Two different types of giant bleb formation following Ahmed Glaucoma valve implantation.

Purpose: This study aims to present two different types of giant bleb formation following Ahmed Glaucoma Valve (AGV) implantation: an anterior enlarged giant bleb and a posterior enlarged giant bleb. Observations: In Case 1, a 70-year-old Japanese male underwent AGV implantation for neovascular glaucoma in his right eye (OD). Preoperatively, the patient's intraocular pressure (IOP) and best corrected visual acuity (BCVA) were 23 mmHg and 0.6, respectively, OD, while using 3 antiglaucoma topical medications. Two months post-surgery, the patient began experiencing double vision. Slit lamp evaluation revealed no abnormalities, IOP and BCVA were 24.0 mmHg and 0.8, respectively, OD. A posteriorly enlarged bleb in the superotemporal quadrant OD was found to be causing displacement on T2-weighted orbital MRI. The patient underwent surgical excision of the anterior bleb wall. By three weeks post-surgery, the double vision resolved; IOP and BCVA were 17 mmHg and 0.7, respectively, and a normal bleb in the slit lamp evaluation was identified OD. In Case 2, a 10-year-old Japanese female underwent AGV implantation for childhood glaucoma associated with congenital cataract OD. Preoperatively, IOP and BCVA were 30 mmHg and 0.5, respectively, OD, while using 3 antiglaucoma topical medications. She underwent pars plana vitrectomy (PPV) in addition to AGV implantation. Seven months post-surgery, slip lamp evaluation revealed an anteriorly enlarged giant bleb that only cause her a cosmetic concern. Conclusions and Importance: There are two types of giant bleb formation following AGV implantation based on the direction of the enlargement: an anterior enlarged giant bleb and a posterior enlarged giant bleb. The introduction of this classification contribute to better understanding and management of this unusual surgical complication.

Intra-operative challenges encountered using the zepto nano-pulse precision capsulotomy device.

Purpose: The Zepto nano-pulse precision capsulotomy is a novel device for capsulorhexis formation during cataract surgery. Few complications or challenges have been reported while using this device. The purpose of this paper is to highlight two intra-operative challenges that were encountered while using the Zepto device. Observations: CASE 1 - A 65-year-old with advanced primary open angle glaucoma (POAG) and an in situ Ahmed Glaucoma Valve located in the anterior chamber. During a planned phacoemulsification procedure, the tube became trapped between the suction cup of the Zepto device and the lens, resulting in a sudden complete collapse of the anterior chamber. The procedure was completed after appropriate interventions. On post-operative day 1 Descemet folds were visible, and corneal endothelial cell density was reduced from 2101 cells/cm2 preoperatively to 1355 cells/cm2 at 19 months postoperatively. CASE 2 - A 66-year-old female with secondary cataract from chronic inflammation post trabeculectomy for advanced POAG. During a planned phacoemulsification procedure, despite synechialysis for the 360° posterior synechiae, the iris tissue was sucked into the suction cup of the Zepto device and became incarcerated over the lens. The procedure was completed after a successful intervention. Conclusions and importance: Although not previously reported and possibly rare, intra-operative complications may be encountered while using the Zepto device, particularly in complex cataract cases. For the patient's safety and satisfactory post-operative and refractive outcomes, caution must be applied.

Rolling removal technique for a tick embedded in the eyelid.

We present the case of a 5-year-old girl with a tick bite on the left upper eyelid margin. We introduce a rolling removal technique using the scleral plug forceps.

One-year Ocular Safety Observation of Workers and Estimations of Microorganism Inactivation Efficacy in the Room Irradiated with 222-nm Far Ultraviolet-C Lamps.

