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Akira Kobayashi,1 Takahiko Hayashi,2 Ami Igarashi,2 Toshiki Shimizu,2 Hideaki Yokogawa,1 Kentaro Yuda,3 Björn Bachmann,4 Satoru Yamagami,2 Kazuhisa Sugiyama1 1Department of Ophthalmology, Kanazawa University Hospital, Ishikawa, Japan; 2Department of Ophthalmology and Department of Visual Sciences, Nihon University School of Medicine, Itabashi, Tokyo, Japan; 3Kikuna Yuda Eye Clinic, Yokohama, Japan; 4Department of Ophthalmology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, GermanyCorrespondence: Akira Kobayashi, Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Takara-machi 13-1, Kanazawa, Ishikawa-ken, 920-8641, Japan, Tel +81-76-265-2403, Fax +81-76-222-9660, Email eyekoba@gmail.comBackground: Currently, the push-in technique through the corneal tunnel using a blunt-tip spatula is used to insert an artificial corneal endothelium (EndoArt) into the anterior chamber (AC). The device is useful for patients with bullous keratopathy; however, it may be difficult to manipulate the very thin implant through hazy cornea. Unlike DMEK graft, it cannot be stained and the F-mark is faint. So, visualizing and orienting the implant is a real challenge especially through a hazy cornea and inadequate AC visualization. Therefore, alternative EndoArt implantation techniques are needed in patients with advanced endothelial dysfunction to avoid complications.Purpose: To report an alternative technique for EndoArt implantation using a Busin glide.Technique: The EndoArt was loaded onto the Busin glide with the concave side of the EndoArt facing upward and was then pulled/pushed into the Busin glide opening. After the Descemet’s membrane and endothelium were detached and removed in a circular fashion in a patient with advanced corneal endothelial decompensation, the Busin glide was inserted into the corneal incision, and the EndoArt was slowly pulled into the AC using retractor forceps. Finally, the air was injected into the AC.Conclusion: The Busin glide-assisted pull-through technique smoothly and securely inserted the EndoArt into the AC without upside-down attachment. This alternative technique can be useful for patients with a history of repeat intraocular surgeries or trauma with severe corneal edema to avoid potential complications such as epithelial implantation cysts or downgrowth.Keywords: endothelial keratoplasty, artificial corneal endothelium, EndoArt, bullous keratopathy, Descemet’s membrane endothelial keratoplasty

Naotatsu Otsuji,1 Kumiya Sugiyama,1,2 Takayoshi Owada,1 Hajime Arifuku,1 Kenya Koyama,1 Hirokuni Hirata,1 Yasutsugu Fukushima1 1Department of Respiratory Medicine and Clinical Immunology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan; 2National Hospital Organization Utsunomiya Hospital, Utsunomiya, Tochigi, JapanCorrespondence: Kumiya Sugiyama, National Hospital Organization Utsunomiya Hospital, 2160, Shimo-Okamoto, Utsunomiya, Tochigi, 329-1193, Japan, Email sugiyama@dokkyomed.ac.jpPurpose: The prognosis of rheumatoid arthritis (RA) with interstitial lung disease (ILD) is particularly poor. Although drugs that do not contribute to the progression of ILD should be used in RA treatment, none have been established. This study evaluated the safety of tocilizumab in terms of ILD activity.Patients and Methods: This study prospectively enrolled all 55 patients with RA complicated by ILD who were treated with tocilizumab at Dokkyo Medical University Saitama Medical Center from April 2014 to June 2022. The outcome measures were MMP-3 and KL-6 as biomarkers of RA and ILD activity, respectively, and the relationship between them was analyzed.Results: Both MMP-3 and KL-6 were significantly improved at 6 months of treatment (P < 0.001 and P < 0.05, respectively), and a weak correlation between MMP-3 and KL-6 was observed (R2 = 0.086, P = 0.087). The group with increased MMP-3 due to RA progression had significantly higher KL-6 at 6 months compared with the group with RA improvement (P < 0.05). Also, the group with ILD progression on computed tomography had significantly higher MMP-3 compared with the groups with improvement or no change of ILD (P < 0.05 and P < 0.01, respectively). The mortality rate was 0% at 6 months, 2.0% at 1 year, 16.7% at 2 years, and 32.4% at 3 years, and mortality from acute exacerbation of ILD due to respiratory infection increased over time.Conclusion: RA activity and ILD activity were found to be related at 6 months of treatment. Tocilizumab does not seem to affect the mechanism of ILD progression, as most patients showed improvement in both MMP-3 and KL-6 with tocilizumab within 6 months, when this drug would be expected to affect the lungs directly. However, respiratory infection exacerbated ILD from 1 year after the start of treatment. As immunosuppressive drugs, including tocilizumab, have a risk of respiratory infection, it is important to identify early signs of infection.Keywords: interstitial lung disease, Krebs von den Lungen-6, KL-6, matrix metalloproteinase-3, MMP-3, rheumatoid arthritis, mortality, tocilizumab

