Gas Tamponade Improved Cilio-Choroidal Effusion Induced by an Ab Interno Trabeculotomy with a Microhook: Two Cases.

Purpose: We treated two patients with ciliary detachment due to an ab interno trabeculotomy. The ciliary detachment was improved by the use of sulfur hexafluoride (SF6) gas or octafluoro propane (C3F8) tamponade. Patients and Methods: Patient 1 was a 52-year-old Brazilian man with primary open angle glaucoma (POAG). His preoperative intraocular pressure (IOP) was 29 mmHg. Patient 2 was a 57-year-old Japanese woman with POAG. Her preoperative IOP was 35 mmHg. Both patients underwent an ab interno trabeculotomy with a microhook. They caused ciliary detachment as a postoperative complication. We could observe their ciliary detachment with anterior segment optical coherence tomography (AS-OCT). Hypotony persisted for 2 months and the patients' ciliary detachment had not improved. They each underwent a pars plana vitrectomy (PPV) with simultaneous 20% SF6 filling. Results: In Patient 1, the use of the SF6 gas tamponade successfully attached the ciliary body. His IOP was increased to 30 mmHg after this resolution of the ciliary detachment. He underwent additional tube shunt surgery. For Patient 2, the SF6 gas tamponade improved the ciliary detachment but the ciliary body could not be attached. We injected 0.6 cc of 100% C3F8 gas into the vitreous cavity, and this gas tamponade was able to attach the ciliary body. Conclusion: AS-OCT is very useful to evaluate ciliary detachment. PPV+Gas tamponade can be a treatment option for ciliary detachment.

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.

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.

Inverted Internal Limiting Membrane Flap versus Internal Limiting Membrane Peeling for Macular Hole Retinal Detachment in High Myopia.

PURPOSE: To compare surgical outcomes between the inverted internal limiting membrane (ILM) flap technique and ILM peeling for macular hole retinal detachment (MHRD) in eyes with high myopia. DESIGN: Multicenter cohort study. PARTICIPANTS: We retrospectively reviewed medical records of consecutive patients treated between June 2008 and September 2018 at 7 hospitals and included 100 eyes with MHRD associated with high myopia in our study. All eyes underwent vitrectomy with the inverted ILM flap technique (57 eyes) or ILM peeling (43 eyes) and were followed up for more than 6 months. METHODS: We estimated odds ratios and their 95% confidence intervals (CIs) for macular hole (MH) closure using multivariate logistic regression analysis. We also examined factors associated with the postoperative best-corrected visual acuity (BCVA) at the final visit using multiple linear regression analysis. MAIN OUTCOME MEASURES: Macular hole closure and postoperative BCVA at the final visit. RESULTS: The MH closure rate was significantly higher in the inverted ILM flap group (80.7%) than in the ILM peeling group (37.2%; P < 0.001). Moreover, postoperative BCVA at the final visit was significantly better in the former group (0.88 ± 0.48 vs. 0.99 ± 0.48; P = 0.03). The retinal attachment rate (ILM flap, 91.2%; ILM peeling, 79.5%; P = 0.229) and recovery rates for the external limiting membrane and ellipsoid zone line (ILM flap, 10.9%; ILM peeling, 0%; P = 0.12) showed no significant intergroup differences. After adjustment for age, axis, tamponade substance, and dye for ILM staining, the inverted ILM flap technique was associated strongly and positively with MH closure (odds ratio, 7.14; 95% CI, 2.72-18.7; P = 0.001). Moreover, the inverted ILM flap technique and preoperative BCVA were associated significantly and positively with the postoperative BCVA at the final visit. CONCLUSIONS: Our findings suggest that the MH closure rate and postoperative visual outcome for eyes with high myopia-associated MHRD are better with the inverted ILM flap technique than with ILM peeling. Thus, vitrectomy with the inverted ILM flap technique should be considered as the initial surgery for MHRD associated with high myopia.

Baerveldt surgery outcomes: anterior chamber insertion versus vitreous cavity insertion.

