Intraocular lens implantation in unilateral congenital cataract with minimal levels of persistent fetal vasculature in the first 18 months of life

Photorefraction with Spot Vision Screener versus Visual Acuity Testing as Community-Based Preschool Vision Screening at the Age of 3.5 Years in Japan

Nationwide in Japan, a community-based vision-screening program in 3.5-year-old children is conducted in three steps: questionnaires and home visual acuity testing as the primary screening; visual acuity testing by nurses and pediatricians’ inspection in community health centers as the secondary screening; and examinations by ophthalmologists as the tertiary screening. In this study, we introduced photorefraction with a Spot vision screener in addition to visual acuity testing to answer the clinical question of whether photorefraction could better detect eye diseases and potentially replace visual acuity testing. Photorefraction was performed on 813 consecutive 3.5-year-old children in a center. The children were sent to tertiary examinations, which were based on the Spot vision screener standard, in addition to the visual acuity testing standard: failure in either eye to pass 0.5 visual acuity in a center. A notice to visit ophthalmologists was issued for 95 children (11%), and documents with the diagnosis were sent back to the Heath Office for 76 children (80%). The rate of children with anisometropic or ametropic amblyopia or accommodative esotropia as treatment-requiring diseases was highest in cases of no pass at both standards (10/15 = 66%), and higher in cases of no pass only at the Spot vision screener standard (13/45 = 28%), compared with cases of no pass only at the visual acuity testing standard (6/33 = 18%, p = 0.0031). Photorefraction, in addition to visual acuity testing and inspection led to additional eye diseases detection at 3.5 years. Visual acuity testing at home would not be omitted in the introduction of photorefraction.

Long-Term Control of Macular Edema With Adalimumab After Cataract Surgery in a Japanese Child With Juvenile Idiopathic Arthritis: Case Report and Review of 26 Japanese Patients

Juvenile idiopathic arthritis–associated uveitis is rare in the Japanese population. In this article, we report a child whose macular edema was controlled for years after cataract surgery with adalimumab, and reviewed 26 Japanese patients in the literature. In this case report, a 4-year-old boy developed band keratopathy, posterior iris synechiae, and complicated cataract in both eyes. Oral prednisolone prescribed at another hospital was discontinued due to high intraocular pressure in both eyes as a steroid responder. At the age of 5 years, he started oral methotrexate 8 mg weekly for recurrent bilateral iridocyclitis and then underwent lensectomy with core vitrectomy in both eyes. Planned intraocular lens implantation was cancelled at surgery because the anterior vitreous had severe inflammatory opacity with diffuse retinal edema in both eyes. Due to persistent macular edema in both eyes 5 months postoperatively, at the age of 6 years, he began to use adalimumab injection 20 mg every 2 weeks. The macular structure depicted by optical coherence tomography became normal in 2 months. At final visit at the age of 11 years, he had the best-corrected visual acuity of 0.8 in the right eye and 0.4 in the left eye, with adalimumab 40 mg every 2 weeks and methotrexate 8 mg weekly. In conclusion, macular edema persistent despite oral methotrexate after cataract surgery could be controlled for long term by adalimumab in a child with juvenile idiopathic arthritis. In the Japanese literature, only 26 additional cases with juvenile idiopathic arthritis–associated uveitis have been reported so far.

Modulating EGFR-MTORC1-autophagy as a potential therapy for persistent fetal vasculature (PFV) disease