Chemically ordered face-centered cubic (fcc) phases consisting mainly of Cr, Co, and Ni were synthesized by annealing a Cr26.7Co26.7Ni26.7Si10B5P5 amorphous alloy. The annealed Cr26.7Co26.7Ni26.7Si10B5P5 sample was composed of Cr4.5BP2, Cr3 Co5Si2, and fcc phases. Synchrotron radiation anomalous X-ray scattering (AXS) measurements confirmed that the annealed Cr26.7Co26.7Ni26.7Si10B5P5 sample had superlattice reflections from an L10-, and/or L12-, and D022-type ordered structure. The diffraction intensities of the superlattice reflections observed in the AXS measurements indicated strong dependence on the incident X-ray energy. The diffraction intensity of the superlattice reflection increased at the X-ray energy near the K-edge of Cr, suggesting that Cr is mainly ordered in the L10- and D022-type structures. Microstructural analysis using scanning transmission electron microscopy (STEM) revealed crystal grains with diameters of approximately 20 nm, showing diffraction spots corresponding to superlattice reflections of 001 and 110, in addition to a two-dimensional diffraction pattern corresponding to the fcc structure. Simultaneous STEM--energy dispersive X-ray spectroscopy analysis indicated that the grains had a higher Cr concentration than the mother alloy composition of Cr26.7Co26.7Ni26.7Si10B5P5. [ABSTRACT FROM AUTHOR]

Koji Nitta,1 Yutaro Yamada,1 Satomi Morokado,1 Kazuhisa Sugiyama2 1Department of Ophthalmology, Fukui-Ken Saiseikai Hospital, Fukui, Fukui Prefecture, Japan; 2Department of Ophthalmology, Kanazawa University, Kanazawa, Ishikawa Prefecture, JapanCorrespondence: Koji NittaFukui-Ken Saiseikai Hospital, Funabashi 7-1, Wadanaka-Cho, Fukui City, Fukui 918-8503, JapanTel +81 776 23 1111Email nitta.koji7001@fukui.saiseikai.or.jpIntroduction: This study assesses two-year efficacy and safety following implantation of a single trabecular micro-bypass stent (iStent®) with concomitant phacoemulsification cataract surgery in Japanese patients with open-angle glaucoma (OAG).Materials and Methods: This retrospective, consecutive case series included eyes that underwent iStent implantation with phacoemulsification and were followed for 24 months postoperative. Efficacy and safety measures included intraocular pressure (IOP), number of glaucoma medications, adverse events, secondary surgeries, visual fields, and endothelial cell counts.Results: Of 73 operated eyes, 53 eyes had 24 months of follow-up and are analyzed. Diagnoses included primary open-angle glaucoma (POAG, n=25), normal-tension glaucoma (NTG, n=16), and pseudoexfoliative glaucoma (PXG, n=12). At 24 months, mean IOP reduced by 18% to 13.6± 3.0 mmHg versus 16.5± 3.4 mmHg preoperatively (p< 0.0001), and mean medication number reduced by 81% to 0.37± 0.74 versus 1.96± 0.98 preoperatively (p< 0.0001). The percentage of medication-free eyes was 77% versus 0% preoperatively, and 81% of eyes had IOP ≤ 15 mmHg versus 42% preoperatively. Results were similarly favorable across glaucoma subtypes (POAG, NTG, PXG). Notably, mean IOP in NTG eyes decreased to 12.8± 1.4 mmHg from 14.4± 3.0 mmHg preoperatively (p=0.03), and medications decreased by 87% to 0.31± 0.70 versus 2.38± 0.72 preoperatively (p< 0.0001). At 24 months, 81% of NTG eyes were medication-free (versus 0% preoperatively); 2 NTG eyes (13%) were on ≥ 2 medications (versus 100% preoperatively). Throughout the follow-up, visual fields and endothelial cell counts remained stable; 1 eye (1.9%) underwent filtration surgery.Discussion: Favorable safety and significant IOP and mediation reductions were achieved through two years following iStent implantation with phacoemulsification in a Japanese population. These gains were achieved across all glaucoma subtypes (including POAG, NTG, PXG).Conclusion: This real-world study supports the viability of iStent implantation to treat Japanese patients with glaucoma and shows that the benefits extend to those with NTG or PXG in addition to POAG.Keywords: microinvasive glaucoma surgery, MIGS, iStent, trabecular micro-bypass, Japanese, normal-tension glaucoma