PURPOSE: We compared the outcomes of Baerveldt glaucoma implant (BGI) surgery between vitreous cavity and anterior chamber insertion. METHODS: We retrospectively analyzed a total of 105 consecutive eyes that underwent BGI surgery and were followed up for ≥ 12 months. BGI surgery was performed via the anterior chamber (AC group 48 eyes) or the pars plana into the vitreous cavity (VC group 57 eyes). Patients' data were examined at 3, 6, and 12 months, and then every 6 months after surgery. We compared the groups' intraocular pressure (IOP), success ratio, visual acuity, number of glaucoma medications, central corneal endothelial cell density (CCECD), reduction ratio of CCECD, and postoperative complications. RESULTS: The mean preoperative and postoperative IOP values were not significantly different between the two groups. In the Kaplan-Meier survival plots, there was no significant between-group difference in the success rate (p = 0.333). The postoperative mean CCECD decreased significantly faster in the AC group than the VC group at all time points. The cases of postoperative corneal edema were 12.5% in AC group and 1.8% in VC group. The risk of postoperative corneal edema was significantly higher in the AC group (p = 0.0136). Risk factors for the rapid reduction of CCECD were "history of trabeculectomy" (p = 0.00283), "insertion into the anterior chamber" (p = 0.001), and "shorter distance between the tube and corneal endothelium" (p = 0.0137). CONCLUSION: There was no significant between-group difference in postoperative IOP, medications, or success rate. Considering the reduction of corneal endothelial cells, insertion into the vitreous cavity seems safer than insertion into the anterior chamber.

Baerveldt® glaucoma implant surgery with the double scleral flap technique to prevent Hoffman elbow exposure.

OBJECTIVE: To compare the efficacy and safety of the Baerveldt® glaucoma implant (BGI) between a preserved donor scleral patch alone and double scleral flaps, comprising a preserved donor scleral patch and an autologous scleral pedicle flap. METHODS: This was an open-label retrospective study. We analyzed the cases of 52 consecutive patients (56 eyes) who underwent BGI surgery with the Hoffman elbow (#BG 102-350, Abbott) and were followed up for >1 year. Twenty-one eyes underwent BGI surgery with a preserved donor scleral patch alone (donor-patch group), and the other 35 eyes underwent BGI surgery with a preserved donor scleral patch and an autologous scleral pedicle flap (double-flap group). The main outcome was the incidence of Hoffman elbow exposure associated with each surgical approach. RESULTS: Three patients in the donor-patch group (14.3%) developed Hoffman elbow exposure, whereas in the double-flap group, no cases had Hoffman elbow exposure (p = 0.048). CONCLUSIONS: The use of the double scleral flaps technique was more efficient in preventing Hoffman elbow exposure.

Results of the Baerveldt® Glaucoma Implant for Neovascular Glaucoma Patients.

Purpose: To evaluate the efficacy and safety of the Baerveldt® glaucoma implant (BGI) for eyes with neovascular glaucoma (NVG). Methods: This was a retrospective study. Thirty-five eyes (31 patients) diagnosed with refractory NVG at Toyama University Hospital were enrolled from January 2012 to December 2015. All patients underwent BGI and were followed up for more than 6 months. Results: The mean age of patients was 62.7±13.9 years old. The mean postoperative follow-up periods was 22.0±12.7 months. The mean preoperative IOP was 35.5±9.6 mmHg and the mean postoperative IOP at 6, 12, 24, 36, 48 month were 12.7±5.9, 12.8±3.7, 12.2±3.3, 13.1±3.3, 15.0±1.4 mmHg respectively. Postoperative visual acuity was not significantly improved. Complications were Hoffmann Elbow erosion in 2 patients who needed additional surgery. The success rate at one year was 82.7%. Postoperative intervention was not required. Conclusion: BGI surgery should be considered a useful treatment to lower the IOP for NVG.

Effects of Vitrectomy on Recurrent Macular Edema due to Branch Retinal Vein Occlusion after Intravitreal Injection of Bevacizumab.

Purpose. To evaluate the effects of pars plana vitrectomy (PPV) on recurrent macular edema due to branch retinal vein occlusion (BRVO) after intravitreal injections of bevacizumab (IVB). Methods. This retrospective study included 22 eyes of 22 patients who underwent single or multiple IVB injections for macular edema due to BRVO and showed a recurrence of macular edema. All patients then underwent PPV and were followed up for more than 6 months after the surgery with examinations of best corrected visual acuity (BCVA) and optical coherence tomography (OCT). OCT parameters were central macular thickness (CMT) and average retinal thickness in a 1-mm-diameter circular region at the fovea (MRT). Results. Mean BCVA, CRT, and MRT were significantly improved from the baseline after PPV. Greater improvement of BCVA, CRT, and MRT was obtained after 1 month of IVB than after 6 months of PPV. No eyes showed worsening of macular edema after the surgery. Conclusion. PPV improved BCVA and recurrent macular edema due to BRVO, but PPV that was less effective than IVB had been in the same patients. PPV may be one of the treatment options for recurrent macular edema due to BRVO after IVB.

