[Clinical features of idiopathic macular holes]

PURPOSE

The purpose of this study was to evaluate the clinical features of idiopathic macular holes.

MATERIALS AND METHODS

The clinical features were examined in consequentive 526 eyes of 480 patients with idiopathic macular hole who underwent vitrectomy.

RESULTS

Sixty-seven% of the patients were female. The mean onset age was 64.4 years of age and 60% of the cases were in their 60's at the time of onset. The mean refractive value was -0.66 dioptor and 40% of the cases were emmetropia with a refractive value between -1.0 dioptor and +1.0 dioptor. The onset age was positively correlated with refractive value. The visual acuity was negatively correlated with onset age, duration after onset, and the size of the macular hole. The duration was positively correlated with onset age. The size of the macular hole was positively correlated with age and duration. The factors for good visual acuity were determined by bilaterality, youth, or small size. Also we found the factors for large size of macular holes to be female gender, long duration of the hole, being in stage 4, and low visual acuity.

CONCLUSIONS

The incidence of idiopathic macular hole is seen more in eyes of patients in their 60's and in emmetropic eyes. Patients with myopic eyes tend to have younger onset. The size of the macular hole in females tends to be larger than in males.

Vitrectomy for macular edema combined with retinal vein occlusion

This study was performed in order to evaluate the effect of vitrectomy in eyes with retinal vein occlusion associated with macular edema. Twenty-nine years eyes (27 patients) with branch retinal vein occlusion (BRVO), and 14 eyes (13 patients) with central retinal vein occlusion (CRVO) both associated with macular edema underwent phacoemulsification, intraocular lens implantation, pars plana vitrectomy and peeling of the posterior hyaloid membrane. Follow-up ranged from 12 to 32 months. Macular edema was reduced, and visual improvement was observed (p < 0.0001 in BRVO, p = 0.0257 in CRVO, paired t-test). Visual outcome was better in eyes with better visual acuity before surgery. Early vitrectomy may be recommended for retinal vein occlusion associated with macular edema.

Cystotomy for diabetic cystoid macular edema

The purpose of this study was to evaluate the role of vitrectomy with cystotomy in the treatment of diabetic cystoid macular edema (CME). Among 22 eyes of 21 patients with diabetic CME underwent phacoemulsification, intraocular lens implantation, pars plana vitrectomy, induction of posterior vitreous detachment, and cystotomy or cystectomy. Follow-up ranged from 3 to 29 months. Under biomicroscopic examination, Cystoid macular edema was eliminated in 16 of 22 eyes during the follow-up period. Ring-shaped residual edema was observed in one eye. Corrected visual acuity improved in 7 of 22 eyes by more than one Snellen line (P = 0.0391, paired t-test), remained the same in 13 eyes, and decreased by more than one line in 2 eyes. This pilot study shows that cystotomy may have a role in the treatment of cystoid macular edema in diabetic patients.

[Refraction and anterior chamber depth change after vitrectomy for pseudophakia]

PURPOSE

To evaluate the association between the vitreous and the refractive error in pseudophakia.

METHODS

Vitrectomy was performed in 67 eyes of 61 patients who underwent cataract surgery. Vitrectomy was needed for epiretinal membrane in 30 eyes, macular edema in 22 eyes, macular hole in 3 eyes, lamelar macular hole in 2 eyes, vitreous opacity in 6 eyes, and vitreous hemorrhage in 4 eyes. Refraction was measured before the operation, and 1 month, 3 months, 6 months, and 12 months after operation. Anterior chamber depth was measured in 10 eyes before the operation, and 1 month, 3 months, and 6 months after operation. We evaluated the refractive error after vitrectomy in 49 eyes that had predicted refraction.

RESULTS

The mean value of refractive change was -0.3 D 1 month postoperatively, and then gradually became positive. The variation of refraction (6-month postoperative refraction minus preoperative refraction) was negatively correlated with preoperative refraction (p = 0.0052, R2 = 0.146). If preoperative refraction was more myopic than -1.5 D, then refraction became positive. If preoperative refraction was not more myopic than -1.5 D, then refraction became negative.

CONCLUSION

About 15% of postoperative refractive error may be associated with the vitreous, but further investigation is required.

[Variables that influence visual acuity after macular hole surgery]

PURPOSE

To evaluate the variables that influence visual acuity and visual improvement after macular hole surgery.

METHODS

Our study included 421 eyes in which maculor holes were successfully closed after surgery and followed up at least 1 year after the last surgery. Surgical techniques were conventional methods (Group 1: 350 eyes) with retinal pigment scalping of the macular hole basis added in the refractory cases (Group 2: 71 eyes). The variables used for the multiple regression were gender, age, preoperative visual acuity, hole stage, duration of symptoms, hole size, and axial length.

RESULTS

The variables that most influenced postoperative visual acuity were as follows: Group 1: gender (r = -0.011, p = 0.016), age (r = -0.17, p = 0.005), preoperative visual acuity (r = 0.51, p < 0.0001), duration of symptoms (r = -0.015, p < 0.0001), and axial length (r = -0.090, p = 0.045). Group 2: age (r = -0.18, p = 0.047), and preoperative visual acuity (r = 0.47, p < 0.0001).

CONCLUSIONS

The variables that influenced visual acuity and visual improvement after macular hole surgery were common. In Group 1: gender, age, preoperative visual acuity, duration of symptoms, and axial length; in Group 2: age and preoperative visual acuity.

Pars plana filtration with multiple laser perforation of the uvea for neovascular glaucoma following proliferative diabetic retinopathy

PURPOSE

To evaluate the effect of pars plana filtration with multiple laser perforation of the uvea in neovascular glaucoma patients following proliferative diabetic retinopathy.