Tsubasa Nishino, Akira Kobayashi, Natsuko Mori, Hideaki Yokogawa, Kazuhisa Sugiyama Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, JapanCorrespondence: Akira KobayashiDepartment of Ophthalmology, Kanazawa University Graduate School of Medical Science, 13-1 Takara-Machi, Kanazawa-shi, Ishikawa-ken 920-8641, JapanTel +81-76-265-2403Fax +81-76-222-9660Email eyekoba@gmail.comPurpose: To investigate in vivo corneal changes of genetically confirmed Reis–Bücklers corneal dystrophy (RBCD) and Thiel–Behnke corneal dystrophy (TBCD) using anterior segment optical coherence tomography (AS-OCT).Design: A single-center, prospective, comparative case series.Methods: Seven patients from 3 pedigrees (3 males, 4 females) with RBCD [Arg124Leu (R124L) heterozygous missense mutation of human transforming growth factor beta-induced (TGFBI) gene] and 4 patients from 3 pedigrees (3 males, 1 female) with TBCD [Arg555Gln (R555Q) heterozygous missense mutation of TGFBI gene] were examined. Six patients with RBCD and three patients with TBCD exhibited recurrence after corneal surgery including penetrating keratoplasty, phototherapeutic keratectomy, and electrolysis. All patients were examined by slit-lamp biomicroscopy followed by AS-OCT. Selected AS-OCT images of the cornea were evaluated qualitatively for changes in shape and degree of light reflection of corneal deposits.Results: Slit-lamp biomicroscopy showed characteristic irregular gray opacities in Bowman’s layer in each dystrophy: a geographic pattern in RBCD and a honeycomb pattern in TBCD. In each dystrophy, distinct characteristic deposits were observed by AS-OCT as a banding lesion in Bowman’s layer and its adjacent epithelium/stroma. In RBCD, the banding lesion was highly reflective and sharply margined at the stroma. In contrast, deposits in TBCD in the same layer showed a saw-tooth pattern toward the epithelium and poorly margined at the stroma.Conclusion: AS-OCT is able to clearly identify characteristic in vivo corneal microstructural changes associated with RBCD and TBCD. As a result, in vivo differentiation of RBCD and TBCD can be achieved.Keywords: Reis–Bücklers corneal dystrophy, Thiel–Behnke corneal dystrophy, anterior segment optical coherence tomography, genetic mutational analysis, human transforming growth factor beta-induced gene, TGFBI