Two krypton-chloride germicidal excimer lamp units (Care222 TRT-104C11-UI-U3, USHIO Inc.) were installed in the examination room of an ophthalmology department. The irradiation dose was set not to exceed the former (i.e., before 2022) threshold limit value (TLV) (22 mJ cm-2 /8 h) recommended by the ACGIH. Section 1: The eyes and lids of the six ophthalmologists (5 wore glasses for myopic correction) who worked in the room for a mean stay of 6.7 h week-1 were prospectively observed for 12 months. Slitlamp examinations revealed neither acute adverse events such as corneal erosion, conjunctival hyperemia, and lid skin erythema nor chronic adverse events such as pterygium, cataract, or lid tumor. The visual acuity, refractive error, and corneal endothelial cell density remained unchanged during the study. Section 2: The irradiation of samples placed on the table or floor using the same fixtures in the room (5-7.5 mJ cm-2 ) was associated with >99% inhibition of φX174 phage and >90% inhibition of Staphylococcus aureus. In conclusion, no acute or chronic health effects in human participants was observed in a clinical setting of full-room ultraviolet germicidal irradiation by 222-nm lamp units, and high efficacy in deactivation of microorganisms was determined in the same setting.

Isolated traumatic aniridia with full and partial iris expulsion in pseudophakic eyes.

BACKGROUND: Total aniridia after ocular trauma without disruption of the intraocular lens (IOL) has been reported in patients with a history of small-incisional cataract surgery. We report one case each of total and partial aniridia after accidental falls experienced by two elderly Japanese women. CASE PRESENTATIONS: Case 1. A 76-year-old woman with a history of small-incisional cataract surgery more than 10 years previously fell onto concrete and had a contusion that affected the left side of her face. At the initial visit, the best-corrected visual acuity (BCVA) was hand motions and the intraocular pressure (IOP) was 38 mmHg in her left eye (OS). A blood clot was present in the well-formed anterior chamber and expulsed iris tissue was seen beneath the conjunctiva. Exploratory surgery showed no scleral laceration other than the previous sclerocorneal tunnel. After hyphema removal, total aniridia and an intact in-the-bag fixed IOL were seen. By 4 months, the BCVA was 1.2 and the IOP was 13 mmHg OS. CASE 2: An 88-year-old woman with a history of small-incisional cataract surgery more than 10 years previously had a fall that resulted in right-sided zygomatic and maxillary bone fractures. The BCVA was light perception and the IOP was 29 mmHg in her right eye (OD). Exploratory surgery showed no scleral laceration and the previous sclerocorneal tunnel was found; iris strand prolapsing from the sclerocorneal tunnel was seen. After hyphema removal, partial iris loss and an intact lens position were seen. By 1 week postoperatively, the BCVA was 0.05 OD and the IOP was 12 mmHg OD. CONCLUSIONS: It has been postulated that previously created small-incision tunnels can function as release valves during blunt trauma by preventing further global rupture and limiting IOL prolapse or retinal injury. Our cases suggested this can happen even long periods after cataract surgery. The case with partial aniridia demonstrated the process of the expulsive aniridia, and its findings do not contradict the postulated mechanisms.

Shortening of interpupillary distance after topical prostaglandin analog eye drop application in an ophthalmic surgeon: A case report.

Purpose: This study reports a case of interpupillary distance (IPD) shortening after instillation of topical prostaglandin analog (PGA) eye drops. Observations: The patient was a 36-year-old ophthalmic vitreoretinal surgeon from Tochigi, Japan, with primary open-angle glaucoma and bilaterally instilled PGA eye drops to decrease intraocular pressure. His IPD had been recorded closely based on surgical microscope settings. The patient had a stable IPD for over five years before the use of PGA drops. The patient noticed IPD shortening associated with latanoprost usage since four years. The IPD shortened further twice with temporal switching to bimatoprost. However, the IPD partially recovered both the times on discontinuing the medication over the course of several months. Conclusions and Importance: Fluctuations in IPD with visible cosmetic changes occur in association with the use of topical PGA eye drops. There might be effects of PGA drops on binocular vision, which are possibly unaddressed and warrant further study.