METHODS

In 18 eyes of 13 patients, after a fornix-based conjunctival incision, two 9 x 3 mm, thin, rectangular scleral flaps were created 3-6 mm posterior to the limbus. The remaining layers of sclera under each flap were removed. The exposed uvea was irradiated at a mean of 60.6 spots with an argon laser just to the point of perforation. After the posterior chamber fluid escaped, the flaps were sutured.

RESULTS

The mean preoperative intraocular pressure (IOP) was 36.4 +/- 9.0 mm Hg. After an average follow-up of 16.6 +/- 5.9 months, the mean final postoperative IOP was 16.6 +/- 4.4 mm Hg. The postoperative IOP was below 21 mm Hg in 3 (16.7%) of the 18 eyes without medication, in 14 (77.8%) on anti-glaucoma eye drops, and in 16 (88. 9%) on anti-glaucoma eye drops and an oral carbonic anhydrase inhibitor. Snellen visual acuity improved by more than 2 lines in 7 of the 18 eyes, worsened by this amount in 3, and remained within baseline +/- 2 lines in 8.

CONCLUSION

This procedure is an effective treatment for neovascular glaucoma patients following proliferative diabetic retinopathy.

Multicenter retrospective study of retinal detachment associated with atopic dermatitis

PURPOSE

Epidemiological and clinical study of retinal detachment associated with atopic dermatitis.

METHODS

A multicenter retrospective study.

RESULTS

We analyzed the records of 417 eyes of 348 patients operated on during 5 years from 1989 to 1993 and followed up for more than 6 months by vitreo-retinal specialists in 33 hospitals throughout Japan. The number of eyes operated on increased yearly from 42 in 1989 to 132 in 1993. These cases associated with atopic dermatitis were 2.3% of the average number of eyes operated on for rhegmatogenous retinal detachment during the same period, but when restricted to the Kanto area or further to Tokyo only, the percentage was as high as 3.8% and 4.7%, respectively.

CONCLUSION

Clinical characteristics of retinal detachment previously reported, such as traumatic slapping or rubbing of the lids by patients as the most likely pathogenetic factor, and high incidence of cataract and proliferative vitreoretinopathy, were confirmed. The primary surgical procedure was scleral buckling in 78% of the cases and vitreous surgery in 22%, and initial and final reattachment rates were 75.3% and 92.6%, respectively.

[Incidence of reopening and variables that influence reopening after macular hole surgery]

PURPOSE

To evaluate the incidence and variables of reopening of macular holes after macular hole surgery.

METHODS

Our study included 467 eyes in which maculor holes were successfully closed after surgery. Surgical techniques consisted of conventional methods (358 eyes) and scalping methods (109 eyes) with retinal pigment scalping of the macular hole basis added in such cases: reoperation, hole size (more than 0.4 disc diameter), duration of symptoms (more than 2 years). Long term incidence of reopening was predicted by life table method. After we compared reopened cases with non-reopened cases, the variables of gender, stage, biocular occurrence, age, duration of symptoms, hole size, preoperative visual acuity, refraction axial length ratio, and intraoperative retinal tears were used for the multiple regression.

RESULTS

Reopening was found in 20 eyes (5.6%) treated by conventional methods and in 10 eyes (9.2%) treated by scalping methods. Survival ratio was 87% for the conventional methods in 6 years and 79% for the scalping methods in 5 years. The variables influencing reopening were as follows: conventional methods: gender (r = 0.065, p = 0.19), biocular occurrence (r = 0.12, p = 0.026), and refraction axial length ratio (r = -0.11, p = 0.045); scalping methods: hole size (r = 0.14, p = 0.25).

CONCLUSIONS

Incidence of reopening in scalping methods was high. The variables that influenced reopening after macular hole surgery were biocular occurrence and refraction axial length ratio in conventional methods. The shape of the eye may be related to reopening.

Vitreous surgery for traumatic macular holes

PURPOSE

To review the anatomic and visual outcomes of a series of patients with traumatic macular holes who underwent vitreous surgery without adjunctive therapy.

METHODS

We performed a retrospective chart review of 23 patients who underwent vitrectomy, fluid-gas exchange, and sulfur hexafluoride gas tamponade for traumatic macular holes. Anatomic success rate and final visual improvement after the surgery were studied.

RESULTS

Medical records of 23 patients (23 eyes) who underwent this procedure were reviewed. Closure of the macular hole was achieved in 16 (70%) eyes with one surgery and in 22 (96%) of the 23 eyes with two surgeries. The mean best-corrected preoperative visual acuity was 20/160, and postoperative visual acuity was 20/60 with a mean (+/- standard deviation) follow-up of 23+/-13 months (range 3-56 months). Fourteen (61 %) of the 23 eyes achieved a best-corrected postoperative visual acuity of 20/60 or better, and 11 (48%) of the 23 eyes achieved 20/40 or better. Twenty (87%) of the 23 eyes achieved at least two lines of visual improvement.

CONCLUSIONS

Vitreous surgery without adjunctive therapy for traumatic macular holes can lead to anatomic success and visual acuity improvement in most eyes.

Vitreous opacification after neodymium:YAG posterior capsulotomy

PURPOSE

To describe the clinical picture in eyes that developed vitreous opacification behind the intraocular lens (IOL) after neodymium:YAG (Nd:YAG) laser posterior capsulotomy and determine whether this type of opacification tends to occur in patients with diabetes.

SETTING

Shinjo Eye Clinic, Miyazaki, Japan.

METHODS

The clinical course in 728 eyes that had Nd:YAG posterior capsulotomy was reviewed.

