Generation of functional conjunctival epithelium, including goblet cells, from human iPSCs

The conjunctival epithelium, which covers the sclera (the white of the eye) and lines the inside of the eyelids, is essential for mucin secretion and the establishment of a healthy tear film. Here, we describe human conjunctival development in a self-formed ectodermal autonomous multi-zone (SEAM) of cells that were derived from human-induced pluripotent stem cells (hiPSCs) and mimic whole-eye development. Our data indicate that epidermal growth factor (EGF) drives the generation of cells with a conjunctival epithelial lineage. We also show that individual conjunctival cells can be sorted and reconstituted by cultivation into a functional conjunctival epithelium that includes mucin-producing goblet cells. Keratinocyte growth factor (KGF), moreover, is necessary for the maturation of hiPSC-derived conjunctival epithelium-particularly the goblet cells-indicating key complementary roles of EGF and KGF in directing the differentiation and maturation, respectively, of the human conjunctival epithelium.

Optimizing correction of coma aberration in keratoconus with a novel soft contact lens

PURPOSE

To report on a second-generation prototype contact lens (modified lens) with enhanced optics to correct coma aberration and compare its performance with that of the prototype contact lens (conventional lens) used to optimise correction of coma aberration in keratoconus (KC).

METHODS

Both lenses were designed as a set of standardised soft contact lenses (SCLs) with asymmetric powers along the posterior surface. The modified lens differs from the conventional lens in that the optical zone is decentred superiorly by 0.7 mm. The on-eye performance was compared between the SCLs and no-lens wearing in terms of manifest refraction, corrected distance visual acuity (CDVA), ocular aberrations, subjective quality of vision, and on-eye lens position relative to the pupil.

RESULTS

Thirty-four KC eyes were included. SCLs significantly decreased coma aberration compared to no-lens wear (none, 0.68 ± 0.27 μm; conventional lens, 0.37 ± 0.28 μm; modified lens, 0.19 ± 0.15 μm; P < 0.001), with the reduction in coma aberration being significantly greater with the modified lens than with the conventional lens (P = 0.018). No significant difference in manifest refraction or CDVA was found among the three conditions. Quality of vision was significantly better with the modified lens than with no SCL wear (P < 0.05) but no differences were found between the SCLs. The on-eye optical center position relative to the pupil was closer to the pupil centre using the modified lens than the conventional lens (P < 0.001).

CONCLUSION

Optimisation of the location of the optical zone in a standardised asymmetric SCL improves correction of coma aberrations and on-eye optical centration.

Chondroitin Sulfate as a Potential Modulator of the Stem Cell Niche in Cornea

Chondroitin sulfate (CS) is an important component of the extracellular matrix in multiple biological tissues. In cornea, the CS glycosaminoglycan (GAG) exists in hybrid form, whereby some of the repeating disaccharides are dermatan sulfate (DS). These CS/DS GAGs in cornea, through their presence on the proteoglycans, decorin and biglycan, help control collagen fibrillogenesis and organization. CS also acts as a regulatory ligand for a spectrum of signaling molecules, including morphogens, cytokines, chemokines, and enzymes during corneal growth and development. There is a growing body of evidence that precise expression of CS or CS/DS with specific sulfation motifs helps define the local extracellular compartment that contributes to maintenance of the stem cell phenotype. Indeed, recent evidence shows that CS sulfation motifs recognized by antibodies 4C3, 7D4, and 3B3 identify stem cell populations and their niches, along with activated progenitor cells and transitional areas of tissue development in the fetal human elbow. Various sulfation motifs identified by some CS antibodies are also specifically located in the limbal region at the edge of the mature cornea, which is widely accepted to represent the corneal epithelial stem cell niche. Emerging data also implicate developmental changes in the distribution of CS during corneal morphogenesis. This article will reflect upon the potential roles of CS and CS/DS in maintenance of the stem cell niche in cornea, and will contemplate the possible involvement of CS in the generation of eye-like tissues from human iPS (induced pluripotent stem) cells.

Quantitative Analysis of the Association Between Follow-Up Duration and Severity of Limbal Stem Cell Deficiency or Visual Acuity in Aniridia

Purpose

This study aimed to quantitatively analyze the association between follow-up duration and the severity of limbal stem cell deficiency (LSCD) or visual acuity in patients with aniridia.

Methods

A total of 52 eyes of 27 patients with aniridia were enrolled at Osaka University Hospital. Medical records were retrospectively reviewed to obtain information on the severity of LSCD and corrected distance visual acuity (CDVA). LSCD severity was based on a modified severity grading scale. We used an ordered logistic regression model to examine the association between follow-up duration and LSCD severity, and a linear regression model with a generalized linear mixed model for the association between follow-up duration and visual acuity.

Results

The mean follow-up duration was 5.2 ± 6.3 years. The mean age at the last follow-up visit was 40.5 ± 18.9 years. The mean CDVA was 1.52 ± 1.09 logMAR. At the last follow-up, 1 examined eye (1.9%) was categorized as stage 0, 7 (13.5%) as Ia, 9 (17.3%) as Ib, 5 (9.6%) as Ic, 2 (3.8%) as IIb, 12 (23.1%) as IIc, and 11 (21.2%) as III. Five eyes (9.6%) were unclassifiable. There was a significant association between follow-up duration and LSCD severity (odds ratio per +1 year, 1.41; P < 0.001). CDVA significantly decreased as follow-up duration increased. Each increase of 1 year in the follow-up duration was associated with a mean difference of +0.021 logMAR (95% confidence interval [CI] 0.01–0.03; P < 0.001).

Conclusions

We quantitatively demonstrate that LSCD severity and visual impairment significantly progress as follow-up duration increases.

The generation of fluorometholone nanocrystal eye drops, their metabolization to dihydrofluorometholone and penetration into rabbit eyes

Fluorometholone is a widely used anti-inflammatory ophthalmic formulation, which elicits a lower ocular hypertensive response than other glucocorticoid medications. This serves to mitigate against the risk of steroid-induced glaucoma. Based on the hypothesis that an improved corneal permeability can increase the bioavailability of a drug, we sought to obtain fluorometholone in suspension with a small particle size. Accordingly, we describe the formulation of fluorometholone nanocrystal eye drops, which have a mean particle size of 201.2 ± 14.1 nm (standard deviation (s.d.)) when measured by dynamic light scattering. Scanning electron microscopy further indicates that fluorometholone nanocrystals are predominantly rectangular in shape. Fluorometholone microcrystals, on the other hand, with a mean particle size of 9.24 ± 4.51 µm (s.d.), tend to have a rod-like morphology. Powder x-ray diffraction revealed that fluorometholone microcrystal and nanocrystal formulations have the same crystal structure, with the main diffraction peaks at 2θ = 10.4 and 15.3°. The nanocrystal formulation was found to be stable, long-term, when stored at 10 °C for up to 6-months. High pressure liquid chromatography (HPLC) of the aqueous humor of rabbit eyes 15-240 mins after the in vivo application of fluorometholone eye drops to the ocular surface revealed that the molecule had been converted to 20α-dihydrofluorometholone (with no evidence of a 20β-dihydrofluorometholone fraction), and that penetration was 2-6 fold higher and longer lasting with the nanocrystal, rather than the microcrystal, formulation. In current study we show how newly generated fluorometholone nanocrystals when administered as eye drops enter the anterior chamber of the eye and become metabolized to dihydrofluorometholone.

Corneal Opacity Induced by Light in a Mouse Model of Gelatinous Drop-Like Corneal Dystrophy

Gelatinous drop-like corneal dystrophy (GDLD) is a severe inherited corneal dystrophy characterized by subepithelial corneal amyloid deposition. We had previously succeeded in identifying the responsible gene, TACSTD2, and subsequently found that the epithelial barrier function is significantly decreased. As with GDLD patients, the knockout mice showed severe loss of tight junction, progressive opacity, and neovascularization in the cornea. We devised an easy method to confirm the loss of the corneal barrier function even before corneal opacity is observed. Furthermore, by using knockout mice, we were able to verify clinical findings, such as the wound healing delay and light-induced acceleration of the disease. This mouse model should prove to be a highly useful tool for investigating the pathology of GDLD and for developing new therapies.

Dynamic Scheimpflug Ocular Biomechanical Parameters in Untreated Primary Open Angle Glaucoma Eyes

Purpose

To characterize the corneal biomechanical properties of glaucoma eyes by comparing the dynamic Scheimpflug biomechanical parameters between untreated glaucoma and control eyes.

Methods

Cross-sectional observational data of dynamic Scheimpflug analyzer (Corvis ST) examinations were retrospectively collected from 35 eyes of 35 consecutive patients with untreated normal tension glaucoma and 35 eyes of 35 healthy patients matched on age and IOP. Ten biomechanical parameters were compared between the two groups using multivariable models adjusting for IOP, central corneal thickness, age, and axial length. The Benjamini-Hochberg method was used to correct for multiple comparison.

Results

In multivariable models, glaucoma was associated with smaller applanation 1 time (P < 0.001, coefficient = −0.5865), applanation 2 time (P = 0.012, coefficient = −0.1702), radius (P = 0.006, coefficient = −0.5447), larger peak distance (P = 0.011, coefficient = 0.1023), deformation amplitude ratio at 1 mm (P < 0.001, coefficient = 0.072), and integrated radius (P < 0.001, coefficient = 1.094). These associations consistently indicate greater compliance of the cornea in glaucoma eyes.

Conclusions

Untreated normal tension glaucoma eyes were more compliant than healthy eyes. The greater compliance (smaller stiffness) of normal tension glaucoma eyes may increase the risk of optic nerve damage. These results suggest the relevance of measuring biomechanical properties of glaucoma eyes.

