中川 卓

BACKGROUND: This study aimed to report and recall a simple method to remove the lens capsule ab externo when performing intrascleral fixation of an intracapsular intraocular lens (IOL) dislocation with reuse of the IOL. CASE PRESENTATION: A 43-year-old Japanese male patient underwent pars plana vitrectomy, phacoemulsification, and IOL fixation for rhegmatogenous retinal detachment in the right eye 10 years prior. A 3-piece IOL was intraocularly fixed during the initial procedure. In December 2023, the patient presented with intracapsular IOL dislocation in his right eye, causing the IOL to descend into the vitreous cavity enveloped by its entire capsule. During surgery, an intravitreal dislocated IOL was placed over the iris with the entire capsule. The haptics on 1 side of the IOL were placed outside the eye through the corneoscleral wound. Subsequently, the lens capsule and Soemmerring's ring surrounding the haptics were removed. After the haptics were placed back over the iris, the same extraction procedure was performed for the remaining haptics. The IOL was intrasclerally fixed using a flange technique through the intrascleral tunnel at the 4 and 10 o'clock positions. One week postsurgery, the best-corrected visual acuity of the right eye was 20/16, and the corneal endothelial cell density was recorded as 2923 cells/mm2 (preoperative: 1650 cells/mm2). DISCUSSION AND CONCLUSIONS: In cases of 3-piece IOL dislocation, employing the ab externo technique for lens capsule extraction has been proven to be a straightforward and efficient method. This approach facilitates the removal of the lens capsule around the IOL. If subsequent damage to the IOL is identified, it allows for easy conversion to replacement.

BACKGROUND: Posterior synechiae of the iris rarely cause secondary angle-closure glaucoma after pars plana vitrectomy, mainly reported in cases with high postoperative inflammation. The face-down position with gas tamponade can cause acute angle-closure glaucoma in phakic eyes owing to relative pupillary block. This report presents a rare case of pseudophakic eye with secondary acute angle-closure glaucoma after 25-gauge pars plana vitrectomy and long-term vitreous gas tamponade for a macular hole. CASE PRESENTATION: A 61-year-old Japanese female patient presented with a chief complaint of right-sided visual impairment that had persisted for several months. Slit-lamp examination revealed deep anterior chamber and moderate nuclear sclerotic cataracts in both eyes. The axial length of the eye was 23.53 mm right eye and 24.05 mm left eye, and the fundus examination revealed a full-thickness macular hole (stage 3) in the right eye. The patient underwent simultaneous cataract surgery and pars plana vitrectomy with 7-mm diameter 3-piece monofocal intraocular lens implantation, internal limiting membrane peeling, and air tamponade. There were no complications during surgery. Due to non-closure of the macular hole, a second pars plana vitrectomy with internal limiting membrane inverted flap and SF6 gas tamponade was performed 13 days later. The patient maintained face-down position after both surgeries, and 6 days after the second surgery, intraocular pressure was elevated to 53 mmHg, and acute angle-closure glaucoma with iris bombe was diagnosed in the right eye. A laser peripheral iridotomy was performed, resulting in a deepened anterior chamber, normalized intraocular pressure, and a closed macular hole. CONCLUSIONS: This case presents a rare occurrence of secondary acute angle-closure glaucoma in a pseudophakic eye after 25-gauge minimally invasive pars plana vitrectomy and SF6 gas tamponade for macular hole. The cause was presumed to be posterior synechiae of the iris or relative pupillary block due to forward pushing of the intracapsular intraocular lens by vitreous gas. In cases where surgery is repeated without achieving macular hole closure, necessitating long-term face-down position, where vitreous gas is retained for an extended period, or when a large-diameter intraocular lens is implanted, secondary acute angle-closure glaucoma should be considered. This applies even when the 25-gauge pars plana vitrectomy is performed not for a highly invasive proliferative diabetic retinopathy but for macular hole repair, especially if the patient has a pseudophakic eye.

We describe a case of serous retinal detachment (SRD) with ciliochoroidal detachment (CCD) that persisted for 2 years and 7 months after minimally invasive glaucoma surgery (MIGS). A 71-year-old woman with primary open-angle glaucoma and cataracts had a central corneal thickness of 489 μm/492 μm and an ocular axis length of 24.05 mm/24.30 mm. She underwent phacoemulsification and intraocular lens implantation in the right eye (OD), along with goniosynechialysis and microhook ab interno trabeculotomy. Postoperative intraocular pressure was 4-6 mmHg in the OD. Five months later, SRD was observed temporally and inferiorly to the macula, with increased choroidal thickness. Best-corrected visual acuity at 5 months was (1.2)/(1.2) (right eye [OD]/left eye [OS]), and intraocular pressure was 6 mmHg/13 mmHg. CCD in the OD was accompanied by choroidal vessel dilation and choroidal vascular hyperpermeability. Two years and 7 months post-surgery, intraocular pressure spiked to 50-54 mmHg but settled at 12 mmHg 1 week later. CCD resolved, and choroidal folds and SRD disappeared, with decreased choroid thickness. Two years and 10 months postoperatively, there was no SRD recurrence at 10 mmHg on two antiglaucoma eye drops, and best-corrected visual acuity remained stable at (1.0)/(1.0). This case suggests that SRD may result from increased choroidal vessel permeability and retinal pigment epithelium dysfunction secondary to prolonged CCD/low IOP after MIGS. The prolonged disease course may be attributed to the balance between aqueous humor excretion and absorption, influenced by the limited size of the cyclodialysis cleft caused by MIGS.