One-year results of photodynamic therapy combined with intravitreal ranibizumab for exudative age-related macular degeneration.

Purpose. To evaluate the effects of photodynamic therapy (PDT) combined with intravitreal injection of ranibizumab (IVR) for exudative age-related macular degeneration (AMD). Methods. Retrospective case series. Thirty eight eyes of 38 patients with exudative AMD underwent combined therapy consisting first of IVR, followed by PDT within a week and the second IVR at 1 month. All patients were followed up for more than 12 months. The best corrected visual acuity (BCVA) and central macular thickness (CMT) were examined. Results. The mean number of IVR and PDT sessions were 2.9 ± 1.3 and 1.1 ± 0.3, respectively. The mean BCVA and CMT were significantly improved to 0.38 logMAR units (P < 0.01) and 240 µm (P < 0.01) at 12 months, respectively. Thirty-six of 38 eyes (94.8%) improved or maintained BCVA at 12 months. Conclusion. PDT combined with IVR for exudative AMD was effective at improving visual acuity and CMT with a low recurrence rate for 12 months.

Intravitreal injection of bevacizumab combined with macular grid laser photocoagulation for macular edema in branch retinal vein occlusion.

PURPOSE: To evaluate the effects of combined therapy of intravitreal injections of bevacizumab (IVB) and additional macular grid laser photocoagulation for recurrent macular edema in branch retinal vein occlusion (BRVO). METHODS: This was a retrospective interventional case series in which 44 eyes of 44 patients with macular edema due to BRVO were studied. The mean follow-up term was 77.2 ± 12.4 weeks. All patients underwent IVB as a primary therapy. After two to three IVB, 19 of the 44 eyes (43.2%) underwent laser photocoagulation in the macular edema area to prevent the recurrence of the edema. In the other 25 eyes (56.8%), macular edema was successfully treated with IVB only. Visual acuity and central macular thickness (CMT) were examined during the follow-up. RESULTS: The mean visual acuity and the mean CMT in both groups improved significantly after the IVB. Following macular grid laser photocoagulation for recurrent macular edema, the mean visual acuity was maintained for 24 weeks, however, the mean CMT increased significantly after 12 weeks. CONCLUSIONS: Additional grid laser photocoagulation for recurrent macular edema in BRVO after IVB maintained mean visual acuity with limited effects on the further recurrence of macular edema.

Use of a hyperdried cross-linked amniotic membrane as initial therapy for corneal perforations.

PURPOSE: To report the use of hyperdried cross-linked (HDCL) amniotic membrane (AM) patching with tissue adhesive as an initial therapy for corneal perforations. METHODS: Cryopreserved AM was cross-linked with 0.1% glutaraldehyde and then dried using far-infrared rays and microwaves (hyperdry method). Three eyes of three patients with corneal perforations of up to 3 mm in diameter were included in this study. They were treated with a single-layer patch of HDCL-AM applied with a tissue adhesive (2-octyl-cyanoacrylate). We also evaluated the resistance of HDCL-AM to collagenases during in vitro digestion testing. RESULTS: In all three cases, the corneal perforations were repaired within 28 days (range, 17-28 days). No recurrence occurred during the follow-up period (3-6 months). In the collagenase digestion testing, the HDCL-AM did not dissolve until 48 h, whereas the cryopreserved AM completely dissolved within 60 min. CONCLUSIONS: Three cases of corneal perforations were successfully managed using HDCL-AM patching with tissue adhesive. The HDCL-AM was resistant to collagenases during in vitro digestion testing. The HDCL-AM was a useful substrate for corneal perforations. This simple surgical technique may be one of the initial therapeutic options for corneal perforations.

[Short-term effects of intravitreal injection of bevacizumab on macular edema due to central retinal vein occlusion].