Novel mutation identified in Leber congenital amaurosis - a case report

Background

Leber congenital amaurosis (LCA) is the earliest onset and the most severe form of all inherited retinal degenerative disorders, characterized by blindness, or severe visual impairment from birth, and typically exhibits clinical and genetic heterogeneity. Recently, 14 causative genes of LCA were reported. We performed whole-exome sequencing (WES) for Japanese siblings, and identified a novel homozygous nonsense mutation in the RPGR-interacting protein 1 (RPGRIP1) gene. We also report their follow-up data over 27 years.

Case presentation

Patient 1 is a 37-year-old male. In 1992, his eye position indicated orthophoria, however, horizontal nystagmus was evident, and he complained of photophobia. His best corrected decimal visual acuity (BCVA) was 0.2 (S + 6.5/C-3.5/170°) OD and 0.1 (S + 6.0/C-2.5/10°) OS. Fundus examination revealed bisymmetrical inferior focal retinal pigment epithelium (RPE) mottling. Bright-flash electroretinogram (ERG) revealed a subnormal pattern, while 30 Hz flicker ERG was non-recordable in both eyes. At his final visit in 2019, his BCVA was 0.09 (S + 3.5/C-3.5/180°) OD and 0.09 (S + 3.0/C-4.0/10°) OS. Patient 2, a 34-year-old female, is the sibling of patient 1. In 1992, her BCVA was 0.05 (S + 6.0) OD and 0.06 (S + 5.0) OS. She was in a chin-up position during visual acuity testing. Horizontal nystagmus was evident, and she also complained of photophobia. Bright-flash ERG was severely attenuated, and 30 Hz flicker ERG was non-recordable in both eyes. At her final visit in 2019, her BCVA was 0.02 (uncorrectable) OD and 0.03 (uncorrectable) OS. There were no other patients with LCA in their family and their parents were non-consanguineous. WES revealed a homozygous, consecutive, two-nucleotide variation in the RPGRIP1 gene (NM_020366: exon15:c.G2294A and c.C2295A, p.C765X), resulting in a premature stop codon. We interpreted this variation as a novel pathogenic mutation of RPGRIP1 that contributes to LCA6 development.

Conclusions

Herein, we report a novel nonsense mutation of RPGRIP1 in two patients with LCA6 and present their long-term follow-up data. These clinical data linked to genotypes provide important information for the development of new treatments, such as gene therapy, as well as for genetic counseling.

HLA-Matched Allogeneic iPS Cells-Derived RPE Transplantation for Macular Degeneration

Immune attacks are key issues for cell transplantation. To assess the safety and the immune reactions after iPS cells-derived retinal pigment epithelium (iPS-RPE) transplantation, we transplanted HLA homozygote iPS-RPE cells established at an iPS bank in HLA-matched patients with exudative age-related macular degeneration. In addition, local steroids without immunosuppressive medications were administered. We monitored immune rejections by routine ocular examinations as well as by lymphocytes-graft cells immune reaction (LGIR) tests using graft RPE and the patient's blood cells. In all five of the cases that underwent iPS-RPE transplantation, the presence of graft cells was indicated by clumps or an area of increased pigmentation at 6 months, which became stable with no further abnormal growth in the graft during the 1-year observation period. Adverse events observed included corneal erosion, epiretinal membrane, retinal edema due to epiretinal membrane, elevated intraocular pressure, endophthalmitis, and mild immune rejection in the eye. In the one case exhibiting positive LGIR tests along with a slight fluid recurrence, we administrated local steroid therapy that subsequently resolved the suspected immune attacks. Although the cell delivery strategy must be further optimized, the present results suggest that it is possible to achieve stable survival and safety of iPS-RPE cell transplantation for a year.

Assessment of a self-assembling peptide gel, SPG-178, in providing a clear operative field for trabeculectomy surgery for glaucoma in an animal model

The presence of blood during ophthalmic surgery is problematic, as it can obstruct a surgeon’s view of the operative field. This is particularly true when performing trabeculectomy surgery to enhance ocular fluid outflow and reduce intraocular pressure as a treatment for glaucoma, one of the most common vision loss conditions worldwide. In this study, we investigated the performance of a transparent, self-assembling peptide gel (SPG-178) and its ability to maintain visibility during trabeculectomy surgery. Unlike the hyaluronic acid gel commonly used in ophthalmic surgery, SPG-178 did not permit the ingress of blood into the gel itself. Rather, it forced blood to flow peripherally to the gel. Moreover, if bleeding occurred under the SPG-178 gel, perfusion with saline was able to effectively flush the blood away along the interface between the SPG-178 and the ocular tissue (in this case scleral) to clear the surgical field of view. In experimental trabeculectomy surgeries with mitomycin C used as an adjuvant, there were no differences in the postoperative recovery of intraocular pressure or bleb morphology with or without the use of SPG-178. SPG-178, therefore, when used in a gel formulation, represents a new material for use in intraocular surgery to ensure a clear operative field with likely beneficial treatment outcomes.

Ocular surface ectoderm instigated by WNT inhibition and BMP4

We sought to elucidate how and when the ocular surface ectoderm commits to its differentiation into the corneal epithelium in eye development from human induced pluripotent stem cells (hiPSCs) under the influence of WNT signaling and the actions of BMP4. These signals are key drivers ocular surface ectodermal cell fate determination. It was discovered that secreted frizzled related protein-2 (SFRP2) and Dickkopf1 (DKK1), which are expressed in neural ectoderm, are both influential in the differentiation of hiPSCs, where they act as canonical WNT antagonists. BMP4, moreover, was found to simultaneously initiate non-neural ectodermal differentiation into a corneal epithelial lineage. Combined treatment of hiPSCs with exogenous BMP4 aligned to WNT inhibition for the initial four days of differentiation increased the ocular surface ectodermal cell population and induced a corneal epithelial phenotype. Specification of a surface ectodermal lineage and its fate is thus determined by a fine balance of BMP4 exposure and WNT inhibition in the very earliest stages of human eye development.

Development of an Infrared Monitor-Guided Bleb Revision Procedure

The needle revision procedure to address failing filtering blebs is a blind technique that might easily damage the scleral flap, conjunctiva, and choroid. We propose a new surgical procedure, infrared monitor-guided bleb revision, to perform bleb revision minimally invasively and effectively, and demonstrate the procedure in a patient. We developed the guided procedure with the infrared monitor to observe the bleb interior with greater contrast. Under the monitor, we dissect the hard fibrotic tissue with a bleb knife and, if necessary, remove adhesions using a needle and vitreous forceps. Finally, 5-fluorouracil is injected into the subconjunctiva. We have performed bleb revisions safely with clear visualization of the scleral flap using an infrared light. In the current case, the patient had good intraocular pressure control for about 1 year. The new infrared monitor-guided bleb revision procedure facilitates successful bleb revisions without damage to the underlying structures.

Generation of knockout rabbits with X-linked severe combined immunodeficiency (X-SCID) using CRISPR/Cas9

Severe immunodeficient mice are widely used to examine human and animal cells behaviour in vivo. However, mice are short-lived and small in size; while large animals require specific large-scale equipment. Rabbits are also commonly employed as experimental models and are larger than mice or rats, easy to handle, and suitable for long-term observational and pre-clinical studies. Herein, we sought to develop and maintain stable strains of rabbits with X-linked severe combined immunodeficiency (X-SCID) via the CRISPR/Cas9 system targeting Il2rg. Consequently, X-SCID rabbits presented immunodeficient phenotypes including the loss of T and B cells and hypoplasia of the thymus. Further, these rabbits exhibited a higher success rate with engraftments upon allogeneic transplantation of skin tissue than did wild type controls. X-SCID rabbits could be stably maintained for a minimum of four generations. These results indicate that X-SCID rabbits are effective animals for use in a non-rodent model of severe immunodeficiency.

Cell jamming, stratification and p63 expression in cultivated human corneal epithelial cell sheets

Corneal limbal epithelial stem cell transplantation using cultivated human corneal epithelial cell sheets has been used successfully to treat limbal stem cell deficiencies. Here we report an investigation into the quality of cultivated human corneal epithelial cell sheets using time-lapse imaging of the cell culture process every 20 minutes over 14 days to ascertain the level of cell jamming, a phenomenon in which cells become smaller, more rounded and less actively expansive. In parallel, we also assessed the expression of p63, an important corneal epithelial stem cell marker. The occurrence of cell jamming was variable and transient, but was invariably associated with a thickening and stratification of the cell sheet. p63 was present in all expanding cell sheets in the first 9 days of culture, but it's presence did not always correlate with stratification of the cell sheet. Nor did p63 expression necessarily persist in stratified cell sheets. An assessment of cell jamming, therefore, can shed significant light on the quality and regenerative potential of cultivated human corneal epithelial cell sheets.

Effects of cataract surgery on symptoms and findings of dry eye in subjects with and without preexisting dry eye

PURPOSE

To compare dry eye symptoms and findings in post cataract surgery eyes' with and without preexisting dry eye.

STUDY DESIGN

Prospective, observational case-control study.

METHODS

Sixty-seven eyes that had undergone cataract surgery were included; 48 were classified into group D (preexisting dry eye) and 19 into group N (no preexisting dry eye). No subjects received perioperative treatment for dry eye. We evaluated between-group differences in symptom scores, corrected distance visual acuity (CDVA), tear film breakup time (BUT), tear film breakup pattern (BUP), and ocular surface fluorescein staining scores, at 1 week, 1 month, and 3 months postoperatively.

RESULTS

Symptoms were unchanged in group N, but improved in group D (P < .001) postoperatively. CDVA was improved after surgery in both groups (P < .001). BUT was shorter preoperatively in group D than in group N although this difference was absent 1 month postoperatively. Fluorescein staining scores significantly increased at 1 month postoperatively in group N (P = .01), but did not change in group D. During the perioperative period, the predominant BUP was the random break pattern in both groups (≥ 85%). From 1 week to 3 months, dimple break patterns decreased in group D (P = .007), whereas spot break patterns increased (P = .01).