Persistent fetal vasculature (PFV) is a human disease that results from failure of the fetal vasculature to regress normally. The regulatory mechanisms responsible for fetal vascular regression remain obscure, as does the underlying cause of regression failure. However, there are a few animal models that mimic the clinical manifestations of human PFV, which can be used to study different aspects of the disease. One such model is the Nuc1 rat model that arose from a spontaneous mutation in the Cryba1 (crystallin, beta 1) gene and exhibits complete failure of the hyaloid vasculature to regress. Our studies with the Nuc1 rat indicate that macroautophagy/autophagy, a process in eukaryotic cells for degrading dysfunctional components to ensure cellular homeostasis, is severely impaired in Nuc1 ocular astrocytes. Further, we show that CRYBA1 interacts with EGFR (epidermal growth factor receptor) and that loss of this interaction in Nuc1 astrocytes increases EGFR levels. Moreover, our data also show a reduction in EGFR degradation in Nuc1 astrocytes compared to control cells that leads to over-activation of the mechanistic target of rapamycin kinase complex 1 (MTORC1) pathway. The impaired EGFR-MTORC1-autophagy signaling in Nuc1 astrocytes triggers abnormal proliferation and migration. The abnormally migrating astrocytes ensheath the hyaloid artery, contributing to the pathogenesis of PFV in Nuc1, by adversely affecting the vascular remodeling processes essential to regression of the fetal vasculature. Herein, we demonstrate in vivo that gefitinib (EGFR inhibitor) can rescue the PFV phenotype in Nuc1 and may serve as a novel therapy for PFV disease by modulating the EGFR-MTORC1-autophagy pathway.

ABBREVIATIONS

ACTB: actin, beta; CCND3: cyclin 3; CDK6: cyclin-dependent kinase 6; CHQ: chloroquine; COL4A1: collagen, type IV, alpha 1; CRYBA1: crystallin, beta A1; DAPI: 4'6-diamino-2-phenylindole; EGFR: epidermal growth factor receptor; GAPDH: glyceraldehyde-3-phosphate dehydrogenase; GFAP: glial fibrillary growth factor; KDR: kinase insert domain protein receptor; MAP1LC3/LC3: microtubule-associated protein 1 light chain 3; MKI67: antigen identified by monoclonal antibody Ki 67; MTORC1: mechanistic target of rapamycin kinase complex 1; PARP: poly (ADP-ribose) polymerase family; PCNA: proliferating cell nuclear antigen; PFV: persistent fetal vasculature; PHPV: persistent hyperplastic primary vitreous; RPE: retinal pigmented epithelium; RPS6: ribosomal protein S6; RPS6KB1: ribosomal protein S6 kinase, polypeptide 1; SQSTM1/p62: sequestome 1; TUBB: tubulin, beta; VCL: vinculin; VEGFA: vascular endothelial growth factor A; WT: wild type.

Outcomes of secondary sulcus intraocular lens implantation in unilateral anterior persistent fetal vasculature

AIM

To evaluate the surgical results of sulcus intraocular lens (IOL) implantation in children with unilateral anterior persistent fetal vasculature (PFV) underwent primary vitrectomy combined with lensectomy and preservation of the peripheral anterior capsule.

METHODS

Twenty-two eyes of 22 children with unilateral anterior PFV who underwent sulcus secondary IOL implantation were analyzed. Main outcome measures were preoperative and postoperative visual acuity, and complications both intraoperatively and postoperatively.

RESULTS

Review of 22 consecutive patients identified best-corrected visual acuity (BCVA) improvement from 1.37±0.84 to 0.73±0.57 logarithm of the minimal angle of resolution (logMAR) after IOL implantation (P<0.001) with a mean follow-up was 16.55±5.86mo. Average age at secondary IOL implantation was 41.05±15.41mo. Three eyes (13.64%) achieved BCVA of 0.3 logMAR at the final visit. Transient intraocular pressure rise (4 eyes; 18.18%), postoperative increased inflammation (3 eyes; 13.64%) and postoperative hypotony (2 eyes; 9.09%) were common complications.

CONCLUSION

Properly preservation of the anterior lens capsule during the primary surgery facilitated secondary sulcus IOL implantation in pediatric patients with anterior PFV, with favorable postoperative visual outcomes and compatible percentage of complications.

