Air-insufflated high-definition dacryoendoscopy yields significantly better image quality than conventional dacryoendoscopy.

PURPOSE: To facilitate the analysis of lacrimal conditions, we utilized high-definition dacryoendoscopy (HDD) and undertook observations with a pressure-controlled air-insufflation system. We report the safety and performance of HDD. METHODS: In this retrospective, non-randomized clinical trial, 46 patients (14 males and 32 females; age range 39-91 years; mean age ± SD 70.3±12.0 years) who had lacrimal disorders were examined with HDD and conventional dacryoendoscopy (CD). The high-definition dacryoendoscope had 15,000 picture element image fibers and an advanced objective lens. Its outer diameter was 0.9-1.2 mm. Air insufflation was controlled at 0-20 kPa with a digital manometer-based pressure-controlled air-insufflation system to evaluate the quality of the image. The HDD had an air/saline irrigation channel between the outer sheath (outer diameter =1.2 mm) and the metal inner sheath of the endoscope. We used it and the CD in air, saline, and diluted milk saline with and without manual irrigation to quantitatively evaluate the effect of air pressure and saline irrigation on image quality. RESULTS: In vivo, the most significant improvement in image quality was demonstrated with air-insufflated (5-15 kPa) HDD, as compared with saline-irrigated HDD and saline-irrigated CD. No emphysema or damage was noted under observation with HDD. In vitro, no significant difference was demonstrated between air-insufflated HDD and saline-irrigated HDD. In vitro, the image quality of air-insufflated HDD was significantly improved as compared with that of saline-irrigated CD. CONCLUSION: Pressure-controlled (5-15 kPa) air-insufflated HDD is safe, and yields significantly better image quality than CD and saline-irrigated HDD.

The Japan Cornea Society Survey of the Current Status of Corneal and Conjunctival Disorders Due to Systemic Antitumor Drugs.

Purpose: To investigate the current status of corneal and conjunctival disorders due to antitumor drugs in Japan. Methods: Questionnaires on corneal and conjunctival disorders due to antitumor drugs were sent to members of the Japan Cornea Society, and data on patients' background, clinical findings, treatment and prognosis of cases between January 2009 and December 2011 were collected and analyzed. Results: Out of all 221 cases from 66 facilities, TS-1Ⓡ had been administered in 210 cases (95.0%). Corneal findings were noted in 192 cases (86.9%), including 161cases (72.9%) of superficial punctate keratopathy, 55 cases (24.9%) of epithelial crack line, 38 cases (17.2%) of sheet-like epithelial abnormality, and 15 cases (6.8%) of corneal erosion. Conjunctival and ciliary findings were observed in 49 cases (22.2%). Lacrimal obstruction and constriction were found in 81cases (36.7%). Logistic regression analyses revealed the discontinuation and switching of antitumor drugs as the significant factor of good prognosis of clinical signs and visual acuity in cases with TS-1Ⓡ administration. Conclusions: Although corneal and conjunctival disorders due to antitumor drugs, especially TS-1Ⓡ, are important adverse effects, the only effective treatment at this time is the discontinuation and switching of antitumor drugs. Future prospective studies are needed to elucidate pathogenesis, aiming to the prediction and prevention of the occurrence.

Medial blepharosynechioplasty: a new surgical concept for severe dry eye.

BACKGROUND: The purpose of this work was to report on the performance of medial blepharosynechioplasty (MBSP), a newly devised technique for treating severe dry eye. METHODS: In this retrospective, nonrandomized clinical trial, three cases with severe dry eye (Sjögren's syndrome) associated with repeated punctal plug loss were treated using MBSP to create a synechia between the upper and lower lid medial borders of the puncta to suppress the lacrimal pump. RESULTS: Postoperative follow-up showed improvement in the corneal condition in all three cases that persisted for 12-35 months. None of the patients had visual impairment. CONCLUSION: MBSP is a promising treatment for severe dry eye and merits further study.