CONCLUSIONS

Cataract surgery has an influence on tear film stability and the ocular surface. There was either a transient improvement or worsening of ocular surface wettability in some patients without preexisting dry eye.

SAT0010 ANTI-CD30 IMMUNOTHERAPY AMELIORATES BONE AND CARTILAGE DESTRUCTION IN EXPERIMENTAL MODEL OF RHEUMATOID ARTHRITIS IN MICE

Background:

CD30 is a member of the TNF-receptor family and commonly expressed on lymphocytes of Hodgkin lymphoma and anaplastic large cell lymphoma. It has been reported that levels of soluble CD30 in serum and joint fluid is significantly elevated in rheumatoid arthritis (RA). Although RA patients may develop lymphoproliferative disorders (LPD) as a result of immunosuppression by MTX or bDMARDs, safety medications after the regression of LPD for RA have not yet been established.

Objectives:

To explore the potential of CD30 targeting therapy for RA.

Methods:

(1) Immuno-histological staining of CD30 was performed for fresh synovial tissues of RA and osteoarthritis (OA). In addition, double immunofluorescence staining of CD30 with CD3, CD20, CD68, CD138 were performed on RA synovial tissue. (2) Brentuximab vedotin (BV) is an anti-CD30 antibody conjugated with monomethyl auristatin E, designed to induce apoptosis of CD30 expressing cells. A multiple myeloma cell line (RPMI8226) was used as a non-lymphoma cell line and plasma cell-like cell line. Immuno-cytological staining for CD30 was performed on RPMI8226. Cells were cultured and harvested on days 0, 1, and 3 to evaluate the effects of BV (50 μl / ml per well). Cytospin specimens were stained by May-Grunwald-Giemsa (MGG) staining for cell counting and by FIFC-terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining for detection of apoptosis. (3) Collagen antibody induced arthritis (CAIA) was induced in DBA/1 mice by arthritogenic cocktail of monoclonal antibodies against type II collagen. BV was administered to the treatment groups (30mg/kg and 70mg/kg n=4 each) and evaluated clinical score, histological findings and levels of SAA, IL-6, and TNFα in serum by ELISA. Student’st-test (two-tailed) was used to determine statistical significance for analysis of synovial tissues and cell line assay. Two way ANOVA with Dunnett’s post hoc analysis was used for multiple comparisons of mice model.

Results:

(1) The number of CD30-positive cells was significantly higher in RA synovial tissue than in OA synovial tissue (p<0.01) (Fig. 1). CD30-positive cells were detected around the lymphoid follicles. Double immunofluorescence showed CD30 and CD138 double-positive cells in the synovial tissue of RA, suggesting CD30 is predominantly expressed by plasma cells. (2) RPMI8226 cells expressed CD30. BV caused apoptosis of RPMI8226 cells, and the number of cells treated with BV decreased to 95% compared to controls. (3) All control mice (n=4) developed severe arthritis, and their scores reached a peak (score: 13.3) on day 10. In the mice of treatment group of 30 mg/kg, paw swelling was slightly decreased, their clinical score reached a peak (score: 9.3) on day 10. In contrast, paw swelling was significantly reduced in the 70 mg/kg treatment group. The peak of the clinical score was 4.3 on day 10 (Fig.2). Histological score evaluated synovitis with infiltration of inflammatory cells, pannus formation, and erosion of bone and cartilage. Histological score of hind paws were 3.0 ± 0.8 for the control group, 2.7 ± 1.0 for 30 mg/kg group, and 0.7 ± 1.1 for 70 mg/kg group (p<0.01), respectively. The serum levels of SAA and IL-6 of treatment group were lower than those of no treatment group (p<0.01).

Conclusion:

We showed the expression of CD30 on synovial tissue of RA and the expression of CD30 on plasma cells. In addition, the current study provides the first evidence that BV depletion of CD30-positive cells suppressed arthritis and osteochondral destruction in CAIA mice. Our results may provide an important clue for the development of an effective treatment for RA with iatrogenic immunodeficiency-related LPD.

Disclosure of Interests:

Minami Matsuhashi: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Yoshihisa Nasu: None declared, Ryuichi Nakahara: None declared, Masahito Watanabe: None declared, Yoshifumi Hotta: None declared, Toshifumi Ozaki: None declared

SAT0068 THE RECENT INCIDENCE OF SURGICAL SITE INFECTION AND DELAYED WOUND HEALING AFTER ELECTIVE ORTHOPAEDIC SURGERIES FOR PATIENTS WITH RHEUMATOID ARTHRITIS WHO TREATED WITH B/TSDMARDS

Background:

In Japan, Methotrexate (MTX) has been approved in 1999, the first biologic DMARD (bDAMRD) in 2003, and the Janus kinase (JAK) inhibitors have been used since 2013. Although it is expected that the recent advancement of drug therapy would contribute the decrease in the incidence of orthopaedic surgeries by preventing structural damages1, 2), we are still facing a considerable number of patients who require surgical interventions3).

Objectives:

To investigate the recent trends of patient’s background who underwent the orthopaedic surgery for rheumatoid arthritis, number of orthopaedic intervention, and the type of the surgery.

Methods:

We reviewed the records of 1569 patients with RA who underwent orthopedic surgeries between 2004 and 2019 in our institution. The mean age of patients was 62.8 (22-88) years-old with disease duration of 20.9 (0.5-64) years. Data of these patients such as age, disease duration, medication (Glucocorticoid; GC, MTX, b/tsDMARD), type of surgeries (total joint replacement; TJR, hand surgery, foot surgery, spine surgery, and others), and preoperative serum CRP level were collected. We analyzed the annual change of these demographic and clinical data. Then, we compared them between CRP negative (<1.5g/l) and CRP positive group. Cochran-Armitage trend test,χ square test, or unpaired T-test was performed for statistical analysis. P <0.05 was considered significant.

Results:

Among all cases, 426 cases (27.2%) were treated with b/tsDMARDs at the time of operation. MTX and GC were used in 937 cases (59.7%) and 1015 cases (64.7%), respectively. The mean age and disease duration of RA showed an increasing trend, although the CRP level was dramatically decreased during the study period. While the rate of MTX use has not changed significantly (p=0.102), the number of cases treated by b/ts DMARD increased significantly to 46.7% (p<0.001). In contrast, the rate of GC use dicreased significantly (p<0.001). Although the annual number of surgeries have not changed, the proportion of cases who performed TJR decreased dramatically (59.6% in 2011, 29.5% in 2019), and the surgeries for hand and foot increased significantly (p<0.001) (Fig 1). The annual mean preoperative CRP level also decreased from 18.8±1.95 to 4.89±0.81 (Fig2). Compared to CRP positive group (n=1,113), the patients in CRP negative group (n=446) showed significantly younger age(p<0.001), shorter disease duration (p=0.031), lower late of GC use, and a higher rate of b/tsDAMRD use. The proportion of patients who underwent TJR was significantly higher in CRP positive group (p<0.001).

Conclusion:

Along with the increasing use of b/tsDMARD, the preoperative disease control of RA, as well as the type of demanded surgeries have dramatically changed.

References:

[1] Yamanaka H, Tanaka E, Nakajima A, et al. A large observational cohort study of rheumatoid arthritis, IORRA: Providing context for today’s treatment options.Mod Rheumatol2020;30:1-6.

[2] Matsumoto T, Nishino J, Izawa N, et al. Trends in Treatment, Outcomes, and Incidence of Orthopedic Surgery in Patients with Rheumatoid Arthritis: An Observational Cohort Study Using the Japanese National Database of Rheumatic Diseases.J Rheumatol2017;44:1575-82.

[3] Momohara S, Tanaka S, Nakamura H, et al. Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis.Mod Rheumatol2011;21:337-42.

Disclosure of Interests:

Yoshifumi Hotta: None declared, Yoshihisa Nasu: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Minami Matsuhashi: None declared, Masahito Watanabe: None declared, Ryuichi Nakahara: None declared, Toshifumi Ozaki: None declared

SAT0023 THE ROLE OF ADAM12 UPREGULATED PROLIFERATION OF SYNOVIAL MEMBRANE IN RHEUMATOID ARTHRITIS

Background:

ADAM12 is a member of a disintegrin and metalloproteinase family and has been reported to participate in the development of a variety of tumors by degrading ECM and shed precursors, thus promoting cell proliferation, invasion, and metastasis1). Additionally, ADAM12 is involved in chondrocyte differentiation from osteoarthritis (OA) patients by regulation of TGFβ1-induced IGF-1 and RUNX-2 expressions2). However, there is no report on the role of ADAM12 for rheumatoid arthritis (RA).

Objectives:

To investigate the expression and role of ADAM12 in the synovial tissue of RA.

Methods:

(1) The expression of ADAM12 in synovial tissues from RA (18 cases), OA (5 cases) and healthy control (HC) (3 cases) was examined by immunohistochemistry. The synovial tissues of HC were obtained during surgery of hemiarthroplasty for bone tumors. Three researchers evaluated the positive cell ratio. The samples were scored according to the percentage of positive staining: 0 points (weak positive, positive expression was less than 5%), 1 point (moderate positive, positive expression was between 5% and 50%) and 2 points (strong positive, positive expression was greater than 50%). In addition, the samples were scored according to the staining intensity: 0 points (weak intensity), 1 point (moderate intensity) and 2 points (high intensity). (2) The cultured synovial fibroblasts obtained from RA patients at the surgery (RASF) were stimulated by TNFα (1, 5, 10 ng/mL), TGFβ1 (1, 5, 10 ng/mL), PDGF-BB (1, 5, 10 ng/mL) and TNFα+TGFβ1+PDGF-BB (all 10 ng/mL), and the expression levels of ADAM12 relative mRNA was examined by real-time PCR. (3) siADAM12 was transfected in RASF, and the proliferation was examined by WST-1 assay, and the expression of ADAM12 protein was examined by western blotting.