Hideaki Yokogawa, Akira Kobayashi, Natsuko Mori, Tsubasa Nishino, Kazuhisa Sugiyama Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, JapanCorrespondence: Hideaki YokogawaDepartment of Ophthalmology, Kanazawa University Graduate School of Medical Science, 13-1 Takara-machi, Kanazawa-shi, Ishikawa-ken 920-8641, JapanTel +81-76-265-2403Fax +81-76-222-9660Email hyoko@med.kanazawa-u.ac.jpPurpose: To describe the visibility of the retina through an air-filled anterior chamber during simultaneous pars plana vitrectomy (PPV) and Descemet’s stripping automated endothelial keratoplasty (DSAEK), and to discuss the technical challenges of a fluid-air exchange under such conditions.Methods: Six eyes from 6 patients with coexisting bullous keratopathy and posterior segment problems such as vitreous opacity, retained silicon oil, intraocular lens subluxation, or aphakia underwent simultaneous PPV and DSAEK. In all cases, after completion of 25-gauge PPV with/without flanged intrascleral intraocular lens fixation, DSAEK donor tissue was inserted into the anterior chamber. Air was then injected into the anterior chamber to attach the donor graft to the back surface of the host cornea. At this point, the visibility of the retina was evaluated using endoillumination and a wide-angle viewing system.Results: In all cases, visibility of the retina through an air-filled anterior chamber, with the DSAEK donor attached, was sufficient to perform a fluid-air exchange.Conclusion: Our clinical observations of such rare but clinically important conditions indicate that simultaneous PPV and DSAEK is possible with fair visualization of the posterior segment including the retina.Keywords: Descemet’s stripping automated endothelial keratoplasty, pars plana vitrectomy

Koji Nitta,1,2 Gaku Tachibana,1,2 Ryotaro Wajima,1,2 Sachie Inoue,3 Tatsuya Ohigashi,4 Naomi Otsuka,4 Hiroaki Kurashima,4 Kazunori Santo,4 Masayo Hashimoto,4 Hidetoshi Shibahara,3 Mai Hirukawa,3 Kazuhisa Sugiyama2 1Department of Ophthalmology, Fukui-Ken Saiseikai Hospital, Fukui, Japan; 2Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan; 3CRECON Medical Assessment Inc., Tokyo, Japan; 4Japan Medical Affairs Group, Santen Pharmaceutical Co., Ltd., Osaka, JapanCorrespondence: Koji Nitta Email nitta.koji7001@fukui.saiseikai.or.jpPurpose: To maintain visual fields and quality of life over a lifetime, medical practice must be conducted taking into consideration not only visual field progression but also future visual field changes that occur over the patients’ expected lifespan. The purpose of this study is to investigate the feasibility of establishing a model that predicts prognosis, estimating the proportion of glaucoma patients with severe visual field defects.Patients and Methods: The data of 191 patients with primary open-angle glaucoma, with a predominance of normal-tension glaucoma, were used for this study. The model was developed based on patients’ backgrounds and risk factors, using Monte Carlo simulation. A “severe visual field defect” was defined as ≤-20 dB. The mean deviation (MD) value for 10,000 virtual patients in each simulation pattern (144 patterns) was calculated using a predictive formula to estimate the MD slope, and the effects of risk factors and intraocular pressure (IOP) reduction on the proportion of patients with severe visual field defects were evaluated.Results: Younger age, later-stage disease, more severe glaucomatous structural abnormalities and the presence of disc hemorrhage were associated with an increase in the progression rate of patients with severe visual field defects. Conversely, lower IOP was associated with a decrease in this rate.Conclusion: Combining regression analysis with Monte Carlo simulation could be a useful method for developing predictive models of prognosis in glaucoma patients.Keywords: glaucoma, epidemiology, prognosis, risk factors, simulation