Dacryoendoscopic observation and incidence of canalicular obstruction/stenosis associated with S-1, an oral anticancer drug.

PURPOSE: To report dacryoendoscopic observations and the incidence of lacrimal obstruction/stenosis associated with S-1, an oral anticancer drug. DESIGN: Retrospective, nonrandomized clinical trial. METHODS: A total of 52 patients (41 men, 11 women; age 42-93 years) who were prescribed the anticancer drug S-1 were studied. Patients who suffered eye complaints following S-1 treatment underwent ophthalmic examination, probing and lacrimal irrigation. Patients whose tear meniscus was high or had abnormal lacrimal irrigation were evaluated by dacryoendoscopy. RESULTS: Overall, 5 of 52 S-1-treated patients (9.6%) experienced lacrimal passage stenosis/obstruction. One patient had punctal stenosis, and four patients had canalicular obstruction/stenosis. The onset of epiphora ranged from 2 to 8 months (4.4 ± 2.2 months, mean ± SD) after the initiation of chemotherapy. CONCLUSIONS: Patients receiving S-1 treatment should be evaluated for potential lacrimal disorders, particularly canalicular obstruction/stenosis. Dacryoendoscopic observation is effective for the diagnosis of this side effect.

[Investigation of epiphora following S-1 therapy].

We report the frequency of lacrimal passage disorder and the outcomes of treatment. This retrospective study was performed on 55 cases that were treated with S-1 for at least 1 month. We asked patients about ocular symptoms. An ophthalmic surgeon examined all patients and diagnosed lacrimal passage disorder in 6 of 55 patients (12. 5%). The mean dose of S- 1 was 10, 300 mg, and the average period to onset of lacrimal passage disorder was 5. 7 months. The causes of epiphora included occlusion/stenosis of lacrimal canaliculus, occlusion of lacrimal puncta and stenosis of nasolacrimal duct. Lacrimal surgery was performed in all 6 patients and epiphora improved. Lacrimal passage disorder may result from systemic treatment of patients with S-1. Symptoms of lacrimal passage disorder improved with early detection and treatment by insertion of a silicone tube.

Conjunctival vasculature patterns influencing the filtering bleb shape following trabeculectomy with limbal-based conjunctival flaps.

PURPOSE: To investigate the correlation between conjunctival vasculature factors and two types of functional bleb shape, cystic and diffuse, formed after trabeculectomy with limbal-based conjunctival flaps. METHODS: Eighty-five eyes of glaucoma patients were consecutively enrolled. After 6 months, functioning blebs were classified as either cystic or diffuse. For each bleb type, the presence of neovascularized vessels in the dissected area (NVc) or the nondissected area (NVi), an avascular area (AVA), or a posterior tarsal artery (PTA) feeding the conjunctiva was analyzed. RESULTS: In 62 eyes with functioning blebs, there were 54 cystic and eight diffuse blebs. AVA was present in 96.3% of the cystic and 25.0% of the diffuse blebs. NVc was present in 100% of the cystic and 62.5% of the diffuse blebs, and NVi in 96.3% of the cystic and 12.5% of the diffuse blebs. A PTA was present in 87.5% of the diffuse blebs, but in only 3.7% of the cystic blebs. AVA, NVi, and NVc were significantly more frequent in cystic blebs, whereas a PTA was more frequent in diffuse blebs. The presence of a PTA in the blebs was negatively related to the presence of AVA, NVc, or NVi. CONCLUSIONS: Avoidance of damage to the PTA during conjunctival dissection might facilitate the formation of a diffuse filtration bleb. The conjunctival vasculature should be considered to avoid cystic avascular bleb formation in trabeculectomy with limbal-based flaps.

Dacryoendoscopic surgery and tube insertion in patients with common canalicular obstruction and ductal stenosis as a frequent complication.