Results:

(1) ADAM12 positive cells were found in synovial lining cells, plasma cells, and vascular endothelial cells. ADAM12 was highly expressed in RA synovial tissues. The immunostaining scores of RA, OA, and HC were 3.9±0.01, 1.9±0.27, and 0.8±0.18, respectively. (2) Stimulation by TNFα, TGFβ1, and PDGF-BB resulted in the upregulation of the expression of ADAM12 relative mRNA in RASF, and TGFβ1 stimulation notably tended to increase the expression by about 5 to 6 times. (3) siADAM12 successfully suppressed the expression of ADAM12 protein and simultaneously suppressed the proliferation of RASF.

Conclusion:

ADAM12 might be involved in the pathogenesis of RA, promoting the cell proliferation of RASF.

References:

[1] Kyeiborg M, Albrechtsen R, Couchman J, et al., Cellular roles of ADAM12 in health and disease, Int J Biochem Cell Biol, 2008

[2] Masahiro H, Keiichiro N, Joe H, et al., Involvement of ADAM12 in Chondrocyte Differentiation by Regulation of TGF-beta1-Induced IGF-1 and RUNX-2 Expressions, Calcif Tissue Int, 2019

Disclosure of Interests:

Masahito Watanabe: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Yoshihisa Nasu: None declared, Ryuichi Nakahara: None declared, Minami Matsuhashi: None declared, Yoshifumi Hotta: None declared, Toshifumi Ozaki: None declared

AB1172 IMPROVEMENT OF DEPRESSION BY JOINT SURGERY IN ESTABLISHED RHEUMATOID ARTHRITIS; RESULTS FROM MULTICENTER PROSPECTIVE COHORT STUDY FOR EVALUATION OF JOINT SURGERY ON PATIENT’S REPORTED OUTCOME

Background:

Total management including reconstructive joint surgery and rehabilitation should be needed for further improvements of physical function for long-standing RA patients. In these days, it is very important to evaluate the effectiveness of joint surgery as well as drug therapy based on patient-reported outcome (PRO)

Objectives:

The purpose of this study is to explore the relationship among depression, clinical variables and other PROs including physical function and to explore whether joint surgery can improve the depression.

Methods:

Multicenter prospective observational cohort study was conducted among patients who underwent elective joint surgery for RA from April 2012 to March 2016 (Study registration: UMIN000012649). In this study, we collected data at baseline and at 6 or 12 months after the surgery. These data were as follow; age, sex, disease duration, drug therapies, and disease activity (DAS), TUG, and patient-reported outcome [HAQ-DI, EQ-5D (QOL), pain and BDI-II (depression)]. Correlation between BDI-II and other variables were determined using multiple liner regression analysis.

Results:

Totally, 346 patients before elective joint surgery were analyzed cross-sectionally. Mean age, disease duration, pain VAS, DAS28, HAQ-DI, EQ-5D and BDI-II were 64.2 years, 17.0 years, 36.2 mm, 3.02, 1.11, 0.641 and 13.0, respectively. 52.6% of elective joint surgeries were in upper limbs and 47.4% were in lower limbs. Multiple liner regression analysis showed that HAQ-DI [B:-0.099 (95%CI:-0.117- -0.08) β:-0.48] pain VAS [B:-0.002 (95%CI:-0.002- -0.001) β:-0.26] and BDI-II [B:-0.003 (95%CI:-0.005- -0.002) β:-0.19] had significant impact on EQ-5D. Furthermore, HAQ-DI [B:3.78 (95%CI:2.54- 5.06) β: 0.33] and pain VAS [B: 0.062 (95%CI: 0.023- 0.101) β 0.17] had significant impact on BDI-II. Especially, walking and eating were independent factors for BDI-II in HAQ-DI categories. These results were confirmed in longitudinal analyses using results from joint surgery in lower limbs (LL; n=138) and upper limbs (UL; n=165), respectively. BDI-II was remarkably improved from 12.1 (mean) to 10.5 in LL and from 14.2 (mean) to 11.9 in UL. Change in HAQ-DI had significant impact on that in BDI-II [LL; B:3.183 (95%CI:0.301- 6.065) β:0.229, and UL; B:2.55 (95%CI:0.19- 4.92) β:0.19] while that in painVAS did not. Especially, the improving in walking category by LL [B:1.38 (95%CI:0.06- 2.70) β:0.18] and in hygiene category by UL [B:2.11 (95%CI:0.79- 3.42) β:0.24] were relevant factors for improving of BDI-II.

Conclusion:

Depression is an important patient-reported outcome for QOL in established RA patients. Improving of physical function with joint surgery in both lower and upper limbs caused improving of depression status. Rheumatologists should take the joint surgery into consideration as effective intervention for treatment of established RA patients with treatment.

Acknowledgments:

This study was funded by a grant from the Ministry of Health, Labour and Walfare (h2424YN002-00) to Naoki Ishiguro.

We thank Drs Tanaka S, Haga N, Yukioka M, Hashimoto J, Miyahara H, Niki Y, Kimura T, Oda H, Funahashi K for their contribution to this study and all medical staff members of each institute for their data collection efforts for their data collection efforts.

Disclosure of Interests:

Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Masayo Kojima: None declared, Hajime Ishikawa: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

SAT0047 RISK FACTORS FOR THE POSTOPERATIVE DELAYED WOUND HEALING IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH A BIOLOGICAL AGENT

Background:

It has been suggested that perioperative use of biological disease-modifying anti-rheumatic drugs (bDMARDs) in rheumatoid arthritis (RA) patients carries risks for the surgical-site infection and the delayed wound healing (DWH); however, the risk of DWH with perioperative use of bDMARDs has not reached a general consensus.

Objectives:

This retrospective study aimed to investigate the risk factors associated with DWH after orthopedic surgery in RA patients treated with bDMARDs.

Methods:

We reviewed medical records of 277 orthopedic procedures for 188 RA patients treated with bDMARDs between from 2014 to 2017 in Niigata Rheumatic Center. As preoperative nutritional status assessment, we evaluated body mass index (BMI), prognostic nutritional index (PNI), and CONtrolling NUTritional status (CONUT). In addition, we evaluated DAS28-CRP, DAS28-ESR, face scale for pain, global health (GH), and Health Assessment Questionnaire-Disability Index (HAQ-DI) to assess the disease activity. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factor for DWH.

Results:

The major characteristics of the patients in 277 procedures were mean age of 63.2 years old and mean disease duration of 18.2 years. Surgical site were hand and wrist (145 procedures), foot and ankle (76), hip and knee (31), elbow and shoulder (24), and spine (1). Seventy-four patients were treated with tocilizumab, 62 with etanercept, 55 with golimumab, 49 with abatacept, 16 with infliximab, 15 with adalimumab, and 6 with certolizumab. According to nutritional assessment in PNI and CONUT, 63% (n=175) and 47% (n=130) were normal nourished patients, respectively.

In 277 procedures, DWH were identified in 24 patients (8.6%). The following variables were significant in the univariate analyses: disease duration (OR 1.053; 95% CI 1.010–1.099; p=0.016), foot and ankle surgery (OR 7.091; 95% CI 2.130–23.603; p=0.001), tocilizumab (OR 0.286; 95% CI 0.093–0.881; p=0.029) (Table 1). These variables were entered into a multivariate model, and it was revealed that pre-operative use of tocilizumab (OR 0.265; 95% CI 0.074–0.953; p=0.042) and procedures in the foot and ankle (OR 6.915; 95% CI 1.914–24.976; p=0.003) were associated with an increased risk of DWH (Table 1).

Conclusion:

As previous study on tocilizumab described, the current retrospective study suggested that pre-operative use of tocilizumab and procedures in the foot and ankle were risk factors for DWH. Pre-operative disease activity and nutritional status were not independent risk factors for an increase in the prevalence of DWH.

References:

[1] Momohara S, Hashimoto J, Tsuboi H et al. Analysis of perioperative clinical features and complications after orthopaedic surgery in rheumatoid arthritis patients treated with tocilizumab in a real-world setting: Results from the multicentre tocilizumab in perioperative period (TOPP) study. Modern rheumatology. 2013, 23: 440-9.

Disclosure of Interests:

Shunji Okita: None declared, Hajime Ishikawa: None declared, Asami Abe: None declared, Satoshi Ito Speakers bureau: Abbvie,Eisai, Akira Murasawa: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Toshifumi Ozaki: None declared

FRI0523 THE RECENT TREND OF ORTHOPAEDIC SURGERIES FOR RHEUMATOID ARTHRITIS. AN ANALYSIS OF 1569 CASES FROM 2004 TO 2019

Background:

In Japan, Methotrexate (MTX) has been approved in 1999, the first biologic DMARD (bDAMRD) in 2003, and the Janus kinase (JAK) inhibitors have been used since 2013. Although it is expected that the recent advancement of drug therapy would contribute the decrease in the incidence of orthopaedic surgeries by preventing structural damages1, 2), we are still facing a considerable number of patients who require surgical interventions3).

Objectives:

To investigate the recent trends of patient’s background who underwent the orthopaedic surgery for rheumatoid arthritis, number of orthopaedic intervention, and the type of the surgery.

Methods:

We reviewed the records of 1569 patients with RA who underwent orthopedic surgeries between 2004 and 2019 in our institution. The mean age of patients was 62.8 (22-88) years-old with disease duration of 20.9 (0.5-64) years. Data of these patients such as age, disease duration, medication (Glucocorticoid; GC, MTX, b/tsDMARD), type of surgeries (total joint replacement; TJR, hand surgery, foot surgery, spine surgery, and others), and preoperative serum CRP level were collected. We analyzed the annual change of these demographic and clinical data. Then, we compared them between CRP negative (<1.5g/l) and CRP positive group. Cochran-Armitage trend test,χ square test, or unpaired T-test was performed for statistical analysis. P <0.05 was considered significant.