Koji Nitta,1,2 Shiro Shimamoto,3 Ryotaro Wajima,2 Gaku Tachibana,2 Yutaro Yamada,1,2 Miyuki Domoto,1 Ryuji Takeda,4,5 Yoshinari Takahashi,6 Kazuhisa Sugiyama2 1Fukui-ken Saiseikai Hospital, Fukui, Japan; 2Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan; 3Shimamoto Ophthalmology Clinic, Fukui, Japan; 4Department of Nutritional Sciences for Well-Being, Faculty of Health Sciences for Welfare, Kansai University of Welfare Sciences, Osaka, Japan; 5Department of Applied Biological Chemistry, Faculty of Agriculture, Kindai University, Nara, Japan; 6Inary Co., Ltd., Tokyo, JapanCorrespondence: Koji NittaDepartment of Ophthalmology, Fukui-ken Saiseikai Hospital, 7-1 Funabashi, Wadanaka-cho, Fukui 918-8503, JapanTel +81 776 23 1111Fax +81 776 28 8515Email nitta.koji7001@fukui.saiseikai.or.jpBackground: This retrospective study evaluated the effect of adjunctive administration of brimonidine 0.1% on disc hemorrhage (DH) in patients with primary open-angle glaucoma or normal-tension glaucoma who were already treated with other anti-glaucoma drugs.Methods: Patients with DH, before adjunctive therapy with brimonidine, were enrolled. Subjects were excluded if their treatment regimen was changed within 1 year after initiation of adjunctive therapy with brimonidine. We investigated the frequency of DH and intraocular pressure (IOP). Both parameters were compared before and after adjunctive administration of brimonidine.Results: The frequency of DH before and after brimonidine administration was 0.67± 0.68 and 0.31± 0.72 times/year, respectively, with a significant decrease (P=0.01), and the mean IOP before and after brimonidine administration was 12.5± 1.9 and 11.2± 2.2 mmHg, respectively, (P=0.0006) with a significant reduction after adjunctive administration.Conclusion: The results of this study supported the hypothesis that the frequency of DH is reduced by brimonidine alongside lowering of IOP.Keywords: disc hemorrhage, intraocular pressure, brimonidine, primary open-angle glaucoma, normal-tension glaucoma

The topological and chemical short-range ordering (TSRO and CSRO) of Pd82Ge18 amorphous alloys prepared by the single-roll liquid quench method were analyzed using a combination of anomalous X-ray scattering and reverse Monte Carlo (RMC) simulation. The degree of development of TSRO and CSRO in the amorphous structure model made with the RMC simulation (RMC model) was evaluated by comparison with the dense random packing model (DRP model) calculated using metallic and covalent atomic radii. In the RMC model, a shortening of the Pd--Ge nearest neighbor correlation and a decrease in the coordination number around Ge were observed. Voronoi polyhedral analysis was performed to evaluate the local geometrical structure around the Pd and Ge atoms. Although the DRP structure can reasonably approximate the local structure around the Pd atoms, the TTP structure corresponding to the local structure in crystalline Pd2Ge develops around the Ge atoms as a characteristic TSRO. However, the preferential coordination of Pd atoms around Ge, which is a CSRO associated with the TTP structure in the crystalline phase, was not observed. These results indicate that strong CSRO does not necessarily accompany the TTP structures in metal-semimetal amorphous alloys. [ABSTRACT FROM AUTHOR]

Tsubasa Nishino, Akira Kobayashi, Hideaki Yokogawa, Natsuko Mori, Kazuhisa SugiyamaDepartment of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, JapanPurpose: To present the changing indications and surgical techniques for keratoplasty during a 16-year period (2003–2018) at a tertiary referral hospital in Japan.Methods: Consecutive keratoplasty cases at Kanazawa University Hospital from January 2003 to December 2018 were retrospectively reviewed. Keratoplasty procedures included penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK), anterior lamellar keratoplasty (ALK), Descemet’s stripping automated endothelial keratoplasty (DSAEK), and Descemet’s membrane endothelial keratoplasty (DMEK). Annual numbers and types of keratoplasty as well as underlying diseases for PK and total keratoplasty procedures were recorded, and annual trends were statistically analyzed using Cochran–Armitage test for trend.Results: A total of 801 keratoplasty procedures (PK, 319 cases; DALK, 57 cases; ALK, 9 cases; DSAEK, 371 cases; and DMEK 45 cases; mean age, 66.9±16.3 years) were performed for 595 patients (302 males [329 eyes, 419 cases], 293 females [345 eyes, 382 cases]) during the 16-year period. The proportion of PK procedures decreased significantly in the beginning and showed a slightly increasing trend after a plateau around 2015. DSAEK was increasing after 2006 and reached a plateau around 2012. Among 10 underlying diseases for total keratoplasty, corneal opacity and dermoid were decreasing linearly. Failed PK and failed DSAEK were increasing linearly in the beginning and reached a plateau followed by a decreasing trend. In terms of the underlying disease for PK, bullous keratopathy was decreasing in the beginning and reached a plateau around 2015. A total of 19 PK procedures were performed on cases with recalcitrant bullous kerstopathy (BK) after 2010.Conclusion: The distribution of keratoplasty procedures and underlying diseases changed significantly over 16 years at a tertiary referral hospital in Japan. PK procedure was significantly decreased and DSAEK procedure was significantly increased. PK for BK decreased significantly; however, PK remains a viable option for other recalcitrant corneal diseases.Keywords: Descemet’s stripping automated endothelial keratoplasty, Descemet’s membrane endothelial keratoplasty, penetrating keratoplasty

