Evaluating photodynamic therapy versus brolucizumab as a second-line treatment for polypoidal choroidal vasculopathy

BACKGROUND

To compare the one-year outcomes between intravitreal brolucizumab (IVBr) monotherapy and photodynamic therapy (PDT) as a second-line treatment in patients with polypoidal choroidal vasculopathy (PCV) who did not respond to first-line therapy.

METHODS

This case-control study included eyes with PCV that do not respond to aflibercept or ranibizumab. The patients were retrospectively registered. We compared outcomes, including best-corrected visual acuity (BCVA), anatomical results, and the need for additional treatments, between IVBr and a combination therapy using PDT as second-line treatments for refractory PCV, after adjusting for potential confounders. We analyzed E-values to evaluate the robustness of the results against unmeasured confounders.

RESULTS

Twenty-two eyes received IVBr, and twenty-four underwent PDT. No apparent differences were observed in BCVA and central macular thickness (CMT) changes from baseline between the groups (IVBr vs. PDT: BCVA, 0.01 ± 0.47 logMAR vs. 0.04 ± 0.18 logMAR, P-value = 0.756; CMT: - 36.3 ± 99.4 μm vs. - 114.7 ± 181.4 μm, P-value = 0.146). Only in the PDT group, five eyes (20.8%) did not require additional treatment after the second-line treatment, the adjusted odds ratio indicating no further treatment needed was 11.98 (95% confidence interval: 1.42-2070.07, P-value = 0.019). The E-value for the adjusted odds ratio was 23.44.

CONCLUSIONS

Both second-line treatments for PCV exhibited similar visual and anatomical outcomes. Only in the PDT-treated eyes were there some patients who did not require further treatment after second-line therapy.

Colour tone of retinal arterioles imaged with a colour scanning laser ophthalmoscope can be an indicator of systemic arterial stiffness

OBJECTIVE

Colour scanning laser ophthalmoscope (cSLO) offers several advantages, including improved image quality and better visualisation of the retinal structures compared with colour fundus photograph (CFP). This study aimed to identify whether cSLO could be used to predict systemic arterial stiffness.

METHODS AND ANALYSIS

We retrospectively analysed the data of 54 patients with 103 eyes. In addition to blood pressure and blood data, all patients had cardio-ankle vascular index (CAVI) measurements, as well as images of the fundus acquired using cSLO and CFP. We determined the retinal artery sclerosis (RAS) index from the colour of the retinal artery in cSLO images, the ratio of arterial to venous diameter (A/V ratio), and Scheie's classification in CFP images. The correlation between each parameter and CAVI was examined using Spearman's rank correlation coefficient, and the correlation between Scheie's classification and CAVI was examined using Steel-Dowass tests.

RESULTS

CAVI showed a significant positive correlation with the RAS index (r=0.679, p<0.001) but not with the A/V ratio or Scheie's classification. Multiple regression analysis showed that the RAS index was significantly and independently correlated with CAVI.

CONCLUSION

cSLO is a non-invasive imaging modality that has the potential to accurately and instantaneously detect early systemic arterial stiffness.

Vortex Veins in Eyes With Pachychoroid Spectrum Disorders Evaluated by the Adjusted Reverse 3-Dimensional Projection Model

Purpose

To compare the distribution of vortex vein ampulla (VVA) between pachychoroid spectrum disorder (PSD) and controls.

Design

A single-center, case-control study.

Participants

This study included 75 PSD, 35 fellow, and 65 control eyes.

Methods

We quantified VVA distribution using a 3-dimensional reverse projection model corrected for image distortion. We investigated the distribution of major drainage veins (MDV), in which macular Haller's vessels directly influx.

Main Outcome Measures

The mean distances from the optic disc to VVAs and the mean angles between VVAs and the fovea-disc line.

Results

The PSD group had significantly fewer VVA in infranasal sector (PSD, fellow, control; 1.6 ± 0.6, 1.8 ± 0.6, 1.9 ± 0.6, respectively, P = 0.026). In supralateral sector, for PSD, fellows, and controls, the mean distances from the optic disc to VVAs were 14.1 ± 1.0 mm, 14.1 ± 1.1 mm, and 13.6 ± 1.4 mm, respectively, and were significantly farther in PSD than in controls (P = 0.023). The mean angles between VVAs and the fovea-disc line were 64.8 ± 5.9°, 66.4 ± 6.4°, and 61.7 ± 6.4°, respectively, and were significantly higher in PSD and fellows than in controls (P = 0.008). The mean distances from the optic disc to MDV in supratemporal sector were 14.1 ± 1.2 and 13.7 ± 1.2 in eyes whose Haller's vessels extended beyond the fovea-disc line (asymmetry), and those that did not, respectively, with the asymmetric eyes significantly farther (P = 0.016).

Conclusions

The VVA position in supralateral sector was farther and higher in PSD than in controls, suggesting that the distribution of VVA may be associated with the development of PSD.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Characteristics Related to Visual Acuity Loss After Successful Photodynamic Therapy for Eyes With Central Serous Chorioretinopathy

PURPOSE

This study aimed to examine baseline characteristics for identifying factors associated with vision loss (VL) in patients with central serous chorioretinopathy (CSC) who successfully responded to photodynamic therapy (PDT).

DESIGN

A retrospective, clinical case-control study.

METHODS

This study included 85 eyes with CSC, which underwent PDT, and resolved serous retinal detachment. These eyes were classified into 2 groups: the VL group (best-corrected visual acuity 6 months after PDT was worse than that at baseline) and the vision maintenance or improved group (the others). Baseline factors were analyzed to determine the characteristics of the VL group and assess the diagnostic potential of these factors.

RESULT

Seventeen eyes were included in the VL group. The mean values of the neurosensory retinal (NSR) thickness, the internal limiting membrane-external limiting membrane thickness (IET), and the external limiting membrane-photoreceptor outer segment thickness (EOT) in the VL group were significantly thinner than those in the vision maintenance or improved group (NSR thickness, 123.2 ± 39.7 µm vs 166.3 ± 49.6 µm, P < .001; IET, 63.1 ± 17.0 µm vs 88.0 ± 25.4 µm, P < .001; EOT, 60.1 ± 28.6 µm vs 78.3 ± 33.1, P = .041). The sensitivity, specificity, and positive and negative predictive values for predicting VL were 94.1%, 50.0%, 32.0%, and 97.1% for NSR thickness; 94.1%, 51.5%, 32.7%, and 97.2% for IET; and 94.1%, 30.9%, 25.4%, and 95.5% for EOT, respectively.

CONCLUSIONS

Pretreatment sensory retinal layer thickness could predict VL after PDT for CSC and may be a helpful reference for PDT.