Results:

Among all cases, 426 cases (27.2%) were treated with b/tsDMARDs at the time of operation. MTX and GC were used in 937 cases (59.7%) and 1015 cases (64.7%), respectively. The mean age and disease duration of RA showed an increasing trend, although the CRP level was dramatically decreased during the study period. While the rate of MTX use has not changed significantly (p=0.102), the number of cases treated by b/ts DMARD increased significantly to 46.7% (p<0.001). In contrast, the rate of GC use dicreased significantly (p<0.001). Although the annual number of surgeries have not changed, the proportion of cases who performed TJR decreased dramatically (59.6% in 2011, 29.5% in 2019), and the surgeries for hand and foot increased significantly (p<0.001) (Fig 1). The annual mean preoperative CRP level also decreased from 18.8±1.95 to 4.89±0.81 (Fig 2). Compared to CRP positive group (n=1,113), the patients in CRP negative group (n=446) showed significantly younger age(p<0.001), shorter disease duration (p=0.031), lower late of GC use, and a higher rate of b/tsDAMRD use. The proportion of patients who underwent TJR was significantly higher in CRP positive group (p<0.001).

Conclusion:

Along with the increasing use of b/tsDMARD, the preoperative disease control of RA, as well as the type of demanded surgeries have dramatically changed.

References:

[1] Yamanaka H, Tanaka E, Nakajima A, et al. A large observational cohort study of rheumatoid arthritis, IORRA: Providing context for today’s treatment options.Mod Rheumatol2020;30:1-6.

[2] Matsumoto T, Nishino J, Izawa N, et al. Trends in Treatment, Outcomes, and Incidence of Orthopedic Surgery in Patients with Rheumatoid Arthritis: An Observational Cohort Study Using the Japanese National Database of Rheumatic Diseases.J Rheumatol2017;44:1575-82.

[3] Momohara S, Tanaka S, Nakamura H, et al. Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis.Mod Rheumatol2011;21:337-42.

Disclosure of Interests:

Yoshifumi Hotta: None declared, Yoshihisa Nasu: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Minami Matsuhashi: None declared, Masahito Watanabe: None declared, Ryuichi Nakahara: None declared, Toshifumi Ozaki: None declared

AB0216 POWER DOPPLER SCORE IS USEFUL TO PREDICT JOINT DESTRUCTION OF HAND AND WRIST JOINT IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Several studies demonstrated that total power Doppler (PD) signal can predict radiographic progression as a change in total van der Heijde-modified total Sharp score (mTSS) in rheumatoid arthritis (RA) patients. However, in some studies, radiographic progression was observed in a different joint compared with the site of a positive PD signal at baseline in many cases.

Objectives:

The aim of this study was to identify the clinical factor of RA patients in association with radiographic progression of hands and wrists and to investigate which joint showed radiographic progression in RA patients. We focused on the correlation of the site of a positive PD signal and the site of radiographic progression.

Methods:

We examined retrospectively of 70 RA patients (67 women, three men) who underwent ultrasonography (US) examination at 32 regions on bilateral hands and wrists from 2014 to 2016. Radiographs of the hands were taken at baseline and at least one year after US (mean, 19.9 months), and radiographic progression was assessed using mTSS system. We performed multivariate logistic regression analysis to investigate the association between baseline factors and radiographic progression. The relationships between radiographic progression of the individual joint and total/each joint PD score were assessed by ROC analysis and Fisher’s exact test.

Results:

Nineteen patients (37.3%) experienced progression of mTSS of hands and wrists. DAS28-CRP (P=0.02) and total PD score (P=0.01) were associated with radiographic progression, and total PD score was significantly associated with radiographic progression (OR 1.22; 95% CI 1.04-1.36; P=0.006) by multivariate logistic regression analysis (Table 1).

Table 1.

Association between the demographic and clinical findings at baseline and radiographic progression over 12 months

a.univariate analysisNo radiographicprogression(n = 51)Radiographicprogression(n = 19)P-valueAge, years63.4 ± 12.758.1 ± 10.60.61Duration of RA, years24.4 ± 13.620.0 ± 5.00.28Usage of Bio, %42.240.40.57Amount of MTX, mg/week4.8 ± 3.34.5 ± 4.30.77Amount of PSL, mg1.5 ± 2.11.8 ± 2.20.73DAS28-CRP2.5 ± 0.72.9 ± 0.60.02*CRP, mg/dl0.4 ± 0.50.7 ± 0.70.10Total PD score2.4 ± 3.36.6 ± 6.10.01*b.multivariate analysisodds ratio95% CIP-valueDAS28-CRP1.630.72 - 3.710.238Total PD score1.191.04 - 1.360.010*

Predictive performance of total PD score was good for radiographic progression of MCP joint (AUC-ROC 0.91) and wrist joint (AUC-ROC 0.85), although poor for PIP joint (AUC-ROC 0.57).

PD score of wrist joint, MCP joint, and PIP joint were significantly associated with radiographic progression of each joint (P<0.01). The sensitivity, specificity, positive predictive value, and negative predictive value of wrist joint PD score were 100%, 57.0%, 8.0%, and 100%, MCP joint PD score were 85.7%, 90.5%, 8.0%, 99.8%, and 8.3%, and PIP joint PD score were 30.0%, 97.2%, 13.6%, and 99.0%, respectively.

Conclusion:

Total PD score of hands and wrists was a strong predictor of radiographic progression, especially in MCP and wrist joint. Evaluation of PD signal in individual joint is a clinically useful method to predict radiographic progression of the same joint, however there are some differences in sensitivity and specificity.

References:

[1]Brown AK, et al. Arthritis & Rheumatism. 2008;58:2958-2967.

[2]McQueen F, et al. Annals of the Rheumatic Diseases. 2011;70:241-244.

Disclosure of Interests:

Shunji Okita: None declared, Ryuichi Nakahara: None declared, Minami Matsuhashi: None declared, Masahito Watanabe: None declared, Yoshihisa Nasu: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Toshifumi Ozaki: None declared

FRI0580 DISCORDANCE BETWEEN OBJECTIVE ELBOW ASSESSMENT AND PATIENTS REPORTED OUTCOMES (PROS) AFTER TOTAL ELBOW ARTHROPLASTY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Patient-reported outcomes (PROs) have become widespread in daily clinical evaluation in patients with rheumatoid arthritis (RA). However, there are few reports for the relationship or discordance between the subjective assessment by the physician and the objective assessment by the patient with RA in surgical treatment.

Objectives:

We examined the relationship or discordance about the PROs in patients with RA who underwent total elbow arthroplasty (TEA).

Methods:

We retrospectively identified 53 elbows of 48 patients with RA who underwent TEA at Okayama University Hospital, collected from January 2012 to December 2016.

We collected clinical data for the grip strength, range of motion, the Mayo Elbow Performance Scale (MEPS) as objective assessments, and the Patient-Related Elbow Evaluation (PREE), Disability of the Arm, Shoulder, and Hand (DASH) Japanese version and Hand20 as subjective assessments.

For statistical analysis, we performed t-tests for pre- and post-operative physical findings and subjective evaluations, and Spearman rank correlation to examine the relationship between objective and subjective assessments.

Results:

The mean age of the patients at the time of arthroplasty was 63 years, the average disease duration was 23 years, and the average postoperative observation period was 32 months. The average DAS28-CRP was 3.01, and biological uses were 18 cases.

The range of motion of the elbow joint and the grip strength was significantly improved postoperatively. All outcome assessments improved significantly except for HAQ (see table1).

There was significantly correlated PREE with DASH, Hand20, and MEPS preoperatively. Postoperative PREE showed a significant and robust correlation in postoperative DASH, Hand20, whereas not associated with postoperative MEPS (see table2).

To investigate the discordance between PREE and MEPS after TEA, we focused on changes in each item of PREE. Pain- and reach-related items improved postoperatively. But, it was difficult to improve in items affected by hand and finger functions, such as “tie shoelaces.”

To explore the effects of finger and hand functions on postoperative assessments, we performed multiple regression analyses. Both preoperative grip strength (unstandardized coefficient [Β] =-0.07; 95%CI -0.148 to -0.006, t value=-2.18, P=0.03) and preoperative Hand20 (B = 0.27, 95%CI 0.029 - 0.518, t=2.25, p=0.02) were significant predictors of postoperative PREE.

Conclusion:

Surprisingly, the PROs of patients and the surgeon’s evaluations correlated well before surgery but resulted in discordance after TEA. We improved elbow functions by TEA, but since rheumatoid arthritis was a polyarticular disorder, improvement of a single joint function did not improve utterly subjective assessment in patients with RA. We found that the upper limb functions after TEA were significantly affected by preoperative finger and hand function. A rheumatologist should consider the dysfunctions of finger and hand when planning for elbow surgery in patients with RA.

Table 1.

Pre- and postoperative range of motion of elbow and forearm, grip strength, and measurement

CharacteristicPreoperativePostoperativeP valueElbow flexion, degree116 ± 19134 ± 9< 0.001- extension-34 ± 21-25 ± 160.005- total arc82 ± 32109 ± 19< 0.001Grip power, mmHg106 ± 66130 ± 740.007DASH50.5 ± 20.535.8 ± 25.4< 0.001Hand2060.4 ± 19.138.9 ± 29.6< 0.001PREE55.6 ± 18.818.5 ± 17.1< 0.001- pain29.7 ± 11.36.5 ± 7.9< 0.001- function25.9 ± 11.512.0 ± 11.9< 0.001- specific function56.9 ± 25.525.4 ± 25.3< 0.001- usual function20.8 ± 11.310.5 ± 11.3< 0.001HAQ-DI1.06 ± 0.701.07 ± 0.800.607MEPS51.3 ± 16.697.9 ± 3.6< 0.001Table 2.