PURPOSE: To examine the short-term effects of intravitreal injections of bevacizumab on macular edema due to central retinal vein occlusion (CRVO). METHODS: Twenty one eyes of 21 consecutive patients with macular edema due to CRVO were included. The patients received intravitreal injections of 1.25 mg bevacizumab at the initial examination. They were followed up with best-corrected visual acuity (BVCA), fluorescein angiography, and central macular thickness (CMT) by optical coherence tomography for more than 4 months. Whenever the macular edema recurred, another intravitreal bevacizumab was given. RESULTS: The mean age of the patients was 68.1 +/- 11.8 and the mean follow up was 6.5 +/- 2.6 months. The mean baseline BVCA (logMAR) and CMT were 0.79 +/- 0.45 and 699 +/- 194 microm, respectively. After treatment, the mean BVCA improved significantly at 1 week (0.52 +/- 0.46, p<0.001), 1 month (0.48 +/- 0.46, p<0.001), 2 months(0.56 +/- 0.43, p<0.02), and 4 months (0.51 +/- 0.47, p<0.001). The mean CMT also decreased significantly at 1 week (296 +/- 86 microm, p<0.001), 1 month (286 +/-132 microm, p<0.001), 2 months (464 +/- 249 microm, p<0.05) and 4 months (362 +/- 198 microm, p<0.001). Similar effects on reducing CMT were obtained both after the initial injection and the second injection of bevacizumab. CONCLUSION: Intravitreal injection of bevacizumab improved visual acuity and macular edema due to CRVO.

A hyperdry amniotic membrane patch using a tissue adhesive for corneal perforations and bleb leaks.

PURPOSE: To evaluate the efficacy of hyperdry amniotic membrane (AM) patching attached using a tissue adhesive for corneal perforations and glaucoma filtering bleb leaks. DESIGN: Prospective, noncomparative, interventional case series. METHODS: Five eyes of 5 patients (glaucoma bleb leaks, 2 eyes; corneal perforations, 3 eyes) were treated with a single-layer patch of dried AM using a biological tissue adhesive. The dried AM was prepared with consecutive far-infrared rays and microwaves (hyperdry method) and was sterilized by gamma-ray irradiation. The dried AM was cut to the desired size and shape, and the tissue adhesive was applied to the amniotic epithelial side of the dried membrane. After applying the tissue adhesive, the dried membrane with glue applied then was positioned to cover the conjunctival bleb leak site or corneal perforation lesion using forceps. A therapeutic hydrogel contact lens then was installed as a bandage. RESULTS: Bleb leaks or corneal perforations were repaired successfully within 21 days in all 5 cases. There were no remarkable adverse effects, and there was no recurrence of bleb leak or corneal perforation. CONCLUSIONS: The hyperdry AM is a useful substrate, and this surgical procedure is a promising method to treat glaucoma filtering bleb leak or corneal perforation, which may result in serious vision-threatening ocular complications.

Late brownish discoloration of an implanted hydrophobic acrylic intraocular lens.

A 79-year-old woman underwent phacoemulsification/ aspiration with a hydrophobic acrylic intraocular lens in the left eye. The intra-operative course was uneventful. Brownish discoloration of the lens optics was noted 16 months postoperatively. To our knowledge, the late discoloration of a hydrophobic acrylic intraocular lens has not previously been reported.

Vitreous Chemokines and Sho (Zheng in Chinese) of Chinese-Korean-Japanese medicine in patients with diabetic vitreoretinopathy.

We examined the levels of vitreous chemokines and Sho (Zheng in Chinese) of Chinese-Korean-Japanese medicine in diabetic patients. Patients undergoing vitrectomy were classified into Group 1 (no diabetic retinopathy), Group 2 (diabetic retinopathy with no or a few new vessels), and Group 3 (diabetic retinopathy with many new vessels). The levels of IL-8, MCP-1, MIP-1alpha, MIP-1beta, and RANTES in the vitreous fluid were measured using cytometric bead array method. Sho was determined by the standard diagnostic method of Chinese-Korean-Japanese medicine. Vitreous levels of IL-8 and MCP-1 in Groups 2 and 3 were higher than those in Group 1. MIP-1alpha, MIP-1beta, and RANTES levels in Groups 2 and 3 were almost the same as those in Group 1. The percentage of patients with Keishibukuryo-gan (Guizhifuling-wan in Chinese) sho in Group 3 was higher than that in Group 1. In conclusion, vitreous levels of IL-8 and MCP-1 were high in patients with diabetic vitreoretinopathy. Keishibukuryo-gan sho may be associated with diabetic vitreoretinopathy.

Ocular findings in Japanese patients with varicella-zoster virus infection.