RESULTS

After Nd:YAG posterior capsulotomy, opacification developed in the vitreous in contact with the IOL in 9 eyes (1.2%). All occurred in diabetic patients, and the vitreous opacification developed within 1 month after the capsulotomy. A vitrectomy was performed in 8 eyes and in 1, the opacification spontaneously absorbed. Vitreous opacification occurred in 8.9% of 101 eyes of diabetic patients, and the prevalence in diabetic eyes was significantly higher than in nondiabetic eyes (P < .0001). Nine of the diabetic eyes were opaque and 92 nonopaque. In the opaque eyes, the prevalence of panretinal photocoagulation was higher than in the nonopaque eyes (P = .013), and hemoglobin Alc (P = .030) was higher; the interval between cataract surgery and Nd:YAG capsulotomy was shorter (P = .047) and the final visual acuity, lower (P = .045).

CONCLUSION

The prevalence of vitreous opacification after Nd:YAG laser posterior capsulotomy was significantly higher in diabetic than in nondiabetic eyes. Viterectomy was effective for this type of opacification.

[Multicenter retrospective study of retinal detachment associated with atopic dermatitis]

PURPOSE

Epidemiological and clinical study of retinal detachment associated with atopic dermatitis.

METHODS

A multicenter retrospective study.

RESULTS

We analyzed 417 eyes of 348 patients operated on during the 5 years from 1989 to 1993 and followed up for more than 6 months by vitreo-retina specialists in 33 hospitals throughout Japan. The number of eyes operated increased yearly from 42 in 1989 to 132 in 1993. These were 2.3% of the average number of the eyes operated on for rhegmatogenous retinal detachment during the same period, but when restricted to the Kanto area or further to Tokyo only, the percentage was as high as 3.8% and 4.7% respectively. Clinical characteristics of retinal detachment previously reported, such as traumatic slapping or rubbing of the lids by patients as the most possible pathogenetic factor, and high incidence of cataract and proliferative vitreoretinopathy, were confirmed. The primary surgical procedure was scleral buckling in 78% of the cases and vitreous surgery in 22%, and initial and final reattachment rates were 75.3% and 92.6%, respectively.

Significance of biologic aggressiveness and proliferating activity in papillary thyroid carcinoma

Papillary thyroid carcinoma is a frequent thyroid cancer. Many factors have been reported to be of prognostic importance, but the significance of biologic factors suggesting aggressiveness and proliferating activity has not been sufficiently documented. Conventional prognostic factors such as age, extrathyroidal invasion, lymph node and distant metastasis, and biologic factors including histologic differentiation, DNA ploidy, S-phase and G2M-phase fractions, and expression of CD44 variant 6 (CD44-v6) obtained from 131 patients who underwent surgery for papillary thyroid carcinoma at Osaka Police Hospital were analyzed retrospectively. Age was closely related to extrathyroidal invasion, G2M-phase fraction, and CD44-v6 expression. Extrathyroidal invasion was independently related to age, gender, and lymph node metastasis. The grade of lymph node metastasis was related to extrathyroidal invasion, gender, distant metastasis, and CD44-v6 expression. Distant metastasis was associated with aneuploid tumors. Cause-specific survival was independently related to biologic factors including extrathyroidal invasion, distant metastasis, DNA ploidy and S-phase fraction. These results suggest that biologic factors indicating aggressiveness and proliferating activity are important for papillary thyroid carcinoma.

Phacoemulsification, intraocular lens implantation, and trabeculotomy to treat pseudoexfoliation syndrome

PURPOSES

To determine the long-term risk/benefit ratio of phacoemulsification and intraocular lens (IOL) implantation combined with trabeculotomy to manage eyes with pseudoexfoliation syndrome and co-existing cataract.

SETTING

Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine; Kurihara Eye Clinic; Departments of Ophthalmology, Tenri Hospital, Kumamoto University, and Matsue Red Hospital; Nagata Eye Clinic, Japan.

METHODS

This multicenter retrospective study comprised 49 eyes of 36 patients with pseudoexfoliation syndrome and co-existing cataract who had the combined procedure for uncontrolled intraocular pressure (IOP) (> 21 mm Hg) even on antiglaucoma medication.

RESULTS

After a mean follow-up of 20.0 months +/- 13.2 (SD), IOP in all 49 eyes was well controlled (< or = 21 mm Hg). Mean IOP at the final examination was 14.6 +/- 2.6 mm Hg on a mean of 0.9 +/- 0.8 glaucoma medications. Complications included an IOP spike in 11 eyes and fibrin exudation in 1 eye.

CONCLUSION

Phacoemulsification and IOL implantation combined with trabeculotomy was an effective treatment for patients with pseudoexfoliation syndrome and cataract.

Independent prognostic factors in breast cancer patients

BACKGROUND

Recently tumor microvessel density has been shown to be a powerful prognostic tool in breast cancer. We attempted to assess its significance as a prognostic factor.

METHODS

We analyzed the medical records of 100 patients using univariate and multivariate analyses of nine factors as follows; age, tumor size, nodal status, estrogen receptor, C-erbB2, p53, microvessel density, DNA ploidy pattern, and S-phase fraction.

RESULTS

Nodal status and microvessel density were independent prognostic indicators for both survival and relapse-free survival. Microvessel density was independent in the node-negative subgroup for survival, but not independent in the node-positive subgroup, while it was independent in both the node-negative and node-positive subgroups for relapse-free survival. Short-term survival rates in the high and low vessel density subgroups were almost the same, and all patients with early death were node-positive.

CONCLUSION

Microvessel density was an important prognostic factor especially in node-negative patients and more significant in long-term survival.

Change in postoperative refractive error when vitrectomy is added to intraocular lens implantation

PURPOSE

To compare the actual and expected refractive errors after intraocular lens (IOL) implantation alone with those after IOL implantation with simultaneous vitrectomy.