Spearman’s correlation coefficients for pre- and postoperative PREE score*

QuestionnairePreoperative Correlation estimateP valuePostoperative Correlation estimateP valueDASH0.56< 0.00010.84< 0.0001Hand200.58< 0.00010.84< 0.0001MEPS- 0.39< 0.01-0.27N.S.

Disclosure of Interests:

ryozo harada: None declared, Keiichiro Nishida Grant/research support from: K. Nishida has received scholarship donation from CHUGAI PHARMACEUTICAL Co., Eisai Co., Mitsubishi Tanabe Pharma and AbbVie GK., Speakers bureau: K. Nishida has received speaking fees from CHUGAI PHARMACEUTICAL Co., Eli Lilly, Janssen Pharmaceutical K.K., Eisai Co. and AYUMI Pharmaceutical Corporation., Yoshihisa Nasu: None declared, Ryuichi Nakahara: None declared

Anterior segment optical coherence tomography and in vivo confocal microscopy in cases of mucopolysaccharidosis

Purpose

To report anterior segment evaluation in patients with mucopolysaccharidosis 1 using anterior segment optical coherence tomography and in vivo confocal microscopy.

Observations

Case 1 involved a 26-year-old man with mucopolysaccharidosis 1 Hurler-Scheie syndrome who presented with a corrected distance visual acuity of 20/67 in the right eye and 20/50 in the left eye because of bilateral corneal opacification. He had undergone bone marrow transplantation at the age of 7 years. Anterior segment optical coherence tomography revealed a very narrow anterior chamber angle; a flat, thickened cornea; and astigmatism with the rule. Confocal microscopy demonstrated hyper-refractive deposits in the corneal epithelial basal layer, decreased subepithelial nerves, and depletion of keratocytes in the anterior and posterior stroma. Endothelial cells were not visible.Case 2 involved an 18-year-old woman who presented with increased corneal opacity in both eyes. Her medical history included mucopolysaccharidosis 1 Hurler syndrome and bone marrow transplantation at the age of 2 years. Her corrected distance visual acuity could not be measured because of severe intellectual disability. Anterior segment optical coherence tomography demonstrated a flat and thick cornea.

Conclusions and importance

Anterior segment optical coherence tomography can provide detailed morphological information for the anterior segment in patients with severe corneal opacification associated with mucopolysaccharidosis 1. Moreover, in vivo confocal microscopy facilitates the detailed observation of corneal cellular changes. Thus, these tools can provide data that would contribute to an increased understanding of corneal changes in patients with mucopolysaccharidosis 1.

RhoJ integrates attractive and repulsive cues in directional migration of endothelial cells

During angiogenesis, VEGF acts as an attractive cue for endothelial cells (ECs), while Sema3E mediates repulsive cues. Here, we show that the small GTPase RhoJ integrates these opposing signals in directional EC migration. In the GTP-bound state, RhoJ interacts with the cytoplasmic domain of PlexinD1. Upon Sema3E stimulation, RhoJ released from PlexinD1 induces cell contraction. PlexinD1-bound RhoJ further facilitates Sema3E-induced PlexinD1-VEGFR2 association, VEGFR2 transphosphorylation at Y1214, and p38 MAPK activation, leading to reverse EC migration. Upon VEGF stimulation, RhoJ is required for the formation of the holoreceptor complex comprising VEGFR2, PlexinD1, and neuropilin-1, thereby preventing degradation of internalized VEGFR2, prolonging downstream signal transductions via PLCγ, Erk, and Akt, and promoting forward EC migration. After conversion to the GDP-bound state, RhoJ shifts from PlexinD1 to VEGFR2, which then terminates the VEGFR2 signals. RhoJ deficiency in ECs efficiently suppressed aberrant angiogenesis in ischemic retina. These findings suggest that distinct Rho GTPases may act as context-dependent integrators of chemotactic cues in directional cell migration and may serve as candidate therapeutic targets to manipulate cell motility in disease or tissue regeneration.

Effect of long-term rigid gas-permeable contact lens wear on keratoconus progression

BACKGROUND/AIMS

To investigate the chronological corneal changes associated with long-term rigid gas-permeable contact lens (RGP-CL) wear in patients with keratoconus (KC).

METHODS

Clinical records of 405 patients with KC or with KC suspect were retrospectively reviewed. Patients with mild-to-moderate KC and uneventful follow-up were classified into the CL (RGP-CL wear) and non-CL (without CL wear) groups. Inclusion criteria were (1) at least 3-year follow-up and (2) Scheimpflug-based corneal imaging examination at each visit. The anterior (ARC) and posterior (PRC) radius of curvature obtained in a 3.0 mm optical zone, the thinnest pachymetry reading of the corneal thickness (Tmin), and maximum keratometry values (Kmax) were investigated as tomographic parameters.

RESULTS

Twenty-two and 15 patients who met the inclusion criteria were included in the CL and non-CL groups, respectively (31 and 20 eyes, respectively). The mean observation periods were 75 (CL group) and 63 (non-CL group) months. A multivariable non-linear regression analysis to assess the change in tomographic parameters over the follow-up period and difference of the trend between the two groups demonstrated no significant differences in the chronological change in ARC, PRC and Tmin between the CL and non-CL groups (p=0.318, p=0.280 and p=0.874, respectively).

CONCLUSION

Based on corneal tomographic evaluation over 5-6 years, the effects of long-term RGP-CL wear had no effect on KC progression.

Association of the CAV1-CAV2 locus with normal-tension glaucoma in Chinese and Japanese

BACKGROUND

The CAV1-CAV2 locus has been associated with primary open-angle glaucoma (POAG) and intraocular pressure. However, its association with normal-tension glaucoma (NTG) was inconclusive. Therefore, we evaluated this association in Chinese and Japanese.

METHODS

Two single-nucleotide polymorphisms (SNPs, rs4236601 and rs1052990) from previous genome-wide association studies of POAG were genotyped in a total of 2220 study subjects: a Hong Kong Chinese cohort of 537 NTG patients and 490 controls, a Shantou Chinese cohort of 102 NTG and 731 controls and an Osaka Japanese cohort of 153 NTG and 207 controls. Subgroup analysis by gender was conducted. Outcomes from different cohorts were combined using meta-analysis.

RESULTS

SNP rs4236601 was significantly associated with NTG in the two Chinese cohorts (P_meta = .0019, OR = 4.55, I² = 0). In contrast, rs4236601 was monomorphic in the Osaka cohort. The association of rs1052990 was insignificant in a meta-analysis combining Chinese and Japanese cohorts (P_meta = .81, OR = 1.05; I² = 64%), and the OR tended towards opposite directions between Chinese (OR = 1.26) and Japanese (OR = 0.69). Gender-specific effects of the SNPs were not statistically significant in the logistic regression or Breslow-day tests of ORs (P > .05), although rs4236601 was significant in males (P = .0068; OR = 10.30) but not in females (P = .14; OR = 2.65) in the meta-analysis of Chinese subjects.

CONCLUSIONS

In this study, we confirmed the association of rs4236601 at the CAV1-CAV2 locus with NTG in Chinese. SNP rs4236601 is monomorphic, and rs1052990 tends towards a different direction in the Japanese cohort. Further studies are warranted to verify the ethnic difference and gender-specific effects of this locus.

Cell-Type-Specific Adhesiveness and Proliferation Propensity on Laminin Isoforms Enable Purification of iPSC-Derived Corneal Epithelium

A treatment for intractable diseases is expected to be the replacement of damaged tissues with products from human induced pluripotent stem cells (hiPSCs). Target cell purification is a critical step for realizing hiPSC-based therapy. Here, we found that hiPSC-derived ocular cell types exhibited unique adhesion specificities and growth characteristics on distinct E8 fragments of laminin isoforms (LNE8s): hiPSC-derived corneal epithelial cells (iCECs) and other non-CECs rapidly adhered preferentially to LN332/411/511E8 and LN211E8, respectively, through differential expression of laminin-binding integrins. Furthermore, LN332E8 promoted epithelial cell proliferation but not that of the other eye-related cells, leading to non-CEC elimination by cell competition. Combining these features with magnetic sorting, highly pure iCEC sheets were fabricated. Thus, we established a simple method for isolating iCECs from various hiPSC-derived cells without using fluorescence-activated cell sorting. This study will facilitate efficient manufacture of iCEC sheets for corneal disease treatment and provide insights into target cell-specific scaffold selection.

Corticosteroid Withdrawal after Complete Resection of Recurrent IgG4-Related Ophthalmic Disease

Corticosteroids are the first-line treatment for immunoglobulin G4-related ophthalmic disease (IgG4-ROD). However, the therapeutic effect of corticosteroids is unpredictable, and recurrences occur frequently. We present a case of a 60-year-old woman with IgG4-ROD of the lacrimal fossa. She was first treated with oral prednisolone, which was tapered within three months. However, proptosis recurred two months after prednisolone withdrawal. En bloc excision of the lesion was performed via the eyelid crease approach. The patient is lesion-free without corticosteroids at 18 months after surgery. Complete resection can be a powerful strategy for IgG4-ROD if a well-defined lesion is located in accessible areas.