We describe three cases of pseudoexfoliation syndrome (PEX) in which good outcomes were achieved after secondary intrascleral intraocular lens (IOL) fixation with capsule preservation for aphakic eyes. Three Japanese patients with PEX underwent phacoemulsification and aspiration (PEA) owing to challenges in IOL intracapsular fixation caused by zonular weakness. Case 1 involved an 83-year-old man with PEX. Six weeks post-PEA, 30-gauge needles were inserted to exit between the capsule and the iris. The IOL was fixed intrasclerally using the double-needle technique. Case 2 involved a 90-year-old man with PEX. The same abovementioned double-needle intrascleral IOL fixation procedure was performed eight weeks post-PEA. Intraoperative vitreous prolapse into the anterior chamber was observed, and anterior vitrectomy was performed. Case 3 involved an 80-year-old man with PEX. Seven weeks post-PEA, the patient underwent the same double-needle intrascleral IOL fixation procedure. Good IOL fixation was achieved in all patients without postoperative iris capture. No serious complications, including retinal detachment and vitreous hemorrhage, were observed. Preserving the capsule during secondary IOL scleral fixation for aphakic eyes can effectively reduce intraoperative vitreous prolapse, minimize surgical invasiveness, suppress iris flutter, and prevent capture of the pupillary IOL, making it a meaningful and acceptable approach, although the long-term risks, such as potential lens capsule drop, should be studied further.

Background and objectives: The initial symptom that triggers granulomatosis with polyangiitis (GPA) diagnosis is rarely ocular. We describe a case with a single ocular lesion identified as probable GPA due to proteinase 3 (PR3)-antineutrophil cytoplasmic antibody (ANCA)-positivity according to the diagnostic criteria of the Ministry of Health in Japan; the lesion repeatedly worsened. Materials and methods: A 25-year-old female visited the Department of Ophthalmology, Asahi General Hospital, with upper eyelid swelling and conjunctival and episcleral hyperemia of the left eye. Both hordeolum and eyelid cellulitis were suspected, as the condition was resistant to treatment with antibiotic eye drops. Episcleritis was suspected due to localized hyperemia in the upper part of the eye. Upon treatment with antibacterial agents and steroid eye drops, the swelling and the hyperemia repeatedly worsened every week. Results: Blood samples were positive for PR3-ANCA, and GPA with an isolated ocular lesion was considered. After oral steroid treatment, the patient had no recurrence for 4 years. There was no systemic involvement in the upper respiratory tract, lungs, or kidneys. Conclusions: Diagnosing GPA with ocular symptoms as initial manifestations is challenging. GPA should be considered in treatment-resistant eyelid, orbital, and episcleral lesions, even at a young age.

RATIONALE: There are reports of safe cataract surgery in eyes with posterior polymorphous corneal dystrophy (PPCD); however, to our knowledge, there are no reports of minimally invasive glaucoma surgery (MIGS) in eyes with PPCD. Herein, we report a case of poor intraoperative visibility with gonioscopy, postoperative corneal edema, and corneal astigmatism in eyes with PPCD treated with trabecular micro-bypass stent combined with cataract surgery. PATIENT CONCERNS/DIAGNOSIS: A 78-year-old man was referred to our hospital for MIGS. He presented with bilateral corneal endothelial vesicular changes and band lesions. Endothelial cell density was 2983/2871 cells/mm2 (right/left eye), central corneal thickness was 581 μm/572 μm, best-corrected visual acuity values (Snellen equivalent) were 20/32 (right) and 20/100 (left), and corneal astigmatism was -2.7D in the right eye and -2.5D in the left eye. INTERVENSIONS/ OUTCOMS: After phacoemulsification and aspiration with intraocular lens implantation with a 2.4-mm corneal incision in both eyes, trabecular micro-bypass stents were inserted successfully despite the poor intraoperative visibility with gonioscopy. One week after surgery, the central corneal thickness was 614 μm/609 μm, and Descemet's membrane folds and mild corneal edema were observed. Best-corrected decimal visual acuity was 20/40 for the right eye and 20/50 for the left eye. In the left eye, total corneal astigmatism increased from -2.5D to -5.5D. Corneal astigmatism and edema showed gradual improvement. LESSONS: Although reports have shown that cataract surgery can be safely performed in eyes with PPCD, MIGS in eyes with PPCD may require caution regarding intraoperative visibility with gonioscopy and visual function in the early postoperative period.

