Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Investigating the clinical validity of the guided progression analysis definition with 10-2 visual field in retinitis pigmentosa

PURPOSE

To investigate the clinical validity of the Guided Progression Analysis definition (GPAD) and cluster-based definition (CBD) with the Humphrey Field Analyzer (HFA) 10-2 test in retinitis pigmentosa (RP).

METHODS

Ten non-progressive RP visual fields (VFs) (HFA 10-2 test) were simulated for each of 10 VFs of 111 eyes (10 simulations × 10 VF sequencies × 111 eyes = 111,000 VFs; Dataset 1). Using these simulated VFs, the specificity of GPAD for the detection of progression was determined. Using this dataset, similar analyses were conducted for the CBD, in which the HFA 10-2 test was divided into four quadrants. Subsequently, the Hybrid Definition was designed by combining the GPAD and CBD; various conditions of the GPAD and CBD were altered to approach a specificity of 95.0%. Subsequently, actual HFA 10-2 tests of 116 RP eyes (10 VFs each) were collected (Dataset 2), and true positive rate, true negative rate, false positive rate, and the time required to detect VF progression were evaluated and compared across the GPAD, CBD, and Hybrid Definition.

RESULTS

Specificity values were 95.4% and 98.5% for GPAD and CBD, respectively. There were no significant differences in true positive rate, true negative rate, and false positive rate between the GPAD, CBD, and Hybrid Definition. The GPAD and Hybrid Definition detected progression significantly earlier than the CBD (at 4.5, 5.0, and 4.5 years, respectively).

CONCLUSIONS

The GPAD and the optimized Hybrid Definition exhibited similar ability for the detection of progression, with the specificity reaching 95.4%.

Investigating the factors affecting myopia in retinopathy of prematurity after laser treatment

BACKGROUND

We investigated the effect of the number of laser shots applied on the myopic variables to elucidate the mechanism of myopia development in laser-treated retinopathy of prematurity (ROP) eyes.

METHODS

A total of 33 eyes of 17 infants with ROP who underwent laser treatment were included in the analysis. Cycloplegic retinoscopic refraction testing was carried out and the spherical equivalent (SE) was calculated. Relationships between SE and various variables (including the number of laser shots applied) were examined. In addition, an age-matched control group without ROP was prepared and ocular structural parameters were compared.

RESULTS

Although there was no statistical difference in axial length (AL) between two groups (p = 0.88), SE was significantly more myopic in the ROP group (p < 0.001). SE was associated with AL, corneal refraction (CR), and crystalline lens power (CLP) in the ROP group. Of these three factors (AL, CR, and CLP), CLP and the number of laser shots applied were significantly correlated (p = 0.003); however, no correlations were observed between the number of laser shots and AL or CR (p = 0.15 and 0.10, respectively). Very similar tendency was observed in the analysis of the difference between right and left eyes in each child.

CONCLUSIONS

In laser-treated ROP eyes, AL, CR, and CLP were related to the degree of myopia. Moreover, the number of shots applied also affected the myopic status in laser-treated ROP eyes. Among AL, CR, and CLP, only CLP was correlated with the laser shots applied.

Predictive capability of material screening by fast neutron activation analysis using laser-driven neutron sources

Bright, short-pulsed neutron beams from laser-driven neutron sources (LANSs) provide a new perspective on material screening via fast neutron activation analysis (FNAA). FNAA is a nondestructive technique for determining material elemental composition based on nuclear excitation by fast neutron bombardment and subsequent spectral analysis of prompt γ-rays emitted by the active nuclei. Our recent experiments and simulations have shown that activation analysis can be used in practice with modest neutron fluences on the order of 10⁵ n/cm², which is available with current laser technology. In addition, time-resolved γ-ray measurements combined with picosecond neutron probes from LANSs are effective in mitigating the issue of spectral interference between elements, enabling highly accurate screening of complex samples containing many elements. This paper describes the predictive capability of LANS-based activation analysis based on experimental demonstrations and spectral calculations with Monte Carlo simulations.

Association with sagittal alignment and osteoporosis-related fractures in outpatient women with osteoporosis

The baseline sagittal vertical axis (SVA) and pelvic tilt (PT) are independent risk factors of osteoporosis-related fractures in women with osteoporosis. We clarified the SVA and PT to predict the incidence of osteoporosis-related fractures.

PURPOSE

Sagittal alignment with osteoporosis women deteriorates with advancing age and sagittal alignment may indicate osteoporosis-related fractures in the future. However, whether the sagittal alignment predicts future osteoporosis-related fracture in patients with osteoporosis has not been clarified. We aimed to investigate the association between sagittal alignment and future osteoporosis-related fractures.

METHODS

This was a retrospective cohort study. Of the 313 participants (mean follow-up period, 2.9 years), 236 were included in the analysis. At baseline, we measured bone mineral density (BMD) of the lumbar spine and the femoral neck, sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis, sacral slope, pelvic tilt (PT), geriatric locomotive function scale (GLFS), two-step value, and stand-up test. The information on medications and the duration of treatment were reviewed from the medical records. Additionally, participants reported their history of falls at baseline. Multiple logistic regression analysis was used to determine the association of future osteoporosis-related fracture, and adjusted Odds ratios (OR) and 95% confidence interval (CI) were calculated with all predictors as covariates. All continuous variables were calculated using standardized OR (sOR).

RESULTS

Osteoporosis-related fractures occurred in 33 of 313 participants (10.5%). Multiple logistic regression analysis showed that a history of falls (OR =4.092, 95% CI: 1.029-16.265, p =0.045), SVA (sOR =4.228, 95% CI: 2.118-8.439, p <0.001), and PT (sOR =2.497, 95% CI: 1.087-5.733, p =0.031) were independent risk factors for future osteoporosis-related fractures.

CONCLUSIONS

This study revealed the SVA and PT to predict osteoporosis-related fractures.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

UMIN000036516 (April 1, 2019).

Comparison of efficacy and safety of accelerated trans-epithelial crosslinking for keratoconus patients with corneas thicker and thinner than 380µm

PURPOSE

Accelerated trans-epithelial cross-linking (ATE-CXL), a therapy to halt keratoconus progression, has the merit of widening the indications for thinner corneas (<380 μm). Since a hypotonic solution affects the swollen cornea, corneas of <380 μm thickness at preoperative measurement can be an indication for ATE-CXL. The aim of this retrospective study was to compare the efficacy and safety of ATE-CXL for keratoconus between corneas with thicknesses <380 μm and ≥380 μm.