Corneal Opacity Induced by Antiglaucoma Agents Other Than Brimonidine Tartrate.

The aim of this study is to report a patient with corneal opacity that developed after the use of topical antiglaucoma medications other than brimonidine tartrate (BT). An 85-year-old woman presented with corneal opacity and neovascularization in both eyes. A diagnosis of glaucoma was made 20 years previously, and antiglaucoma agents were prescribed (latanoprost, tafluprost, timolol maleate, travoprost, bimatoprost, ripasudil hydrochloride hydrate, and brinzolamide/timolol maleate) for both eyes. Ocular examination revealed semicircular fan-shaped corneal sterile infiltration with neovascularization. Anterior-segment optical coherence tomography (OCT) showed marked corneal opacity and thickened corneal stroma. The topical drugs were discontinued and replaced with 0.1% betamethasone eye drops. Two weeks after topical drugs were discontinued and replaced with betamethasone, the corneal sterile infiltration markedly improved, although the corneal opacity remained across the stromal layer. In addition, corneal opacity, intermixed with separate transparent sections, was observed as a striped shape. OCT showed an improvement of the thickened corneal stroma. Six weeks after the initial visit, the remaining corneal opacity could be seen as a mixture of opaque and nonopaque areas in stripes. The corneal stromal thickness decreased almost back to the normal range, while the area of the corneal opacity remained unchanged. In vivo laser confocal microscopy showed hyperreflective materials with needle-like structures in the corneal stroma. The corneal opacity showed several similarities to the previous reports of the cases treated with BT. Therefore, clinicians should be mindful of a possible development of corneal opacity in patients treated with antiglaucoma medications other than BT.

Systemic factors associated with intraocular pressure among subjects in a health examination program in Japan.

BACKGROUND: To elucidate the possible effect of various systemic factors on intraocular pressure (IOP) using a dataset from a health examination program database in Japan. METHODS: This cross-sectional study included 1569 subjects selected from the 2287 subjects who comprised the database. Various systemic parameters including age, sex, height, body weight, waist circumference, percent body fat, blood pressure (BP), pulse rate, body mass index, 28 blood examination values, intimal medial thicknesses of both carotid arteries, and intraocular pressure (IOP) values measured by non-contact tonometry in both eyes were collected. The possible correlation between the IOP and other parameters was assessed initially by univariate analyses followed by multivariate analyses. RESULTS: Stepwise multivariate analyses, which included all parameters extracted by the univariate analyses (p<0.1) and sex, identified the same six parameters as indicators of the IOP values for each right and left IOP model. Among the parameters, age (r = -0.05 and -0.04/year for right and left IOPs, respectively) was associated negatively and the percent body fat (r = 0.06 and 0.05/%), systolic BP (r = 0.02 and 0.03/mmHg), pulse rate (r = 0.03 and 0.03/counts/minutes), albumin (r = 1.12 and 1.00/g/dL), and hemoglobin A1c (r = 0.38 and 0.44/%) were associated positively with the IOP in each eye. CONCLUSIONS: Older age was associated with low IOP, while factors reflecting the metabolic syndrome were associated with high IOP in our study population.

Multiple ocular manifestations in a case of cat scratch disease without systemic signs.

A 43-year-old woman presented with impaired vision and redness in her left eye of 2 weeks duration. She had a pet cat that scratched her forehead 3 weeks before she presented to us. She had no systemic signs such as lymphadenopathy, fever, or fatigue. The respective right and left corrected visual acuities were 20/16 and 20/2000. The anterior chamber of the left eye exhibited inflammation; a fundus examination of that eye revealed optic disc swelling and a serous macular detachment with hard stellate exudates. Based on the recent cat scratch and the ocular findings, cat scratch disease (CSD) was suspected. The results of serologic testing showed elevated titres of IgM and IgG antibodies to Bartonella henselae. Administration of doxycycline and a steroid was initiated. This report describes the occurrence of multiple ocular manifestations of CSD in both the posterior and the anterior segment.