PURPOSE: To investigate the relationship between intraocular pressure (IOP) and axial length (AL) and to compare the refractive predicted error in patients who have undergone cataract surgery alone or in combination with trabeculotomy. SETTING: Hospital. DESIGN: Single-center, retrospective, case-control. METHODS: The medical records of patients who had undergone cataract surgery alone or in combination with trabeculotomy using the Tanito microhook were retrospectively reviewed. Patients were grouped into cataract surgery alone (CAT) or cataract surgery combined with trabeculotomy (LOT) groups. Demographic data, preoperative and postoperative IOP and AL, and surgically induced astigmatism (SIA) were analyzed before and 1 month postoperatively to evaluate the interplay between IOP, AL, and refractive outcomes. RESULTS: 52 eyes (52 patients) underwent LOT, and 67 eyes (67 patients) underwent CAT. The mean IOP at baseline did not differ between the groups; the change in IOP (dIOP) was significantly higher in the LOT group than in the CAT group. The mean AL at baseline and the change in AL (dAL) were 24.0 ± 1.2 mm and 0.16 ± 0.11 mm, respectively, in the LOT group, and 23.8 ± 1.1 mm and 0.11 ± 0.070 mm, respectively, in the CAT group. The difference in dAL was also significant. In the LOT group, dIOP and dAL were significantly correlated. The mean SIA vectors did not significantly differ between the groups. CONCLUSIONS: AL decreased because of the reduction in IOP after cataract surgery combined with trabeculotomy. Consequently, the refractive target error was greater, and the postoperative refractive outcome showed a tendency toward hyperopia.

PURPOSE: To clarify the characteristics of intraocular lens (IOL) dislocation requiring IOL suture or intraocular scleral fixation. METHODS: This retrospective consecutive case series included 21 eyes (21 patients) who required sutured or sutureless intrascleral IOL fixation following IOL extraction owing to IOL dislocation at the outpatient clinic in the Department of Ophthalmology, Saitama Red Cross Hospital, Japan, between January and December 2019. Medical records were retrospectively reviewed for background diseases, location of the dislocated IOL (intracapsular/extracapsular), insertion of a capsular tension ring (CTR), and the period from IOL insertion to dislocation. RESULTS: We included 21 eyes of 21 patients who required IOL suture or intrascleral fixation for IOL dislocation at our clinic from January to December 2019 were included. The most common background disease was pseudoexfoliation syndrome (four cases), followed by atopic dermatitis, dysplasia/dehiscence of the zonule, post-retinal detachment surgery, high myopia, and uveitis (three cases each). At the time of dislocation, the IOLs were either intracapsular (16 cases, including 3 cases with CTR insertion) or extracapsular (5 cases). The time from IOL insertion to IOL dislocation was 13.7 ± 8.1 years (maximum: 31.3 years, minimum: 1.7 years). CONCLUSIONS: In this study, all 21 cases represented late IOL dislocations occurring after 3 months postoperatively. Among these late IOL dislocation cases, IOL dislocation occurred in a short-medium period of time, especially in those with CTR insertion and weakness/dehiscence of the zonule, with an average of 3 to 5 years postoperatively. We propose referring to these cases as intermediate-term IOL dislocation.

Purpose: This study evaluated the effectiveness and safety of first and revised second-generation trabecular microbypass stent insertion [iStent (IS) and iStent inject W (IW)] in cataract surgery. Design: Single-center, retrospective, cohort study. Methods: The study included 176 eyes that received trabecular microbypass stents combined with cataract surgery at the Saitama Red Cross Hospital between September 2017 and September 2021. Patients were divided into IS and IW groups depending on the implant type. Demographic characteristics, intraocular pressure (IOP), and the number of antiglaucoma medications (Med) were analyzed preoperatively and 12 months postoperatively. In addition, postoperative complications were compared between the groups. Results: IS and IW were implanted in 86 eyes and 90 eyes, respectively. IOP and Med at 1, 3, 6, 9, and 12 months decreased significantly from baseline in both groups (P = 0.04, P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively, for IOP in the IS group; P = 0.02, P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively, for IOP in the IW group; P = 0.03, P = 0.002, P < 0.001, P < 0.001, and P < 0.001, respectively, for Med in the IS group; and P < 0.001 for all time points for Med in the IW group). IOP did not vary significantly between the groups at 1, 3, 6, 9, and 12 months postoperatively. Med was significantly lower in IW than IS at 1, 3, 6, 9, and 12 months postoperatively (P < 0.001, P < 0.001, P = 0.002, P = 0.002, and P = 0.002, respectively). Hyphema and IOP >30 mm Hg (spike) occurred in 1.2% and 4.4%, and 1.2% and 3.3% of patients in the IS and IW groups, respectively. The probability of successful discontinuation of medications at 12 months postoperatively was 10.5% and 41.1%, respectively (P < 0.001). Conclusions: Postoperative Med was significantly lower in the IW group. Simultaneous insertion of IW in patients with glaucoma requiring cataract surgery may be preferred to IS because it reduces the burden of Med.