PURPOSE: To report the performance of a new technique and strategy for treating common canalicular obstruction (CCO). Since ductal stenosis is a frequent complication of CCO, access to the whole lacrimal passage is important for CCO treatment. METHODS: In a retrospective, nonrandomized clinical trial, 46 patients (57 CCO cases, 42-93 years old) were treated with either dacryoendoscopic canalicular incision (EI) dacryoendoscope-guided tube insertion (EGT), EI plus inferior meatal dacryocystorhinostomy (iDR)/EGT, EI plus endonasal dacryocystorhinostomy (enDCR), or external canaliculo-DCR depending on the degree of ductal stenosis. The dacryoendoscope was used for incisional positioning, examination and guidance. RESULTS: Ductal stenoses/obstructions were complicated in 14 of 57 CCO cases (24.5%). The success rate after 6-25 months of postoperative follow-up was 89.5% (51/57 cases). The success rates after EI/EGT alone, EI plus enDCR, and EI/EGT plus iDR were 90.4% (38/42 cases), 100% (4/4 cases), and 90% (9/10 cases), respectively. In one case, false passages through the submucosa of the canaliculi were identified, and the surgical approach was converted from EI/EGT to canaliculo-DCR. CONCLUSIONS: EI/EGT alone is an effective, minimally invasive method for treatment of simple CCO. Additional lacrimal surgery (iDR/ EGT, enDCR, and canaliculo-DCR) is effective for complicated CCO.

A pilot study to detect glaucoma with confocal scanning laser ophthalmoscopy compared with nonmydriatic stereoscopic photography in a community health screening.

PURPOSE: To assess the efficacy and practical usefulness of the Heidelberg Retina Tomograph II (HRT II) compared with nonmydriatic stereoscopic photography in a public glaucoma screening. METHODS: We examined 1173 local residents, aged 40 years or older, who visited a community health screening in Komatsu City. Initial glaucoma screening consisted of noncontact pneumotonometry, nonmydriatic stereoscopic fundus photography, and HRT II. When glaucoma was suspected, the subjects were referred for a definitive examination, in which slit-lamp biomicroscopic examination, Goldmann applanation tonometry, Humphrey 30-2 test, gonioscopy, and optic nerve head evaluation were performed. RESULTS: A total of 97.2% (2279/2345) of the nonmydriatic stereoscopic optic disc photographs could be interpreted and 93.4% (2189/2345) were good images. HRT II measurements were successful in 99.0% (2322/2345) of eyes, and acceptable images were obtained in 91.9% (2154/2345) of eyes. On the basis of clinical diagnoses, 94 eyes of 60 participants were diagnosed with glaucoma. The sensitivity of nonmydriatic stereoscopic photographs for personal-level analysis and eye-level analysis was 95.8% and 95.5%, respectively. Using Moorfield's regression analysis, HRT sensitivity and specificity were 72.3% to 91.5% and 84.0% to 93.1%, respectively, for personal-level analysis, and 60.3% to 72.6% and 89.7% to 95.6%, respectively, for eye-level analysis. CONCLUSION: Although HRT II did not detect glaucoma as well as optic nerve stereophotographs in this Japanese population, it may play a role in community health screening.

Elevation of intracellular ca(2+) concentration induced by hypoxia in retinal ganglion cells.