MATERIALS AND METHODS

Thirty-four eyes of 27 patients who underwent ATE-CXL (30 mW/cm²; 3 minutes) with completion of a 24-month follow-up, were enrolled and divided into two groups: Group 1, thinnest corneal thickness (TCT), <380 μm (n = 10) and Group 2, TCT, ≥380 μm (n = 24). A hypotonic solution was administered to Group 1 until the corneal thickness increased by >380 μm before UV-A irradiation. We measured uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), maximum and average keratometric values (Kmax and AveK), central corneal thickness (CCT), TCT by anterior segment optical coherence tomography, and corneal endothelial cell density (ECD) using specular microscopy. The changes from baseline to 24 months postoperatively between the two groups were compared accordingly.

RESULTS

The changes in Kmax and AveK from baseline to 24 months in Group 1 (ΔKmax: -7.8±7.7 D, ΔAveK: -4.3±6.1 D) showed significant decreases compared to those in Group 2 (ΔKmax: 0.2±3.0 D, ΔAveK: 0.6±2.7 D) (p = 0.004 and p = 0.001), and there were no significant changes from baseline to 24 months postoperatively in UCVA, BCVA, CCT, TCT, and ECD in both groups.

CONCLUSION

ATE-CXL is effective and safe for keratoconic corneas in both groups. The effect of reducing keratometric values was greater in the group with thinner corneas.

Detecting Progression of Retinitis Pigmentosa Using the Binomial Pointwise Linear Regression Method

Purpose

A method of evaluating central visual field (VF) progression in eyes with retinitis pigmentosa (RP) has still to be established. We previously reported the potential merit of applying a binomial test to pointwise linear regression (binomial PLR) in glaucoma progression. In the current study, we investigated the usefulness of binomial PLR in eyes with RP.

Methods

A series of 10 VFs (VF 1–10, Humphrey field analyzer, 10-2 test) from 196 eyes of 103 patients with RP were collected retrospectively. The PLR was performed by regressing the total deviation of all test points with the complete series of 10 VFs. The accuracy (positive predictive value, negative predictive value, and false-positive rate) and the time required to detect VF progression with shorter VF series (from VF 1–5 to VF 1–9) were compared across the binomial PLR, a permutation analysis of PLR (PoPLR), and a mean deviation (MD) trend analysis.

Results

In evaluating VF progression, the binomial PLR was comparable with the PoPLR and MD trend analyses in its positive predictive value (0.55 to 0.95), negative predictive value (0.67 to 0.92), and false-positive rate (0.01 to 0.05). The binomial PLR required significantly less time to detect VF progression (5.0 ± 2.0 years) than the PoPLR and MD trend analyses (P < 0.01, P < 0.001, respectively).

Conclusions

The application of a binomial PLR achieved reliable and earlier detection of central VF progression in eyes with RP.

Translational Relevance

A binomial PLR was useful in assessing VF progression in RP.

Predicting 10-2 Visual Field From Optical Coherence Tomography in Glaucoma Using Deep Learning Corrected With 24-2/30-2 Visual Field

Purpose

To investigate whether a correction based on a Humphrey field analyzer (HFA) 24-2/30-2 visual field (VF) can improve the prediction performance of a deep learning model to predict the HFA 10-2 VF test from macular optical coherence tomography (OCT) measurements.

Methods

This is a multicenter, cross-sectional study. The training dataset comprised 493 eyes of 285 subjects (407, open-angle glaucoma [OAG]; 86, normative) who underwent HFA 10-2 testing and macular OCT. The independent testing dataset comprised 104 OAG eyes of 82 subjects who had undergone HFA 10-2 test, HFA 24-2/30-2 test, and macular OCT. A convolutional neural network (CNN) DL model was trained to predict threshold sensitivity (TH) values in HFA 10-2 from retinal thickness measured by macular OCT. The predicted TH values was modified by pattern-based regularization (PBR) and corrected with HFA 24-2/30-2. Absolute error (AE) of mean TH values and mean absolute error (MAE) of TH values were compared between the CNN-PBR alone model and the CNN-PBR corrected with HFA 24-2/30-2.

Results

AE of mean TH values was lower in the CNN-PBR with HFA 24-2/30-2 correction than in the CNN-PBR alone (1.9dB vs. 2.6dB; P = 0.006). MAE of TH values was lower in the CNN-PBR with correction compared to the CNN-PBR alone (4.2dB vs. 5.3 dB; P < 0.001). The inferior temporal quadrant showed lower prediction errors compared with other quadrants.

Conclusions

The performance of a DL model to predict 10-2 VF from macular OCT was improved by the correction with HFA 24-2/30-2.

Translational Relevance

This model can reduce the burden of additional HFA 10-2 by making the best use of routinely performed HFA 24-2/30-2 and macular OCT.

Comparison of refractive outcomes after combined cataract and glaucoma surgery: trabeculectomy and glaucoma drainage device implantation

PURPOSE

To investigate the refractive outcome of combined cataract surgery and glaucoma drainage device (GDD) implantation compared with trabeculectomy and cataract surgery.

SETTING

Department of Ophthalmology, National University Health System, Singapore.

DESIGN

Retrospective cohort study.

METHODS

206 eyes were enrolled for analysis: 50 had combined cataract surgery and trabeculectomy (trabeculectomy group), 50 had combined cataract surgery and GDD implantation (GDD group), and 106 had cataract surgery alone (control group). Refractive prediction error and absolute prediction error of each glaucoma surgery group were compared with the control group. Subgroup analysis was performed in the following axial length (AL) subgroups: short (<22.5 mm), medium (≥22.5 to <25.5 mm), and long (≥25.5 mm).

RESULTS

In total, 206 eyes were examined. There was no statistically significant difference in the overall refractive prediction error between the GDD (0.00 ± 0.54 diopters [D]) and the control group (0.10 ± 0.53 D, P = .58). There was significant myopic refractive prediction error in the trabeculectomy group (-0.18 ± 0.88 D, P = .020). In eyes with short AL, a greater absolute prediction error was observed in the GDD group (-0.75 ± 0.43 D, P = .039).

CONCLUSIONS

Apart from a significant deviation in short AL eyes, combined cataract surgery and GDD implantation demonstrated no significant postoperative refractive prediction error.

Retinal vessel shift and its association with axial length elongation in a prospective observation in Japanese junior high school students

PURPOSE

To investigate retinal vessel shift (RVS) and its association with axial length (AL) elongation in junior high school students.

METHODS

Total 161 eyes of 161 healthy junior high school students were prospectively studied. Optical AL and anterior chamber depth (ACD) measurements, and fundus photography were performed in the first and third grades. Eyes of subjects in the first and third grade that had perfect matching among all the retinal vessels were allocated to the RVS(-) group, otherwise allocated to the RVS(+) group. In the RVS(+) group, the peripapillary retinal arteries angle (PRAA) was measured for quantitative analysis of RVS; the angle between the major retinal arteries. The variables related to PRAA were identified using model selection with the corrected Akaike information criterion.

