中川 卓

Background/Objectives: Schlemm canal-based minimally invasive glaucoma surgery (MIGS) can be combined with cataract surgery, but topical glaucoma therapy alone is not a sufficient indication for adding MIGS. This review addresses when cataract surgery alone may be sufficient, when combined cataract surgery and MIGS may be appropriate, and when filtration surgery should be considered. Methods: This narrative review used a targeted PubMed/MEDLINE search of English-language literature published from January 2000 to May 2026 to support source identification and reference selection. The review focused on cataract surgery combined with Schlemm canal- or trabecular meshwork-targeted MIGS, including stent-based Schlemm canal procedures and trabeculotomy/goniotomy-based procedures, medication burden, ocular surface disease, refractive and visual outcomes, corneal endothelial safety, complications, angle visibility, guideline-based decision-making, and patient selection. Final references were selected according to clinical relevance to cataract-surgeon decision-making and evidence priority, with emphasis on guidelines, systematic reviews or meta-analyses, randomized or prospective comparative studies, pivotal or long-term studies, large real-world or post-market studies, and clinically informative safety, refractive, endothelial, imaging, or complication-related studies. Results: Stent-based Schlemm canal procedures and trabeculotomy/goniotomy-based procedures can provide additional IOP and medication reduction compared with cataract surgery alone in selected eyes with mild-to-moderate open-angle glaucoma. Stent-based procedures generally have a lower hyphema risk, whereas trabeculotomy/goniotomy-based procedures may provide comparable or greater IOP reduction in selected eyes but are associated with more frequent hyphema. In normal-tension glaucoma or low-baseline-IOP eyes, the expected benefit is often medication reduction or modest IOP lowering rather than reliable achievement of very low target IOP. Available refractive evidence remains limited and procedure-specific, but suggests that major refractive instability is uncommon in appropriately selected eyes. Conclusions: The decision to combine Schlemm canal-based MIGS with cataract surgery should be goal-directed rather than based solely on the presence of topical therapy. Practical selection should integrate glaucoma subtype, disease stage, baseline and target IOP, expected phacoemulsification-only IOP reduction, medication burden, ocular surface status, adherence, angle visibility, endothelial reserve, refractive objectives, and future filtration surgery options.

BACKGROUND: Acanthamoeba keratitis (AK) is a sight-threatening corneal infection that may initially lack typical epithelial or perineural findings and mimic other infectious or inflammatory anterior segment disorders. Endotheliitis-like presentations of AK with stromal edema, keratic precipitates, Descemet membrane folds, and anterior chamber inflammation have been reported, but progression to severe stromal necrosis with spontaneous sloughing of necrotic corneal tissue is rarely documented. CASE PRESENTATION: A 48-year-old contact lens wearer presented with right eye pain, redness, and decreased vision. Initial examination at a local clinic revealed anterior chamber inflammation without epithelial defects, radial keratoneuritis, or a ring infiltrate, and topical betamethasone was started before referral. At referral (0 weeks; 12 days after symptom onset), slit-lamp examination revealed diffuse stromal edema, fine keratic precipitates, Descemet membrane folds, and anterior chamber inflammation, closely mimicking viral corneal endotheliitis. Aqueous humor polymerase chain reaction for human herpesviruses 1-8 was negative. Because viral endotheliitis or noninfectious anterior uveitis was considered, topical corticosteroids and systemic prednisolone were administered (initially 30 mg/day and was gradually tapered). During follow-up, the clinical appearance evolved toward AK, and anti-infective therapy was revised. Corneal scraping was performed, but direct microscopy and bacterial and fungal cultures were negative. PCR testing of a corneal scraping specimen for Acanthamoeba, bacteria, and fungi was negative. Despite treatment, stromal necrosis progressed to severe corneal melting. At 34 weeks after referral, necrotic corneal tissue spontaneously sloughed as a sequestrum and was submitted for pathological evaluation. Hematoxylin and eosin and periodic acid-Schiff staining revealed necrotic corneal stromal tissue with inflammatory cell infiltration and multiple double-walled cystic structures consistent with Acanthamoeba cysts, confirming AK. CONCLUSIONS: This case illustrates a diagnostically challenging form of AK that initially mimicked corneal endotheliitis, yielded negative scraping-based microbiological tests, and was ultimately confirmed by histopathologic examination of spontaneously sloughed necrotic stromal tissue. Severe AK rarely manifests as necrotic stromal sequestration and spontaneous sloughing, in addition to the more commonly recognized destructive outcomes such as corneal thinning, perforation, or keratoplasty-requiring disease. Repeated diagnostic reassessment is important in contact lens wearers with atypical endotheliitis-like keratitis, particularly when the disease progresses despite antiviral or anti-inflammatory therapy.

