Sex-specific difference in age distribution of congenital lower eyelid epiblepharon in a Japanese population Abstract Purpose To examine the sex-specific differences in age distribution of Japanese patients with congenital lower eyelid epiblepharon. Study design A retrospective, observational study. Methods A total of 291 patients (87 men, 204 women) who underwent modified Hotz for correction of congenital lower eyelid epiblepharon were included in this study. Data on sex, age at surgical intervention, and affected side were collected. Patients’ age was classified according to the orbital growth pattern (0-3 years, 4-6 years, 7-12 years, 13-15 years, and ≥ 16 years). The sex-specific difference in age distribution was analysed using Pearson’s chi-squared test. Results Among male patients, 75 (86.2%) underwent surgery during 4-12 years of age. Only 2 (2.3%) boys had surgery at 13-15 years and 1 had it while he was ≥ 16 years. Among female patients, 11 (5.4%) underwent surgery at 13-15 years and 59 (28.9%) at ≥ 16 years. The age distribution was significantly different between sexes (P < 0.001). Conclusion Among patients aged ≥13 years, there were more women compared to men. This implies that congenital lower eyelid epiblepharon is more persistent in females and may reflect slower and less orbital growth from 13 years of age and onwards in females. The results suggest that as long as there are no severe corneal complications and no risk for amblyopia, conservative management may be a good option for males since spontaneous resolution is likely to occur. However, for females aged 13 years or more, the threshold for surgical intervention should be lower.

No increase in incidence of post-intravitreal injection endophthalmitis without topical antibiotics: a prospective study Abstract Purpose In our previous report, intravitreal injection using 0.25% povidone-iodine to irrigate the conjunctival sac together with pre- and post-injection topical antibiotics achieved an incidence of post-injection endophthalmitis significantly lower than other reports. In this study, we examined whether similarly low incidence is achieved without using any topical antibiotics. Study design Prospective cohort study. Methods We evaluated intravitreal injections of anti-vascular endothelial growth factor agents conducted by vitreoretinal specialists at the outpatient injection room of a single university hospital. This study had two protocols. First stage: We performed more than 3000 injections with pre-injection but without post-injection topical antibiotics. Final stage: After confirming no case of endophthalmitis in the first stage, we performed more than 12,500 injections without either pre- or post-injection topical antibiotics. In both protocols, we used 0.25% povidone-iodine to sterilize the conjunctival sac both before and after injection. Results First stage was performed between April 2015 and January 2016. No case of suspected or proven infectious endophthalmitis occurred in 6039 injections [95% confidence interval (CI) 0–0.000497%]. Final stage was performed between February 2016 and November 2017. No case of suspected or proven infectious endophthalmitis occurred in 12,523 injections (95% CI 0–0.00024%). This result was comparable to our previous study using both pre- and post-injection topical antibiotics (0/15,144 injections, 95% CI 0–0.000198%). Conclusion Using conjunctival sac irrigation with 0.25% povidone-iodine before and after intravitreal injection, the incidence of endophthalmitis remains low even when the use of pre- or post-injection topical antibiotics is discontinued.

Twelve-month efficacy and safety of glaucoma filtration device for surgery in patients with normal-tension glaucoma Abstract Purpose To assess the efficacy and safety of filtration surgery using the EX-PRESS glaucoma filtration device in patients with normal-tension glaucoma (NTG). Study design Prospective, single-arm, multicenter interventional case series. Methods Eyes with NTG underwent EX-PRESS implantation with or without cataract surgery. The efficacy and safety were assessed at 1 day; 1 and 2 weeks; and 1, 3, 6, and 12 months after surgery. The main outcome measure was reduction in intraocular pressure (IOP) from baseline at 3, 6, and 12 months after surgery. Safety assessments included adverse event incidence, postoperative inflammation, and corneal endothelial cell density. Results Thirty-two Japanese patients (37 eyes) with NTG were enrolled. The mean IOP decreased from 14.8 ± 2.3 mmHg at baseline to 10.0 ± 3.1 mmHg at 12 months after surgery (mean reduction 4.9 ± 4.2 mmHg [31.1%]; P < .0001). IOP-lowering medication use decreased from a mean of 3.3 medications per eye before surgery to 0.1 medications per eye at 12 months after surgery. IOP reductions > 20% were achieved by 61.5% of the eyes at 12 months. Adverse events were typical for filtration procedures, and none was deemed device-related. Postoperative inflammation was mild and self-limiting. The mean corneal endothelial cell density had decreased by 3.3% at 12 months after surgery. Conclusion The EX-PRESS glaucoma filtration device is safe and effective for filtration surgery in patients with NTG, providing mean IOP reduction consistent with recommendations based on the Collaborative NTG Study.