Visual Evoked Potential Recovery by Subretinal Implantation of Photoelectric Dye-Coupled Thin Film Retinal Prosthesis in Monkey Eyes With Macular Degeneration

Retinal prosthesis or artificial retina is a promising modality of treatment for outer retinal degeneration, caused by primary and secondary loss of photoreceptor cells, in hereditary retinal dystrophy and age‐related macular degeneration, respectively. Okayama University‐type retinal prosthesis (OUReP) is a photoelectric dye‐coupled polyethylene film which generates electric potential in response to light and stimulates nearby neurons. The dye‐coupled films were implanted by vitreous surgery in the subretinal space of monkey eyes with macular degeneration which had been induced by cobalt chloride injection from the scleral side. A pilot 1‐month observation study involved 6 monkeys and a pivotal 6‐month observation study involved 8 monkeys. Of 8 monkeys in 6‐month group, 3 monkeys underwent dye‐coupled film removal at 5 months and were observed further for 1 month. The amplitude of visual evoked potential which had been reduced by macular degeneration did recover at 1 month after film implantation and maintained the level at 6 months. Optical coherence tomography showed no retinal detachment, and full‐field electroretinograms maintained a‐wave and b‐wave amplitudes, indicative of no retinal toxicity. Pathological examinations after 6‐month implantation showed structural integrity of the inner retinal layer in close apposition to dye‐coupled films. The implanted films which were removed by vitrectomy 5 months later showed light‐evoked surface electric potentials by scanning Kelvin probe measurement. The photoelectric dye‐coupled film (OUReP), which serves as a light‐receiver and a displacement current generator in the subretinal space of the eye, has a potential for recovering vision in diseases with photoreceptor cell loss, such as retinitis pigmentosa and age‐related macular degeneration.

Visual evoked potential in rabbits' eyes with subretinal implantation by vitrectomy of Okayama University-type retinal prosthesis (OURePTM)

Okayama University-type retinal prosthesis (OUReP^TM) is a photoelectric dye-coupled polyethylene film which generates electric potential in response to light and stimulates nearby neurons. This study aims to test surgical feasibility for subretinal film implantation and to examine functional durability of films in subretinal space. Dye-coupled films were implanted subretinally by vitrectomy in the right eye of normal white rabbits: 8 rabbits for 1 month and 8 rabbits for 6 months. The implanted films were removed by vitrectomy in 4 of these 8 rabbits in 1-month or 6-month implantation group. The films were also implanted in 4 rhodopsin-transgenic retinal dystrophic rabbits. Visual evoked potential was measured before film implantation as well as 1 or 6 months after film implantation, or 1 month after film removal. The films were successfully implanted in subretinal space of retinal detachment induced by subretinal fluid injection with a 38G polyimide tip. The retina was reattached by fluid-air exchange in vitreous cavity, retinal laser coagulation, and silicone oil injection. The ratios of P₂ amplitudes of visual evoked potential in the implanted right eye over control left eye did not show significant changes between pre-implantation and post-implantation or post-removal (paired t-test). In Kelvin probe measurements, 4 pieces each of removed films which were implanted for 1 or 6 months showed proportional increase of surface electric potential in response to increasing light intensity. The film implantation was safe and implanted films were capable of responding to light.

Outcomes of small gauge pars plicata vitrectomy for patients with persistent fetal vasculature: a report of 105 cases

AIM

To evaluate the surgical outcomes in eyes with persistent fetal vasculatures (PFV) managed by small gauge pars plicata vitrectomy.

METHODS

Consecutive patients with PFV treated by small gauge pars plicata vitrectomy at Beijing Tongren Eye Center between January 2010 and January 2013 were retrospectively reviewed.

RESULTS

A total of 118 eyes of 105 patients with PFV were included and undergone small gauge pars plicata vitrectomy, of which 84 (71.2%) eyes had lensectomy and 16 (13.6%) eyes had lens aspiration and immediate intraocular lens implantation. The percentage of sutured scleral incision of 23 gauge vitrectomy (71.7%, 33/46) was higher than that of the 25 gauge vitrectomy (18.1%, 13/72). At last follow-up, visual acuity remained stable in 34 eyes (28.8%) and improved in 84 eyes (71.2%). Age at surgery (less than 2y), anterior type of PFV, and immediate IOL implantation were associated with postoperative improved visual acuity. Sixty five (55.1%) eyes had retinal detachment preoperatively, among which 33 (50.8%, 33/65) eyes had retinal reattachment or partial retinal reattachment.

