Iris prolapse after non-penetrating trabeculectomy with sinusotomy and mitomycin C.

Non-penetrating trabeculectomy (NPT) is effective in preventing numerous postoperative complications encountered with trabeculectomy. Recently, NPT has been modified to further reduce intraocular pressure (IOP) by combining other techniques. However, these modified NPT methods would make the globe even weaker than NPT alone. Here, we report a case of iris prolapse caused by blunt ocular trauma after NPT with sinusotomy and mitomycin C treatment. A 68-year-old man, who underwent NPT with sinusotomy and mitomycin C treatment, suffered from blunt ocular trauma to his left eye 28 days after surgery. The iris prolapsed from the sinusotomy site. Iridectomy, scleral suturing, and pars plana vitrectomy were performed. The bleb was absent post-re-operatively. Iris prolapse occurs uncommonly following simple NPT. However, additional sinusotomy and mitomycin C treatment render the globe weaker, and iris prolapse might occur. Iris prolapse increases risks in developing secondary infections and a loss of the filtration bleb. Thus, precautions are needed postoperatively.

A case of mycotic endophthalmitis after triamcinolone acetonide-assisted pars plana vitrectomy.

Only two cases of bacterial endophthalmitis after triamcinolone acetonide (TA)-assisted pars plana vitrectomy (PPV) have been reported. As far as we are aware there has been no report of fungal endophthalmitis occurring after TA-assisted PPV. We report a case of endophthalmitis due to Fusarium after TA-assisted PPV. An otherwise healthy 61-year-old woman suffered from branch retinal vein occlusion with macular edema, which led to reduced visual acuity and metamorphopsia. Because she complained of severe discomfort, TA-assisted PPV was performed to reduce the macular edema. At the end of the surgery 4 mg TA was injected into the vitreous cavity. Two weeks after the surgery her visual acuity had improved to 20/20. Six weeks after the surgery her visual acuity decreased to 20/200 but without pain. Slit lamp examination showed no conjunctival hyperemia and no inflammatory cell infiltration in the anterior chamber. Fundus examination showed several small, creamy-white, circumscribed retinal lesions, epiretinal membranes, vitreoretinal traction, and rhegmatogenous retinal detachment. PPV was performed again. Intra-operative light microscopy revealed filamentous fungi in the epiretinal membrane, which was removed during the second PPV. Five days after the second surgery, retinal detachment recurred. A third PPV with encircling procedures and silicone oil tamponade was performed. Fungal cultures from the epiretinal membrane were identified as Fusarium sp. Seven months after the third surgery the silicone oil was removed. The retina remained attached and visual acuity was 20/200. Any patient who has undergone TA-assisted PPV should be carefully followed up for possible post-operative endophthalmitis, even if the anterior segment abnormality is minor.

A case of multiple evanescent white dot syndrome treated by steroid pulse therapy.

Multiple evanescent white dot syndrome (MEWDS) is characterized by acute visual loss which is usually spontaneously restored after a few months. While occasional treatments with local or oral steroids have been reported, these are hardly effective. A 25-year-old man, a Sumo wrestler, was diagnosed with MEWDS, and as he wanted a quick recovery to compete in an upcoming tournament treatment with steroid pulse therapy was initiated 8 days after the symptoms appeared. Before treatment, visual acuity in his left eye was 20/400. Multiple white dots were seen at the level of the deep retina or retinal pigment epithelium, and the Mariotte's blind spot extended to the center of the visual field. Immediately after the end of steroid pulse therapy, left visual acuity increased to 20/25, and left visual field recovered remarkably. No white dots were seen funduscopically. Steroid pulse therapy might provide early improvement of visual functions, and we believe it could be a treatment option for initiating an early recovery from MEWDS. However, steroid pulse therapy may also result in lethal damage including disorders of the circulatory organs. Thus, it should only be applied in limited situations in which patients had rapid decline in visual function and needs for social return at an early stage like that of our patient.

Histopathological study of the anterior lens capsule with a double-ring sign.

BACKGROUND: A 'double-ring' sign may be seen during continuous curvilinear anterior capsulorhexis in cataract surgery. This sign has been attributed to partial splitting of the anterior lens capsule at the continuous curvilinear anterior capsulorhexis edge. Because horizontal intracapsular splits away from the capsule edge have also been reported, a double-ring sign has been hypothesized to be a precursor to true exfoliation. We report new histopathological findings for both anterior capsule and lens epithelium changes, the latter being similar to those of true exfoliation. METHODS: Three anterior capsules from two patients with a double-ring sign during capsulorhexis were examined via light and transmission electron microscopy. RESULTS: Light microscopy revealed step formations in the capsule edges and surface-parallel intracapsular splits in the anterior capsules. Transmission electron microscopy revealed stratified, banded structures consisting of alternating electron-dense and -lucent granular belts (300-400 nm) at the central area of the anterior capsule, as well as vacuole-like spaces and expansion of intercellular spaces in the lens epithelium. CONCLUSIONS: The thickened, stratified structure of the anterior capsule suggests abnormal lens epithelium in patients with a double-ring sign. The horizontal splits in the anterior capsule, with concomitant epithelial changes, i.e., the vacuole-like spaces and widened intercellular spaces, support the relation between a double-ring sign and true exfoliation.