Increased incidence of endophthalmitis after vitrectomy relative to face mask wearing during COVID-19 pandemic

BACKGROUND/AIMS

To determine the incidence and causative pathogens of endophthalmitis after vitrectomy during strict face mask wearing in the COVID-19 period.

METHODS

This was a retrospective multicentre study including 31 ophthalmological institutions of the Japanese Retina and Vitreous Society or Japan-Clinical Retina Study group. Patients who had undergone vitrectomy during 2019, the pre-COVID-19 period, and from July 2020 to June 2021, the COVID-mask period, were studied. The results of cataract surgery were used as a control. The total number of vitrectomies and the total number of postoperative endophthalmitis were determined. Then, the differences in the incidence of postoperative endophthalmitis between the pre-COVID-19 period and the COVID-mask period, and the type of pathogens causing the endophthalmitis were studied.

RESULTS

The incidence of postvitrectomy endophthalmitis was significantly lower in the pre-COVID-19 period with 16 568 surgeries and 18 endophthalmitis cases (0.11%) than in the COVID-mask period of 14 929 surgeries and 31 endophthalmitis cases (0.21%; p=0.031, OR=1.913, 95% CI 1.078 to 3.394). In the pre-COVID-19 period, 4 of the 18 eyes were culture positive, and all were of the Staphylococcus family. In the COVID-mask period, 9 of the 31 eyes were culture positive, and 4 cases were related to oral commensals including Streptococcus spp, which are reportedly very rare in endophthalmitis after vitrectomy.

CONCLUSIONS

It is necessary for physicians to be aware of the higher incidence of postvitrectomy endophthalmitis during the COVID-mask period, and to treat their patients appropriately.

Effect of the macular shape on hole findings in idiopathic macular hole differs depending on the stage of the macular hole

This study aimed to investigate the relationship between macular shape and idiopathic macular hole (MH) findings using an objective method. We present retrospective observational case series on patients with MH. The shape of the macular area was quantified using quadratic equations, and the ocular shape (OS) index was calculated. The correlation between the OS index and macular hole findings for each stage was evaluated. Pearson's correlation coefficient showed a significant correlation between the OS index and horizontal hole diameter (p = 0.044), bottom diameter (p = 0.006), and vertical bottom diameter (p = 0.024) in stage 2. For stage 4, there was a negative and significant correlation between the OS index and age (p = 0.037), and horizontal (p = 0.021) and vertical (p = 0.027) bottom diameter. Multiple regression analysis showed that the horizontal (p = 0.0070) and vertical (p = 0.031) bottom diameter and OS index were independently and positively correlated in stage 2. In stage 4, the OS index was independently and negatively correlated with the horizontal (p = 0.037) and vertical (p = 0.048) bottom diameter. The ocular shape of the macula affects MH findings, and its impact depends on its stage.

A Photodynamic Therapy Index for Central Serous Chorioretinopathy to Predict Visual Prognosis Using Pretreatment Factors

PURPOSE

This study aimed to establish a treatment index based on functional outcomes of photodynamic therapy (PDT) for central serous chorioretinopathy (CSC).

DESIGN

A retrospective clinical case-control study.

METHODS

This was a single-institute study. Eighty (80) eyes with CSC, who were treated by PDT and whose subretinal fluid resolves within 6 months were divided into two groups: those with poor visual outcome (PVO) (best-corrected visual acuity [BCVA] ≤ 0.5 6 months post-PDT), and the remaining eyes (better visual outcome [BVO]). The areas under the curve (AUC) and cutoff values from receiver operating characteristic curves were examined. These was used to predict the groups using pretreatment BCVA and the thickness of each retinochoroidal layer.

RESULT

Twenty-one (21) eyes were in the PVO group and 59 eyes in the BVO group were included. The AUCs were 0.959 for BCVA, 0.959 for the thickness from the internal limiting membrane to the external limiting membrane (IET), 0.820 for the thickness from the external limiting membrane to the photoreceptor outer segment layer, 0.715 for the subfoveal retinal thickness, and 0.515 for the subfoveal choroidal thickness. The BCVA and IET cut-off values were 0.267 logMAR and 71.5 µm, respectively. Using the combination of the cutoff values of BCVA and IET, the highest values for the sensitivity, specificity, positive predictive value, and negative predictive value were 95.2%, 94.9%, 85.0%, and 98.0%, respectively.

CONCLUSION

The combination of pre-PDT BCVA and IET in CSC can accurately predict the post-treatment visual prognosis. These values could be used as a treatment index of PDT for CSC.

NORMAL PERIPHERAL CHOROIDAL THICKNESS MEASURED BY WIDEFIELD OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

Choroidal stasis plays an important role in the pathogenesis of many conditions and leads to choroidal thickening. However, the normal peripheral choroidal thickness (PCT) pattern remains unknown. This study investigated PCT and associated factors using ultrawidefield optical coherence tomography in healthy eyes.

METHODS

This cross-sectional study included 120 healthy eyes (57 males; age, 52.0 ± 20.5 years). We used choroidal thickness maps created by ultrawidefield optical coherence tomography (viewing angle, 200°) with real-shape correction. The peripheral area was defined from 60° to 100° and further separated vertically and horizontally. The PCT and the correlations between PCT and subjects' characteristics were examined.

RESULTS

The PCT were 227.1 ± 57.0 µ m, 199.6 ± 53.9 µ m, 196.6 ± 57.1 µ m, and 148.0 ± 38.2 µ m in supratemporal, infratemporal, supranasal, and infranasal areas, respectively. The thickest peripheral sector was most frequently observed in supratemporal (69.2%). The PCT negatively correlated with age in all regions ( P -values < 0.001) and axial length in supratemporal, supranasal, and infranasal areas ( P -values ≤ 0.003). The temporal PCT was thicker on the side contiguous with the posterior pole Haller's vessels ( P -values ≤ 0.020).

CONCLUSION

The PCT is associated with age, axial length, and the running pattern of Haller's vessels.

Effect of photodynamic therapy on choroid of the medial area from optic disc in patients with central serous chorioretinopathy

PURPOSE

To explore the effect of photodynamic therapy (PDT) on the choroid of medial area from optic disc and factors correlated with treatment outcomes, we evaluated choroidal changes using ultra-widefield optical coherence tomography (UWF-OCT) after PDT for central serous chorioretinopathy (CSC).

METHODS

In this retrospective case-series, we included CSC patients who received a standard-dose of full-fluence PDT. UWF-OCT were examined at baseline and 3 months after treatment. We measured choroidal thickness (CT), classified into central, middle, and peripheral sectors. We examined CT changes after PDT by sectors and treatment outcome.

