Paecilomyces lilacinus-induced Scleritis Following Bleb-associated Endophthalmitis after Trabeculectomy

Paecilomyces lilacinus (P. lilacinus) is a rare cause of fungal scleritis. We herein report a case of P. lilacinus-induced scleritis following bleb-associated endophthalmitis after trabeculectomy that was successfully treated with surgical excision of the affected sclera in combination with antifungal medication. An 85-year-old female underwent trabeculectomy of the left eye. A dellen formed in the corneal periphery due to limbal elevation of the filtering bleb and progressed to an infectious corneal ulcer, leading to blebitis. Eight days after the onset of blebitis, the patient was diagnosed with endophthalmitis, which resolved after vitrectomy. The growth of P. lilacinus was identified on swabs of the conjunctiva and the corneal specimen. Scleritis developed after the resolution of the endophthalmitis, and an early excision of the affected sclera, in addition to antifungal medication, resolved it completely. However, the scleritis recurred in a different region of the left eye. After 7 months of antifungal medication, the left eye showed no residual infection. When treating P. lilacinus-induced scleritis, surgical excision of the affected sclera has been shown to be an effective treatment strategy. Nevertheless, it is possible that the infection may recur in another part of the eyeball after the complete resolution of the primary lesion

Autologous Internal Limiting Membrane Transplants Successfully Close a Large Parafoveal Retinal Hole

　Parafoveal retinal holes (PRHs) are one of the complications that can occur after internal limiting membrane (ILM) peeling during macular surgery. Here we describe a patient in whom an exceptionally large PRH (1,069-μm dia.) was successfully closed by repeated autologous ILM transplantation

Magnetic resonance imaging findings of age-related distance esotropia in Japanese patients with high myopia

Purpose This study aimed to investigate the characteristics of the extraocular muscles and the orbital connective tissue pulleys in Japanese patients with age-related distance esotropia (ARDE) and high myopia using magnetic resonance imaging (MRI). Methods This was a retrospective case-series study. High-resolution coronal MRI scans of 12 orbits were obtained in 6 patients with ARDE and high myopia (age range: 51–69 years). We analyzed the images to determine the positions of the rectus muscle pulleys relative to the center of the globe, the integrity of the lateral rectus-superior rectus muscle (LR-SR) band, and the LR angle (the angle between the major axis of the LR and the vertical plane). Results The distance esotropia ranged from 4 to 25∆, and 3 cases exhibited vertical deviations. The mean (±standard deviation (SD)) axial length was 28.5 (± 1.6) mm. The mean positions of the medial rectus muscle pulley and LR pulley were 1.3 mm inferior and 1.4 mm inferior, respectively, to those seen in the normal control group in our previous study (P = 0.002 and P = 0.05, respectively). All 12 orbits had abnormal elongated LR-SR bands, and 8 orbits (67%) displayed ruptured LR-SR bands. The LR angle (mean±SD; 18.8° ± 8.5°) increased significantly with the inferior displacement of the LR pulley (R2 = 0.77, P = 0.0002). Conclusions Inferior displacement of the LR pulley and abnormal LR-SR bands were seen in Japanese ARDE patients with high myopia, as was found in ARDE patients without high myopia. The LR angle might be useful for judging the degree of LR pulley displacement

Clinical Parameters Reflecting Globe/orbit Volume Imbalances in Japanese Acquired Esotropia Patients with High Myopia but without Abduction Limitations

In high myopia, eye dislocation due to increased globe volume or tight orbital volume causes acquired esotro-pia. GOR (globe/orbit volume ratio), an indicator of the degree of progression of this pathology, was investi-gated the relationships among easily obtained clinical parameters. In this retrospective study, 20 eyes from 10 acquired esotropia patients with high myopia but without abduction limitations were examined. The mean age of the patients was 63.7 ± 8.2 years (mean ± standard deviation). Volumes were measured on the three-dimen-sional fast imaging employing steady-state acquisition magnetic resonance imaging images using the vol-ume-measurement function. Correlations between GOR and the displacement angle of the globe (DA), axial length (AL), and equatorial diameter (ED) were investigated. Mean DA, AL, ED, and GOR values were 107.5 ± 8.5°, 28.86 ± 1.92 mm, 25.00 ± 1.16 mm, and 0.36 ± 0.05, respectively. Only AL was correlated with GOR (p < 0.0001, R2 = 0.6649); DA (p = 0.30, R2 = 0.0633) and ED (p = 0.91, R2 = 0.0008) were not. AL was the only clinically available parameter to indicate globe/orbit volume imbalances in acquired esotropia with high myopia but without abduction limitation. AL may be important for the clinical assessment of the progression of this pathology

Retinal Nerve Fiber Layer Defect and Paracentral Scotoma after Internal Limiting Membrane Peeling with a Nitinol Loop

Internal limiting membrane (ILM) peeling is an important maneuver in vitrectomy for macular holes (MHs). A nitinol loop is a surgical instrument designed to create an edge on the ILM and peel the ILM safely and consistently. The effect of using a nitinol loop for ILM peeling on the retina is not clear. We report here on a case of an idiopathic full-thickness MH in an adult woman, in whom retinal damage was revealed after her ILM was peeled using a nitinol loop