RESULTS

Forty-two eyes (26.1%) were allocated to the RVS(+) group. There were seven patterns in the RVS of those in the RVS(+) group, including clockwise shift in the supra temporal area (5 eyes), infra temporal area (7 eyes), and nasal area (9 eyes); anticlockwise shift in the supra temporal area (7 eyes), infra temporal area (5 eyes), and nasal area (2 eyes); and distal shift in the temporal area (7 eyes). The optimal model for the PRAA narrowing included larger AL and body weight in the first grade, and greater AL elongation.

CONCLUSION

Various (seven) RVS patterns were observed in about 25% of the junior high school students within two years. RVS was associated with AL elongation, and useful to reveal the mechanism of myopic retinal stretch.

Investigating the clinical usefulness of definitions of progression with 10-2 visual field

BACKGROUND/AIM

To investigate the clinical validity of the Guided Progression Analysis definition (GPAD) and cluster-based definition (CBD) with the Humphrey Field Analyzer 10-2 test in diagnosing glaucomatous visual field (VF) progression, and to introduce a novel definition with optimised specificity by combining the 'any-location' and 'cluster-based' approaches (hybrid definition).

METHODS

64 400 stable glaucomatous VFs were simulated from 664 pairs of 10-2 tests (10 sets × 10 VF series × 664 eyes; data set 1). Using these simulated VFs, the specificity to detect progression and the effects of changing the parameters (number of test locations or consecutive VF tests, and percentile cut-off values) were investigated. The hybrid definition was designed as the combination where the specificity was closest to 95.0%. Subsequently, another 5000 actual glaucomatous 10-2 tests from 500 eyes (10 VFs each) were collected (data set 2), and their accuracy (sensitivity, specificity and false positive rate) and the time needed to detect VF progression were evaluated.

RESULTS

The specificity values calculated using data set 1 with GPAD and CBD were 99.6% and 99.8%. Using data set 2, the hybrid definition had a higher sensitivity than GPAD and CBD, without detriment to the specificity or false positive rate. The hybrid definition also detected progression significantly earlier than GPAD and CBD (at 3.1 years vs 4.2 years and 4.1 years, respectively).

CONCLUSIONS

GPAD and CBD had specificities of 99.6% and 99.8%, respectively. A novel hybrid definition (with a specificity of 95.5%) had higher sensitivity and enabled earlier detection of progression.

Predicting the central 10 degrees visual field in glaucoma by applying a deep learning algorithm to optical coherence tomography images

We aimed to develop a model to predict visual field (VF) in the central 10 degrees in patients with glaucoma, by training a convolutional neural network (CNN) with optical coherence tomography (OCT) images and adjusting the values with Humphrey Field Analyzer (HFA) 24–2 test. The training dataset included 558 eyes from 312 glaucoma patients and 90 eyes from 46 normal subjects. The testing dataset included 105 eyes from 72 glaucoma patients. All eyes were analyzed by the HFA 10-2 test and OCT; eyes in the testing dataset were additionally analyzed by the HFA 24-2 test. During CNN model training, the total deviation (TD) values of the HFA 10-2 test point were predicted from the combined OCT-measured macular retinal layers’ thicknesses. Then, the predicted TD values were corrected using the TD values of the innermost four points from the HFA 24-2 test. Mean absolute error derived from the CNN models ranged between 9.4 and 9.5 B. These values reduced to 5.5 dB on average, when the data were corrected using the HFA 24-2 test. In conclusion, HFA 10-2 test results can be predicted with a OCT images using a trained CNN model with adjustment using HFA 24-2 test.

A Prediction Method of Visual Field Sensitivity Using Fundus Autofluorescence Images in Patients With Retinitis Pigmentosa

Purpose

The purpose of this study was to investigate the association between fundus autofluorescence (FAF) and visual field (VF) sensitivities in eyes with retinitis pigmentosa (RP). We also investigated the model we developed to predict VF sensitivity using the FAF ring and its prediction accuracy.

Methods

The training dataset consisted of 51 eyes of 28 patients, and the testing dataset consisted of 42 eyes of 25 patients with RP. VF and FAF measurements were conducted using the Humphrey Field Analyzer (HFA) 10-2 test and Optos. The HFA 10-2 test was divided into three sectors according to the association with the FAF (IN, ON, and OUT). Moreover, concentric curves were drawn at 1-degree intervals outside the FAF ring and OUT was divided into six sectors (from OUT1 to OUT6 toward the periphery). Finally, the total deviation (TD) value was predicted using age and visual acuity (VA) in the whole field, and each of the eight sectors was compared.

Results

The TD value decreased significantly from IN, ON, and then toward OUT6. The absolute prediction error with the FAF ring (average, 7.6 dB) was significantly smaller than that without the FAF ring (average, 8.7 dB). The absolute prediction error with the FAF ring was significantly smaller in the central areas (IN, 4.4 dB and ON, 5.3 dB) than those in the peripheral areas (OUT1-6, 6.8-9.1 dB).

Conclusions

VF sensitivity decreases in association with the FAF ring. We developed a model to predict 10-2 VF sensitivity values using the FAF ring, which enabled us to predict 10-2 TD values.

Short wavelength automated perimetry and standard automated perimetry in central serous chorioretinopathy

Short wavelength automated perimetry (SWAP) is known for detecting the early reduction of retinal sensitivity (RS) in glaucoma. It’s application in retinal diseases have also been discussed previously. We investigated the difference in RS measured between standard white-on-white automated perimetry (WW) and blue-on-yellow SWAP in central serous chorioretinopathy (CSC). The overall RS (W-RS, S-RS) as well as the RS inside and outside of the serous retinal detachment (SRD) region were investigated in 26 eyes of 26 CSC patients using WW and SWAP. The central retinal thickness, central choroidal thickness, SRD area (SRDa), and SRD height at the fovea were measured using optic coherence tomography. RS inside the SRD region was lower than that of outside for both perimetries (both p < 0.001). The difference between RS inside and outside of the SRD region was greater in SWAP compared to WW (p < 0.001). Univariate analysis revealed significant correlations between SRDa and both W-RS and S-RS (both p < 0.001); moreover, multivariate analysis indicated that only S-RS was selected as the optimal model for SRDa. Our study demonstrated that SWAP was detected the decrease in RS more accurately than WW in CSC. These results may suggest the usefulness of SWAP for detecting change of retinal function in CSC.

Predicting the Glaucomatous Central 10-Degree Visual Field From Optical Coherence Tomography Using Deep Learning and Tensor Regression

PURPOSE

To predict the visual field (VF) of glaucoma patients within the central 10° from optical coherence tomography (OCT) measurements using deep learning and tensor regression.