RESULTS

Twenty-two eyes of 21 patients (20 males; mean age 58.7 ± 12.3 years) were included. CT reduction after PDT was significant in all sectors, including peripheral areas: supratemporal, 330.5 ± 90.6 μm vs. 237.0 ± 53.2 μm; infratemporal, 240.0 ± 89.4 μm vs. 209.9 ± 55.1 μm; supranasal, 237.7 ± 59.8 vs 209.3 ± 69.3 μm; infranasal, 172.6 ± 47.2 μm vs. 155.1 ± 38.2 μm (P < 0.001, for all). In patients with retinal fluid resolution, despite no apparent difference in baseline CT, there was more significant reduction after PDT in supratemporal and supranasal peripheral sectors, compared with patients without resolution: supratemporal, 41.9 ± 30.3 μm vs. -1.6 ± 22.7 μm; supranasal, 24.7 ± 15.3 μm vs. 8.5 ± 3.6 μm (P < 0.019, for both).

CONCLUSIONS

Whole CT decreased after PDT, including in medial areas from optic disc. This may be associated with the treatment response of PDT for CSC.

Wayfinding artificial intelligence to detect clinically meaningful spots of retinal diseases: Artificial intelligence to help retina specialists in real world practice

AIM/BACKGROUND

To aim of this study is to develop an artificial intelligence (AI) that aids in the thought process by providing retinal clinicians with clinically meaningful or abnormal findings rather than just a final diagnosis, i.e., a "wayfinding AI."

METHODS

Spectral domain optical coherence tomography B-scan images were classified into 189 normal and 111 diseased eyes. These were automatically segmented using a deep-learning based boundary-layer detection model. During segmentation, the AI model calculates the probability of the boundary surface of the layer for each A-scan. If this probability distribution is not biased toward a single point, layer detection is defined as ambiguous. This ambiguity was calculated using entropy, and a value referred to as the ambiguity index was calculated for each OCT image. The ability of the ambiguity index to classify normal and diseased images and the presence or absence of abnormalities in each layer of the retina were evaluated based on the area under the curve (AUC). A heatmap, i.e., an ambiguity-map, of each layer, that changes the color according to the ambiguity index value, was also created.

RESULTS

The ambiguity index of the overall retina of the normal and disease-affected images (mean ± SD) were 1.76 ± 0.10 and 2.06 ± 0.22, respectively, with a significant difference (p < 0.05). The AUC used to distinguish normal and disease-affected images using the ambiguity index was 0.93, and was 0.588 for the internal limiting membrane boundary, 0.902 for the nerve fiber layer/ganglion cell layer boundary, 0.920 for the inner plexiform layer/inner nuclear layer boundary, 0.882 for the outer plexiform layer/outer nuclear layer boundary, 0.926 for the ellipsoid zone line, and 0.866 for the retinal pigment epithelium/Bruch's membrane boundary. Three representative cases reveal the usefulness of an ambiguity map.

CONCLUSIONS

The present AI algorithm can pinpoint abnormal retinal lesions in OCT images, and its localization is known at a glance when using an ambiguity map. This will help diagnose the processes of clinicians as a wayfinding tool.

Quantification of Anterior Chamber Particles Using Anterior Segment Optical Coherence Tomography in Angle-Closure Glaucoma Patients after Laser Iridotomy

Purpose: To determine whether the degree of particle density in the anterior chamber can be evaluated objectively and quantitatively by anterior segment optical coherence tomography (AS-OCT) in cases after laser iridotomy (LI). Methods: This was a retrospective observational study. All of the subjects who received LI for angle-closure glaucoma between January 2018 and May 2019 at Kagoshima University Hospital were studied. AS-OCT recordings were made before, immediately after, and one week after LI in 22 eyes of 14 consecutive patients. The anterior chamber particle (ACP) index was defined as the ratio of the number of particles in the anterior chamber to the total area of the anterior chamber. The ACP index was determined by binarization of the AS-OCT images and analysis with the ImageJ program. Results: The mean age of the participants was 75.4 ± 8.9 years, with a range of 61−91 years. The ACP index before the LI was 0.78 ± 0.68, and it was significantly increased to 7.72 ± 2.64 immediately after the LI (paired t-test, p < 0.01). The ACP index returned to the pre-LI density of 0.92 ± 0.48 one week after the LI. Conclusions: We successfully quantified the degree of anterior chamber particles accumulation by analyzing images obtained by AS-OCT. This simple and repeatable technique should be useful because the particles, including inflammatory cells, in the anterior chamber can be evaluated non-invasively and objectively.

Comparison of multicolor scanning laser ophthalmoscopy and optical coherence tomography angiography for detection of microaneurysms in diabetic retinopathy

This study aimed to evaluate the usefulness of multicolor (MC) scanning laser ophthalmoscopy (MC-SLO) in detecting microaneurysm (MA) in eyes with diabetic retinopathy (DR). This was a retrospective cross-sectional study. Eyes with DR underwent fluorescein angiography (FA), MC-SLO, optical coherence tomography angiography (OCTA), and color fundus photography (CFP) were analyzed. The foveal region was cut in an 6 × 6 mm image and the number of MA in each image was counted by retina specialists to determine the sensitivity and positive predictive value. FA results were used as the ground standard. MAs were classified as those with early, late, or no dye leakage based on FA images. Fifty-four eyes of 35 patients with an average age of 64.5 ± 1.24 years were included. The sensitivity of MA detection was 37.3%, 15.3%, and 4.12% in MC-SLO, OCTA, and CFP, respectively (P < 0.01 in each pair).The positive predictive value was 66.4%, 46.4%, and 27.6% in MC, OCTA, and CFP, respectively (P < 0.01 in each pair). Sensitivity for MAs with early leakage was 36.4% in MC-SLO, which was significantly higher than 4.02% in OCTA. MC-SLO was more useful in detecting MA in eyes with DR than OCTA.

Silicone oil versus gas tamponade for primary rhegmatogenous retinal detachment treated successfully with a propensity score analysis: Japan Retinal Detachment Registry

Background/aims

To compare the effects of silicone oil tamponade (SOT) to that of gas tamponade (GT) on the best-corrected visual acuity (BCVA) after successful vitrectomy for retinal detachment (RD).

Methods

A retrospective, multicentre, nationwide study with RD who were registered in the Japan-RD Registry. All cases with RD treated with successful vitrectomy between February 2016 and March 2017 were studied. A propensity score matching was performed using the preoperative findings as covariates to adjust the relevant confounders. The primary outcome was the estimated mean difference of the postoperative BCVA in 6 months between eyes treated with SOT to those treated with GT.

Results

Of the 3446 cases registered, 2097 cases met the entry criteria. There were 2042 eyes that had GT and 55 eyes that had SOT. Primary success was defined as a reattached retina with no tamponade at 6 months. After propensity score matching, each group contained 40 cases. The preoperative BCVA was 0.966±0.738 logMAR units in the GT group and 1.270±0.945 logMAR units in the SOT group (p=0.177). Six months postoperatively, the BCVA in the GT group was significantly better at 0.309 logMAR units in the GT group than the 0.671 logMAR units in the SOT group (p=0.002).