Recent trends of ocular complications in patients with atopic dermatitis Abstract Purpose To elucidate the recent trends in prevalence and characteristics of ocular complications of atopic dermatitis (AD). Study Design Cross-sectional observational study. Methods Among AD patients who visited our department between 2012 and 2015, 70 patients (140 eyes; recent AD group) who gave informed consent to participate in the study were analyzed. Following a medical interview, ophthalmological examinations were conducted for ocular complications related to AD. The data were compared to those of 280 AD patients (560 eyes) analyzed in a similar study conducted at our department in 1991–1993 (previous AD group). Results Blepharitis was found in 58 eyes (41%) in the recent AD group, and the frequency was significantly lower compared to the previous AD group (294 eyes, 53%) (p < 0.05). Tears in retina or pars plana ciliaris occurred in 22 eyes (4%) in the previous AD group, compared with none in the recent AD group (p < 0.01). Retinal detachment was observed in 12 eyes (2%) in the previous AD group, and none in the recent AD group (p < 0.01). Atopic keratoconjunctivitis (AKC) increased significantly in the recent AD group compared to the previous AD group (74.3% vs. 39.5%) (p < 0.001). Patients with a habit of slapping around the eye decreased significantly from 32.5% in the previous AD group to 12.1% in the recent AD group (p < 0.001). Conclusions Ocular complications in AD patients show a trend of decrease in recent years, which presumably is attributed to educational activities to increase patient awareness and advances in therapeutic strategy.

Current practice in the management of branch retinal vein occlusion in Japan: Survey results of retina specialists in Japan Abstract Purpose To elucidate the current clinical practice patterns of branch retinal vein occlusion (BRVO) management by retina specialists in Japan in the era of anti-vascular endothelial growth factor (VEGF) therapy. Study design A voting survey using an answer pad system. Methods On May 28, 2017, forty-one retina specialists were surveyed on the pathology and clinical practice of BRVO management. Results Most specialists (77.5%) use fundus examination and optical coherence tomography (OCT) for diagnosis of macular edema (ME) secondary to BRVO. All assess the condition of the ellipsoid zone (EZ) and external limiting membrane (ELM) and consider this a visual prognostic factor. For ME secondary to BRVO, anti-VEGF therapy is the first choice, and most specialists (82.4%) select initial injection followed by a pro re nata (PRN) regimen. For switching to other treatment options for persistent cases, combination therapy of anti-VEGF injections and laser therapy is the most common choice (35.9%), whereas 25.6% select vitreous surgery and 15.4% select adding steroid injections. Conclusions Our survey presents the current opinions on the diagnosis and treatment of BRVO by retina specialists in Japan, and reveals the common views about damage to the EZ/ELM as a factor of poor prognosis and anti-VEGF therapy as the first line treatment, highlighting various opinions on initiation and switching of therapy.