PURPOSE: Subthreshold micropulse laser (SMPL) is more clinically efficient for the treatment of diabetic macular edema (DME) than the conventional continuous-wave (CW) laser. We aimed to characterize transcriptome changes after the application of these lasers and to compare the transcripts. METHODS: Human pluripotent stem cell-derived retinal pigment epithelial cells were exposed to laser irradiation. Differentially expressed genes (DEGs), distribution of heat shock protein (Hsp) family, gene expression profile, and gene ontology (GO) enrichment analysis based on RNA sequencing data were investigated at 3 h and 24 h after irradiation. RESULTS: CW laser induced more DEGs than SMPL (1771 vs. 520 genes). The expression of the Hsp family was confirmed in both groups: however, the induction patterns was different for different genes. GO enrichment analysis revealed that CW laser upregulated the expression of DEGs involved in vasculature development (GO: 0001944), related to apoptosis and repair after cell injury whereas SMPL upregulated the expression of DEGs involved in photoreceptor cell maintenance (GO: 0045494), photoreceptor cell development (GO: 0042461), and sensory perception of light stimuli (GO: 0050953). CONCLUSIONS: The results provide insights into the genetic responses and may contribute to the understanding of the molecular mechanisms of laser-induced thermal effects.

BACKGROUND: Severe intraocular hemorrhage is a rare complication of cataract surgery due to the recent generalization of minimal-incision cataract surgery. We report a case of a massive intraocular hemorrhage that probably originated from the central retinal artery after cataract surgery, in which hemostasis was difficult to achieve during vitrectomy. CASE PRESENTATION: An 86-year-old woman was referred to our department for intraocular lens (IOL) dislocation after undergoing cataract surgery. Massive intraocular hemorrhage was observed during the initial visit to our department. She underwent pars plana vitrectomy (PPV) and IOL repositioning under local anesthesia. However, the hemorrhage could not be removed completely because of continued massive intraoperative bleeding from the posterior fundus, and it was extremely difficult to achieve hemostasis during the initial surgery. At 7 days after the initial surgery, PPVs were performed under general anesthesia. Bleeding significantly decreased in the second surgery compared to the first. The bleeding probably originated from the central retinal artery on the optic disc; hemostasis was obtained by coagulation of the bleeding site with intraocular diathermy. After the second surgery, there was no exacerbation of bleeding and the patient's condition was stable. However, the patient's visual acuity showed no light perception after the second surgery. CONCLUSIONS: Massive intraocular hemorrhage may occur from the central retinal artery after undergoing cataract surgery. In such cases, surgery with general anesthesia with a lower maintained blood pressure (instead of surgery under local anesthesia) should be recommended, considering the possibility of difficult hemostasis in the event of bleeding from the retinal artery.

Suprachoroidal effusion (SCE) is a rarely observed complication due to the recent generalization of clear corneal small-incision cataract surgery. We report a case of anterior chamber shallowing (ACS) from the early stage of surgery and SCE during clear corneal small-incision cataract surgery. A 69-year-old man was referred to our department for primary open-angle glaucoma and grade 2 nuclear cataract. The intraocular pressure (IOP) was 18 and 12 mm Hg in the right and left eyes with the instillation of three antiglaucoma eye drops in both eyes, respectively, and deep anterior chamber and normal axial length were observed. At the age of 70 years, which was 4 months after the initial visit to our department, the IOP of the right eye increased to 30 mm Hg. Hence, cataract surgery and microhook ab interno trabeculotomy (μLOT) of the right eye were scheduled. Mild ACS was observed during continuous curvilinear capsulorhexis (CCC), and ACS worsened as the surgery progressed, making the surgery progressively challenging. SCE was observed by fundus examination after phacoemulsification and cortex removal, and the wound was immediately closed with a suture. The IOP was 28 mm Hg on postoperative day (POD) 1 and decreased to 14 mm Hg on POD 5. SCE disappeared on POD 12. On POD 18, intraocular lens implantation into the bag and μLOT were performed under general anesthesia. Subsequently, the IOP decreased to 15 mm Hg 3 months after the surgery. Mild ACS was already present at the time of CCC, so it is possible that SCE occurred in the early stage of surgery. If ACS is observed intraoperatively, especially if there are SCE risk factors, such as hypertension, glaucoma, and lung cancer, as in this case, and even if the eye has deep anterior chamber and normal axial length preoperatively, fundoscopic examination should be performed even at an early stage of clear corneal small-incision cataract surgery to rule out SCE.

Melanoma is one of the most aggressive types of cancer wherein resistance to treatment prevails. Therefore, it is important to discover novel molecular targets of melanoma progression as potential treatments. Here we show that paired-like homeodomain transcription factor 1 (PITX1) plays a crucial role in the inhibition of melanoma progression through regulation of SRY-box transcription factors (SOX) gene family mRNA transcription. Overexpression of PITX1 in melanoma cell lines resulted in a reduction in cell proliferation and an increase in apoptosis. Additionally, analysis of protein levels revealed an antagonistic cross-regulation between SOX9 and SOX10. Interestingly, PITX1 binds to the SOX9 promoter region as a positive regulatory transcription factor; PITX1 mRNA expression levels were positively correlated with SOX9 expression, and negatively correlated with SOX10 expression in melanoma tissues. Furthermore, transcription of the long noncoding RNA (lncRNA), survival-associated mitochondrial melanoma-specific oncogenic noncoding RNA (SAMMSON), was decreased in PITX1-overexpressing cells. Taken together, the findings in this study indicate that PITX1 may act as a negative regulatory factor in the development and progression of melanoma via direct targeting of the SOX signaling.