DESIGN

Cross-sectional study.

METHODS

Humphrey 10-2 VFs and OCT measurements were carried out in 505 eyes of 304 glaucoma patients and 86 eyes of 43 normal subjects. VF sensitivity at each test point was predicted from OCT-measured thicknesses of macular ganglion cell layer + inner plexiform layer, retinal nerve fiber layer, and outer segment + retinal pigment epithelium. Two convolutional neural network (CNN) models were generated: (1) CNN-PR, which simply connects the output of the CNN to each VF test point; and (2) CNN-TR, which connects the output of the CNN to each VF test point using tensor regression. Prediction performance was assessed using 5-fold cross-validation through the root mean squared error (RMSE). For comparison, RMSE values were also calculated using multiple linear regression (MLR) and support vector regression (SVR). In addition, the absolute prediction error for predicting mean sensitivity in the whole VF was analyzed.

RESULTS

RMSE with the CNN-TR model averaged 6.32 ± 3.76 (mean ± standard deviation) dB. Significantly (P < .05) larger RMSEs were obtained with other models: CNN-PR (6.76 ± 3.86 dB), SVR (7.18 ± 3.87 dB), and MLR (8.56 ± 3.69 dB). The absolute mean prediction error for the whole VF was 2.72 ± 2.60 dB with the CNN-TR model.

CONCLUSION

The Humphrey 10-2 VF can be predicted from OCT-measured retinal layer thicknesses using deep learning and tensor regression.

Deep learning model to predict visual field in central 10° from optical coherence tomography measurement in glaucoma

BACKGROUND/AIM

To train and validate the prediction performance of the deep learning (DL) model to predict visual field (VF) in central 10° from spectral domain optical coherence tomography (SD-OCT).

METHODS

This multicentre, cross-sectional study included paired Humphrey field analyser (HFA) 10-2 VF and SD-OCT measurements from 591 eyes of 347 patients with open-angle glaucoma (OAG) or normal subjects for the training data set. We trained a convolutional neural network (CNN) for predicting VF threshold (TH) sensitivity values from the thickness of the three macular layers: retinal nerve fibre layer, ganglion cell layer+inner plexiform layer and outer segment+retinal pigment epithelium. We implemented pattern-based regularisation on top of CNN to avoid overfitting. Using an external testing data set of 160 eyes of 131 patients with OAG, the prediction performance (absolute error (AE) and R² between predicted and actual TH values) was calculated for (1) mean TH in whole VF and (2) each TH of 68 points. For comparison, we trained support vector machine (SVM) and multiple linear regression (MLR).

RESULTS

AE of whole VF with CNN was 2.84±2.98 (mean±SD) dB, significantly smaller than those with SVM (5.65±5.12 dB) and MLR (6.96±5.38 dB) (all, p<0.001). Mean of point-wise mean AE with CNN was 5.47±3.05 dB, significantly smaller than those with SVM (7.96±4.63 dB) and MLR (11.71±4.15 dB) (all, p<0.001). R² with CNN was 0.74 for the mean TH of whole VF, and 0.44±0.24 for the overall 68 points.

CONCLUSION

DL model showed considerably accurate prediction of HFA 10-2 VF from SD-OCT.

The usefulness of the Deep Learning method of variational autoencoder to reduce measurement noise in glaucomatous visual fields

The aim of the study was to investigate the usefulness of processing visual field (VF) using a variational autoencoder (VAE). The training data consisted of 82,433 VFs from 16,836 eyes. Testing dataset 1 consisted of test-retest VFs from 104 eyes with open angle glaucoma. Testing dataset 2 was series of 10 VFs from 638 eyes with open angle glaucoma. A VAE model to reconstruct VF was developed using the training dataset. VFs in the testing dataset 1 were then reconstructed using the trained VAE and the mean total deviation (mTD) was calculated (mTDVAE). In testing dataset 2, the mTD value of the tenth VF was predicted using shorter series of VFs. A similar calculation was carried out using a weighted linear regression where the weights were equal to the absolute difference between mTD and mTDVAE. In testing dataset 1, there was a significant relationship between the difference between mTD and mTDVAE from the first VF and the difference between mTD in the first and second VFs. In testing dataset 2, mean squared prediction errors with the weighted mTD trend analysis were significantly smaller than those form the unweighted mTD trend analysis.

Use of micropulse trans-scleral cyclophotocoagulation for acute rise in intraocular pressure due to anterior segment inflammation

PURPOSE

The aim of this study was to report the use of micropulse trans-scleral cyclophotocoagulation as an adjunct therapy for two cases of medically uncontrolled intraocular pressure spikes due to anterior segment inflammation.Case description: Case 1 had previous cataract surgery and exhibited an intraocular pressure spike due to phacoantigenic uveitis (right eye intraocular pressure = 52 mmHg). Despite medical treatment, the right eye intraocular pressure remained high (43 mmHg), thus micropulse trans-scleral cyclophotocoagulation was carried out as a rescue therapy. After micropulse trans-scleral cyclophotocoagulation, the intraocular pressure at 1 day and 3 weeks was 9 and 16 mmHg, respectively. Case 2 had a history of previous blunt ocular trauma and 180° of angle recession. Both eyes were pseudophakia and underwent right eye Nd:YAG laser capsulotomy for posterior capsular opacification. Immediately after the procedure, the right eye intraocular pressure increased to 64 mmHg. Due to poor response to medical therapy, rescue micropulse trans-scleral cyclophotocoagulation was performed. After micropulse trans-scleral cyclophotocoagulation, the intraocular pressure at 1 day and 2 months was 12 and 21 mmHg, respectively.

CONCLUSION

Micropulse trans-scleral cyclophotocoagulation successfully decreased intraocular pressure in both cases of acute rise in intraocular pressure. Micropulse trans-scleral cyclophotocoagulation can potentially be useful as a rescue procedure to safely reduce medically uncontrollable intraocular pressure spike due to anterior segment inflammation.

Visualizing the dynamic change of Ocular Response Analyzer waveform using Variational Autoencoder in association with the peripapillary retinal arteries angle

The aim of the current study is to identify possible new Ocular Response Analyzer (ORA) waveform parameters related to changes of retinal structure/deformation, as measured by the peripapillary retinal arteries angle (PRAA), using a generative deep learning method of variational autoencoder (VAE). Fifty-four eyes of 52 subjects were enrolled. The PRAA was calculated from fundus photographs and was used to train a VAE model. By analyzing the ORA waveform reconstructed (noise filtered) using VAE, a novel ORA waveform parameter (Monot1-2), was introduced, representing the change in monotonicity between the first and second applanation peak of the waveform. The variables mostly related to the PRAA were identified from a set of 41 variables including age, axial length (AL), keratometry, ORA corneal hysteresis, ORA corneal resistant factor, 35 well established ORA waveform parameters, and Monot1-2, using a model selection method based on the second-order bias-corrected Akaike information criterion. The optimal model for PRAA was the AL and six ORA waveform parameters, including Monot1-2. This optimal model was significantly better than the model without Monot1-2 (p = 0.0031, ANOVA). The current study suggested the value of a generative deep learning approach in discovering new useful parameters that may have clinical relevance.