SETTING

Shinjo Eye Clinic, Miyazaki, Japan.

METHOD

One hundred thirty-six eyes had cataract extraction and implantation of a single-piece IOL using a frown incision, continuous annular anterior capsule tear, phacoemulsification, and intracapsular lens fixation. Thirty-six eyes also had vitrectomy.

RESULTS

Mean postoperative refractive error was 0.55 diopter (D) +/- 1.34 (SD) in eyes having no vitrectomy and 0.04 +/- 1.24 D in those having vitrectomy. The difference between groups was statistically significant (P = .047; t-test).

CONCLUSION

The refraction after simultaneous IOL implantation and vitrectomy shifted toward myopia by a mean of 0.50 D compared with that after IOL implantation alone.

Trabeculotomy combined with phacoemulsification and implantation of an intraocular lens for the treatment of primary open-angle glaucoma and coexisting cataract

BACKGROUND AND OBJECTIVE

The authors previously reported the usefulness of trabeculotomy ab externo for the treatment of primary open-angle glaucoma in adult patients. In an attempt to elucidate the long-term risk-to-benefit ratio of this surgical modality in combination with cataract surgery, the authors conducted a retrospective study of the surgical effects and complications of a triple procedure: phacoemulsification, implantation (of an intraocular lens), and trabeculotomy (PIT).

PATIENTS AND METHODS

The authors conducted a retrospective study of patients treated with PIT at multiple hospitals. Intraocular pressure (IOP) and visual function data were obtained from patients after PIT as an initial surgical treatment in cases where antiglaucoma medications failed to resolve uncontrolled IOP (higher than 21 mm Hg). Included in this study were 96 eyes of 64 patients with primary open-angle glaucoma and coexisting cataract. The mean follow-up period was 22.6 +/- 14.7 months (range 3-56 months).

RESULTS

In 94 (98%) of the 96 eyes, the IOP was well controlled, having achieved a level of 21 mm Hg or lower at the final examinations. The mean preoperative IOP of the 33 eyes that underwent the triple procedure using a single flap method (PIT-I) was 24.3 +/- 3.9 mm Hg, with an average of 2.1 +/- 1.1 medications. At the final examinations, the mean IOP had dropped to 16.0 +/- 1.2 mm Hg, with an average of 1.2 +/- 1.2 medications. The mean preoperative IOP of the 63 eyes that underwent the triple procedure using a double flap method (PIT-II) was 26.2 +/- 6.2 mm Hg, with an average of 1.9 +/- 1.2 medications. At the final examination, the mean IOP for this group was 15.6 +/- 2.9 mm Hg, with an average of 1.0 +/- 0.9 medications.

CONCLUSION

The long-term results from this multicenter study showed that the triple procedure, PIT, can be useful and effective as an initial surgical treatment for open-angle glaucoma in glaucoma patients with coexisting cataract.

[Vitreous surgery for macular hole followed membrane peeling]

We performed vitreous surgery for macular holes following membrane peeling. The cases were five eyes of five females aged 42 to 67 years at the time of membrane peeling, out of 441 eyes of 414 patients who underwent membrane peeling. One eye had secondary epiretinal membrane combined with ocular sarcoidosis, two eyes had idiopathic epiretinal membrane, and two eyes had idiopathic vitreoretinal traction syndrome. The presumed interval from membrane peeling to macular hole formation was 5 to 90 months (average 14 months). For treatment of the macular holes, membrane peeling and SF6 gas tamponade were performed. In four eyes of the five eyes, the macular hole was closed. In the remaining eye, removal of the retinal pigment epithelium from the base of macular hole and application of fibrin glue were used in addition to SF6 gas tamponade, but the macular hole was not closed. The follow-up term was 10-24 months (average 17.6 months). Geometrical mean visual acuity was 0.34 before membrane peeling, 0.94 at maximum after membrane peeling, 0.19 after macular hole formation, 0.51 at maximum after macular hole surgery, and 0.44 at the final visit.

A Case of Microangiopathic Hemolytic Anemia Associated with Breast Cancer: Improvement with Chemoendocrine Therapy

Microangiopathic hemolytic anemia (MAHA) is a term which describes the association of hemolytic anemia with red cell fragmentation caused by microangiopathy mechanically. This paper reports a 45-year-old woman with bone metastases from breast cancer. She developed MAHA and disseminated intravascular coagulation (DIC). Although the prognosis of MAHA associated with malignant tumor has been very poor, she achieved remission of the syndrome after chemoendocrine therapy.

[Results of vitrectomy for macular packer after reattachment surgery for rhegmatogenous retinal detachment]

I analyzed the visual results in 184 eyes which had undergone vitrectomy and membrane peeling for macular pucker following treatment for rhegmatogenous retinal detachment. Patient age ranged from 9 to 83 (mean : 55) years, time between reattachment surgery and vitrectomy from 3 to 63 (mean : 15) months, and follow-up from 12 to 96 (mean : 39) months. For the analysis, visual acuity was examined 12 months after the last surgery in 93 pseudophakic eyes and 38 phakic eyes (patients age < 45) and 6 months in 53 phakic eyes (patient age > or = 45). When Y = log 1.5-log (postoperative acuity) and X = log 1.5-log (preoperative acuity), the regression line Y = 0.421 X (R2 = 0.765, p < 0.0001) was obtained. The regression line was Y = 0.395 X (R2 = 0.759, p < 0.0001) for pseudophakic eyes, and Y = 0.488 X (R2 = 0.777, p < 0.0001) for phakic eyes. Thus postoperative visual acuity was higher in pseudophakic eyes than in phakic eyes. When calculated from the pseudophakic line, mean postoperative acuity was 0.2 for preoperative acuity of 0.01, 0.5 for 0.1, and > 1.0 for > 0.5. Postoperative acuity was inversely correlated with the duration between reattachment surgery and vitrectomy (R2 = 0.544, p < 0.0001), and with the patient age (R2 = 0.0046, p = 0.0033). Better postoperative acuity, therefore, was associated with earlier vitrectomy.