Pseudodrusen pattern and development of late age-related macular degeneration in the fellow eye of the unilateral case Abstract Purpose To investigate whether the development of late age-related macular degeneration (AMD) in fellow eyes with pseudodrusen is associated with the pseudodrusen pattern in patients with unilateral exudative AMD. Study design Retrospective observational study. Methods A retrospective analysis was performed on 73 patients with unilateral exudative AMD showing pseudodrusen in their fellow eyes. Eyes were classified according to pseudodrusen pattern, which was determined based on maximum pseudodrusen ribbon length. Results During the mean follow-up period of 35.5±18.6 months, 21 (28.8%) eyes developed late AMD. Among these eyes, 15 (71%) developed exudative AMD and six (29%) developed geographic atrophy (GA). Development of late AMD in fellow eyes occurred with significantly more prevalence in patients showing a ribbon-dominant type pseudodrusen pattern in their fellow eye than dot-dominant type (P=0.0005, log-rank test). Cox-regression analysis revealed that development of late AMD in fellow eyes is associated with the presence of ribbon-dominant pseudodrusen in the fellow eyes (hazard ratio 4.15, 95% confidence interval (CI) 1.59–10.8), along with older age (hazard ratio 1.10, 95% CI 1.03–1.17), a history of smoking (hazard ratio 17.2, 95% CI 1.11–263), the presence of large soft drusen in the fellow eye. (hazard ratio 5.49, 95% CI 1.29–21.1) and retinal angiomatous proliferation (hazard ratio 5.02, 95% CI 1.90–13.2) Conclusions Fellow eyes with ribbon-dominant pseudodrusen in patients with unilateral exudative AMD are likely to develop late AMD.

Arteriovenous crossing associated with branch retinal vein occlusion Abstract Branch retinal vein occlusion (BRVO) is defined as the focal occlusion of a first or second-order branch of retinal vein, which occurs most frequently at an arteriovenous (AV) crossing. Direct ophthalmoscopy, color fundus photography, and fluorescein angiography facilitate observation of AV crossings parallel to the retinal plane. Optical coherence tomography (OCT), with its high-depth resolution, enables observation of retinal lesions perpendicular to the retinal plane. OCT angiography (OCTA) provides depth-resolved images of the retinal vasculature by segmenting three-dimensional data. In this review, we discuss novel findings related to affected AV crossings associated with BRVO obtained via OCT and OCTA. The high-depth resolution of OCT or OCTA is useful for observation of the narrowed vein and determination of the vessel position of the affected AV crossing. Studies using OCT and OCTA have shown that BRVO caused by a venous overcrossing is more prevalent than previously reported, and that venous narrowing was significantly greater in instances caused by a venous overcrossing than in those caused by an arterial overcrossing. Moreover, OCTA also revealed that the retinal nonperfusion area size was larger in eyes with BRVO caused by a venous overcrossing than in those with BRVO caused by an arterial overcrossing. This contrasts with earlier findings obtained by conventional imaging modalities predating OCT, which showed that an arterial overcrossing was more common than a venous overcrossing at the causative venous occlusion site in eyes with BRVO. This review discusses these findings and their significance in the study of AV crossing associated with BRVO.

Association of an age-related maculopathy susceptibility 2 gene variant with the 12-month outcomes of intravitreal aflibercept combined with photodynamic therapy for polypoidal choroidal vasculopathy Abstract Purpose To determine the association of age-related maculopathy susceptibility 2 (ARMS2) gene polymorphisms with the 12-month outcomes of intravitreal aflibercept combined with photodynamic therapy (IVA+PDT) in polypoidal choroidal vasculopathy (PCV). Study design Interventional cohort study. Methods This was a retrospective study of 48 consecutive treatment-naïve PCV patients. The patients underwent IVA+PDT as the initial therapy and were followed up for more than 12 months under a pro re nata regimen. The single nucleotide polymorphism (SNP) at rs10490924 in the ARMS2 gene was genotyped using the TaqMan assay. The clinical characteristics and outcomes of IVA+PDT were compared among the 3 genotypes at rs10490924. Multivariate regression analysis was performed to evaluate the influence of the clinical cofactors on the association of rs10490924 with the visual outcome at 12 months after the first IVA+PDT. Results No significant difference was found in the baseline characteristics among the 3 genotypes (n = 9, 23, and 16 for the GG, GT, and TT genotypes, respectively). All the patients, regardless of genotype, showed a significant improvement in vision, central retinal thickness, and subfoveal choroidal thickness at all time points measured after the initial IVA+PDT. The number of treatments was significantly smaller in the patients with the GG genotype than in those with the GT or the TT genotype. On multivariate logistic regression analysis, the number of the T allele at rs10490924 was significantly associated with the chance of retreatment after the initial IVA+PDT. Conclusion The presence of the G allele at rs10490924 in the ARMS2 gene is likely associated with a lower chance of retreatment after IVA+PDT in patients with PCV.