RATIONALE: Morgagnian cataracts represent a hypermature stage of cataract formation characterized by cortical liquefaction and a sunken nucleus. Spontaneous rupture of the lens capsule is extremely rare but can result in dislocation of the lens nucleus into the anterior chamber. PATIENT CONCERNS: A 75-year-old woman presented with mild ocular pain and decreased vision in her left eye for 1 week. She had undergone pars plana vitrectomy for retinal detachment approximately 35 years earlier. DIAGNOSES: Slit-lamp biomicroscopy revealed a dense brown lens nucleus dislocated into the anterior chamber with evidence of spontaneous capsular rupture. B-scan ultrasonography showed no retinal detachment. INTERVENTIONS: Lens nucleus extraction combined with pars plana vitrectomy was performed without intraocular lens implantation. The lens nucleus, located in the anterior vitreous cavity at the beginning of surgery, was elevated onto the iris surface using a light guide and a Sinskey hook and subsequently removed through a superior corneoscleral incision. OUTCOMES: Postoperatively, the eye remained quiet with stable intraocular pressure, although visual recovery was limited (0.04) because of preexisting chorioretinal atrophy. LESSONS: This case highlights a rare occurrence of spontaneous capsular rupture and dislocation of the lens nucleus in a Morgagnian cataract following vitrectomy. Long-term zonular and capsular weakening after vitrectomy may predispose to delayed rupture. Early cataract surgery and regular follow-up are essential to prevent spontaneous rupture and subsequent lens-induced inflammation and glaucoma in hypermature cataracts.

PURPOSE: To evaluate the clinical performance of "Direct Strip PCR," a multiplex solid-phase real-time polymerase chain reaction (PCR) kit, for diagnosing infectious uveitis. STUDY DESIGN: Multicenter, prospective, diagnostic accuracy study METHODS: We analyzed 475 ocular-fluid samples (336 aqueous humor and 139 vitreous fluid) from 29 sites in Japan. Direct Strip PCR, an IVD-grade multiplex real-time PCR kit targeting HSV-1, HSV-2, VZV, EBV, CMV, HHV-6, HTLV-1, Toxoplasma gondii, and Treponema pallidum requiring no DNA extraction and incorporating internal controls, was compared with quantitative PCR (qPCR) for concordance and DNA copy-number correlation. RESULTS: All 9 of the target pathogens were detected. Direct Strip PCR showed excellent agreement with qPCR, with percent positive agreement (PPA), percent negative agreement (PNA), and percent overall agreement (POA) in aqueous humor of 98.0%, 99.2%, and 98.5%, respectively, and in vitreous fluid of 95.7%, 97.1%, and 96.4%, respectively, indicating high concordance for positive and negative results. All the values exceeded predefined 90% thresholds agreed upon with the Pharmaceuticals and Medical Devices Agency, meeting the required performance criteria. Discordant results were infrequent (10/4275 targets) and involved low-copy samples near the detection limit. The DNA copy numbers correlated strongly between the methods (r = 0.948-0.996). No adverse events were reported. CONCLUSION: Direct Strip PCR demonstrated high concordance with qPCR, reliably detected major pathogens of infectious uveitis, and yielded quantitative results that correlated with the qPCR results, supporting disease monitoring. Its solid-phase, extraction-free, and per-run calibration-free format provides a practical basis for regulatory submissions and global dissemination of multiplex PCR.

Background: This study aims to characterize the clinical features and outcomes of tattoo-associated sarcoid-like uveitis using a multicenter uveitis registry given the limited existing data. Design: This is a retrospective study. Participants: Ten patients (20 eyes) diagnosed with tattoo-associated sarcoid-like uveitis took part in the study. Methods: The data of patients newly evaluated at participating registry centers from January 2000 to June 2025 were reviewed. Demographic data, treatments, visual acuity, recurrence, glaucoma/intraocular pressure (IOP)-lowering therapy, extraocular involvement, and histologic confirmation were extracted when available. Main Outcome Measures: Recurrence, glaucoma/IOP-lowering therapy, extraocular involvement, and change in logarithm of the minimum angle of resolution (logMAR) from presentation to final follow-up were measured. Results: Seven (70%) patients were male, and the patients' mean age was 35.1 ± 7.8 years. All patients exhibited bilateral ocular involvement. Histologic confirmation at the tattoo site was documented in five (50%) patients. The mean logMAR visual acuity was 0.12 ± 0.31 at presentation and 0.16 ± 0.42 at the final follow-up (median follow-up: 20 months). All patients received topical corticosteroids; periocular steroids were administered in seven cases (70%), oral systemic steroids in four (40%), adalimumab in two (20%), and cyclosporin in one (10%). Seven cases (70%) developed uveitis recurrence, and eight received glaucoma/IOP-lowering therapy (80%). Extraocular inflammation affected the skin/tattoo in seven patients (70%) and the axillary lymph nodes in one (10%). This finding is definitive; however, this is also true even when the organ/body part is plural (e.g., lungs). Conclusions: Tattoo-associated sarcoid-like uveitis often follows a chronic course with frequent recurrence and uveitic glaucoma. Thus, close ophthalmic monitoring and coordinated systemic evaluation may be warranted.