Shortening of Interpupillary Distance after Instillation of Topical Prostaglandin Analog Eye Drops.

PURPOSE: To investigate changes in the interpupillary distance (IPD) after continual instillation of topical prostaglandin analogs (PGAs) in glaucoma patients as an objective indicator of prostaglandin-associated periorbitopathy (PAP). DESIGN: Retrospective, comparative case series. METHODS: A total of 152 institutional patients with glaucoma were enrolled in this study. Inclusion criteria were visual acuities exceeding 10/20 bilaterally and no intraocular surgery during observation. Intervention/observation procedures: First-time bilateral instillation of bimatoprost, travoprost, latanoprost, or tafluprost and IPDs measured by automatic refractometry. IPDs, intraocular pressures (IOPs), and refractive errors were measured before and after continual drug administration (treatment, 2-24 months). MAIN OUTCOME MEASUREMENTS: Post-treatment changes in IPDs. A total of 61 untreated patients served as controls. RESULTS: The IPDs shortened significantly (P < 0.001) after treatment (-0.80 ± 2.1 mm); the IPDs of control subjects remained unchanged (0.05 ± 0.96 mm; P = 0.69). The IPD change after bimatoprost instillation (-2.20 ± 0.97 mm) was significantly (P < 0.001) greater than with other PGAs (-0.65 ± 2.09 mm). The IOPs decreased significantly (P < 0.001) (-3.7 ± 4.3 mm Hg); the refractive errors did not change significantly (P < 0.099) (-0.07 ± 0.69 diopter) post-treatment. The percentages of subjects with 2-mm or greater decreases in IPD after bimatoprost, travoprost, latanoprost, or tafluprost were 85.7%, 20.0%, 18.2%, and 17.2%, respectively, and with 3-mm or greater decreases in IPD 35.7%, 12.0%, 14.5%, and 12.1%, respectively. The specificities were 93.4% and 100% in the control group, respectively, with IPD threshold changes of 2 and 3 mm or more, respectively. CONCLUSIONS: The IPD decreased significantly after topical PGAs within 24 months. The effect was significantly greater with bimatoprost than with other PGAs. The noninvasive, immediate automatic refractometry measurement may be an objective numerical indicator of PAP.

Estimations of Retinal Blue-Light Irradiance Values and Melatonin Suppression Indices Through Clear and Yellow-Tinted Intraocular Lenses.

Spectral transmittance values in the wavelength range of 300 to 800 nanometers were measured using a spectrophotometer for 18 intraocular lenses (IOLs) including clear (ZCB00) and yellow-tinted (ZCB00V, both from AMO Japan) IOLs with three different lens powers. Also measured were the blue-light irradiance (BLI) values, which might reflect retinal damage caused by sunlight, and the melatonin suppression indices (MSIs), which might reflect the nonvisual photoreception function, through these IOLs. The BLIs (in mWcm-2) calculated were 7.62, 7.50, and 7.46 for the +10-diopter (D), +20-D, and +30-D ZCB00 IOLs, respectively; 4.10, 3.92, and 4.00 for the +10-D, +20-D, and +30-D ZCB00V IOLs, respectively; 5.76 for phakic eyes; and 15.00 for aphakic eyes. The MSIs (in mWcm-2sr-1) calculated were 1.18, 1.19, and 1.18 for the +10-D, +20-D, and +30-D ZCB00 IOLs, respectively; 0.98, 0.94, and 0.95 for the +10-D, +20-D, and +30-D ZCB00V IOLs, respectively; 1.03 for phakic eyes; and 1.21 for aphakic eyes. The data from the six clear IOLs (SA60AT, Alcon Japan; VA-60BBR, Hoya; AU6 K, Kowa, N4-18B, Nidek; X-60, Santen; KS-3Ai, Staar Japan) and seven yellow-tinted IOLs (SN60AT; YA-60BBR, Hoya; AU6N, Kowa; N4-18YG, Nidek; NX-60, Santen; KS-AiN, Staar Japan; XY-1, Hoya) reported previously also were discussed. Compared to aphakic eyes, ZCB00 and ZCB00V IOLs reduce the BLI values by 49-50% and 73-74%, respectively; and currently available ultraviolet-blocking clear and yellow-tinted IOLs reduce the BLI values by 43-82%, respectively. Yellow-tinted IOLs absorb more circadian rhythm-associated light than clear IOLs. Although the data presented in this study cannot be applied directly to IOL implanted in patients, the balance between photoprotection and photoreception must be considered when using IOLs in a clinical setting.