BACKGROUND: Cytomegalovirus (CMV) has been known to cause unilateral corneal endotheliitis with keratic precipitates and localized corneal edema, iridocyclitis, and secondary glaucoma. CMV endotheliitis is diagnosed based on clinical manifestations and viral examination using qualitative polymerase chain reaction (PCR) of the aqueous humor. CASE PRESENTATION: An 80-year-old woman was referred to our department for bullous keratopathy. Pigmented keratic precipitates were found in the right eye without significant anterior chamber inflammation. After 8 months there was inflammation relapse with mutton fat keratic precipitates and PCR on aqueous humor was performed, with negative results for CMV, herpes simplex virus, and varicella zoster virus. Keratic precipitates disappeared with steroid instillation, and Descemet-stripping automated endothelial keratoplasty (DSAEK) was performed for the right eye. CMV-DNA was positive at 6.0 × 102 copies/ GAPDH 105 copies in real time PCR of corneal endothelial specimen removed during DSAEK with negative results for all the other human herpes viruses. After diagnosis of CMV corneal endotheliitis, treatment with systemic and topical ganciclovir was initiated and there was resolution of symptoms. No recurrence of iridocyclitis or corneal endotheliitis was observed at 6 months follow up. CONCLUSIONS: This case report suggests that PCR should be performed using the endothelium removed during DSAEK for bullous keratopathy of an unknown cause, even if PCR for aqueous humor yields negative results.

Down syndrome critical region (DSCR)-1 functions as a feedback modulator for calcineurin-nuclear factor for activated T cell (NFAT) signals, which are crucial for cell proliferation and inflammation. Stable expression of DSCR-1 inhibits pathological angiogenesis and septic inflammation. DSCR-1 also plays a critical role in vascular wall remodeling associated with aneurysm development that occurs primarily in smooth muscle cells. Besides, Dscr-1 deficiency promotes the M1-to M2-like phenotypic switch in macrophages, which correlates to the reduction of denatured cholesterol uptakes. However, the distinct roles of DSCR-1 in cholesterol and lipid metabolism are not well understood. Here, we show that loss of apolipoprotein (Apo) E in mice with chronic hypercholesterolemia induced Dscr-1 expression in the liver and aortic atheroma. In Dscr-1-null mice fed a high-fat diet, oxidative- and endoplasmic reticulum (ER) stress was induced, and sterol regulatory element-binding protein (SREBP) 2 production in hepatocytes was stimulated. This exaggerated ApoE-/--mediated nonalcoholic fatty liver disease (NAFLD) and subsequent hypercholesterolemia. Genome-wide screening revealed that loss of both ApoE and Dscr-1 resulted in the induction of immune- and leukocyte activation-related genes in the liver compared with ApoE deficiency alone. However, expressions of inflammation-activated markers and levels of monocyte adhesion were suspended upon induction of the Dscr-1 null background in the aortic endothelium. Collectively, our study shows that the combined loss of Dscr-1 and ApoE causes metabolic dysfunction in the liver but reduces atherosclerotic plaques, thereby leading to a dramatic increase in serum cholesterol and the formation of sporadic vasculopathy.

OBJECTIVE: The calcineurin-NFAT (nuclear factor for activated T cells)-DSCR (Down syndrome critical region)-1 pathway plays a crucial role as the downstream effector of VEGF (vascular endothelial growth factor)-mediated tumor angiogenesis in endothelial cells. A role for DSCR-1 in different organ microenvironment such as the cornea and its role in ocular diseases is not well understood. Corneal changes can be indicators of various disease states and are easily detected through ocular examinations. Approach and Results: The presentation of a corneal arcus or a corneal opacity due to lipid deposition in the cornea often indicates hyperlipidemia and in most cases, hypercholesterolemia. Although the loss of Apo (apolipoprotein) E has been well characterized and is known to lead to elevated serum cholesterol levels, there are few corneal changes observed in ApoE-/- mice. In this study, we show that the combined loss of ApoE and DSCR-1 leads to a dramatic increase in serum cholesterol levels and severe corneal opacity with complete penetrance. The cornea is normally maintained in an avascular state; however, loss of Dscr-1 is sufficient to induce hyper-inflammatory and -oxidative condition, increased corneal neovascularization, and lymphangiogenesis. Furthermore, immunohistological analysis and genome-wide screening revealed that loss of Dscr-1 in mice triggers increased immune cell infiltration and upregulation of SDF (stromal derived factor)-1 and its receptor, CXCR4 (C-X-C motif chemokine ligand receptor-4), potentiating this signaling axis in the cornea, thereby contributing to pathological corneal angiogenesis and opacity. CONCLUSIONS: This study is the first demonstration of the critical role for the endogenous inhibitor of calcineurin, DSCR-1, and pathological corneal angiogenesis in hypercholesterolemia induced corneal opacity.