Outcomes of vitrectomy combined with subretinal tissue plasminogen activator injection for submacular hemorrhage associated with polypoidal choroidal vasculopathy Abstract Purpose To examine the outcomes of vitrectomy with subretinal tissue plasminogen activator (tPA) injection and postoperative intravitreal antivascular endothelial growth factor (VEGF) injection for submacular hemorrhage (SMH) associated with polypoidal choroidal vasculopathy (PCV). Study design Retrospective, consecutive case series. Methods Patients who underwent vitrectomy for SMH associated with PCV and who were followed up for at least 12 months were included. Surgery consisted of vitrectomy with subretinal tPA and air tamponade. Postoperative intravitreal anti-VEGF was administered pro re nata. The following were examined: best-corrected visual acuity (BCVA) at baseline, at 1 month, and at the final visit; the percentage of patients requiring anti-VEGF postoperatively; and the number of injections administered. Results This study included 23 eyes of 23 patients (21 men, 2 women) with a mean age of 72.5 ± 9.0 years. The mean duration from disease onset to surgery was 9.0 ± 6.6 days. The mean maximum SMH size was 5.8 ± 4.8 disc diameters. The mean follow-up period was 33 ± 14 months. The BCVA was significantly improved when compared with baseline 1 month after surgery and at the final visit. Postoperative anti-VEGF was required for 91% of the eyes. In eyes that underwent anti-VEGF therapy until the final visit, the mean injection number was 4.1/year. Conclusions Vitrectomy with subretinal tPA and air tamponade improved visual acuity in patients with SMH associated with PCV. Postoperative intravitreal anti-VEGF injection maintained the improved BCVA throughout a mean period of 33 months.

Clinical characteristics of scleritis patients with emphasized comparison of associated systemic diseases (anti-neutrophil cytoplasmic antibody-associated vasculitis and rheumatoid arthritis) Abstract Purpose We evaluated patient profiles, clinical features, associated systemic diseases, treatment modalities, and ocular complications in cases of scleritis and episcleritis. Study design Retrospective. Methods Clinical data of 128 patients referred to the ophthalmology clinic at Jichi Medical University Hospital during the 4-year period from April 2011 to March 2015, and diagnosed with scleritis or episcleritis were examined. Gender, average onset age, unilateral or bilateral manifestation, classification type, associated systemic diseases, and treatments were retrospectively investigated. Results The cohort consisted of 57 men and 71 women. Average onset age was 54.3 ± 17.4 years. Diffuse anterior scleritis was the most common type. It was noted in 43 (32.8%) patients, followed by episcleritis in 35 (27.3%), nodular anterior scleritis in 23 (18.0%), necrotizing anterior scleritis in 22 (17.2%), and posterior scleritis in 6 (4.7%). Eighteen (81.8%) of 22 patients with necrotizing anterior scleritis required some type of systemic medication, including corticosteroid, cyclophosphamide, cyclosporine, azathioprine, methotrexate, or rituximab administration. Forty (31.3%) had associated systemic diseases, which included 10 with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis and 8 with rheumatoid arthritis (RA). Patients with ANCA-associated vasculitis had a tendency to develop scleritis first and had significantly worse visual prognoses compared to those with RA. Conclusions Approximately 30% of the patients with scleritis and episcleritis had complications involving systemic diseases, including ten patients with ANCA-associated vasculitis and 8 with RA. ANCA-associated vasculitis was more often diagnosed after scleritis and patients suffered poorer visual prognoses than those with RA.