CONCLUSION

The results suggest that cases with PFV have a potential for developing good visual acuity after small gauge pars plicata vitrectomy with favorable anatomic outcomes and acceptable rate of serious surgical complications.

Subretinal implantation of Okayama University-type retinal prosthesis (OURePTM) in canine eyes by vitrectomy

Okayama University-type retinal prosthesis (OUReP^TM) is a photoelectric dye-coupled polyethylene film which generates electric potential in response to light and stimulates nearby neurons. This study aims to test surgical feasibility of subretinal implantation and functional durability of dye-coupled films in the subretinal space. The dye-coupled films were implanted subretinally by 25-gauge vitrectomy in the right eye of 11 normal beagle dogs: 2 dogs served for film removal after 5-month film implantation, 3 dogs for film removal after 3-month film implantation, 3 dogs for 3-month film implantation and pathological examination, and 3 dogs for sham surgery. The surface electric potential of the removed dye-coupled films in response to light was measured by the Kelvin Probe system. At surgery, rolled-up dye-coupled films in 5 × 5 mm square size could be inserted into subretinal space of retinal detachment induced by fluid injection with a 38-gauge polyimide tip. Retinal attachment was maintained by silicone oil injection in vitreous cavity. At autopsy, the retina in all dogs maintained the ganglion cell layer, inner and outer nuclear layers while it lost the outer segments in some part. All 5 sheets of removed dye-coupled films maintained the dye color. One sheet of the 5-month implanted film showed proportional increase of surface potential in response to increasing light intensity. Subretinal implantation of OUReP^TM by vitrectomy was technically feasible in canine eyes, and OUReP^TM maintained the function of generating light-evoked surface potential after 5 months in subretinal implantation.

Surgical treatment and visual outcomes of cataract with persistent hyperplastic primary vitreous

AIM

To evaluate the surgical treatment and visual outcomes of eyes with cataract and persistent hyperplastic primary vitreous (PHPV).

METHODS

This retrospective study included patients with cataract and PHPV treated with various strategies. Anterior PHPV was treated using phacoemulsification with underwater electric coagulation on posterior capsule neovascularization, posterior capsulotomy, anterior vitrectomy, and intraocular lens (IOL) implantation. Posterior PHPV was treated with lensectomy, posterior vitrectomy, retinal photocoagulation, and IOL implantation or silicone oil tamponade. Visual acuity (VA), pattern visual evoked potential (P-VEP), anatomic recovery, postoperative complications, and amblyopia outcome were examined. Subjects were followed-up for 3-48mo after surgery.

RESULTS

Of the 30 patients (33 eyes) with congenital cataract and PHPV included (average age, 39.30±35.47mo), 9 eyes had anterior PHPV and 24 had posterior PHPV. Thirty-two eyes were surgically treated. Eyes with anterior PHPV received an IOL during one-stage (6 eyes) and two-stage (3 eyes) implantation. Postoperative complications included retinal detachment (1 eye) and recurrent anterior chamber hemorrhage (1 eye). In eyes with posterior PHPV, 6 and 11 eyes received IOLs in one- and two-stage procedures, respectively. Silicone oil was retained in 2 eyes, and IOLs were not implanted in 4 eyes. VA significantly improved in 25 eyes following operations and 3-48mo of amblyopia treatment. P-VEP P₁₀₀ was improved following surgery in both PHPV types.

CONCLUSION

Our surgical strategies are appropriate and effective for anterior and posterior PHPV. Early surgical intervention and amblyopia therapy result in positive treatment outcomes.