The dysfunction and cell death of retinal pigment epithelial (RPE) cells are hallmarks of late-stage dry (atrophic) age-related macular degeneration (AMD), for which no effective therapy has yet been developed. Previous studies have indicated that iron accumulation is a source of excess free radical production in RPE, and age-dependent iron accumulation in RPE is accelerated in patients with dry AMD. Although the pathogenic role of oxidative stress in RPE in the development of dry AMD is widely accepted, the mechanisms of oxidative stress-induced RPE cell death remain elusive. Here, we show that ferroptotic cell death, a mode of regulated necrosis mediated by iron and lipid peroxidation, is implicated in oxidative stress-induced RPE cell death in vitro. In ARPE-19 cells we observed that the ferroptosis inhibitors ferrostatin-1 and deferoxamine (DFO) rescued tert-butyl hydroperoxide (tBH)-induced RPE cell death more effectively than inhibitors of apoptosis or necroptosis. tBH-induced RPE cell death was accompanied by the three characteristics of ferroptotic cell death: lipid peroxidation, glutathione depletion, and ferrous iron accumulation, which were all significantly attenuated by ferrostatin-1 and DFO. Exogenous iron overload enhanced tBH-induced RPE cell death, but this effect was also attenuated by ferrostatin-1 and DFO. Furthermore, mRNA levels of numerous genes known to regulate iron metabolism were observed to be influenced by oxidative stress. Taken together, our observations suggest that multiple modes of cell death are involved in oxidative stress-induced RPE cell death, with ferroptosis playing a particularly important role.

This corrects the article DOI: 10.1038/hr.2017.31.

Salt-sensitive hypertension is associated with severe organ damage. Generating oxygen radicals is an integral component of salt-induced kidney damage, and activated leukocytes are important in oxygen radical biosynthesis. We hypothesized that a high-salt diet causes the upregulation of immune-related mechanisms, thereby contributing to the susceptibility of Dahl salt-sensitive rats to hypertensive kidney damage. For verifying the hypothesis, we investigated leukocytes adhering to retinal vessels when Dahl salt-sensitive rats were challenged with a high-salt (8% NaCl) diet using acridine orange fluoroscopy and a scanning laser ophthalmoscope. The high-salt diet increased leukocyte adhesion after 3 days and was associated with a significant increase in mRNA biosynthesis of monocyte chemotactic protein-1 and intercellular adhesion molecule-1 (ICAM-1) -related molecules in the kidney. Losartan treatment did not affect increased leukocyte adhesion during the early, pre-hypertensive phase of high salt loading; however, losartan attenuated the adhesion of leukocytes during the hypertensive stage. Moreover, the inhibition of leukocyte adhesion in the pre-hypertensive stage by anti-CD18 antibodies decreased tethering of leukocytes and was associated with the attenuation of functional and morphological kidney damage without affecting blood pressure elevation. In conclusion, a high-salt challenge rapidly increased leukocyte adhesion through the over-expression of ICAM-1. Increased leukocyte adhesion in the pre-hypertensive stage is responsible for subsequent kidney damage in Dahl salt-sensitive rats. Immune system involvement may be a key component that initiates kidney damage in a genetic model of salt-induced hypertension.

Angiotensin II (Ang II) reportedly enhances regulator of G-protein signaling 2 (RGS2), thus making a negative feedback loop for Ang II signal transduction. However, few studies have reported whether Ang II receptor (ATR) antagonists influence RGS2 mRNA expression. We investigated RGS2 mRNA expression when Ang II binding to ATR was blocked with Ang II subtype-1 receptor (AT1R) blockers using vascular smooth muscle cells from the thoracic aorta of male Wistar rats. RGS2 mRNA expression significantly increased with Ang II stimulation, and this increase was almost completely abolished by olmesartan, a potent AT1R-specific blocker. Ang II subtype-2 receptor (AT2R) was not involved in Ang II-mediated RGS expression. In contrast, the AT1R blocker, losartan, partially decreased Ang II-mediated RGS2 mRNA expression because this antagonist directly stimulated RGS2 mRNA expression in Ang II-free medium. EXP3174, which is an active metabolite of losartan, almost completely blunted Ang II-mediated RGS2 mRNA expression without direct stimulation of RGS2 mRNA expression. Moreover, pretreatment with olmesartan abolished Ang II-mediated RGS2 mRNA expression. Treatment with a protein kinase C inhibitor partially decreased losartan-mediated RGS2 mRNA expression. These results suggest that AT1R blockers inhibit RGS2 mRNA expression in response to Ang II via an AT1R-mediated mechanism. However, the AT1R blocker, losartan, behaves as a direct agonist for RGS2 mRNA expression via AT1R through protein kinase C-dependent and -independent pathways. In conclusion, losartan exhibits dual effects on RGS2 mRNA expression, and the direct upregulation of RGS2 mRNA expression may provide a new strategy for the treatment of hypertension.