Congenital Multiple Ocular Motor Nerve Palsy Complicated by Splitting of the Lateral Rectus Muscle

We report a case of congenital multiple ocular motor nerve palsy combined with splitting of the lateral rectus muscle (LR). A 59-year-old Japanese female was investigated for worsening esotropia after corrective surgery. She presented with left hypertropia (35Δ) and esotropia (45-50Δ). Orbital magnetic resonance imaging (MRI) showed reduced belly sizes in the superior rectus, inferior rectus, and superior oblique muscles and splitting of the LR, extending from the origin to the belly, in the left eye. Splitting of the LR belly was detected on MRI in a case of congenital multiple ocular motor nerve palsy

KCNJ13 Gene Deletion Impairs Cell Alignment and Phagocytosis in Retinal Pigment Epithelium Derived from Human-Induced Pluripotent Stem Cells

Purpose: The purpose of this study was to establish and analyze a cell model of Leber congenital amaurosis type 16 (LCA16), which is caused by mutations in the KCNJ13 gene encoding Kir7.1, an inward-rectifying potassium ion channel. Methods: The two guide RNAs specific to the target sites in the KCNJ13 gene were designed and KCNJ13 knock-out (KO) human-induced pluripotent stem cells (hiPSCs) were generated using the CRISPR/Cas9 system. The KCNJ13-KO hiPSCs were differentiated into retinal pigment epithelial cells (hiPSC-RPEs). The KCNJ13-KO in hiPSC-RPEs was confirmed by immunostaining. Phagocytic activity of hiPSC-RPEs was assessed using the uptake of fluorescently labeled porcine photoreceptor outer segments (POSs). Phagocytosis-related genes in RPE cells were assessed by quantitative polymerase chain reaction. Results: Most of the translated region of the KCNJ13 gene was deleted in the KCNJ13-KO hiPSCs by the CRISPR/Cas9 system, and this confirmed that the Kir7.1 protein was not present in RPE cells induced from the hiPSCs. Expression of RPE marker genes such as BEST1 and CRALBP was retained in the wild-type (WT) and in the KCNJ13-KO hiPSC-RPE cells. However, phagocytic activity and expression of phagocytosis-related genes in the KCNJ13-null hiPSC-RPE cells were significantly reduced compared to those of WT. Conclusions: We succeeded in generating an RPE model of LCA16 using hiPSCs. We suggest that Kir7.1 is required for phagocytosis of POSs by RPE cells and that impaired phagocytosis in the absence of Kir7.1 would be involved in the retinal degeneration found in LCA16

POEMS Syndrome in a 20-year-old Patient Diagnosed Following a Complaint of Reduced Visual Acuity

We report a case of POEMS syndrome in a 20-year-old patient diagnosed after visiting an eye clinic with a chief complaint of reduced visual acuity. A male university student aged 20 years was referred to our department complaining of blurred vision in both eyes that had persisted for 1 month. He also noted headache, nausea, and paresthesia in the lower extremities around the same time. The visual acuity of his right and left eye was 20/40 and 20/20, respectively. Optic disc edema and serous retinal detachment were present. Brain magnetic resonance imaging showed no intracranial abnormalities, while elevated cerebrospinal fluid pressure, reduced nerve conduction velocity in both lower extremities, hepatosplenomegaly, M proteinemia, high blood VEGF levels, osteoblastic and osteolytic changes in the spine, and atypical plasma cells in bone lesions were noted. From the above findings, the patient was diagnosed with POEMS syndrome. He received high-dose dexamethasone, thalidomide, and radiotherapy on the sacral mass, followed by high-dose melphalan with autologous stem-cell support, and showed subsequent systemic and ophthalmologic improvement. Here, we report the youngest case ever of POEMS syndrome with ocular manifestation. If patients have optic disc edema in both eyes with no intracranial space-occupying lesion, POEMS syndrome should be considered in differential diagnosis, regardless of age

Lights-out Surgery for Strabismus Using a Heads-Up 3D Vision System

During strabismus surgery using illumination from a light source, patients complain of photophobia. The NGENUITYⓇ (Alcon) system is equipped with a high-dynamic-range (HDR) camera. A 4K display viewed by wearing circularly polarized glasses provides clear three-dimensional images of the operative field. A light source is usually required for surgeries of the anterior segment (including strabismic surgery), but the digital processing function of the NGENUITYⓇ system allows image display in relatively dark regions even without a light source. We devised a novel ‘lights-out’ surgery that does not use a microscope’s light source, and we examined the usefulness of this technique in 2 cases of strabismic surgery. We performed strabismus surgery using the NGENUITYⓇ system in two patients between January and June 2018. The HDR function was used, and the aperture was opened to the maximum while the gain was adjusted. Surgery was conducted without using the microscope’s light source. We report the 2 cases’ results and evaluate the novel method. The surgeries were performed without problem even though the microscope’s light source was not used. The patients’ photophobia was alleviated. Lights-out surgery is a potentially useful modality for strabismus surgery