Conclusions

Even after successful surgery for RD, eyes that experienced SOT had poorer BCVA than eyes treated with GOT. SOT should be considered cautiously.

Precis

Propensity score analysis of eyes with rhegmatogenous RD showed that postoperative vision was worse in eyes treated once with silicone oil than with gas even after completely successful surgery.

Artificial intelligence for classifying uncertain images by humans in determining choroidal vascular running pattern and comparisons with automated classification between artificial intelligence

Purpose

Abnormalities of the running pattern of choroidal vessel have been reported in eyes with pachychoroid diseases. However, it is difficult for clinicians to judge the running pattern with high reproducibility. Thus, the purpose of this study was to compare the degree of concordance of the running pattern of the choroidal vessels between that determined by artificial intelligence (AI) to that determined by experienced clinicians.

Methods

The running pattern of the choroidal vessels in en face images of Haller’s layer of 413 normal and pachychoroid diseased eyes was classified as symmetrical or asymmetrical by human raters and by three supervised machine learning models; the support vector machine (SVM), Xception, and random forest models. The data from the human raters were used as the supervised data. The accuracy rates of the human raters and the certainty of AI’s answers were compared using confidence scores (CSs).

Results

The choroidal vascular running pattern could be determined by each AI model with an area under the curve better than 0.94. The random forest method was able to discriminate with the highest accuracy among the three AIs. In the CS analyses, the percentage of certainty was highest (66.4%) and that of uncertainty was lowest (6.1%) in the agreement group. On the other hand, the rate of uncertainty was highest (27.3%) in the disagreement group.

Conclusion

AI algorithm can automatically classify with ambiguous criteria the presence or absence of a symmetrical blood vessel running pattern of the choroid. The classification was as good as that of supervised humans in accuracy and reproducibility.

Quantitative evaluations of vortex vein ampullae by adjusted 3D reverse projection model of ultra-widefield fundus images

The purpose of this study was to determine the number and location of vortex vein ampullae (VVA) in normal eyes. This was an observational retrospective study. Montage images of one on-axis and two off-axis ultra-widefield images of 74 healthy eyes were enhanced, and reverse projected onto a 3D model eye. The number and distance between the optic disc to each VVA in the four sectors were compared. The significance of correlations between these values and age, sex, visual acuity, refractive error, and axial length was determined. The mean number of VVA was 8.10/eye with 1.84, 2.12, 2.19 and 1.95 in upper lateral, lower lateral, upper nasal, and lower nasal sectors, respectively. The mean number of VVA/eye was significantly greater in men at 8.43 than women at 7.76 (P = 0.025). The mean distance between the optic disc and VVA was 14.15 mm, and it was 14.04, 15.55, 13.29 and 13.66 mm in the upper lateral, lower lateral, upper nasal and lower nasal sectors, respectively (all P < 0.05). The number and location of VVA can be obtained non-invasively, and the number was significantly higher in men than women. This technique can be used to determine whether these values are altered in a retinochoroidal disease.

Association of foveal avascular zone with the metamorphopsia in epiretinal membrane

This study was to investigate the relationship between the metamorphopsia and foveal avascular zone (FAZ) parameter in eyes with epiratinal membrane (ERM). We studied patients with an ERM visited retinal service unit at the Kagoshima University Hospital or Shirai Hospital. The best-corrected visual acuity (BCVA), and the degree of metamorphopsia by M -CHARTS™ were evaluated. The 3 × 3 mm optical coherence tomography angiography (OCTA) images of the superficial layer were obtained. Area (mm²), the circularity, eigen value were calculated using ImageJ software. The relationship between visual function, such as best corrected visual acuity (BCVA) and metamorphopsia, and FAZ parameters were studied by Pearson's correlational coefficient. Fifty-four eyes of 51 patients (24 men and 27 women) with an ERM were studied. The mean age of the patients was 69.6 ± 8.20 years. The mean BCVA and metamorphopsia score was 0.31 ± 0.29 logMAR units and 0.49 ± 0.42. There was no significant relationship between BCVA and FAZ parameters. While, metamorphopsia score was significantly and negatively correlated with all of FAZ parameters (area R = - 0.491, P < 0.001; circularity R = - 0.385, P = 0.004; eigenvalue ratio R = - 0.341; P = 0.012). Multiple regression analysis showed the FAZ area was solely and significantly correlated with metamorphopsia score (β - 0.479, P < 0.001). The size but not the shape of the FAZ was significantly correlated with the degree of metamorphopsia suggesting that it could be an objective parameter of metamorphopsia in ERM patients.

Quantitative analyses of diameter and running pattern of choroidal vessels in central serous chorioretinopathy by en face images

This study was to investigate the choroidal vessels in eyes with central serous chorioretinopathy (CSC) quantitatively. We studied 41 CSC eyes and their fellow eyes, and 41 normal eyes of 41 age-adjusted individuals. En-face optical coherence tomography image of the top 25% slab of Haller’s layer was analyze. The mean vessel area, vessel length, and vessel diameter were calculated. The running pattern of the vessels was quantified and used to determine the degree of symmetry, the “symmetry index”. The vessel area of CSC eyes was not significantly different from that of fellow eyes but significantly larger than that of normal eyes. The vessel length of CSC eyes was not significantly different from fellow eyes but significantly shorter than that of normal eyes. The mean vessel diameter was larger in CSC eyes than in the fellow eyes and the normal eye. The symmetry index was not significantly different in CSC eyes from that of their fellow eyes but was smaller than that of normal eyes. The quantitative analysis showed that eyes with CSC had larger choroidal vessels and asymmetrical vessels running in Haller’s layer.

Running pattern of choroidal vessel in en face OCT images determined by machine learning-based quantitative method

PURPOSE

To evaluate the new method to quantitate the running pattern of the vessels in Haller's layer in en face optical coherence tomographic (OCT) images using the new algorithm.

METHODS

A retrospective and cross-sectional study. The en face image of top 25% slab of Haller's layer was analyzed. The vascular area in these images was calculated after binarization. Then, the vessels were thinned, and the total length of the vessels and the mean vessel diameter were calculated. Based on the angle of vessel running, "natural oblique vessel" was defined. The ratio of the natural oblique vessel to the whole vessels was defined as the "symmetry index". To examine the reproducibility of the software, the images obtained on two different examination dates of the same subject (25 eyes of 25 healthy subjects) were analyzed. Also, to compare the symmetry index and subjective evaluations, 180 eyes and 180 healthy subjects were analyzed. The subjective evaluations classified the images into 3 groups, the Symmetrical, Semi-symmetrical, and Asymmetrical types. Symmetry index was compared in each group.