Clinical decision upon resection or observation of ocular surface dermoid lesions with the visual axis unaffected in pediatric patients

Ocular surface or epibulbar dermoid lesions may present as limbal dermoids at the corneal limbus or dermolipomas in the conjunctival fornix. The purpose of this study is to review clinical features of ocular surface dermoids (grade I), with the visual axis unaffected, in pediatric patients, in order to find key features for making clinical decision, either resection or observation. The study involved 13 consecutive patients with limbal dermoids or fornix dermolipomas which did not affect the visual axis, seen in 11 years at a referral-based institution. Eight patients underwent surgical resection at the age, ranging from 1 to 18 (median, 4) years, with concurrent preauricular appendage resection in 3 patients. Limbal dermoids in 6 patients presented dome-shaped elevation from the ocular surface, and extended in inferotemporal quadrant for 1-2 clock hours. The remaining 2 patients showed dermolipomas in the temporal conjunctival fornix. Postoperative astigmatism at the final visit ranged from 0 to 7 (median, 2.9) diopters in 6 patients with limbal dermoids while ranged from 0 to 1 diopters in 2 patients with fornix dermolipomas. All patients with meaningful astigmatism wore glasses before and after the surgery, resulting in no apparent ametropic or anisometropic amblyopia. Observation was chosen in 5 patients with the age at initial visit, ranging from 0 to 2 (median, 1) years, and the age at the final visit, ranging from 2 to 6 (median, 3) years. Flat limbal dermoids, extending for 1-2 clock hours, were noted in 3 patients, a dome-shaped limbal dermoid for 1 clock hour in one, and a fornix dermolipoma in one. Three patients had preauricular appendages. No patient, except for one with a dome-shaped limbal dermoid, showed astigmatism, greater than one diopter. In conclusions, dome-shaped limbal dermoids were excised while flat limbal dermoids observed. The age at surgery varied largely in pediatric patients with limbal dermoids (grade I) or fornix dermolipomas which did not affect the visual axis. The surgical timing was influenced by surgical scheduling for preauricular appendage resection, determined by a plastic surgeon. Surgical decision was made for cosmetic purposes, but not for medical needs to avoid amblyopia.

How far is observation allowed in patients with ectopia lentis?

Surgical timing for ectopia lentis has not been well described until now. The purpose of this study is to find a benchmark as to how far observation would be allowed in children with ectopia lentis when they and their families are reluctant to go through surgery. Retrospective review was made on 15 consecutive patients (14 children and one adult) with ectopia lentis in both eyes, seen at a referral-based institution in 5 years from April 2008 to March 2013, to survey the reasons for continuing observation or deciding surgical intervention. The diagnoses were Marfan syndrome in six patients, familial ectopia lentis in six, and sporadic ectopia lentis in three. Observation was continued in nine patients with the age at the final visit, ranging from 4 to 17 (median 9) years, because six children had good visual acuity at both near and distant viewing with glasses, and three children had visual acuity of 0.4 at near viewing despites poor visual acuity at distant viewing with glasses. In contrast, lensectomy was determined in six patients (5 children and one adult) with the age at surgery, ranging from 4 to 36 (median 9) years, and the age at the final visit, ranging from 7 to 42 (median 11) years, mainly because of poor visual acuity at near and distant viewing. More specific causes for surgeries in five children were the optical axis to become aphakic due to the progression of ectopia in the course in two children, lens dislocation to the anterior chamber after blunt eye injury in one child, and difficulty in studying at school classes in two children. One adult patient developed cataract in ectopic lenses. Lensectomy, combined with anterior vitrectomy, was done from two limbal side ports with a 25-gauge infusion cannula and vitreous cutter. Two patients at the age of 16 and 36 years, additionally, underwent intraocular lens-suturing in both eyes. In conclusions, observation was continued in children with ectopia lentis who had good visual acuity at near viewing. The visual acuity at near viewing, 0.4 or better, would give a benchmark for continuing observation in children with ectopia lentis.