Early changes of vascular lesions and responses to combined photodynamic therapy in patients with polypoidal choroidal vasculopathy

PURPOSE

To evaluate early changes of vascular lesions and their associations with the early responses to combined photodynamic therapy (PDT) in eyes with polypoidal choroidal vasculopathy (PCV).

METHODS

This study evaluated 19 eyes of 19 patients with PCV who underwent PDT combined with anti-vascular endothelial growth factor injections and were followed for 3 months. All subjects were examined 1 week and 1, 2, and 3 months after combined PDT. "Active" cases were defined as recurrence or persistence of serous retinal detachment or subretinal hemorrhage detected within 3 months. Branching vascular networks (BVNs) were evaluated by optical coherence tomography angiography (OCTA) and polyps by indocyanine-green angiography.

RESULTS

In total, 16%, 58%, 84%, and 89% of eyes displayed BVNs 1 week, 1, 2, and 3 months after PDT, respectively. BVNs were detected significantly more often 1 month after PDT in the "active" group than "inactive" group (89% vs. 30%, p = 0.020). There were significantly higher overall proportions of BVNs detected by OCTA in the "active" group than "inactive" group (p = 0.0058).

CONCLUSION

In most cases, BVNs disappeared once and gradually appeared again within 3 months. Detecting BVNs using OCTA from early phases could be a helpful biomarker to assess the early responses to PDT in eyes with PCV.

Poor penetration of cefcapene into aqueous humor after oral administration of cefcapene pivoxil to patients undergoing cataract surgery

OBJECTIVES

Studies on the penetration of orally administered cephalosporins to the aqueous humor are scarce. Therefore, in this study, we determined the concentration of cefcapene, a third-generation cephalosporin administrated orally as pivalate ester (cefcapene pivoxil), in the aqueous humor of patients undergoing cataract surgery to assess its potential for preventing postoperative endophthalmitis.

METHODS

Forty-four patients were administered a single dose of 100 mg cefcapene pivoxil preoperatively. Blood and aqueous humor samples were obtained at the time of surgery, and cefcapene concentrations were measured using ultra-performance liquid chromatography with tandem mass spectrometric detection.

RESULTS

The samples were obtained from 41 eyes of 39 patients (two patients underwent surgery in both eyes). The median cefcapene concentrations in the aqueous humor after 1-2 h, 2-3 h, and later than 3 h were 8.3, 18.4, and 23.7 ng/mL, respectively. The median cefcapene concentrations in serum after 1-2 h, 2-3 h, and later than 3 h were 198.5, 287.2, and 170.3 ng/mL, respectively. Aqueous humor penetration of cefcapene after 1-2 h, 2-3 h, and later than 3 h was 4.1, 7.9, and 13.5% respectively.

CONCLUSIONS

Aqueous humor penetration of orally-administered cefcapene pivoxil in patients undergoing cataract surgery was poor. Therefore, cefcapene pivoxil was unlikely to be effective for preventing endophthalmitis after cataract surgery.

Correlation Between the Myopic Retinal Deformation and Corneal Biomechanical Characteristics Measured With the Corvis ST Tonometry

Purpose

We previously reported that the retinal deformation due to myopia was represented by the peripapillary retinal arteries angle (PRAA). In this study, we investigated the relationship between the PRAA and biomechanical properties measured with Corvis ST (CST) tonometry.

Methods

Thirty-four normative eyes of 34 subjects who underwent CST measurement were enrolled. The PRAA was calculated from a fundus photograph. Variables related to the PRAA were identified from age, axial length, spherical equivalent refractive error, and 10 CST parameters using model selection with the second-order bias-corrected Akaike information criterion index.

Results

The PRAA was best described with axial length (coefficient = −5.66, P < 0.0001), maximum deflection amplitude (mm; coefficient = 130.5, P = 0.0004), and deflection amplitude ratio (DA ratio) 2 mm (coefficient = −25.8, P = 0.0032), where mm was the amount of the maximum corneal apex movement and DA ratio 2 mm was the ratio between the deformation amplitudes at the apex and 2 mm away from the apex. The optimal model was significantly better than the model only with axial length (P = 0.0014, analysis of variance).

Conclusions

The PRAA was significantly better described with the CST parameters compared to the axial length model only; eyes with small PRAA (larger myopic retinal deformation) showed narrow and shallow maximum corneal deflection.

Translational Relevance

The Corvis ST parameters, which represents corneal biomechanical characteristics, were associated with myopic retinal deformation.

Observation of two types of charge-density-wave orders in superconducting La2-xSrxCuO4

The discovery of charge- and spin-density-wave (CDW/SDW) orders in superconducting cuprates has altered our perspective on the nature of high-temperature superconductivity (SC). However, it has proven difficult to fully elucidate the relationship between the density wave orders and SC. Here, using resonant soft X-ray scattering, we study the archetypal cuprate La_2-xSr_xCuO₄ (LSCO) over a broad doping range. We reveal the existence of two types of CDW orders in LSCO, namely CDW stripe order and CDW short-range order (SRO). While the CDW-SRO is suppressed by SC, it is partially transformed into the CDW stripe order with developing SDW stripe order near the superconducting T_c. These findings indicate that the stripe orders and SC are inhomogeneously distributed in the superconducting CuO₂ planes of LSCO. This further suggests a new perspective on the putative pair-density-wave order that coexists with SC, SDW, and CDW orders.

To fully elucidate the relationship between density wave orders and superconductivity in high-T_c cuprates remains difficult. Here, the authors reveal two types of charge-density-wave orders and their intertwined relationship with spin-density-wave order and superconductivity in La_2-xSr_xCuO_4.

Validating the efficacy of the binomial pointwise linear regression method to detect glaucoma progression with multicentral database

BACKGROUND/AIM

We previously reported the benefit of applying binomial pointwise linear regression (PLR: binomial PLR) to detect 10-2 glaucomatous visual field (VF) progression. The purpose of the current study was to validate the usefulness of the binomial PLR to detect glaucomatous VF progression in the central 24°.