[Incidence of lack of posterior vitreous detachment in retinal detachment caused by flap tear in the elderly]

I investigated whether posterior vitreous detachment is invariably associated with retinal detachment in the elderly caused by flap retinal tears. Of 97 eyes which underwent vitrectomy, Weiss' ring was not observed in 10 eyes during both the preoperative slit lamp microscope examination and the intraoperative surgical microscope observation. I proved by surgically detaching the posterior vitreous in 5 out of those 10 eyes that the posterior vitreous had not yet become detached before the operation. My results suggest that posterior vitreous detachment may not be associated with 5 to 10% of cases of retinal detachment caused by flap retinal tears.

Vitrectomy for diffuse macular edema in cases of diabetic retinopathy

PURPOSE

To ascertain the effects of posterior vitreous detachment for diffuse diabetic macular edema.

METHODS

We performed vitrectomy on 58 eyes of 41 consecutive patients with diabetic macular edema without posterior vitreous detachment. Follow-up was done at 12 months postoperatively.

RESULTS

In 57 of 58 eyes after vitrectomy and posterior vitreous detachment, macular edema resolved, and diffuse fluorescein leakage disappeared in 35 of 36 eyes examined at the 12th month. Visual improvement was statistically significant (P < .0001, paired t test).

CONCLUSION

In eyes with diffuse diabetic macular edema and without posterior vitreous detachment, vitrectomy with posterior vitreous detachment may be effective.

[Results of macular hole surgery]

Macular hole surgery in 133 eyes of 128 patients resulted in anatomical success (closure and disappearance of the macular hole) in 79% (105 eyes) with the follow-up ranging from 3 to 36 months (8.1 +/- 5.5 months). The anatomical success was correlated with short estimated duration of symptoms, small size of the macular hole and lack of findings suggestive of a long-standing macular hole. Postoperative visual acuity in the anatomically successful cases was correlated with the preoperative visual acuity (positive correlation), the patient age (inverse correlation), and the estimated duration of symptoms (inverse correlation). After macular hole surgery on 63 eyes with 12 months or more in estimated duration of symptoms, 0.3 or more disc diameter in the size, 0.1 or more in preoperative visual acuity, and patient age of more than 70 years, anatomical success was obtained in 95% (60 eyes) and visual acuity of 1.0 or more in 22% (14 eyes), and 0.5 or more in 71% (45 eyes). These conditions, thus, are those indicating good anatomical and functional results.

[Anterior chamber inflammation after cataract intraocular lens surgery in postvitrectomy eyes]

We determined the anterior chamber inflammation by means of laser flaremetry after cataract intraocular lens surgery for the nuclear cataract that developed after vitrectomy. Cases (38 eyes of 36 patients) were divided into the following four groups according to their pathologies indicating vitrectomy; proliferative diabetic retinopathy (PDR, 14 eyes), idiopathic posterior vitreous membrane syndrome (PVMS, 9 eyes), rhegmatogenous retinal detachment (RRD, 8 eyes), and branch retinal vein occlusion (BRVO, 7 eyes). Mean intervals between the two surgeries were 31, 23, 27 and 18 months, respectively. Phacoemulsification and aspiration through the self-sealing sclerocorneal wound and intraocular lens implantation in the bag were performed. The mean flare count was already high before the cataract surgery in all groups. Postoperative course of mean flare count was an overlap of two waves, one (P1) with a peak on day 1 followed by rapid decrease and the other (P7) with a peak on day 7 followed by slow decrease. Peak values of P1 were higher than the day 1 value after cataract surgery without fundus pathology, and higher in PDR and BRVO groups than in PVMS and RRD groups. P7 was like that observed after vitrectomy and there was close similarity among the groups.

[Induction and properties of nitric oxide synthase in rat retinal pigment epithelial cells in culture]

We investigated the production of nitric oxide (NO) and nitric oxide synthase (NOS) by rat retinal pigment epithelial cells (RPE) in culture.

METHODS

RPE was isolated from the eyes of 7-10 day-old rats and cultured in Dulbecco's modified Eagle medium with 10% fetal calf serum. NO2- concentration in the culture medium was determined with the Griess reaction. NOS was assayed by measuring 3H citrulline as the reaction product. RT-PCR was performed on the isolated RNA fractions from RPE.

RESULTS

Rat RPE produced NOS with the combined stimulation of the bacterial endotoxin and cytokines including interferon gamma. PCR experiments showed that stimulated RPE expressed a gene product corresponding to inducible-type NOS. The enzyme required arginine, NADPH, and tetrahydrobiopterin for the reaction. The specific activity of the crude RPE extract was approximately 270 pmol/min/mg.

CONCLUSION

Like bovine RPE, rat RPE produced NOS by the immunological stimulation. Induced NOS and the product NO may play important roles in inflammation of the eye.

Histological and immunohistochemical study of idiopathic epiretinal membrane

We used electron microscopy and light-microscopic immunohistochemistry of cellular and extracellular markers to characterize the cellular and extracellular components of 15 surgically resected idiopathic epiretinal membranes (IEMs). Ten specimens from the eyes with posterior vitreous detachment (PVD) consisted of inner limiting membrane, collagen layer and a flattened cell layer. Six out of the 10 specimens were also examined immunohistochemically, and fibronectin and type I, II, III and IV collagens were identified in a characteristic lamellar construct in the IEMs. On the other hand, 5 specimens obtained from the eyes without PVD consisted mainly of a thick layer of collagen fibrils with or without a flattened cell layer. Two of the 5 specimens were also examined immunohistochemically, and the collagen fibrils in the specimens were identified as type II collagen. Glial cells (glial fibrillary acidic protein-immunoreactive cells) were also identified in 3 specimens. These results indicate that there are some variations in the IEMs.