PURPOSE: To analyze the mechanism of hypoxia-induced changes of the intracellular Ca(2+) concentration ([Ca(2+)](i)) in retinal ganglion cells (RGCs). METHODS: Fluo-3 was applied to the cut edge of the optic nerve of 6-week-old rats. The retina was sliced, and the Ca images were captured. A hypoxic condition was created by superfusing the retinal slice with an oxygen/glucose-deprived solution. RESULTS: The retrograde staining method filled the RGCs selectively. Fifteen minutes of hypoxic conditions induced an increase in [Ca(2+)](i) in the RGCs (Delta0.13 +/- 0.03, n = 23). Application of 60 microM DL-2-amino-5-phosphonovaleric acid partially blocked the hypoxia-induced [Ca(2+)](i) increase in dendrites (Delta0.03 +/- 0.02, n = 4, P < 0.05) but not in the somata (Delta0.12 +/- 0.02, n = 9). The RGC dendrites showed a further increase in [Ca(2+)](i) after being switched back to an oxygenated solution (Delta0.14 +/- 0.04, n = 4). Neither 6-cyano-7-nitroquinoxaline-2,3-dione disodium, DL: -threo-beta-benzyloxyaspartate, nifedipine, nor bepridil inhibited the hypoxia-induced [Ca(2+)](i) increase. A Ca(2+)-free superfusion prevented the hypoxia-induced [Ca(2+)](i) increase in the somata (Delta0.07 +/- 0.02, n = 5, P < 0.05) but not in the dendrites (Delta0.16 +/- 0.005, n = 4). CONCLUSIONS: The mechanism of the hypoxia-induced increase in [Ca(2+)](i) differs between somata and dendrites. The N-methyl-D-aspartate channel of dendrites seems to be the main route of Ca(2+) influx.

The inhibitory effect of nilvadipine on calcium channels in retinal ganglion cells in goldfish.

PURPOSE: Our aim was to examine the inhibitory effect of nilvadipine on voltage-gated calcium (Ca) channels in solitary ganglion cells. METHODS: Eyes were excised from goldfish. Ganglion cells were enzymatically dissociated from isolated retina. Whole-cell currents were recorded with the perforated-patch clamp technique. RESULTS: Depolarizing step pulses to more than -48 mV evoked a slowly inactivating inward Ca current. The current-voltage relation for the nilvadipine-sensitive current was bellshaped, and the peak current reached a maximum at -8 mV in the presence and absence of nilvadipine. Nilvadipine block of voltage-gated Ca current was dose-dependent between 1 and 100 microM. The half-maximum inhibitory dose was 35 microM. CONCLUSIONS: The inhibitory effect of orally administered nilvadipine on Ca channels had a mild influence in ganglion cells.

Nasolacrimal duct obstruction classified by dacryoendoscopy and treated with inferior meatal dacryorhinotomy: Part II. Inferior meatal dacryorhinotomy.

PURPOSE: To report the performance of a newly devised technique, inferior meatal dacryorhinotomy (iDR), for membranous PNLDO (lower PNLDO). DESIGN: Retrospective, nonrandomized clinical trial. METHODS: Forty cases (37 patients) who ranged in age from 42 to 89 years old with lower PNLDO were treated by iDR, which is intubation that is assisted by dacryoendoscope, nasal endoscope, and radio-frequency scalpel. The obstructed site was incised with a radio-frequency scalpel without osseous ablation, after which silicone tubes were placed temporarily. RESULTS: Postoperative follow-up evaluation showed that the success rate was 87.5% after 6 months to 2 years. CONCLUSION: The iDR technique is minimally invasive and effective for lower PNLDO.

Nasolacrimal duct obstruction classified by dacryoendoscopy and treated with inferior meatal dacryorhinotomy. Part I: Positional diagnosis of primary nasolacrimal duct obstruction with dacryoendoscope.

PURPOSE: To investigate the site of primary nasolacrimal duct obstruction (PNLDO) using a dacryoendoscope and nasal endoscope. DESIGN: Retrospective, observational case series. METHODS: After local anesthesia, dacryoendoscopy and nasal endoscopy were performed in 149 cases (138 Japanese subjects) of PNLDO. Membranous nasolacrimal duct obstruction was termed as lower PNLDO, and occlusion at sac/duct junction termed as higher PNLDO. RESULTS: The incidence of lower PNLDO was 26.8% (40 of 149 cases), and 109 cases (73.2%) were diagnosed with higher PNLDO. CONCLUSIONS: The dacryoendoscope is extremely useful to observe directly and evaluate the site of obstruction with accuracy in PNLDO. The higher and lower PNLDO may have a different etiologies.