RESULTS

The inter-measurement correlation coefficient (ICC) of the vessel area, vessel length, and vessel diameter were 0.955, 0.934, and 0.954, respectively. The ICC of the symmetry index was 0.926. The symmetry index of the Symmetrical type was 60.4 ± 7.2%, that of the Semi-symmetry type was 56.2 ± 4.6%, and that of the Asymmetry type was 52.6 ± 5.2%.

CONCLUSIONS

The present algorithm can analyze vessels in Haller's layer of the en face images of choroid in an objective manner with good repeatability.

Ability of MultiColor scanning laser ophthalmoscope to detect non-glaucomatous retinal nerve fiber layer defects in eyes with retinal diseases

PURPOSE

To compare the ability of ocular fundus images obtained by Spectralis MultiColor scanning laser ophthalmoscope (MC-SLO) to that obtained by conventional color fundus images (CF) in detecting non-glaucomatous nerve fiber layer defects (NFLDs).

METHODS

A cross-sectional, retrospective study. Patients with retinal diseases who had ocular examination with both the MC-SLO and CF instruments at the Kagoshima University from December 2016 to February 2017 were studied. Eyes that had NFLDs with non-glaucomatous optic discs were analyzed. The visibility of the NFLDs was classified into three grades: grade 0, not visible; grade 1, barely visible; and grade 2, clearly visible. The NFLD grade for blue, green, and red scanning lights of the MC-SLO, merged images with three wavelengths and the color and red-free images were determined by two ophthalmologists. These scores were compared by Steel-Dwass tests.

RESULTS

Thirty-one eyes of 26 patients with a mean age of 63.1 ± 11.2 years were studied. There were 14 eyes with diabetic retinopathy, 11 eyes with age-related macular degeneration, 3 eyes with a branch retinal vein occlusion, and 3 eyes with an epiretinal membrane/macular hole. Both the intra-rater (0.631-0.790) and inter-rater (0.637-0.733) agreements were good. NFLDs were detected by the blue wavelength in all cases and by green wavelength and merged wavelengths in 90.3% of the images. The mean NFLD grade was 1.58 ± 0.49 for blue light images, 1.13 ± 0.54 for green light images, 0.07 ± 0.24 for red light images, and 1.16 ± 0.56 for merged images. The NFLD score for blue wavelength was significantly higher than that for green and red wavelength images (P < 0.05 and P < 0.01) but not significantly higher than that for the merged images. NFLDs were detected in 12 eyes (38.7%) in the color images and 16 eyes (51.6%) in the red-free images. The NFLD score for the CF and the red-free image was 0.41 ± 0.55 and 0.70 ± 0.67 which is significantly lower than that of blue MC-SLO images.

CONCLUSION

The images obtained by MC-SLO are superior to that obtained by CF in detecting NFLDs in eyes with retinal diseases. We recommend MC-SLO imaging to screen for NFLDs in eyes with retinal diseases.

Choroidal Vasculature from Ultra-Widefield Images without Contrast Dye and Its Application to Vogt-Koyanagi-Harada Disease

PURPOSE

To develop a method to obtain ultra-widefield choroidal vessel images with a fundus camera without using dye, and its application in Vogt-Koyanagi-Harada (VKH) disease.

DESIGN

Experimental study and case series.

PARTICIPANTS

Patients with unilateral retinal disorders and those with VKH disease who had undergone ultra-widefield imaging were studied.

METHODS

Indocyanine green angiography (ICGA) and the 635-nm wavelength Optos ultra-widefield fundus photography (Optos, United Kingdom) images (Optos_635-nm) were processed by KagoEye 3 software. The 2 types of images were overlapped. The degree of overlapped blood vessel areas of the ICGA image was taken as the matching ratio. The matching ratio was obtained for the peripheral, posterior pole, and overall areas. In addition, changes in the fundus findings were followed up with Optos_635-nm image analysis in patients with VKH disease. The degree of visibility of the choroidal vessels was evaluated for 5 stages. The clarity scores and the longitudinal findings were compared.

MAIN OUTCOME MEASURES

The matching ratios between the ICGA images and the Optos_635-nm images processed by KagoEye3 software were determined.

RESULTS

Initially, 10 healthy eyes were studied. The matching ratios for the overall area, the peripheral area, and the posterior pole area of the ICGA image and the Optos_635-nm image were 64.09%, 74%, and 63.10%, respectively. The correlations between the choroidal blood vessel matching ratio and the ocular axial length and refractive error were not significant, but the matching ratio was correlated significantly with the age. The average clarity score in 12 VKH disease patients was 1.6 ± 0.85 before treatment, which was significantly improved to 4.2 ± 0.75 after 1 month (P < 0.05). Many hyporeflective spotty lesions were observed on the Optos_635-nm images, which coincided with hyperfluorescent dots on the ICGA images. The lesions gradually disappeared and the vortex vein became visible after treatment.

CONCLUSIONS

The ultra-widefield Optos_635-nm images processed by KagoEye3 software can exaggerate images of the choroidal vessels in widefield fundus images without using dye. Because this method is noninvasive, it is applicable to a variety of diseased and healthy eyes.

Objective evaluation of size and shape of superficial foveal avascular zone in normal subjects by optical coherence tomography angiography

This study was conducted to investigate the size and shape of the foveal avascular zone (FAZ) determined by optical coherence tomography angiography (OCTA) and the relationship of the size and shape to the clinical findings in normal subjects. This was a cross-sectional study with seventy eyes of 70 volunteers. The size of the superficial FAZs were assessed by its area, length of perimeter, and Feret’s diameter, and the shape by the circularity, axial ratio, roundness, and solidity. The correlations between each parameter and the clinical findings were statistically determined. The coefficients of variation (CV) of the parameters of FAZ size were higher than that of the parameters of FAZ shape. The refractive error and axial length were significantly correlated with area-related factors. The central macular thickness (CMT) was significantly correlated with all parameters. Although the CMT was a critical factor that was significantly correlated with the size and shape characteristics of the FAZ, the shape might be a better factor for characterizing the FAZ than the size because of the low CV of shape-related factors and the characteristics are less affected by the other ocular factors.