Patch Grafting Using an Ologen Collagen Matrix to Manage Tubal Exposure in Glaucoma Tube Shunt Surgery.

PURPOSE: To report the results using an ologen Collagen Matrix as a patch graft in eyes with tubal exposure after tube shunt surgery. CASE REPORTS: Case 1 was an 82-year-old man with tubal exposure in his right eye 26 months after receiving a Baerveldt glaucoma implant. The tube was covered by surrounding conjunctival tissue combined with subconjunctival placement of an ologen Collagen Matrix as a patch graft. Two years after implantation, the tube was not exposed. Anterior-segment optical coherence tomography (AS-OCT) showed dense conjunctival tissue over the tube. Case 2 was an 82-year-old man with peripheral keratitis, anterior scleritis, and secondary glaucoma in the right eye who underwent tube shunt surgery using an Ahmed glaucoma valve and cataract surgery. Intraoperatively, scleritis-related scleral thinning prevented the tube from being covered fully by an autologous scleral flap. An ologen Collagen Matrix was placed over the scleral flap as a patch graft. Seventeen months after implantation, the tube was not exposed. Case 3 was a 52-year-old man with diabetic maculopathy and steroid-induced glaucoma in the right eye who underwent tube shunt surgery using an Ahmed glaucoma valve. Intraoperatively, a flap defect prevented the tube from being covered fully by an autologous scleral flap. An ologen Collagen Matrix was placed over the scleral flap as a patch graft. Three weeks postoperatively, AS-OCT showed thick subconjunctival tissue over the tube. Three months after implantation, the tube was not exposed. CONCLUSIONS: The ologen Collagen Matrix can be used successfully as a patch graft to prevent and treat tubal exposure after tube shunt surgery.

Short-term results of microhook ab interno trabeculotomy, a novel minimally invasive glaucoma surgery in Japanese eyes: initial case series.

PURPOSE: To report the first early postoperative results and safety profile after microhook ab interno trabeculotomy (µLOT). METHODS: This initial retrospective observational case series included 24 consecutive glaucomatous eyes of 17 Japanese patients (7 men, 10 women; mean age ± standard deviation, 66.7 ± 17.9 years) who underwent µLOT. The trabeculotomy extent, surgical time, perioperative complications, interventions for complications and additional glaucoma surgeries during the follow-up for more than 3 months were collected by reviewing the medical and surgical records. The intraocular pressure (IOP), numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), anterior chamber (AC) flare and corneal endothelial cell density (CECD) were compared preoperatively and postoperatively. RESULTS: The trabecular meshwork was incised for a mean of 3.6 ± 0.5 clock hours temporally, 3.7 ± 0.5 clock hours nasally and total 7.3 ± 0.6 clock hours during the 6.2 ± 1.6-min surgery. The mean preoperative IOP of 25.9 ± 14.3 mmHg and number of antiglaucoma medication of 3.3 ± 1.0 decreased significantly (p = 0.0002 and p = 0.005, respectively) to 14.7 ± 3.6 mmHg and 2.8 ± 0.8 at the final visit at 188.6 ± 68.8 days postoperatively. Compared with preoperatively, the final VA, AC flare and CECD did not change significantly. Hyphema with niveau formation (nine eyes, 38%) and washout of hyphema (two eyes, 8%) were the most common postoperative complication and intervention, respectively. At the final visit, 19 eyes (79%) achieved successful IOP control of 18 mmHg or less and a 15% reduction or greater. CONCLUSION: Microhook trabeculotomy normalizes the IOP during the early postoperative period in patients with glaucoma.