Natsuko Mori,1,2 Hideaki Yokogawa,1 Akira Kobayashi,1 Tsubasa Nishino,1,3 Kazuhisa Sugiyama11Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan; 2Department of Ophthalmology, Saiseikai Kanazawa Hospital, Kanazawa, Japan; 3Department of Ophthalmology, Toyama Prefectural Central Hospital, Toyama, JapanPurpose: This study aimed to elucidate the frequency of surgery-induced iris abnormalities after Descemet membrane endothelial keratoplasty (DMEK) and their impact on postoperative clinical outcomes.Methods: In this retrospective study, medical records of 32 eyes from 28 consecutive patients (mean age, 65.7±13.4 years; 14 men, 18 women) who underwent DMEK (or triple DMEK) were reviewed. In all patients, inferior peripheral iridectomy was created leaving full intracameral air tamponade at the end of surgery. Sulfur hexafluoride gas was not used in any cases. Surgery-induced iris abnormalities such as pupillary shape changes and iris depigmentation were evaluated by 3 masked observers. Pre-existing abnormalities were excluded. Eyes were divided into two groups based on the presence of surgery-induced iris changes: Group A (with iris abnormalities) and Group B (without). Impacts on postoperative clinical outcomes such as vision and endothelial cell density were analyzed.Results: Surgery-induced iris abnormalities were seen in 15 eyes (Group A, 9 with pupillary shape change and 6 with iris depigmentation; 46.9%), and 17 eyes showed no abnormalities (Group B, 53.1%). No significant differences were detected between groups in age, sex, indication, simultaneous cataract surgery, pre- and 6-month postoperative vision, donor age, donor endothelial cell density, and 6- and 12-month postoperative endothelial cell density.Conclusions: Surgery-induced iris abnormalities were noted in almost half of the eyes after DMEK (46.9%) in this study. However, there was no association between visual outcomes or postoperative endothelial cell density and the iris changes.Keywords: surgery-induced iris abnormalities, DMEK

Tsubasa Nishino, Akira Kobayashi, Hideaki Yokogawa, Natsuko Mori, Toshinori Masaki, Kazuhisa Sugiyama Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan Purpose: To report a 10-year review of endothelial keratoplasty (EK) procedures, Descemet’s stripping automated endothelial keratoplasty (DSAEK) and Descemet’s membrane endothelial keratoplasty (DMEK), and underlying diseases at a tertiary referral hospital in Japan. Study design: A single-center, retrospective case series. Methods: We retrospectively reviewed all medical records of bullous keratopathy (BK) surgically treated by EK (DSAEK/DMEK) at Kanazawa University Hospital from January 2007 to December 2016. Changes or modifications to the annual number of EK procedures and underlying diseases were analyzed. Results: During this period, 320 EK procedures (DSAEK: 288 cases, DMEK: 32 cases) were performed on 250 patients. Total annual EKs gradually increased from 19 to 45 cases between 2007 and 2016. The annual number of DSAEKs was stable, although the proportion of DSAEKs to other procedures decreased significantly as re-DSAEKs and DMEKs increased. BK after argon laser iridotomy (ALI) was the leading cause in 2007, followed by Fuchs’ endothelial dystrophy (FED) and failed penetrating keratoplasty. In 2016, BK after trabeculectomy (TLE) was most prevalent, followed by failed DSAEK, failed penetrating keratoplasty, and pseudophakic BK. The decreased ALI and FED, and increased BK after TLE and failed DSAEK were statistically significant. Conclusion: The distribution of EK procedures (DSAEK/DMEK) and underlying diseases changed over 10 years at a tertiary referral hospital in Japan. The proportion of re-DSAEK and DMEK increased among all EK procedures. Most significantly, among the underlying diseases, decreased ALI and FED and increased TLE and failed DSAEK were observed. Extended multicenter analysis may further elucidate the changes in EK procedures and the causes of BK in Japan. Keywords: argon laser iridotomy, trabeculectomy, reoperation, Fuchs’ endothelial dystrophy