Reproducibility and differences in area of foveal avascular zone measured by three different optical coherence tomographic angiography instruments

This study was performed to compare the area of the foveal avascular zone (FAZ-area) obtained by three optical coherence tomography angiography (OCTA) instruments. This was a cross-sectional, non-interventional study of twenty-seven healthy right eyes. The superficial and deep FAZ-area was measured manually with three OCTA instruments: Triton (Topcon), RS3000 (Nidek), and CIRRUS (Zeiss). The intra-rater, inter-rater, and inter-instrument correlation coefficients (CC) were assessed. The intra-rater and inter-rater CC were significantly high for the superficial and deep FAZ-areas (P < 0.001). The inter-instrument CC (95% confidence interval) for the superficial FAZ-area was 0.920 (0.803–0.965) for Triton vs RS3000, 0.899 (0.575–0.965) for RS3000 vs CIRRUS, and was 0.963 (0.913–0.983) for CIRRUS vs Triton (P < 0.001). For the deep FAZ-area, the inter-instrument CC was 0.813 (0.633–0.910) for Triton vs RS3000, 0.694 (0.369–0.857) for RS3000 vs CIRRUS, and 0.679 (0.153–0.872) for CIRRUS vs Triton (P < 0.001). The superficial FAZ-area (mm²) was 0.264 ± 0.071 with Triton, 0.278 ± 0.072 with RS3000 and 0.257 ± 0.066 with CIRRUS. For deep FAZ-area, it was 0.617 ± 0.175 with Triton, 0.646 ± 0.178 with RS3000 and 0.719 ± 0.175 with CIRRUS. The FAZ-area from these instruments was clinically interchangeable. However, the absolute values of FAZ-area are significantly different among them. These differences must be considered in comparing the FAZ-areas from different OCTA instruments.

Acute bacterial endophthalmitis after scleral buckling surgery with chandelier endoillumination

Purpose

The non-contact wide-angle viewing system (WAVS) with chandelier endoillumination is being used more commonly during scleral buckling surgery for rhegmatogenous retinal detachments although its safety has not been established. We report our findings in a case of bacterial endophthalmitis that developed after scleral buckling surgery with WAVS and chandelier endoillumination.

Observations

A 42-year-old man underwent scleral buckling surgery for a rhegmatogenous retinal detachment in his right eye using a WAVS with chandelier endoillumination. Three days after the surgery, the patient noticed a marked decrease in his vision with ocular pain. Slit-lamp examination showed dense infiltration in the anterior chamber and vitreous body. Pars plana vitrectomy with antibiotic irrigation was done immediately, and Staphylococcus epidermidis was detected in the vitreous fluid. After vancomycin 6/day for 4 weeks, the inflammation gradually subsided, and the visual acuity recovered to 20/20 in 3 months.

Conclusions and importance

Acute bacterial endophthalmitis can develop after scleral buckling surgery performed with WAVS and chandelier endoillumination.

Histologic activity of the liver in children with transfusion-associated chronic hepatitis C

Adults with chronic hepatitis C develop cirrhosis over a period of 6 to 20 years, but there are few reports of this disorder in children. To determine the histologic activity of chronic hepatitis C in children, we examined 31 biopsy specimens from 25 children (age range 3-16 years) with this disease. All patients were seropositive for antibody to hepatitis C virus by second-generation testing, and for HCV-RNA by the polymerase chain reaction. All cases were transfusion-associated. Patients were divided into two groups according to underlying disease: malignant disease or aplastic anemia (Group A, 17 cases) and non-malignant disease (Group B, eight cases). All patients in Group A, but only one in Group B, had received multiple transfusions. All patients in Group A had received intensive courses of cytotoxic and immunosuppressive agents. The histologic diagnosis was made using the standard criteria and Knodell's histology activity index. Chronic persistent hepatitis was more common in Group B (six patients) than in Group A (three patients). Chronic aggressive hepatitis 2B was found only in Group A (five patients). The mean histology activity index score was higher in Group A than in Group B (8.5 vs. 5.7). Six patients (four in Group A and two in group B) subsequently had a liver biopsy. The pathological diagnosis did not change after the second biopsy in any patient in Group B, while two patients in Group A showed a rapid progression of hepatitis. In each category of the histology activity index, periportal necrosis and intralobular necrosis were more severe in Group A than in Group B.(ABSTRACT TRUNCATED AT 250 WORDS)

Monomelic muscle atrophy

Two patients with slowly progressive muscle atrophy limited to only one leg are reported. They had pes equinovarus deformity and muscle weakness in the affected leg but no symptom in the other limbs. Muscle biopsies from the affected leg showed dystrophic changes consisting of variation in muscle fiber size, endomysial fibrosis, and necrotic and regenerating fibers. Dystrophin was normally expressed at the surface membrane of the muscle fibers. These two patients possibly had a variant of distal muscular dystrophy, though a neural influence could not be completely excluded.

[Neurological complications of varicella-zoster virus (VZV) infection]

Sixty cases with varicella-associated neurological disorders from Japanese literature during recent 11 years were analyzed and compared with previous reports. Chief diseases were encephalitis (encephalopathy) (23.3%), cerebellar ataxia (21.7%), meningitis (18.3%), cerebral infarction (13.3%) and facial palsy (8.3%). Cerebellar ataxia, meningitis and cerebral infarction were found in young children under 9 years, and other disorders were seen also in older children and adults. Some cases had neurological symptoms before the appearance of skin rash. The number of cells in cerebrospinal fluid was increased in meningitis, encephalitis and myelitis. Though neurological complications due to varicella were rare, prognosis was not necessarily good, including several cases with death or severe sequelae. In our 4 cases of herpes zoster meningitis, marked intrathecal VZV-specific antibody production was found and they showed high antibody index. Oligoclonal band was found in one case. The pathogenesis of neurological complications of VZV infection was considered to be caused by direct viral invasion in herpes zoster and at least in some cases of varicella. Therapy with antiviral agents is necessary and vaccination is recommended for prevention.

[Time-course changes of regional cerebral blood flow by SPECT with N-isopropyl-p-[123I]-iodoamphetamine in childhood partial seizures]

Single photon emission computed tomography (SPECT) with N-isopropyl-p-[123I]-iodoamphetamine was performed twice at different times in 18 children suffering from partial seizures to evaluate the time-course changes of the hemodynamics in the focal region. Comparison of the 2 SPECT images revealed that a decreased regional cerebral blood flow (CBF) in the first was normalized in 4 cases (22.2%) and contracted in 7 cases (38.9%). The region of decreased blood flow in the second was contralateral to that in the first in 1 case (5.6%) and unchanged in 6 cases (33.3%). Most of the normalized and contracted cases were those in which clinical seizures disappeared and the EEG findings were normalized. In these cases which responded to treatment, the decreased regional CBF was also found to be improved. Repeated SPECT appears to be useful for evaluating the therapeutic efficacy. On the other hand, most of the unchanged cases were those in which clinical seizures were frequent or uncontrolled, or which persistently showed the abnormalities in their EEG. SPECT was considered to reflect well the conditions of the epileptic foci. These results indicate that repeated SPECT for observing the time-course changes of the regional CBF represents a useful technique with can be applied in evaluating the therapeutic efficacy or deciding the time to discontinue treatment and for pathogenetic elucidation of the epileptic foci.