METHODS

Series of 15 VFs (Humphrey Field Analyzer 24-2 SITA-standard) from 341 eyes of 233 patients, obtained over 7.9±2.1 years (mean±SD), were investigated. PLR was performed by regressing the total deviation of all test points. VF progression was determined from the VF test points analyses using the binomial test (one side, p<0.025). The time needed to detect VF progression was compared across the binomial PLR, permutation analysis of PLR (PoPLR) and mean total deviation (mTD) trend analysis.

RESULTS

The binomial PLR was comparable with PoPLR and mTD trend analyses in the positive predictive value (0.18-0.87), the negative predictive value (0.89-0.95) and the false positive rate (0.057-0.35) to evaluate glaucomatous VF progression. The time to classify progression with binomial PLR (5.8±2.8 years) was significantly shorter than those with mTD trend analysis (6.7±2.8 years) and PoPLR (6.6±2.7 years).

CONCLUSIONS

The binomial PLR method, which detected glaucomatous VF progression in the central 24° significantly earlier than PoPLR and mTD trend analyses, shows promise for improving our ability to detect visual field progression for clinical management of glaucoma and in clinical trials of new glaucoma therapies.

Relentless Placoid Chorioretinitis: A Case Series of Successful Tapering of Systemic Immunosuppressants Achieved with Adalimumab

Background

Adalimumab, a human anti-tumor necrosis factor-ɑ monoclonal antibody, was recently reported to be effective in lowering the risk of recurrence of noninfectious uveitis. This is the first case series of adalimumab administrations for relentless placoid chorioretinitis (RPC) patients.

Case Presentation

We report 2 cases of RPC where successful treatments were achieved with adalimumab. A 34-year-old woman developed conjunctival hyperemia, mild iridocyclitis, and multiple atrophic retinal lesions, along with exudative changes that were widespread from the posterior pole to peripheral retina in both eyes. The diagnosis of RPC was made based on the characteristic recurrences of choroiditis despite systemic corticosteroid and cyclosporine. Adalimumab therapy was introduced to the patient, and thereafter no recurrence was observed while tapering the immunosuppressive agents. The second case was a 22-year-old man with visual deterioration in both eyes who exhibited widespread multiple chorioretinal atrophic lesions. We diagnosed the case as RPC based on characteristic clinical findings and recurring chorioretinitis during tapering of systemic corticosteroids. Adalimumab therapy was administrated, and immunosuppressant dosage was successfully reduced without any recurrences.

Conclusions

In the current two RPC cases, adalimumab was quite effective and useful to reduce the dosages of systemic immunosuppressants. Further study is necessary to confirm the effectiveness of adalimumab in RPC patients.

Retinal sensitivity in angioid streaks

PURPOSE

To investigate retinal sensitivity in eyes with angioid streaks (AS).

METHODS

This study was a retrospective observational case series. A total of 13 eyes from 9 patients with AS underwent ophthalmologic examination, including fundus autofluorescence (FAF), spectral domain optical tomography (SD-OCT), and microperimetry. Retinal pigment epithelium (RPE) atrophy was assessed using FAF. Outer retinal atrophy, more specifically, disruption of the ellipsoid zone, was evaluated using SD-OCT images. The association between retinal sensitivity, RPE atrophy or outer retinal atrophy, and patient demographic characteristics or ophthalmologic findings were investigated.

RESULTS

The mean area of outer retinal atrophy was 14.5 ± 12.9 mm², significantly larger than the mean area of RPE atrophy (9.0 ± 9.0 mm²; P = 0.0028). The average retinal sensitivity in the area of RPE atrophy was 2.4 ± 5.6 dB, that in the area of outer retinal atrophy outside RPE atrophy was 14.6 ± 7.5 dB, and that in the area without any atrophy was 25.6 ± 5.1 dB. Reticular pseudodrusen (RPD) was observed in 5 eyes. Eyes with RPD showed a greater extent of both outer retinal atrophy and RPE atrophy than those without RPD and a greater decrease in mean retinal sensitivity.

CONCLUSIONS

In eyes with AS, especially in those with RPD, large areas of outer retinal atrophy and RPE atrophy were observed, and the retinal sensitivity in the areas was correspondingly decreased.

Relationship Between the Shift of the Retinal Artery Associated With Myopia and Ocular Response Analyzer Waveform Parameters

PURPOSE

We have recently reported that the retinal stretch due to myopia is closely related to the peripapillary retinal arteries angle (PRAA) (Yamashita et al., Invest Ophthalmol Vis Sci 2013;54:5481-5488). The purpose of the current study was to investigate the relationship between retinal artery position and Ocular Response Analyzer (ORA) waveform parameters.

METHODS

In 43 eyes of 41 healthy subjects, ORA measurements were carried out and the PRAA was calculated from fundus photographs. Then, the variables related to PRAA were identified from 40 variables of age, axial length (AL), keratometry, ORA corneal hysteresis (CH), ORA corneal resistant factor (CRF), and 35 ORA waveform parameters, using the Lasso regression and model selection with the second-order bias-corrected Akaike information criterion index.

RESULTS

The optimal model for PRAA included AL, CRF, and three ORA waveform parameters (aindex, w2, and slew1). This optimal model was significantly better than the model with AL-only, the model only with AL and CH, and the model only with AL and CRF (P < 0.0001, P < 0.0001, P < 0.0001, respectively; analysis of variance).

CONCLUSIONS

The PRAA was significantly better represented by using AL and ORA parameters including waveform parameters, compared with AL alone, with AL and CH alone, and with AL and CRF alone.

TRANSLATIONAL RELEVANCE

ORA waveform, which represents corneal biomechanical properties, was associated with myopic retinal stretch.

Early Detection of Glaucomatous Visual Field Progression Using Pointwise Linear Regression With Binomial Test in the Central 10 Degrees

PURPOSE

We previously reported that it was beneficial to apply binomial pointwise linear regression (PLR) to detect 24-2 glaucomatous visual field (VF) progression, compared to mean deviation (MD) trend analysis and permutation analysis of PLR (PoPLR). The purpose of the current study was to validate the usefulness of the binomial PLR method to detect VF progression in the central 10 degrees in glaucoma patients.

DESIGN

Reliability assessment.

METHODS

A series of 15 VFs (Humphrey Field Analyzer 10-2 SITA-standard) from 97 eyes in 69 primary open-angle glaucoma patients, obtained over 8.5 ± 1.3 years (mean ± SD), were investigated. PLR was performed by regressing the total deviation of all test points on the series of 15 VFs. VF progression was determined from the analyses of VF test points using the binomial test (1-sided, P < .025). The time needed to detect VF progression was also investigated. The results were compared with PoPLR and MD trend analyses.