Generation and validation of a PITX2-EGFP reporter line of human induced pluripotent stem cells enables isolation of periocular mesenchymal cells

PITX2 (Paired-like homeodomain transcription factor 2) plays important roles in asymmetric development of the internal organs and symmetric development of eye tissues. During eye development, cranial neural crest cells migrate from the neural tube and form the periocular mesenchyme (POM). POM cells differentiate into several ocular cell types, such as corneal endothelial cells, keratocytes, and some ocular mesenchymal cells. In this study, we used transcription activator-like effector nuclease technology to establish a human induced pluripotent stem cell (hiPSC) line expressing a fluorescent reporter gene from the PITX2 promoter. Using homologous recombination, we heterozygously inserted a PITX2-IRES2-EGFP sequence downstream of the stop codon in exon 8 of PITX2 Cellular pluripotency was monitored with alkaline phosphatase and immunofluorescence staining of pluripotency markers, and the hiPSC line formed normal self-formed ectodermal autonomous multizones. Using a combination of previously reported methods, we induced PITX2 in the hiPSC line and observed simultaneous EGFP and PITX2 expression, as indicated by immunoblotting and immunofluorescence staining. PITX2 mRNA levels were increased in EGFP-positive cells, which were collected by cell sorting, and marker gene expression analysis of EGFP-positive cells induced in self-formed ectodermal autonomous multizones revealed that they were genuine POM cells. Moreover, after 2 days of culture, EGFP-positive cells expressed the PITX2 protein, which co-localized with forkhead box C1 (FOXC1) protein in the nucleus. We anticipate that the PITX2-EGFP hiPSC reporter cell line established and validated here can be utilized to isolate POM cells and to analyze PITX2 expression during POM cell induction.

Identification of TIE2 as a susceptibility gene for neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

The endothelial and cell-specific angiopoietin-Tie pathway plays an important regulatory role in angiogenesis. In this study, we investigated the associations of the TIE2 (tyrosine kinase, endothelial, TEK) gene with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV), using haplotype-tagging single-nucleotide polymorphisms (SNPs) analysis.

METHODS

This study involved totally 2343 subjects, including a Hong Kong Chinese cohort (214 nAMD patients, 236 PCV patients and 433 control subjects), a Shantou Chinese cohort (189 nAMD patients, 187 PCV patients and 531 control subjects) and an Osaka Japanese cohort (192 nAMD patients, 204 PCV patients and 157 control subjects). Thirty haplotype-tagging SNPs in TIE2 were genotyped in the Hong Kong cohort using TaqMan technology. Two SNPs (rs625767 and rs2273717) showing association in the Hong Kong cohort were genotyped in the Shantou and Osaka cohorts. The SNP-disease association of individual and pooled cohorts were analysed.

RESULTS

Two SNPs (rs625767 and rs2273717) showed suggestive association with both nAMD and PCV in the Hong Kong cohort. In the meta-analysis involving all the three cohorts, rs625767 showed significant associations with nAMD (p=0.01; OR=0.82, 95% CI 0.70 to 0.96; I²=0%), PCV (p=0.02; OR=0.83, 95% CI 0.71 to 0.97; I²=27%) and pooled nAMD and PCV (p=0.002; OR=0.82, 95% CI 0.72 to 0.93; I²=0%), with low inter-cohort heterogeneities.

CONCLUSION

This study revealed TIE2 as a novel susceptibility gene for nAMD and PCV in Japanese and Chinese. Further studies in other populations are warranted to confirm its role.

Detection of Subclinical Corneal Ectasia Using Corneal Tomographic and Biomechanical Assessments in a Japanese Population

PURPOSE

To test the detection of subclinical corneal ectasia using integrated Scheimpflug tomography and biomechanical assessment in a Japanese population.

METHODS

This prospective, case-control study included 23 patients with very asymmetric ectasia (VAE) and 70 normal controls. Patients with VAE had defined clinical ectasia in one eye and a fellow eye with normal topography (VAE-NT). Objective topography for confirming normal topography in VAE-NT cases included having 0% similarity and 0% severity derived from Placido-disk based topography. Scheimpflug-based corneal tomography and corneal biomechanical assessment were performed. The Belin/Ambrósio Enhanced Ectasia Deviation index (BAD-D), Corvis Biomechanical Index (CBI), and Tomographic Biomechanical Index (TBI) were compared and their discriminating ability for detecting ectasia was assessed.

RESULTS

For differentiating normal and VAE-NT eyes, the areas under the receiver operating curve for the BAD-D, CBI, and TBI were 0.668, 0.660, and 0.751, respectively. The TBI cut-off of 0.259 provided 52.17% sensitivity and 88.57% specificity. Fourteen VAE-NT cases (60.9%) were abnormal in at least one of the criteria of the BAD-D > 1.60 (39.1%), CBI > 0.5 (26.1%), or TBI > 0.29 (43.5%). Conversely, nine VAE-NT cases (39.1%) exhibited normal values for the BAD-D, CBI, and TBI.

CONCLUSIONS

In the current study, 40% of VAE-NT eyes were classified as normal by the BAD-D, CBI, and TBI. Although some of these cases may truly represent unilateral ectasia, further advances are needed to enhance ectasia detection and characterize the susceptibility for ectasia progression. [J Refract Surg. 2019;35(6):383-390.].

Objective Evaluation Of On-Eye Optical Quality Of Daily Disposable Silicone Hydrogel Contact Lens With Internal Wetting Agents

Purpose

To investigate the on-eye optical quality of a daily disposable silicone hydrogel contact lens with internal wetting agent.

Patients and methods

Study subjects were daily disposable soft contact lens wearers (N=20) who were instructed to wear daily disposable hydrogel etafilcon A lens (without added wetting agent) or daily disposable silicone hydrogel senofilcon A lens (with an internal wetting agent), for a week. Subjects wore their respective lenses bilaterally and disposed of the pair of lenses daily. At the end of the 1-week test-wear period, the on-eye visual performances of the lens and the ocular surfaces were evaluated. A wavefront sensor measured sequential ocular higher-order aberrations (HOAs) for 10 s after the blink. The aberration data were analyzed in the central 4-mm diameter up to the sixth-order Zernike polynomials. Total HOAs, fluctuation index (FI), and stability index (SI) of the total HOAs over time were compared between the two lenses. Ocular surface evaluation with fluorescein was performed following the wavefront measurement.

Results

The senofilcon A lens had significantly lower average total HOAs, FI, and SI (p<0.001, p=0.001, p=0.007, respectively) than the etafilcon A lens. After 1-week wear of each lens, corneal staining was observed in eight subjects (40%) with the etafilcon A lens and in two subjects (10%) with the senofilcon A lens. The senofilcon A lens had significantly lower incidence of corneal staining than the etafilcon A lens (p=0.041).

Conclusion

Quantitative sequential measurement of HOAs objectively showed the possibility of better and more stable optical quality with silicone hydrogel daily disposable contact lens with the internal wetting agent than with hydrogel lens without the added wetting agent.

Quantitative evaluation of visual function in patients with cornea verticillata associated with Fabry disease

PURPOSE

To evaluate the visual function of patients with cornea verticillata associated with Fabry disease through quantitative evaluations of contrast sensitivity function and straylight.

METHODS

We enrolled 28 eyes of 14 patients with Fabry disease (mean age, 37.1 ± 17.2  years) and 20 eyes of 20 age-matched healthy controls. Comprehensive ophthalmological examinations were performed and contrast sensitivity and letter contrast sensitivity were measured for all patients, following which the area under the log contrast sensitivity function (AULCSF) was calculated. Straylight was quantified using a straylight metre. Furthermore, subgroup analysis was performed according to the whorl-like pattern of cornea verticillata (mild and typical groups).

RESULTS

All 28 eyes showed cornea verticillata. Visual acuity and letter contrast sensitivity values were the same for normal eyes and those with Fabry disease. AULCSF differed by 0.15 log[s] between the eyes with Fabry disease and the control eyes (p < 0.001), while straylight differed by 0.45 log[s] between the two groups (p < 0.001). Subgroup analysis based on the whorl-like pattern of cornea verticillata showed that AULCSF and straylight differed by 0.11 log[s] and 0.08 log[s], respectively, between the typical and mild groups (p = 0.036 and p = 0.147, respectively).

CONCLUSION

Although cornea verticillata associated with Fabry disease does not affect the visual acuity and letter contrast sensitivity, more comprehensive testing of visual function by the inclusion of straylight and grating contrast sensitivity measurements shows clear functional deficits in these patients.

Chronological Observations of Iris Flocculi in a Japanese Family with Thoracic Aortic Aneurysm and Dissections

Iris flocculi, a type of hereditary iris pigment epithelial cyst, have been reported in association with smooth muscle α-2 actin (ACTA2) gene as the causative gene of familial thoracic aortic aneurysm and dissections (FTAAD). The purpose of the report was to examine morphological changes in the shape of flocculi and iris features over time by comparing infants to adults with FTAAD combined with iris flocculi. A Japanese family with FTAAD and bilateral iris flocculi and the Arg149Cys gene mutation was included. A slit-lamp photograph and anterior segment optical coherence tomography (AS-OCT) were used to evaluate the structure and location of iris flocculi. AS-OCT was also used to measure the internal shape and iris thickness of the dilated pupil muscle. A morphological change in the cyst was confirmed to be existent in the youngest cases. Pigment discoloration and iris atrophy of the iris body were observed in all cases. Besides, a decrease in iris thickness was observed with AS-OCT measurement. Changes across generations in iris flocculi occurred in a Japanese family with TAAD. ACTA2 gene abnormalities may cause iris atrophy and decrease thickness in addition to iris flocculi in early life. The prognosis is poor when FTAAD is combined with iris flocculi, and prevention of cardiovascular disease is necessary based on earlier findings of its emergence.

Bilateral serous retinal detachment associated with subretinal fibrin-like material in a case of pregnancy-induced hypertension

Purpose

To describe a case of bilateral serous retinal detachment (SRD) associated with subretinal fibrin-like material (SRFM) in pregnancy-induced hypertension (PIH).