Successful pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension associated with anticardiolipin antibodies: report of a case

Chronic pulmonary thromboembolism with pulmonary hypertension is a rare but most unique syndrome in the broad spectrum of pulmonary embolism. This report describes a successful pulmonary thromboendarterectomy performed for a totally occluded right pulmonary artery on a 43 year old man who presented with positive cardiolipin antibodies. The surgery was performed through a median sternotomy with cardiopulmonary bypass and intermittent periods of deep hypothermic circulatory arrest. We are convinced that this method allows for complete removal of the thrombotic obstruction and should be the procedure of choice for patients with very proximal obstruction of a pulmonary artery.

[Pre- and postoperative nutritional assessment of cardiac cachexia]

Pre- and postoperative nutritional states were studied in fifty patients undergoing cardiac surgery. Seven of them were cardiac cachectic patients. There was no hospital death except one patient with cardiac cachexia. Preoperative measurements showed decreased %standard body weight (80.7%), %standard AMC (86.1%), and %standard TSF (61.5%) in cachectic patients. Resting energy expenditure (REE) and circulating blood volume were significantly higher in cachectic patients throughout the pre- and postoperative periods, and a significant correlations were admitted between them (p less than 0.05). REE increased to 33.6 kcal/kg/day 1 week after operation. Serum proteins, including rapid turnover proteins (RTP), when expressed in g/dl or mg/dl, did not show any difference between two groups. However by correction with circulating plasma volume and body weight (mg/kg), cardiac cachectic patients had significantly higher protein contents preoperatively and seventh post-operative day (p less than 0.05). There was no difference in urinary excretion of 3-methylhistidine between two groups throughout the study period, but urinary excretion of urea was higher in 1st and 3rd postoperative days in non cachectic patients. Serum cortisol and urinary excretion of vanillymandelic acid were higher, and serum insulin level tended to be lower in cachectic patients postoperatively. These results indicate that, in cardiac cachexia, increased blood volume and hypermetabolic state cause higher energy expenditure, resulting in weight loss and chronic heart failure.

[Surgical results of pulmonary thromboendarterectomy for chronic pulmonary thromboembolism]

Chronic pulmonary thromboembolism may produce severe respiratory insufficiency and progressive pulmonary hypertension resulting in an intractable right ventricular failure. Although the pathogenesis of this syndrome has not been completely understood, medical treatment usually has little effect and only surgery can be a life saving remedy. Since 1986, seven patients with this syndrome have had pulmonary thromboendarterectomy at the First Department of Surgery, Chiba University Medical Center. Surgery is indicated mainly for patients who present with a mean pulmonary arterial pressure greater than 30 mmHg. All procedures were performed through a unilateral thoracotomy with a cardiopulmonary bypass on stand-by use. Two patients (#1 and #6) needed bilateral surgery which was carried out in two stages, in the remainder only a right side being operated on. When a major pulmonary artery was clamped, the systolic pulmonary arterial pressure rose to equalize or even exceeded that of systemic artery, however since no further hemodynamic deterioration was observed, cardiopulmonary bypass was not used in any case. Although the key feature of this procedure is commonly said to establish an exact cleavage plane between thrombus and arterial wall, it can be carried out without difficulty through thoracotomy approach. Grasping the thrombus, blunt dissection is further proceeded until the entire thrombotic material comes free as a cast of the vessels. All patients survived the operation without major complications including severe reperfusion pulmonary edema. Postoperative catheterization, performed one month following surgery, demonstrated a marked reduction of pulmonary arterial pressure with significantly reduced pulmonary arterial resistance (PAR).

Central nervous system damage following surgery using cardiopulmonary bypass--a retrospective analysis of 1386 cases

In order to determine the incidence and risk of central nervous system damage (CNSD) which accompanies cardiovascular surgery, a retrospective analysis was carried out on 1386 patients who received surgery utilizing cardiopulmonary bypass. CNSD occurred in 32 of the 1386 patients, the total incidence being 2.3 per cent. The major risk factors which led to a high incidence of CNSD were found to be reoperation, thrombus in the left atrium (TLA) and calcification of the ascending aorta (Cal aAo). In the primary surgical series, CNSD was found in only 29 of 1350 patients (2.2 per cent), however, of a total 36 patients who underwent reoperation, 3 (8.3 per cent) patients developed CNSD (p less than 0.05). In a surgical series done on 562 patients with mitral valve disease, the prevalence of CNSD was much higher in patients who suffered TLA than in those who did not, being 4/85 cases (4.7 per cent) vs 11/477 cases (2.3 per cent), respectively. Moreover, a significantly higher incidence of CNSD was noted in patients with Cal aAo, occurring in 6/10 cases (60 per cent) with Cal aAo vs 4/333 cases (1.2 per cent) without Cal aAo (p less than 0.001). The results of this study showed that patients with CNSD, who had received coronary artery bypass surgery and aortic arch replacement tended to follow a poor clinical course, suggesting that atheromatous plaque embolization may be the leading cause of the poor prognosis following CNSD in patients having undergone cardiopulmonary bypass.

[Open aortic technique for DeBakey type II dissection]

Two patients with chronic dissecting aneurysm (DeBakey type II) underwent graft replacement using open aortic technique. During proximal anastomosis, the body temperature of the patients was lowered to 23 degrees C and open distal anastomosis was performed under circulatory arrest of the lower body using selective perfusion to the brain. Graft-to-aorta anastomosis was performed in distal ascending aorta (case 1) and in aortic arch (case 2), after the approximation of inner and outer layer of the false lumen. Two patients survived operations, and the postoperative courses and postoperative angiograms were satisfactory. Open aortic technique was considered to be applied not only to patients with arch aneurysm or arch dissection but also to patients with DeBakey type II or type I dissection.

A chronic contained rupture of an abdominal aortic aneurysm complicated with severe back pain

Chronic contained rupture of an abdominal aortic aneurysm is an uncommon occurrence with the aneurysms usually small-to-moderate in size. Diagnosis may be difficult because patients present with both atypical and chronic symptoms. Pressure erosion of the lumbar spine is presumably a highly significant associated disorder, but an enhanced computed tomographic scan is the most reliable method for the correct diagnosis. We report on a 46-year-old man who developed severe back pain which was initially thought to result from spinal disease. Retrospective review of computed tomographic scans taken two years before admission revealed the beginning of the leakage of the aneurysm. Remarkably, the patient remained stable two years after the rupture.