RESULTS

The binomial PLR was comparable to PoPLR and MD trend analyses in the positive predictive value (0.19 to 0.80), the negative predictive value (0.86 to 1.0), and the false positive rate (0.0 to 0.13) to evaluate glaucomatous VF progression. The time needed to detect VF progression (4.2 ± 1.8 years) was significantly shorter with the binomial PLR method compared with PoPLR and MD trend analysis (P = .04, P = .012, respectively).

CONCLUSIONS

The binomial PLR method detected glaucomatous VF progression in the central 10 degrees significantly earlier than PoPLR and MD trend analyses.

Optic disc cupping characteristics of normal pressure hydrocephalus patients with normal-tension glaucoma

We examined the potential association of idiopathic normal pressure hydrocephalus (iNPH) with the generation of normal-tension glaucoma (NTG), to explore possible relationships between intracranial pressure (ICP) and the presence of glaucoma, and to compare disc morphology of NTG patients with or without iNPH. We investigated 20 iNPH patients, examined the prevalence of glaucoma, and compared the optic discs of NTG patients with iNPH (n = 11) and age-matched NTG patients without iNPH (n = 16). All data were collected prior to the treatment of iNPH, to eliminate the possibility that the treatment may have contributed to the progression of NTG. The diagnoses of NTG were made using visual field data, intraocular pressure measurements, fundoscopy, and optical coherence tomography (OCT). Using OCT, the optic nerve disc depth was also measured. The ICP was higher in the iNPH with NTG compared to iNPH without NTG (p = 0.0425), and the cupping depths of the discs of NTG patients with iNPH were significantly shallower compared with those of NTG patients without iNPH (p = 0.0097). Based on the difference in cupping depth, NTG patients with iNPH may have a different morphology from typical glaucoma patients, which could in turn reflect a different pathogenesis compared to NTG patients without iNPH.

PCR Analysis Methods for Detection and Identification of Beer-Spoilage Lactic Acid Bacteria

Polymerase chain reaction (PCR) analysis enables rapid and accurate detection of beer-spoilage lactic acid bacteria (LAB). Hop resistance genes, horA and horC, are utilized as genetic markers to determine the spoilage ability of LAB strains. PCR analysis of horA and horC, combined with multiplex PCR methods of 12 beer-spoilage species, enables simultaneous and comprehensive detection easily and inexpensively.

Corneal biomechanical properties are associated with the activity and prognosis of Angioid Streaks

The aim of the current study is to investigate corneal biomechanical properties in detail using Ocular Response Analyzer (ORA) and Corvis ST (CST) tonometry and to analyze the association between corneal biomechanical properties and the frequency of intravitreal anti-vascular endothelial growth factor (VEGF) injections (F_IV) in AS eyes with choroidal neovascularization (CNV). Twenty-eight eyes of 15 patients with AS were enrolled. Mean age of AS patients was 67.9 ± 9.8 years. ORA and CST measurements were carried out, in addition to comprehensive ophthalmic examinations. LogMAR visual acuity (VA) and ΔVA (the change of VA from baseline to the final visit) were calculated in each eye. Also, the relationships between F_IV, and the variables of initial age at the observation period, axial length, and corneal biomechanical properties were investigated in eyes with AS using linear mixed model with model selection using AICc. In 28 AS eyes, 16 eyes underwent intravitreal anti-VEGF injections during follow-up period. Lower corneal hysteresis (CH), higher corneal resistant factor (CRF) and higher CST measured the DA ratio were associated with the increase of F_IV in AS eyes (p = 0.01, p = 0.002, p = 0.027, respectively), suggesting the usefulness for monitoring of corneal biomechanical properties.

Investigating the Usefulness of Fundus Autofluorescence in Retinitis Pigmentosa

PURPOSE

To investigate the relationship between visual field (VF) loss and the rings of the ellipsoid zone (EZ) and autofluorescence (AF) in patients with retinitis pigmentosa (RP).

DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 28 eyes of 15 patients with a clinical diagnosis of RP.

METHODS

The VF was measured at a 1-degree interval on the horizontal or vertical lines, within the central 10 degrees from fixation, using MP-3 microperimetry (Nidek Co. Ltd., Aichi, Japan), and the sensitivity deviation from the normative database was calculated. OCT was performed, and the EZ was identified. Fundus AF was also measured, and the AF ring was identified. The VF test points were categorized according to their relationship with the EZ line and AF ring. The relationship between mean retinal sensitivity deviations on both the horizontal and vertical lines and the diameters of the EZ line and the AF ring in the corresponding directions was analyzed. The relationship between visual sensitivity deviation and the locations against EZ line and AF rings was also investigated.

MAIN OUTCOME MEASURES

The relationship between the visual sensitivity deviation and the locations against EZ line and AF rings.

RESULTS

The diameter of the AF ring had a significantly stronger relationship with mean retinal sensitivity deviation compared with the diameter of the EZ line in both the horizontal and vertical directions. Test point location inside/on/outside the AF ring was significantly related to retinal sensitivity deviation independent of the location inside/outside the EZ line (P < 0.001, linear mixed model).

CONCLUSIONS

Visual sensitivity damage is significantly associated with the EZ lines and AF rings. The development of the AF ring is related to the decrease of visual function independent of and stronger than the EZ line.

Choroidal structure as a biomarker for visual acuity in intravitreal aflibercept therapy for polypoidal choroidal vasculopathy

PURPOSE

To investigate the relationship between choroidal structure and visual acuity after intravitreal aflibercept therapy for polypoidal choroidal vasculopathy (PCV).

METHODS

We conducted a retrospective, single-centre and observational study including 18 eyes of 18 patients with PCV (73.8 ± 10.2 years of age) who were treated with three monthly intravitreal aflibercept injections followed by additional treatments in a treat-and-extend protocol. The cross-sectional images of the macula were obtained with enhanced depth imaging optical coherence tomography at baseline, at 3 months, and at 12 months. The choroidal layer was divided into luminal or stromal segments by applying binarization processing to calculate these areas. The relationships between age, spherical equivalent, best-corrected visual acuity (BCVA), baseline value, or changes in the luminal or the stromal areas, and the BCVA change at 12 months were analysed using multiple regression analyses and model selection procedures.

RESULTS

Both stromal and luminal areas were decreased at 3 and 12 months compared to baseline areas (5% and 9% at 3 months, 6% and 12% at 12 months, p < 0.0001, p < 0.0001, p < 0.0001 and p < 0.0001, respectively). Greater improvement of visual acuity (VA) at 12 months was significantly associated with younger age, greater spherical equivalent, worse baseline BCVA, greater baseline luminal area, and smaller baseline stromal area.

CONCLUSIONS

Choroidal structure might be useful as a new biomarker for potential Visual outcomes after intravitreal aflibercept therapy for PCV.