[Anterior chamber inflammation after vitrectomy in posterior vitreous membrane syndrome and phacoemulsification and intraocular lens implantation]

We studied the anterior chamber inflammation with a laser flaremeter after transvitreal membrane peeling surgery for posterior vitreous membrane syndrome and cataract intraocular lens surgery, through separate surgery and combined surgery. In 16 eyes with vitrectomy and membrane peeling, mean flare count had one peak of 11 photons/msec at postoperative days 5 through 7. In 10 eyes with phacoemulsification and aspiration with posterior chamber lens implantation, the mean flare count had two peaks of 11 photons/msec at postoperative day 1 and in postoperative week 2. In 25 eyes with combined surgery of vitrectomy and cataract intraocular lens surgery, the mean flare count was similar to the summation of that of each simple surgery. In these 25 eyes, in 9 eyes with sutures, the mean flare count had two peaks of 37 photons/msec at postoperative day 1 and 27 photons/msec at postoperative week 2, and in 16 eyes with self sealing wounds, the mean flare count had one peak of 22 photons/msec at postoperative week two. In 14 vitrectomized eyes with cataract-intraocular lens surgery, the mean flare count was as high as in combined surgery. In eyes with self sealing wounds, the flare count at postoperative day one was significantly lower than that of sutured eyes.

Clinical features of retinal detachment in the elderly

We conducted a retrospective study of 636 eyes (624 patients, aged 65 years or more) to identify the clinical features of nontraumatic retinal detachment in the elderly. The incidence of retinal detachment due to a macular hole in our series (21%) was much higher than those described in previous reports, suggesting a racial difference between Japanese and Caucasian patients. Tractional tear was seen more commonly in patients of less advanced age. In addition, in our series of elderly patients, we demonstrated (1) a preponderance of retinal breaks in the upper temporal quadrant, (2) a high incidence of aphakic retinal detachment, (3) a preponderance of females to be affected and (4) broad detachment of the retina that involved the macula.

[Combined pars plana vitrectomy, lens removal and intraocular lens implantation for complications of diabetic retinopathy. Surgical results in 120 cases]

We performed combined vitrectomy, lens removal and posterior chamber intraocular lens implantation for proliferative diabetic retinopathy in 120 eyes of 101 patients. Follow-up periods ranged from 3 to 63 months, with a mean of 17 months. Three lens removal methods were used: extracapsular cataract extraction (14 eyes), phacoemulsification and aspiration (49 eyes), and pars plana phacoemulsification (57 eyes). Preoperative rubeosis iridis or neovascular glaucoma was found in 21 eyes. Gas or temporary silicone oil tamponade was employed in 32 eyes. Surgical results were good, and the postoperative vision was finger counts or below only in 13 eyes. Thus the combined surgery proved to have no serious problems. Our results indicate two important points. (1) It is best to chose either of the following two methods for the lens surgery: phacoemulsification with continuous circular capsulorhexis, self sealing sclerocorneal incision, and in-the-bag fixation of the posterior chamber lens, or pars plana phacoemulsification leaving the anterior capsule, rub off and aspirating the lens epithelial cells, continuous circular capsulorhexis, and posterior chamber lens implantation in front of the anterior capsule from a self-sealing sclerocorneal wound. (2) It is mandatory to do complete vitrectomy and cut out the vitreous gels incarcerated in the sclerotomy site.

[Objective evaluation of apparent accommodation of pseudophakic eyes]

In 23 (9 males and 14 females) pseudophakic eyes which had a biconvex type intraocular lens (IOL) implanted after cataract extraction, we objectively measured changes in the anterior chamber (AC) depth caused by axial movement of the IOL accompanying accommodation of the contralateral phakic fellow eye, using a Schimpflug slit image with an anterior eye segment image analysis system (Nidek, EAS-1000, Japan). In 114 phakic eyes of 57 persons as controls, AC depths accompanying accommodation from distances of 5 m to 30 cm and 10 cm decreased with increasing age. The decreased mean value of AC depth with accommodation from distances of 5 m to 30 cm was 0.17 mm in patients in their teens, 0.15 mm in patients in their 20 s, 0.10 mm in the 30 s, 0.06 mm in the 40 s, 0.05 mm in the 50 s, and 0.03 mm in the 60 s. The decrease of AC depth with accommodation at a distance of 10 cm was 0 in patients in their 60 s. In the pseudophakic eye changes in anterior chamber depth caused by focusing at short distances were less than 0.04 mm, and decreasing rate of anterior chamber depth (DRAC) was less than 1% in all the pseudophakic eyes. Movement of IOL on the optical axis was too subtle to account for apparent accommodation of the pseudophakic eye.

[Prospective longitudinal studies on lens changes after vitrectomy--quantitative assessment by fluorophotometry and refractometry]

We prospectively evaluated lens changes after vitrectomy on 55 patients with vitreoretinal interface syndrome such as idiopathic epiretinal membrane, vitreomacular traction syndrome, and impending stages of idiopathic senile macular hole. Postoperative changes in crystalline lenses were assessed by fluorophotometric measurement of lens autofluorescence, measurement of refractive errors and biomicroscopic evaluation of progression of nuclear sclerosis. Examinations were repeated prior to surgery and at 1, 3, 6, and 12 months postoperatively. While autofluorescene and light transmittance of the lens were not affected by vitrectomy in patients less than 50 years old, older patients showed a significant increase of autofluorescence and decreased transmittance as early as 3 months after surgery. The refraction became myopic with time especially in the older patient group. Nuclear cataract was also found on biomicroscopic examination in the older patients as early as 1 month after surgery and progressed with time. The older the patients were, the more prominent those lens changes were.