PURPOSE: We sought to identify the anti-angiogenic molecule expressed in corneal keratocytes that is responsible for maintaining the avascularity of the cornea. METHODS: Human umbilical vein endothelial cells (HUVECs) were cultured with either human dermal fibroblasts or with human corneal keratocytes under serum-free conditions. The areas that exhibited blood vessel formation were estimated by immunostaining the cultures with an antitibody against CD31, a blood vessel marker. We also performed microarray gene-expression analysis and selected one molecule, angiopoietin-like 7 (ANGPTL7) for further functional studies conducted with the keratocytes and in vivo in mice. RESULTS: Areas showing blood vessel formation in normal serum-free medium were conditions were markedly smaller when HUVECs were co-cultured with corneal keratocytes than when they were co-cultured with the dermal fibroblasts under the same conditions. Microarray analysis revealed that ANGPTL7 expression was higher in keratocytes than in dermal fibroblasts. In vitro, inhibiting ANGPTL7 expression by using a specific siRNA led to greater tube formation than did the transfection of cells with a control siRNA, and this increase in tube formation was abolished when recombinant ANGPTL7 protein was added to the cultures. In vivo, intrastromal injections of an ANGPTL7 PshRNA into the avascular corneal stroma of mice resulted in the growth of blood vessels. CONCLUSIONS: ANGPTL7, which is abundantly expressed in keratocytes, plays a major role in maintaining corneal avascularity and transparency.

PURPOSE: Prolonged use of topical antifungal agents may compromise corneal epithelial integrity. Here, we used an in vitro model of human stratified corneal epithelium to compare the ocular toxicity profiles of 4 different antifungal eye drops. METHODS: Human corneal epithelial cell sheets were cultured in a serum-free medium containing 0.1% micafungin, 1% voriconazole, 5% pimaricin, 0.1% amphotericin B, or controls (saline or 5% glucose). Cell viability and barrier function were measured by WST-1 assay and carboxyfluorescein permeability assay, respectively. Cell migration was measured on a wound healing assay. RESULTS: WST-1 assay and carboxyfluorescein permeability assay revealed that amphotericin B was the most toxic drug, followed by pimaricin, micafungin, and voriconazole. Cell migration on a wound healing assay was decreased in the following order, amphotericin B, pimaricin, micafungin, and voriconazole. CONCLUSIONS: Topical micafungin and voriconazole appeared to be the least toxic to the corneal epithelium. Drug prescription should consider not only fungal species and susceptibility but also ocular toxicity and stage of treatment.

AIM: To evaluate the stromal bed quality and endothelial damage after femtosecond laser (FSL) cuts into the deep corneal stroma. METHODS: Using a 150-kHz FSL, a lamellar cut was aimed at a depth of 100, 300, or 500 μm in porcine corneas. Stromal bed smoothness was graded from light microscopy and scanning electron microscopy images. Rabbit corneas were cut at remaining thicknesses of 70, 100 and 150 μm using the FSL. The effects of peeling off the corneal flap and the distance between laser spots (2 or 4 μm) were examined. RESULTS: The ratio of damaged cells in the group with a remaining depth of 70 μm was significantly larger than that in the groups with a remaining depth of 150 μm. The ratio of damaged cells in the group with a 4-μm spot separation and the flap peeled off was significantly larger than that in the group with a 4-μm spot separation and the flap not peeled off. CONCLUSIONS: Corneal endothelial damage is likely to increase when the remaining depth is less than 70 μm, and peeling off the flap damages corneal endothelial cells when the remaining depth is less than 100 μm.

PURPOSE: We determined the plausible functional role of angiopoietin-like protein 2 (Angptl2) in inflammatory corneal hemangiogenesis and lymphangiogenesis in vivo. METHODS: Corneal hemangiogenesis and lymphangiogenesis were induced by suturing 10-0 nylon 1 mm away from the limbal vessel in Angptl2 knockout and K14-Angptl2 transgenic mice. We analyzed Angptl2 and interleukin 1β (IL-1β) expressions in normal and vascularized corneas by real-time RT-PCR and immunohistochemistry. Corneal hemangiogenic and lymphangiogenic responses, and macrophage infiltration were assessed by immunofluorescent microscopic studies using specific antibodies against CD31, LYVE-1, and F4/80, and compared to their corresponding background. Subconjunctival injection of Angptl2 siRNA to the sutured corneas was also performed. RESULTS: Angptl2 mRNA expression increased markedly in the neovascularized corneas compared to the normal cornea. Angptl2 protein was expressed strongly in the corneal epithelium and stroma of the vascularized cornea. The regions showing hemangiogenesis and lymphangiogenesis were increased significantly in K14-Angptl2 mice and reduced in Angptl2(-/-) mice compared to their corresponding background strains. In contrast to control mice, the number of F4/80-positive cells, as well as the expressions of F4/80 and IL-1β were found to be higher in K14-Angptl2 mice and lower in Angptl2(-/-) mice. Subconjunctival injection of Angptl2 siRNA significantly inhibited hemangiogenesis and lymphangiogenesis in the sutured corneas. CONCLUSIONS: Our findings demonstrated Angptl2 to be upregulated in corneal inflammation, and highlight that corneal hemangiogenesis and lymphangiogenesis may be driven by Angptk2 overexpression via macrophage infiltration and IL-1β expression. Angptl2 may be a novel therapeutic target for preventing blindness.