Intraoperative floppy-iris syndrome associated with use of antipsychotic drugs.

OBJECTIVE: We report 3 cases of intraoperative floppy-iris syndrome (IFIS) during cataract surgery in patients without a history of selective α1-blocker use but with a long-term history of antipsychotic drug use. We reviewed previously reported cases of antipsychotic drug-associated IFIS cases. DESIGN: Observational case series. RESULTS: In case 1, bilateral IFIS developed in a 39-year-old man with chronic angle-closure glaucoma. He had used several classes of antipsychotic drugs to treat schizophrenia, including the first-generation antipsychotic drugs haloperidol and chlorpromazine, the dopamine system stabilizer aripiprazole, the dopamine serotonin antagonists olanzapine and quetiapine, and the serotonin dopamine antagonists risperidone and blonanserin for 7 years. In case 2, a 63-year-old woman with schizophrenia had used aripiprazole, quetiapine, and risperidone for more than 10 years. In case 3, a 65-year-old woman with an organic mental disorder had used haloperidol for more than 10 years. At least 5 cases of antipsychotic drug-induced IFIS have been reported in the literature. CONCLUSIONS: Any class of antipsychotic drugs can cause IFIS. Although antipsychotic drug-induced IFIS can be mild, surgeons should be alert to the possibility of IFIS when they treat patients with current and past use of antipsychotic drugs.

Patch Grafting Using a Cryopreserved Descemet Stripping Automated Endothelial Keratoplasty Flap for Treating Corneal Perforation.

A 73-year-old woman with a corneal perforation of undetermined etiology was treated with corneal patch grafting. A residual partial-thickness corneal button obtained during a previous Descemet stripping automated endothelial keratoplasty (DSAEK) surgery and stored at -80°C in Optisol GS for 3 months was used as a patch graft. Five days postoperatively, the anterior chamber was reformed and the perforation was masked by the donor cornea. During the next several weeks, gradual displacement of the anterior edge of the donor cornea in the limbal direction occurred. Seven weeks postoperatively, further displacement of the donor cornea resulted in unmasking of the perforated area. At this time, the corneal defect was closed by stromal scar tissue and corneal epithelium. Five months postoperatively, best corrected visual acuity was 1.0 without marked astigmatism and intraocular pressure was 9 mm Hg in the left eye. From this case, we learned that cryopreserved DSAEK flaps stored longer than reported previously can be used as patch grafts to treat emergency conditions. Scar tissue can fill a corneal stromal defect 1 mm in diameter during temporary patch grafting for less than 2 months.

A Case Report of Preoperative, Intraoperative, and Postoperative Anterior Chamber Shallowing Resulting from Different Mechanisms.

A 54-year-old woman with an epiretinal membrane in her left eye accompanied by a shallow anterior chamber due to primary angle closure glaucoma underwent vitrectomy and cataract surgery. During the cataract surgery, immediately after the ultrasonic tip had been removed from the anterior chamber, anterior chamber flattening occurred. An intraoperative fundus examination showed the development of acute intraoperative choroidal effusion. Postoperatively, the anterior chamber remained shallow even after the choroidal detachment had subsided; capsular bag distension seen by ultrasound biomicroscopy suggested the development of early postoperative capsular block syndrome. After neodymium:yttrium-aluminium-garnet laser capsulotomy, the anterior chamber deepened. Depending on the perioperative period, the mechanism of a flat anterior chamber can change, and understanding the underlying mechanisms is required for appropriate treatment.