Epiretinal membrane of proliferative diabetic retinopathy: an immunohistochemical study

Nineteen cases of epiretinal membrane (ERM) in proliferative diabetic retinopathy were studied using immunohistochemical methods. Antibodies against type I-IV collagen, fibronectin (FN), glial fibrillary acidic protein (GFAP), vimentin and the monoclonal antibody (MAB) against human Müller cells were used to examine the membranes. Type II collagen was found on one side of the ERMs in 95% of the cases. The other types of collagen, FN and vimentin were also identified in most cases. Müller cells (GFAP- and MAB-positive) were found in 2/19 cases (11%), and astrocytes (GFAP-positive but MAB-negative) were found in 10/19 cases (53%). These results suggest that type II collagen (vitreal collagen) may act as a scaffolding in the formation of ERMs and that glial elements of the ERMs consist mainly of astrocytes.

Surgical techniques and visual prognosis in retinal detachment due to macular hole

In 250 eyes with retinal detachment due to macular hole, the visual prognosis of each surgical technique was evaluated. (1) Macular diathermy adversely affected the visual prognosis. (2) Macular buckling+macular diathermy produced a poorer visual prognosis than macular buckling alone. (3) The visual prognosis resulting from gas tamponade alone or vitrectomy+gas tamponade was better than that resulting from macular diathermy. It is not clear whether there is a significant difference in visual prognosis between gas tamponade alone and vitrectomy+gas tamponade. (4) Macular laser photocoagulation does not adversely affect the visual prognosis. Judging from these results, gas tamponade, which has the possibility of better visual prognosis and less operation stress, should be selected as the initial technique.

Intravitreal neovascular tissue of proliferative diabetic retinopathy: an immunohistochemical study

Intravitreal neovascular tissue in 8 cases of proliferative diabetic retinopathy was investigated using immunohistochemical techniques. All 8 cases yielded positive immunoreactivity for type II collagen (vitreous collagen). The intravitreal neovascular tissue was classified into two groups (A or B), depending upon the distribution of type II collagen. In group A (3 cases), blood vessels were entirely surrounded by vitreous collagen, and in group B (5 cases), the vessels proliferated on one side of a mass of vitreous collagen. Type I and III collagens were distributed diffusely within the extracellular space of the tissue, whereas type IV collagen and fibronectin (FN) formed a basement membrane-like foundation for the newly formed vessels. Glial fibrillary acidic protein (GFAP)-immunoreactive cells were not clearly detected in any of the cases. Neovascular tissue typically proliferated on the posterior vitreous surface (as found in group B), but was also found to penetrate the vitreous gel (as found in group A). As neovascular tissue proliferation proceeded, types I, III and IV collagens and FN were produced. Glial cells (GFAP-positive cells) were not essential for neovascular tissue formation.

[Pars plana lensectomy preserving a clear anterior capsule in vitreous surgery]

The anterior capsule was preserved intact in pars plana lensectomy in 14 cases of pars plana vitrectomy carried out for proliferative diabetic retinopathy in 9 cases, sarcoid uveitis in one case, proliferative vitreo-retinopathy in 3 cases and retinal detachment with a giant break in one case. Follow-up periods ranged from 6 to 17 months, with a mean of 11 months. Simultaneous posterior chamber intraocular lens implantation anterior to the anterior capsule was performed in 7 cases, and in one case secondary implantation was performed 4 months later. In 11 cases anterior capsules remained clear and in 9 of them lens epithelial cells had been thoroughly removed up to the equator using a Terry squeegee. Posterior synechia occurred in 4 cases in which air or gas tamponade had been done. This method allows complete anterior vitrectomy and is adaptable not only to simultaneous but also secondary posterior chamber intraocular lens implantation.

[Posterior chamber lens implantation concurrent with vitrectomy for proliferative diabetic retinopathy]

Combined operation of cataract removal with posterior chamber intraocular lens implantation and pars plana vitrectomy were performed on 25 eyes in 22 patients with cataract concurrent with diabetic retinopathy. In 21 eyes, extracapsular cataract extraction followed by intraocular lens insertion, aiming at in-the-bag fixation, was performed, and in 4 eyes pars plana lensectomy with anterior capsule left and intraocular lens insertion between the iris and anterior capsule was carried out. Mean postoperative follow-up period was 14 months, ranging from 3 to 32 months. Visual acuity on the last examination was 0.5 or better in 2 eyes (8%), 0.1 or better in 12 eyes (48%), and worse than 0.05 in 9 eyes (36%). Major postoperative complications were fibrin reaction (20 eyes, 80%), pupillary deformation (19 eyes, 76%), pupil capture by intraocular lens (3 eyes, 12%), rhegmatogenous retinal detachment (1 eye, 4%), neovascular glaucoma (2 eyes, 8%), and recurrent vitreous hemorrhage (13 eyes, 52%). Intraocular pressure was well controlled in neovascular glaucoma cases. At the last examination ocular fundus was invisible due to vitreous hemorrhage in two eyes.

Treatment of pars planitis with cryotherapy

Cryotherapy was performed on 28 eyes exhibiting massive exudates (snowbank) over the pars plana and the ora serrata. Twenty-six patients ranging in age from 8 to 52 years were treated and then followed up for a median of 34 months. Eleven eyes needed repeat cryotherapy. After cryotherapy, retinal vasculitis and vitreous opacities decreased in most eyes. Although only 3 of 5 eyes with a snowbank greater than 90 degrees and treated over 1 year from the onset achieved visual acuity of 20/25 or better, all 12 eyes with a snowbank smaller than 60 degrees and treated within 3 months after the onset maintained a visual acuity of 20/25 or better. The prognosis was not different from the 20 eyes that received systemic steroid treatment and the 8 eyes that received no systemic steroids. We recommend cryotherapy as the primary treatment for pars planitis with a snowbank.