PURPOSE: To investigate the toxicity profiles of seven antiglaucoma topical eye drops and benzalkonium chloride (BAC) using stratified cultivated human corneal epithelial cell sheets (HCES) in a serum-free culture system. METHODS: A range of prostaglandin analogies and preservatives, including BAC, sofZia (SZ), sodium benzoate (SB), and polyquaternium-1 (PQ) were tested. The barrier function and cell viability were examined by a carboxyfluorescein permeability assay and WST-1 assay. Histological evaluation of the HCES was also performed after application of each solution. RESULTS: The carboxyfluorescein permeability assay had a higher sensitivity for the detection of toxicity of test solutions than the WST-1 assay or histological examination. Latanoprost BAC, latanoprost/timolol BAC, and 0.02% or higher concentration of BAC were the most toxic, followed by latanoprost SB, latanoprost preservative-free, BAC 0.002%, and travoprost/ latanoprost PQ. Travoprost SZ and tafluprost BAC (preserved with 0.001% BAC) was the least toxic in our experimental conditions. CONCLUSIONS: The carboxyfluorescein permeability assay using HCES in a serum-free system was the most useful for the quantification of toxicity of ophthalmic solutions. Among the regimens examined, a BAC concentration of 0.001% or lower or non-BAC preservative sofZia was suggested to be the least toxic to the ocular surface.

PURPOSE: To compare the longitudinal change of frequency doubling technology (FDT) perimetry and standard automated perimetry (SAP) results in SAP-normal hemifield in open-angle glaucoma (OAG) eyes with low-to-normal intraocular pressure (IOP). MATERIALS AND METHODS: FDT perimetry with the N-30 full threshold protocol and SAP using the Humphrey Field Analyzer with the 30-2 Swedish Interactive Threshold Algorithm-standard protocol were periodically performed for at least 3 years in 39 eyes of 39 OAG patients with low-to-normal IOP and visual field damage confined to only one hemifield. The time courses of the mean of the threshold values of FDT and the mean of total deviations (TDs) in SAP-normal and SAP-abnormal fields were analyzed using a linear mixed model. RESULTS: The average follow-up was 4.9 years and the average IOP during follow-up was 12.6 mm Hg with or without medication. The aging effect-corrected rate of change in the mean FDT threshold values was significantly negative (P=0.004) in the SAP-normal hemifield, whereas that of mean of TD values by SAP did not significantly differ. In the SAP-abnormal hemifield, the rate of change was significantly negative for both tests (P<0.001). The mean of the slope of the mean TD values in the SAP-abnormal hemifield was significantly more negative than that in the SAP-normal hemifield (P=0.011), whereas that of the mean FDT threshold values showed no significant difference between the 2 hemifields. CONCLUSIONS: FDT is useful for monitoring functional damage in the SAP-normal hemifield in OAG eyes with low-to-normal IOP.

症例1:エタンブトール(EB)19.4mg/kg/dayを約9ヵ月内服後、視力障害、中心比較暗点を認めた74歳女性症例について検討した。EBを中止してメコバラミンに変更したところ、視力と視野は徐々に回復し、半年後には中心比較暗点も消失した。症例2:EB 750mg/dayを約8ヵ月内服後、視力障害、中心比較暗点を認めた85歳男性症例について検討した。EBを中止してカリジノゲナーゼ等に変更したところ、視力と視野は回復傾向となった。EB視神経症を念頭に置き、EB視神経症発症の危険因子(用量、年齢、基礎疾患等)を持っている患者本人に定期的な眼科受診を指示・指導することが重要だと考えられた。

緑内障の最大の病因である眼圧制御機構および唯一の治療法である薬物による眼圧下降機序と,それに伴う慢性進行性の緑内障性視神経症の病態解明には,in vivo実験系である動物眼での解析が必須である.遺伝子改変が可能で多くの実験ツールが存在する優れた実験動物であるマウスを用いた,眼圧および緑内障分野への応用はまだ始まったばかりである.2000年以降マウスの眼圧測定が可能になり,ヒトと同様な眼圧に対する基礎的な情報が得られ,日内変動,体位,時計遺伝子など多くの眼圧制御機構があることが明らかになった.さらに薬物による眼圧下降機序は,房水動態による生理的な解析から,一歩進んで受容体を中心とした分子レベルでの機序が解明されるに至った.次に緑内障疾患モデルとして高眼圧マウスが作製され,遺伝子改変マウスを用いた効率的な網膜神経節細胞障害評価法が見出され,神経線維の障害パターンが解析された.マウス眼とヒト眼との相同性を踏まえたうえで,マウス動物モデルにより眼圧制御機構や網膜神経節細胞障害の機序に迫ることが可能である.(著者抄録)