Daisuke Takemoto, Tomomi Higashide, Yoshiaki Saito, Shinji Ohkubo, Sachiko Udagawa, Hisashi Takeda, Kazuhisa Sugiyama Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan Purpose: We conducted a prospective study in patients with normal-tension glaucoma (NTG) who received either isopropyl unoprostone or latanoprost. We compared the drugs in terms of their effects on intraocular pressure (IOP) and visual field loss progression over a 3-year period. Study design: Prospective, randomized controlled study. Methods: We enrolled 48 patients with newly diagnosed NTG at Kanazawa University Hospital. Eligible patients were randomly allocated (1:1) to receive either unoprostone or latanoprost ophthalmic solutions. The primary outcomes were IOP changes and visual field deterioration within 36 months. Visual field changes were analyzed: the cumulative survival rates were calculated in terms of mean deviation, pattern standard deviation, and total deviation of the upper or lower hemi-visual field, each visual field sector, and guided progression analysis. In addition, we evaluated the progression of glaucomatous optic disc changes using fundus photography and confocal scanning laser ophthalmoscopy. Results: The mean pretreatment IOP was 15.0±2.4 mmHg in the Unoprostone group and 15.2±1.9 mmHg in the Latanoprost group. The mean IOP during the treatment period was 13.7±2.3 mmHg in the Unoprostone group and 13.0±1.8 mmHg in the Latanoprost group. In both groups, the IOP decreased significantly (p

Tsugihisa Sasaki,1 Tsutomu Sounou,2 Hideki Tsuji,3 Kazuhisa Sugiyama4 1Sasaki Eye Clinic, Mikuni, Sakai, 2Department of Ophthalmology, Keiju Kanazawa Hospital, 3Department of Ophthalmology, Cancer Institute Hospital, 4Department of Ophthalmology and Visual Science, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan Purpose: To facilitate the analysis of lacrimal conditions, we utilized high-definition dacryoendoscopy (HDD) and undertook observations with a pressure-controlled air-insufflation system. We report the safety and performance of HDD.Methods: In this retrospective, non-randomized clinical trial, 46 patients (14 males and 32 females; age range 39–91 years; mean age ± SD 70.3±12.0 years) who had lacrimal disorders were examined with HDD and conventional dacryoendoscopy (CD). The high-definition dacryoendoscope had 15,000 picture element image fibers and an advanced objective lens. Its outer diameter was 0.9–1.2 mm. Air insufflation was controlled at 0–20 kPa with a digital manometer-based pressure-controlled air-insufflation system to evaluate the quality of the image. The HDD had an air/saline irrigation channel between the outer sheath (outer diameter =1.2 mm) and the metal inner sheath of the endoscope. We used it and the CD in air, saline, and diluted milk saline with and without manual irrigation to quantitatively evaluate the effect of air pressure and saline irrigation on image quality.Results: In vivo, the most significant improvement in image quality was demonstrated with air-insufflated (5–15 kPa) HDD, as compared with saline-irrigated HDD and saline-irrigated CD. No emphysema or damage was noted under observation with HDD. In vitro, no significant difference was demonstrated between air-insufflated HDD and saline-irrigated HDD. In vitro, the image quality of air-insufflated HDD was significantly improved as compared with that of saline-irrigated CD.Conclusion: Pressure-controlled (5–15 kPa) air-insufflated HDD is safe, and yields significantly better image quality than CD and saline-irrigated HDD. Keywords: pressure-controlled air-insufflated, high-definition dacryoendoscopy, saline-irrigated dacryoendoscopy, emphysema