An investigation of visual hallucinations associated with voriconazole administration to patients with hematological malignancies

Voriconazole (VRCZ) is commonly administered to treat fungal infections in patients with hematological malignancies. Some of these patients experience VRCZ-associated visual hallucinations. We conducted a retrospective survey to investigate the characteristic features of this side effect. Patients with hematological malignancies who were treated with VRCZ for a fungal infection after hospitalization at Ichinomiya municipal hospital between 1 October 2005 and 31 December 2015 were included in this study (n = 103). Fifteen of these (14.6%) reported visual hallucinations that started on day 1-7. Seven of these 15 patients developed this symptom rapidly (day 1 or 2). Three patients had transient symptoms (lasting 2-12 days), 6 patients experienced hallucinations throughout the treatment, and the duration was unknown in 6 patients. Eleven patients experienced visual hallucinations when their eyes were closed (73 %) and these disappeared when they opened their eyes. One patient had visual hallucinations with open eyes, while the state of the eyes was unknown in 3 patients. The patients saw a range of images including people, animals, landscapes, and foods; several reported seeing images like those found in movies. In addition, 9 of 15 patients (60%) with visual hallucinations had visual disturbances. This was a higher proportion than that observed in patients who did not develop hallucinations (17 of 88; 19.3 %; P < 0.05). However, we found no significant difference between the blood VCRZ concentrations of patients who developed or did not develop visual hallucinations. This study indicated that most of these patients had visual hallucinations that manifested on eye closure, and they did not progress to serious mental illness. Our findings emphasized the importance of fully explaining the features of this symptom to each patient prior to starting VRCZ administration in order to reduce anxiety. In addition, since VRCZ discontinuation will compromise patient management, therapeutic drug monitoring should be used to increase the likelihood of successful therapy.

Bovine leukemia virus G4 enhances virus production

The nonstructural G4 gene of bovine leukemia virus (BLV) has been thought to function in virus replication. However, the discovery of the AS1 gene on the antisense strand of the G4 gene has affected this interpretation. In this study, we investigated the function of G4 in virus production independent of the AS1 gene using a reverse genetic approach, and briefly examined the association of the G4 protein with Tax, which is also a nonstructural protein that promotes virus replication. First, we constructed a mutant molecular clone of BLV with a nonsense mutation in G4 that had a minimal effect on the AS1 gene. Comparison of the wild-type and mutant molecular clones indicated that the nonsense mutation resulted in a reduction of virus in the culture supernatant and accumulation of viral RNA (vRNA) in cells. Moreover, G4 and Tax expression in cells was shown to synergistically enhance virus production. Therefore, we suggest that G4 enhances virus production through abrogation of vRNA accumulation.

Distribution of Tomato spotted wilt virus in dahlia plants

Tomato spotted wilt virus (TSWV) causes significant losses in the production of the ornamental plant Dahlia variabilis in Japan. The purpose of this study was to examine the distribution of TSWV in dahlia plants and identify plant parts that can be used in the selection of TSWV-free plants. The distribution of TSWV was investigated using reverse transcriptional polymerase chain reaction (RT-PCR) and tissue blot immunoassay. The detection rate of TSWV in latent infected compound leaves was the highest in the petiole, and it decreased from the veins and rachis to the lamina. The tissue blot immunoassays of the leaflets showed an uneven distribution of TSWV, especially along the edge of the leaf blade. In stems, the detection rate of TSWV was high partway up the stem compared to that in the upper and the lower parts of the stem during the vegetative growth stage. A highly uneven distribution was observed in the bulb. Our results indicated that middle parts of the stem as well as the petioles, rachis, and veins of compound leaves are suitable for detection of TSWV in dahlias. This study is the first to report uneven distribution of TSWV in dahlia plants.

SIGNIFICANCE AND IMPACT OF THE STUDY

In this study, the distribution of Tomato spotted wilt virus (TSWV) in various parts of dahlia plants was investigated for the first time. The distribution of TSWV was uneven in compound leaves, leaflets, stems, and bulbs. The middle parts of the stem or the petiole and leaf veins should be sampled to detect TSWV when selecting healthy plants.

Design protocol of microjet mixers for achieving desirable mixing times with arbitrary flow rate ratios

We extensively examined the performance of microjet mixers.

Impact of levofloxacin dose adjustments by dispensing pharmacists on adverse reactions and costs in the treatment of elderly patients

Ensuring an appropriate dosage of renally eliminated drugs for patients with renal insufficiency is important for preventing adverse drug reactions. We investigated the effectiveness of interventions by pharmacists in a hospital pharmaceutical department. The comparative study was performed at Gifu Municipal Hospital in Japan from March to August 2011, and included an intervention (142 patients) and a control group (98 patients). Upon receiving a prescription of levofloxacin for patients aged > or = 75 years, pharmacists evaluated the patients' kidney function and adjusted the appropriate dosage at the time of dispensation. In the intervention and control groups, levofloxacin-induced adverse reactions developed in 6 of 142 (4.2%) and 13 of 98 (13.3%) patients, respectively (p < 0.05). The cost of reducing levofloxacin per patient was yen 191.1 and yen 0 in the intervention and control groups, respectively. The cost per patient for adverse reaction treatments and examinations was yen 15.5 and yen 290.0 in the intervention and control groups, respectively. The intergroup difference in the total cost per patient was yen 465.6. Dose adjustment of levofloxacin at the time of dispensation by the pharmacist for patients aged > or = 75 years resulted in a decrease in the incidence of adverse reactions and cost. These findings can be applied not only to hospitals, but also to community pharmacies, because the intervention, which is a manual system, is simply performed when pharmacists are dispensing drugs.

PBSC collection from family donors in Japan: a prospective survey

Severe adverse events (SAE) and late hematological malignancies have been reported after PBSC donation. No prospective data on incidence and risk factors have been available for family donors so far. The Japan Society for Hematopoietic Cell Transplantation (JSHCT) introduced therefore in 2000 a mandatory registration system. It defined standards for donor eligibility and asked harvest centers to report any SAE immediately. All donors were examined at day 30 and were to be contacted once each year for a period of 5 years. Acute SAEs within day 30 were reported from 47/3264 donations (1.44%) with 14 events considered as unexpected and severe (0.58%). No donor died within 30 days. Late SAEs were reported from 39/1708 donors (2.3%). The incidence of acute SAEs was significantly higher among donors not matching the JSHCT standards (P=0.0023). Late hematological malignancies in PBSC donors were not different compared with a retrospective cohort of BM donors (N:1/1708 vs N:2/5921; P=0.53). In conclusion, acute and late SAEs do occur in PBSC donors at relatively low frequency but risk factors can be defined.