Observations

Angiography of a 31-year-old primigravida with PIH who developed acute bilateral SRD with SRFM after caesarean section showed choroidal hypoperfusion and dye leakage. Optical coherence tomography revealed irregularity of the ellipsoid zone and retinal pigment epithelium. The patient's visual acuity was hand motion in the both eyes at the initial examination. After 30 days, SRD and SRFM spontaneously disappeared. Moreover, the EZ returned and the visual acuity significantly improved to 20/25 in the right and 20/20 in the left eye.

Conclusions and importance

Although there are reports on central serous chorioretinopathy or Vogt-Koyanagi-Harada disease, there have been no studies on SRFM complications in patients with PIH. In the current case, we speculated that SRFM was associated with acute intense choroidal ischemia and inflammation secondary to this ischemic condition. Distinguishing whether inflammation necessitating treatment is involved in SRFM may be difficult. Short observation intervals and frequent examinations are important to ensure that treatment timings are not missed.

Deep learning based noise reduction method for automatic 3D segmentation of the anterior of lamina cribrosa in optical coherence tomography volumetric scans

A deep-learning (DL) based noise reduction algorithm, in combination with a vessel shadow compensation method and a three-dimensional (3D) segmentation technique, has been developed to achieve, to the authors best knowledge, the first automatic segmentation of the anterior surface of the lamina cribrosa (LC) in volumetric ophthalmic optical coherence tomography (OCT) scans. The present DL-based OCT noise reduction algorithm was trained without the need of noise-free ground truth images by utilizing the latest development in deep learning of de-noising from single noisy images, and was demonstrated to be able to cover more locations in the retina and disease cases of different types to achieve high robustness. Compared with the original single OCT images, a 6.6 dB improvement in peak signal-to-noise ratio and a 0.65 improvement in the structural similarity index were achieved. The vessel shadow compensation method analyzes the energy profile in each A-line and automatically compensates the pixel intensity of locations underneath the detected blood vessel. Combining the noise reduction algorithm and the shadow compensation and contrast enhancement technique, medical experts were able to identify the anterior surface of the LC in 98.3% of the OCT images. The 3D segmentation algorithm employs a two-round procedure based on gradients information and information from neighboring images. An accuracy of 90.6% was achieved in a validation study involving 180 individual B-scans from 36 subjects, compared to 64.4% in raw images. This imaging and analysis strategy enables the first automatic complete view of the anterior LC surface, to the authors best knowledge, which may have the potentials in new LC parameters development for glaucoma diagnosis and management.

KLF4 prevents epithelial to mesenchymal transition in human corneal epithelial cells via endogenous TGF-β2 suppression

Introduction

Krüppel-like factor 4 (KLF4) is considered one of the Yamanaka factors, and recently, we and others have shown that KLF4 is one of the transcription factors essential for reprogramming non-human corneal epithelial cells (HCECs) into HCECs. Since epithelial to mesenchymal transition (EMT) suppression is vital for homeostasis of HCECs via regulation of transcription factors, in this study, we aimed to investigate whether KLF4 prevents EMT in HCECs and to elucidate the underlying mechanism within the canonical TGF-β signalling pathway, which is involved in corneal epithelial wound healing.

Methods

HCECs were collected from cadaver donors and cultivated. We generated KLF4-knockdown (KD) HCECs using siRNA transfection and analysed morphology, gene or protein expression, and endogenous TGF-β secretion. KLF4 was overexpressed using lentiviral KLF4 expression vectors and underwent protein expression analyses after TGF-β2 treatment.

Results

KLF4-KD HCECs showed a fibroblastic morphology, downregulation of the epithelial markers, keratin 12 and keratin 14, and upregulation of the mesenchymal markers, fibronectin 1, vimentin, N-cadherin, and SLUG. Although E-cadherin expression remained unchanged in KLF4-KD HCECs, immunocytochemical analysis showed that E-cadherin–positive adherens junctions decreased in KLF4-KD HCECs as well as the decreased total protein levels of E-cadherin analysed by immunoblotting. Moreover, within the TGF-β canonical signalling pathway, TGF-β2 secretion by HCECs increased up to 5 folds, and several TGF-β–associated markers (TGFB1, TGFB2, TGFBR1, and TGFBR2) were significantly upregulated up to 6 folds in the KLF4-KD HCECs. SMAD2/3, the main signal transduction molecules of the TGF-β signalling pathway, were found to be localised in the nucleus of KLF4-KD HCECs. When KLF4 was overexpressed, cultivated HCECs showed upregulation of epithelial markers, keratin 14 and E-cadherin, indicating the contributory role of KLF4 in the homeostasis of human corneal epithelium in vivo. In addition, KLF4 overexpression in HCECs resulted in decreased SMAD2 phosphorylation and altered nuclear localisation of SMAD2/3, even after TGF-β2 treatment.

Conclusions

These results show that KLF4 prevents EMT in HCECs and suggest a novel role of KLF4 as an endogenous TGF-β2 suppressor in the human corneal epithelium, thus highlighting the potential of KLF4 to prevent EMT and subsequent corneal fibrotic scar formation by attenuating TGF-β signalling.

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KLF4 inhibited EMT within corneal epithelia.

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TGF-β expression of human corneal epithelial cells is regulated by KLF4.

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KLF4 prevented phosphorylation and nuclear localisation of SMAD2.

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KLF4 may be an important transcription factor in wound healing.

Evaluation of retinal nonperfusion in branch retinal vein occlusion using wide-field optical coherence tomography angiography

PURPOSE

To characterize wide-field optical coherence tomography angiography (OCTA) features of retinal nonperfusion in eyes with branch retinal vein occlusion (BRVO).

METHODS

Automated scanning of five 12 × 12-mm areas of swept-source OCTA and wide-field fluorescein angiography (FA) images was performed in a consecutive case series of 27 eyes in 27 patients with BRVO in this institutional cross-sectional study. The correlation between the areas of retinal nonperfusion detected by both examinations was assessed. Panoramic images obtained in five 12 × 12-mm OCTA scans in eyes with retinal nonperfusion were binarized or skeletonized, and the associations between vascular parameters such as vascular density (VD) and vascular length (VL) with the wide-field FA characteristics were evaluated.

RESULTS

The mean area of retinal nonperfusion in the OCTA images was 81.0 ± 66.8 mm² (range, 0.0-188.8). The mean areas of retinal nonperfusion in FA and the total FA images were, respectively, 84.7 ± 72.5 mm² (range, 0.0-221.9) and 184.1 ± 167.7 mm² (range, 0.0-515.0). The mean VD was 27.6 ± 3.5% (range, 19.6-33.7), and the mean VL was 12.4 ± 8.5% (range, 5.4-31.3). Separate regression analyses of the areas of retinal nonperfusion in FA (p = 0.0004, R²  = 0.4627) and the total FA (p = 0.0008, R²  = 0.4214) images showed a significant association with the VL.

CONCLUSIONS

OCTA images based on wide-field technologies can quantitatively evaluate retinal nonperfusion in eyes with BRVO.

Retrospective Validation of the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Criteria in a Japanese Cohort

PURPOSE

We aimed to externally validate the performance of new screening criteria for retinopathy of prematurity (ROP) developed in the Postnatal Growth and Retinopathy of Prematurity (G-ROP) study among a Japanese cohort.

DESIGN

Validation of screening criteria.

METHODS

We reviewed premature infants screened for ROP between September 2009 and May 2017 at a single institution. The G-ROP criteria, except hydrocephalus, were applied as a prediction model for infants with both a known outcome of ROP and serial measurements of weight gain. We assessed sensitivity and specificity for treatment-requiring ROP, and reduction in the number of infants who receive ROP screening and in the number of retinal examinations.

RESULTS

Of 692 premature infants screened for ROP, 537 had information of ROP outcome and weight gain. In this cohort, 81 infants required treatment for ROP; in 218 infants, ROP regressed spontaneously; and 238 infants did not develop any ROP. The G-ROP model reached a sensitivity of 100% (95% confidence interval [CI], 95.4%-100%) and specificity of 28.9% (95% CI, 24.9%-33.2%). No infants required any treatment for ROP before the date of risk determination. The number of infants requiring screening and the number of examinations would have been reduced by 24.5% and 12.9%, respectively.

CONCLUSIONS

This is the first validation study of the G-ROP criteria in a developed country other than North America. The criteria demonstrated high sensitivity in this Japanese cohort, even though the criterion of hydrocephalus was excluded.

Association between disorganization of retinal inner layers and visual acuity after proliferative diabetic retinopathy surgery

We report to evaluate if disorganization of the retinal inner layers (DRIL) obtained by swept-source optical coherence tomography (SS-OCT) predicts the postoperative best-corrected visual acuity (BCVA) to treat proliferative diabetic retinopathy (PDR). Twenty-one eyes of 21 patients who underwent vitrectomy for PDR were studied retrospectively. BCVA and SS-OCT images were obtained until 6 months postoperatively. The associations between BCVA and SS-OCT parameters measured in a 1-mm central foveal area were evaluated. The DRIL length, external limiting membrane disruption, and ellipsoid zone (EZ) disruption 1 month postoperatively were associated positively with the postoperative logarithm of the minimum angle of resolution (logMAR) BCVA at 1, 3, and 6 months (1 month, p = 0.009, p = 0.013, p = 0.001; 3 months, p = 0.03, p = 0.021, p = 0.002; and 6 months, p = 0.021, p = 0.013, and p = 0.005, respectively). The eyes with a 500-µm or longer DRIL 1 month postoperatively (19%, 4/21 eyes) had significantly worse VA at 1, 3, and 6 months postoperatively (p = 0.007, p = 0.008, and p = 0.020, respectively). Multilinear regression analysis of all visits until 6 months postoperatively showed that the DRIL was correlated more significantly (p = 0.0004) with logMAR BCVA than the disrupted EZ length. The DRIL in the early postoperative period may predict the visual outcomes after treating PDR.