PURPOSE: To examine ocular findings in Japanese patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis. METHODS: A retrospective study was conducted. Information on the ocular, cutaneous, systemic, and virologic findings on pediatric and adult patients was obtained from medical records. RESULTS: A total of 77 (45 male and 32 female) patients were enrolled in the study: 4 children had varicella, 68 adults had herpes zoster ophthalmicus, and 5 adults had acute retinal necrosis. Children with varicella had eruptions on the eyelid. Patients with herpes zoster ophthalmicus had eruptions, conjunctivitis, keratitis, iridocyclitis, and other findings. Patients with acute retinal necrosis had intracameral cells and retinal lesions. Some patients with herpes zoster ophthalmicus had malignancy, type 2 diabetes mellitus, or other disease. One pregnant woman developed acute retinal necrosis shortly after varicella infection. A total of 48% of patients with negative Hutchinson sign had ocular lesions, while all patients with positive sign showed ocular lesions. Patients with varicella and herpes zoster ophthalmicus had good visual acuity at the last visit. Some patients with acute retinal necrosis had poor visual acuity at the last visit. CONCLUSIONS: Patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis had several ocular complications. Some patients with acute retinal necrosis had poor visual outcomes. Ophthalmologists should be aware that acute retinal necrosis may develop shortly after varicella infection.

Congenital corneal staphyloma associated with aphakia.

A neonate had a globular mass bulging through the eyelids of the left eye. Computed tomography revealed a large ectatic corneal lesion and the absence of a lens. The enucleated globe revealed that the posterior surface of the ectatic cornea was lined by iris tissue, indicating corneal staphyloma.

Effect of topical iganidipine on experimental elevation of aqueous flare induced by prostaglandin E(2) and EP agonists in pigmented rabbits.

We evaluated the role of topical iganidipine on experimental aqueous flare elevation in rabbits. Transcorneal diffusion of prostaglandin E(2) (PGE(2)), 25 microg/ml or 7.09 x 10(-2) mmol/l, or highly selective agonists for prostaglandin E(2) receptor subtypes (EP), 25 microg/ml, was achieved with the use of a glass cylinder to produce aqueous flare elevation in pigmented rabbits. Iganidipine was topically administered before application of PGE(2) or EP agonists. Aqueous flare was measured with a laser flare cell meter. Topical instillation of 0.1% iganidipine once or twice inhibited 64 +/- 8% (p < 0.01) and 84 +/- 9% (p < 0.01) of PGE(2)-induced aqueous flare elevation, respectively. Two instillations of 0.1% iganidipine inhibited 95 +/- 5% (p < 0.01) of EP2-agonist(ONO-AE1-259-01)-induced flare elevation and 98 +/- 3% (p < 0.01) of EP4-agonist(ONO-AE1-392)-induced flare rise. Topical iganidipine may have anti-inflammatory activity in the eye.

Effects of isopropyl unoprostone, latanoprost, and prostaglandin E(2) on acute rise of aqueous flare in pigmented rabbits.

PURPOSE: To evaluate the effect of isopropyl unoprostone, latanoprost, and prostaglandin E(2) (PGE(2)) on aqueous flare elevation. METHODS: Isopropyl unoprostone (0.12%) or latanoprost (0.005%) was topically instilled. Transcorneal diffusion of PGE(2), 25 microg/ml, using a glass cylinder, was achieved in pigmented rabbits. Aqueous flare was measured with a laser flare cell meter. RESULTS: Topical instillation of isopropyl unoprostone induced aqueous flare elevation in rabbit eyes. Also, topical isopropyl unoprostone additionally induced aqueous flare elevation in eyes with transcorneal diffusion of PGE(2). Latanoprost did not induce flare elevation. CONCLUSION: Isopropyl unoprostone induced aqueous flare elevation in rabbits, and latanoprost did not produce aqueous flare elevation.

Effect of topical betaxolol on the acute rise of aqueous flare induced by highly selective agonists for prostaglandin E2 receptor subtypes in pigmented rabbits.

PURPOSE: To evaluate the role of topical betaxolol on experimental ocular inflammation in rabbits. METHOD: Transcorneal diffusion of highly selective agonists for prostaglandin E2 receptor subtypes (EP), 25 microg/ml, with the use of a glass cylinder, was performed to produce aqueous flare elevation in pigmented rabbits. Betaxolol was topically administered before EP agonist application. Aqueous flare was measured with a laser flare cell meter. RESULTS: Performing topical instillation of 0.5% betaxolol 4 times inhibited 52 +/- 9% of EP2-agonist (ONO-AE1-259-01)-induced aqueous flare elevation. The inhibition of flare elevation was dependent on the number of betaxolol instillations. Betaxolol did not suppress the elevation induced by an EP4 agonist (ONO-AE1-392). CONCLUSION: Betaxolol inhibited EP2-agonist-induced aqueous flare elevation in pigmented rabbits.