multipurpose lens care products via an online survey conducted among soft contact lens (SCL) wearers in Japan. METHODS: The subjects were 1000 men and women aged 15-44 years who reported that they cleaned their SCL by using multipurpose solution at least twice a week. Via the internet, they were asked questions about SCL care, the use of a rubbing step when cleaning SCL, cleaning and replacing lens cases, and recommended SCL care methods. RESULTS: Of the 1000 SCL wearers enrolled, 94.3% performed lens care every day lenses were worn, 64.2% reported rubbing the lenses every time, 57.9% rubbed the lenses for at least 10 seconds per side, and 64.7% reported they rubbed the lenses on both sides. Further, 61.2% reported that they had been given an explanation of SCL cleaning at an eye clinic or contact lens store. Only 49.8% of subjects reported that they cleaned the lens case every time and 61.7% replaced the case within 3 months. Only 19.5% had been given an explanation about lens case care. Half of the subjects reported they had been given no recommendation to use specific SCL care products or could not remember whether or not they had. The most common reason for the recommendation was good compatibility with their type of lens. CONCLUSION: More education is needed in Japan regarding methods of SCL care to ensure correct lens cleaning with inclusion of a rubbing step, as well as sufficient cleaning and replacement of the lens case. Of particular interest is the finding that many subjects were not given an explanation about proper SCL care and lens case cleaning and replacement at the time of lens purchase or prescription.