Surgical techniques and reattachment rates in retinal detachment due to macular hole

We evaluated reattachment rates of the transvitreal and transscleral techniques for treating 250 eyes with retinal detachment due to macular hole. The initial success rate of the transvitreal approach was 56% (53/94). There was no difference between the results of gas tamponade alone and vitrectomy and gas tamponade. The initial success rate of the transscleral approach was 83% (130/156). Macular diathermy and macular buckling showed a higher reattachment rate than macular diathermy alone. The final success rates were the same (95%), regardless of which approach was selected as an initial technique. The patients whose initial transvitreal reattachment failed and who underwent additional transvitreal procedures (including macular laser photocoagulation) showed a success rate of 93%. We believe that gas tamponade, which has possibility of better visual prognosis, should be selected as an initial technique because the final success rate was found to be the same regardless of the initial surgical techniques.

[A case report of synchronous double cancer of the lung and esophagus]

A 69-year-old man was admitted to our department with complaint of difficult swallowing. Upper gastrointestinal examination showed esophageal cancer and squamous cell carcinoma of the middle thoracic esophagus was revealed histologically. Chest X-ray showed the atelectasis of the B-3 region of right upper lobe of the lung. Further examinations revealed histologically squamous cell carcinoma growing from B-3 bronchus. Finally, he was diagnosed as synchronous double carcinoma of the lung and the esophagus. Simultaneous operation was performed on May 20, 1988. First, right upper lobectomy of the lung and wedged resection of right main bronchus were performed. Esophagectomy and antesternal esophageal reconstruction using the gastric tube was added. The postoperative course was satisfactory without any severe complications. The synchronous double cancer of the lung and the esophagus is rare. Our case indicates that simultaneous resection of both cancer and esophageal reconstruction can be safely performed.

Müller cells in detached human retina express glial fibrillary acidic protein and vimentin

We investigated the expression of vimentin and glial fibrillary acidic protein (GFAP) within Müller cells in normal human retinas and in detached human retinas of proliferative vitreoretinopathy (PVR) cases using the immunogold method. Müller cells in normal retinas showed vimentin immunoreactivity and faint GFAP immunoreactivity; however, in detached retinas they showed distinct GFAP immunoreactivity as well as vimentin immunoreactivity. Immunoelectron microscopic observation revealed that intermediate filaments (IF) within Müller cells in normal retinas showed vimentin immunoreactivity and that those within Müller cells in detached retinas showed both vimentin and GFAP immunoreactivity. Double staining for vimentin and GFAP showed that in detached retinas, these two protein immunoreactivities were observed in the same filaments. These results indicate that IF of human Müller cells consist of vimentin under normal conditions and that Müller cells in detached retinas contain different IF, which consist of vimentin and GFAP.

Cancer cell emboli in the pectoral lymphatics of patients with breast cancer

In order to investigate the possibility of local recurrence in the pectoral muscles of patients who undergo modified radical mastectomies, the cancer cell involvement of the lymphatics associated with the pectoralis major muscle was studied in 39 patients who underwent a standard radical mastectomy for Stage I-III breast cancer. Cancer cell emboli were found in the transpectoral lymphatics of 2 patients (2/39 = 5.1 per cent) and in the pectoral fascial lymphatics of 6 patients (6/39 = 15.4 per cent). Two patients with fascial lymphatic cancer cell emboli were from a group of 14 patients with intramammary lymphatic tumor emboli of a low degree (ly 1). The other 6 patients with cancer cell emboli in either the pectoral fascia or the transpectoral lymphatics were from a group of 11 patients with intramammary lymphatic tumor emboli of a moderate degree (ly 2). There was a significant relationship between the intramammary and the pectoral lymphatic cancer cell emboli (Chi square test: (p less than 0.05). The results of this study therefore indicate that lymphatic cancer cell emboli in the pectoral fascia and muscle are an important risk factor for patients who undergo a modified radical mastectomy.

Angle-closure glaucoma with pupillary block mechanism in cicatricial retinopathy of prematurity

A 22-year-old man with mild cicatricial retinopathy of prematurity without retrolental mass developed angle-closure glaucoma following pupillary block mechanism. A large lens and a shallow anterior chamber of the premature eye contributed to this mechanism.

Involvement of fibronectin in in vitro regeneration of retinal pigment epithelium

Argon laser photocoagulation was placed on the confluent monolayer of cultured chick retinal pigment epithelial cells as a model of the regeneration process of retinal pigment epithelium after laser burn. The intense fibrillar net immunofluorescent pattern of fibronectin appeared on the burnt area from 2 h after the laser application, before the beginning of tissue reconstruction. Fibronectin was observed for several days, then became undetectable before the complete regeneration of retinal pigment epithelial cells. This indicates that fibronectin is involved in the early regeneration process of retinal pigment epithelium.

Subretinal strands. Tissue culture and histological study

Subretinal strands in proliferative vitreoretinopathy removed during vitreous surgery in ten cases were studied histologically; tissue culture was taken from five of the ten cases to obtain more material for investigation. Tissue culture was successful in all five cases. The cultured tissue just next to the original strand preserved the characteristics of the original tissue, whereas the portion distal from the original strand did not. Definite and/or suspected retinal pigment epithelial cells (RPE) were found in seven of ten original strands and four of five samples of cultured material. RPE were considered to be a predominant component of subretinal strands.