Akira Kobayashi, Hideaki Yokogawa, Natsuko Mori, Toshinori Masaki, Kazuhisa Sugiyama Department of Ophthalmology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan Objective: To report the in vivo laser confocal microscopy findings of corneas with keratoconus, with special attention to abnormality of Bowman’s layer and sub-Bowman’s fibrous structures (Kobayashi-structures [K-structures]).Methods: Sixteen keratoconic eyes in 8 consecutive patients with keratoconus (4 males, 4 females, mean age, 41.1 years) were included in this study. Slit-lamp biomicroscopic photos were taken with or without fluorescein staining. The existence of anterior corneal mosaic (ACM) after eyelid rubbing under fluorescein staining was documented. In vivo laser confocal microscopic examinations were performed for all patients in both the central cone and the peripheral cornea to examine the existence of K-structures.Results: According to the Amsler–Krumeich scale, the eyes were graded as follows: stage 1 (n=3), stage 2 (n=1), stage 3 (n=1), and stage 4 (n=11). ACM was observed in 7 eyes (61.1%) in the cone area and 16 eyes (100%) in the peripheral cornea among all keratoconic eyes enrolled in this study. In addition, K-structures were observed in the 7 eyes (61.1%) and 16 eyes (100%) in the peripheral cornea among all keratoconic eyes. The presence of the K-structures was completely matched (100%) with the presence of ACM in both the central cone and the peripheral cornea. In 11 eyes with stage 4 keratoconus, ACM and K-structure was absent in 9 eyes (81.8%) in the cone area. On the contrary, in 5 eyes with mild-to-moderate keratoconus (grade 1 to 3), ACM and K-structure was present in all eyes (100%) in the cone area. The absent ratio of ACM and K-structures in the cone area was significantly higher in stage 4 severe keratoconus compared to mild-to-moderate keratoconus (grade 1 to 3) (Fisher, P=0.005).Conclusion: The existence of ACM and K-structures in both the central cone and the peripheral cornea showed perfect accord in patients with keratoconus, indicating a strong association of ACM and K-structures in patients with keratoconus. With the progress of the keratoconus, it seemed that ACM and K-structure progressively disappeared, suggesting Bowman’s layer abnormalities due to keratoconus. Further study in larger groups of patients with keratoconus is required to fully understand the significance of ACM/K-structures in keratoconic eyes and their association with Bowman’s layer. Keywords: keratoconus, anterior corneal mosaic, K-structure, confocal microscopy

Koji Nitta,1 Kazuhisa Sugiyama,2 Ryotaro Wajima,1 Gaku Tachibana1 1Department of Ophthalmology, Fukui-ken Saiseikai Hospital, Fukui, 2Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan Purpose: The purpose of this study was to clarify differences between highly myopic and non-myopic primary open-angle glaucoma (POAG) patients, including normal-tension glaucoma patients.Patients and methods: A total of 269 POAG patients were divided into two groups: patients with ≥26.5 mm of axial length (highly myopic group) and patients with

Hideaki Yokogawa, Akira Kobayashi, Natsuko Mori, Kazuhisa Sugiyama Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan Purpose: To produce a two-dimensional reconstruction map of dendritic lesions in patients with herpes simplex keratitis (HSK) using in vivo confocal microscopy.Methods: Four eyes of four patients (mean 65.8 years) with HSK presenting with a dendritic lesion were enrolled. Slit-lamp biomicroscopy and in vivo laser confocal microscopy were performed. Acquired confocal images at the level of the epithelium were arranged and mapped into subconfluent montages. Changes in the shape and degree of light reflection of abnormal cells and deposits around dendritic lesions as well as other corneal layers were qualitatively evaluated.Results: Mapping of dendritic lesion was successful in all cases, and the subconfluent montages clearly showed the larger image of dendritic lesion. In all cases, the dendritic lesion consisted of hyperreflective irregular epithelial cells, and was surrounded by distorted and elongated epithelial cells. In three cases, hyperreflective deposits were noted at the midline of the lesion. The corneal stroma showed a hyperreflective honeycomb pattern. In two cases, inflammatory cells were observed at the level of endothelial cell layer.Conclusion: Mapping of dendritic lesions in patients with HSK was successful in all patients using in vivo confocal microscopy. Cellular level observation of dendritic lesion at a relatively larger magnification may help understand the in vivo morphological change of HSK. Further study in more patients with HSK and nonherpetic dendritic lesion is needed to utilize confocal microscopy images in differential diagnosis and follow-up of the epithelial lesions with dendrite. Keywords: herpetic epithelial keratitis, in vivo confocal microscopy, fluorescein slit-lamp photograph, hyperreflective irregular epithelial cells, dendritic lesion