[A case of traumatic tricuspid regurgitation]

Tricuspid regurgitation due to nonpenetrating trauma occurred in a 60-year-old male patient who had received chest trauma in a motorcycle accident. He was admitted because of shortness of breath and palpitation on exertion. On admission physical examinations revealed pulsated and dilated jugular veins, hepatomegaly, and systolic murmur. The chest X-ray film showed an enlarged heart and electrocardiograms revealed complete right bundle branch block. Echocardiography demonstrated systolic prolapse of the tricuspid anterior leaflet into the right atrium. Right atrial v wave pressure was 20 mmHg. Tricuspid valve replacement with a Carpentier-Edwards 33 mm using super interpose method was performed successfully 13 years after the trauma. At operation, it was found that the chordae tendineae of the anterior leaflet was ruptured.

[A case report of hypertrophic obstructive cardiomyopathy after the correction of atrioventricular septal defect]

A 47-year-old woman who had closure of an atrioventricular septal defect and repair of mitral cleft developed severe dyspnea on effort 6 years after surgery. An echocardiography showed asymmetric left ventricular hypertrophy and a left cardiac catheterization revealed marked intraventricular pressure gradient and moderately severe mitral regurgitation. The patient underwent mitral valve replacement through transseptal approach during empty beating heart. Symptomatic relief was obtained and marked reduction of intraventricular systolic pressure gradient was noted in postoperative cardiac catheterization about 40 days after the operation. Mitral valve replacement should be considered for the treatment of hypertrophic obstructive cardiomyopathy in severe cases with associated morphological abnormality of mitral leaflet or severe mitral regurgitation.

[Long-term results of the 19 mm low-profile bileaflet valve prosthesis in the small aortic anulus]

Between April, 1979, and November, 1986, 20 patients underwent aortic valve replacement (AVR) in the small aortic anulus with either 19 mm St. Jude Medical valve prosthesis or 19 mm Duro-Medics valve prosthesis, which are relatively new, low-profile bileaflet valve prostheses. There were two male and 18 female patients ranging from 35 to 69 years old (mean, 54.7 years). Average body surface area was 1.37 +/- 0.11 m2 (range 1.20 to 1.55 m2). One patient died of arrhythmia at 22 postoperative day. The 19 survivors have been followed up for as long as 61 months (mean, 31.2 months). There were two late complications, cerebral infarctions, and event free ratio was 0.85 at five years. All long-term survivors were in New York Heart Association Functional Class I (15 patients) and Class II (three patients). Preoperative and postoperative echocardiograms demonstrated significant decreases in mean left ventricular end-diastolic diameter (LVDd) (48.9 +/- 8.3 mm vs 42.2 +/- 5.7 mm; p less than 0.01) and in left ventricular end-systolic diameter (LVDs) (32.2 +/- 8.2 mm vs 25.7 +/- 4.9 mm; p less than 0.01). Mean left ventricular wall thickness was decreased to 24.5 +/- 3.7 mm from 25.8 +/- 6.4 mm. The average peak systolic gradient at rest with Doppler ultrasound was 26.0 +/- 9.3 mmHg (range nine to 36 mmHg). Though transprosthetic gradient did occur in patients who received 19 mm low-profile bileaflet valves in narrow aortic roots, progressive prosthetic stenosis was not observed and small aortic prostheses provide acceptable palliation for long-term results clinically.

[A new trial assessment of left ventricular function before and after aorto coronary bypass surgery--application of ejection vector (E.V.)]

In 34 patients underwent aorto coronary bypass, left ventriculography was analyzed and ejection indexes (E.F. 100, E.F. 50, E.V. = 2 X E.F. 50/E.F. 100) were calculated. There was not difference in ejection indexes of patients between who had been complicated with preoperative myocardial infarction and not. E.F. 100 was not changed postoperatively, otherwise, E.F. 50 and E.V. showed significant increase. In 15 patients whose quality of life remarkably was improved postoperative period, E.F. 100 was not changed but E.F. 50 and E.V. were significantly increased. Four patients could not perform exercise test to full dose because of intractable ischemic calf pain. In twelve patients, whose left ventricular function was improved at postoperative exercise test, their E.F. 100 was found to be unchanged, but in contrast, E.F. 50 and E.V. were increased significantly. In conclusion, we found that E.V. could become to be more sensitive indicator of left ventricular function compared with E.F. 100 before and after aorto coronary bypass surgery.

Early and late results of valvular surgery in the elderly

From January, 1979 to June, 1986, 70 consecutive elderly patients (30 males and 40 females) age 65 years or older underwent open heart surgery for valvular heart diseases at Mitsui Memorial Hospital in Tokyo. Seventeen patients (24.3%) were septuagenarians. Porcine bioprosthesis (Carpentier-Edwards) was inserted for the mitral and the tricuspid position, and mechanical valve (Björk-Shiley or Duromedics) for the aortic position. Every patients received an anticoagulant (warfarin) postoperatively all through the follow-up period. The mean duration of follow-up was 43 months and the cumulative follow-up was 195 patient-years. Fifteen patients died in hospital after operation, giving an operative mortality rate of 21.4%. Cardiac death occurred in only 5 and the other 10 patients died of other causes such as sepsis, cerebrovascular accident, and agranulocytosis, showing that these patients were already in an advanced stage of cardiac failure. Late death occurred in 5 patients, but there was no clear-cut cardiac death documented. The actuarial survival rates at 3 years and 5 years were 71.6% and 65.9% for all patients, and 90.5% and 83.3% for early survivors. The functional and symptomatic improvement of 49 late survivors was remarkable. Thirty-eight patients (77.6%) are now NYHA class I and II. The incidence of thromboembolic and hemorrhagic episodes was fairly low--2% and 3% per patient year, respectively. Although the operative mortality is rather high in this study, it is clear that the surgical management of elderly patients with life-threatening valvular lesions results in substantial functional improvement and good prognosis in surviving patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunoglobulin therapy in the West syndrome

An examination was made of high dose non-treated immunoglobulin (NTIG) therapy at an early stage of the West syndrome (WS). Six patients with cryptogenic WS who suffered attacks ranging from 15 days to 6 months (mean 70 days) and 5 patients with symptomatic WS who suffered attacks ranging from 14 days to 4 months (mean 32 days), were administered NTIG 6-10 times intravenously at 100-200 mg/kg of body weight at intervals of 2 or 3 weeks. All patients with cryptogenic WS showed complete remission in accordance with normalized electroencephalogram (EEG) without following anticonvulsants medication. Of the 5 patients with symptomatic WS one patient showed cessation of clinical seizures in agreement with EEG improvement and 2 other patients revealed transient cessation of clinical seizures with recurrence. In cases of complete remission, the energy percentage of the power spectrum for each frequency band displayed a tendency toward gradual decrease of delta wave band in correspondence with the increase of theta wave band percentage after NTIG therapy, suggesting that high dose NTIG may be useful for early treatment of cryptogenic WS and for inhibiting brain deterioration owing to epileptic encephalopathy.