PURPOSE:The causes of floaters include posterior vitreous detachment and fundus hemorrhage, both of which are risk factors for retinal tears. We observed the vitreous of patients with floaters using swept source optical coherence tomography. METHODS:Fundus examination was performed, and the vitreous was observed using swept source optical coherence tomography in 202 eyes of 202 patients with floaters. Patients with uveitis, diabetic retinopathy, and other fundus diseases were excluded. RESULTS:Swept source optical coherence tomography revealed posterior vitreous detachment in 145 of 202 eyes (71.8%) and dot reflex like stardust in the vitreous in 42 of 202 eyes (20.8%). Posterior vitreous detachment occurred in 35 of 42 eyes (83.3%) and 110 of 160 eyes (68.8%) in the stardust (+) and stardust (-) groups, respectively; a significant difference was observed (P <0.001). In the stardust (+) group, 11 of 42 eyes (26.2%) had retinal tears with posterior vitreous detachment and 21 of 42 eyes (50.0%) had fundus hemorrhage. Three of 160 eyes (1.9%) and 4 of 160 eyes (2.5%) in the stardust (-) group had retinal tears with posterior vitreous detachment and fundus hemorrhage, respectively. Both tears and fundus hemorrhage were more frequent in the stardust (+) group than in the stardust (-) group (P <0.001). CONCLUSION:The stardust sign on swept source optical coherence tomography indicates the risk of retinal tear.

Afatinib is a second-generation epidermal growth factor receptor (EGFR) inhibitor that has been shown to be effective against EGFR-mutated non-small cell lung cancer (NSCLC) resistant to conventional EGFR inhibitors such as gefitinib and erlotinib. Although ocular side effects of gefitinib and erlotinib have been reported, those for afatinib have yet to be definitively established. This report presents details on the first case of unilateral iridocyclitis associated with the side effects of afatinib therapy. A 75-year-old Japanese male ex-smoker with EGFR-mutated NSCLC underwent afatinib therapy for multiple metastases. At 2 weeks, bilateral conjunctivitis developed. Topical medication and a 1-week afatinib washout period resulted in the improvement of the conjunctivitis. However, 3 days after the resumption of afatinib, the patient developed unilateral granulomatous anterior uveitis in his right eye. Best-corrected visual acuity (BCVA) measurement indicated a decimal visual acuity of 0.2, while the slit-lamp findings were characterized by granulomatous inflammation, keratic precipitates, Koeppe nodules and posterior synechiae. There was no evidence suggesting other intraocular inflammatory disease or metastatic tumor. The left eye was intact. The use of topical medication including steroids and a washout of afatinib resulted in a gradual subsiding of the anterior uveitis. After resolution of the anterior uveitis, oral afatinib was resumed. BCVA of the right eye finally recovered to a decimal acuity of 1.0. Ophthalmologists should be aware of the possibility that side effects associated with afatinib could cause granulomatous anterior uveitis.

PURPOSETo obtain sequential flat (en face) images of posterior precortical vitreous pockets (PPVPs) using swept-source optical coherence tomography (SS-OCT).METHODSWe performed SS-OCT in the right eyes of 112 volunteers (mean age, 30.1 years; mean refraction, -2.5 diopters) while sitting using 12-mm horizontal, vertical scans of the 12- × 9-mm plane × 2.6-mm depth through the macula and optic disc. En face images of the posterior vitreous were obtained by En-View, a SS-OCT program.RESULTSSwept-source OCT visualized the PPVPs and Cloquet's canals in all subjects; the PPVPs appeared as boat-shaped lacunae in the horizontal scan and extended superiorly as clefts in the vertical scan. En face imaging showed PPVPs and Cloquet's canals as two oval lacunae near the vitreoretinal interface and a septum between the nasal border of the PPVPs and Cloquet's canals. In all cases, the lacunas of the PPVPs were larger than those of Cloquet's canals. In 99 (88.4%) of 112 eyes, the PPVPs and Cloquet's canals were fused by connecting channels. The mean width of the connecting channels was 920.2 ± 37.4 μm, and the mean height was 288.6 ± 20.0 μm. On the anterior en face images, the PPVPs became crescent-shaped in all eyes.CONCLUSIONSUsing SS-OCT, we obtained en face images of PPVPs and Cloquet's canals in vivo. The en face images of the PPVPs near the retina showed oval shapes that changed to crescents, which corresponded to the superior edge of the PPVPs. The PPVPs were fused with Cloquet's canal by a flat-shaped connecting channel.

Rebamipide was initially developed and approved for use in treating gastric ulcers and lesions associated with gastritis. Discovery of its ability to increase gastric mucin led to investigations of its effect on ocular surface mucin and the subsequent development for use in dry eye patients. Investigations have confirmed that rebamipide increases corneal and conjunctival mucin-like substances along with improving corneal and conjunctival injury. Clinically, rebamipide ophthalmic suspensions can effectively treat tear deficiency and mucin-caused corneal epithelial damage, and can restore the microstructure responsible for tear stability. Topical rebamipide has also been shown to be effective in treating other ocular surface disorders such as lagophthalmos, lid wiper epitheliopathy, and persistent corneal erosion. Rebamipide's ability to modify epithelial cell function, improve tear stability, and suppress inflammation in the absence of any known major side effects suggest that it may be a beneficial first drug of choice for severe dry eye treatment and other ocular surface disorders. This review summarizes the history and development of this innovative dry eye treatment from its initial use as an - effective stomach medication to its current use in the treatment of dry eye in Japan.

PURPOSE:To observe vitreous changes in high myopia using swept-source optical coherence tomography (SS-OCT).METHODS:We performed slit-lamp biomicroscopy and SS-OCT in the highly myopic right eyes of 151 patients (mean age, 52.7 years; mean refraction, -11.4 diopters [D]) and the right eyes with no myopia of 363 healthy control volunteers (mean age, 52.8 years; mean refraction, -1.4 D). To estimate the sizes of the posterior precortical vitreous pockets (PPVPs), we measured the height between the fovea and the anterior border of the PPVPs.RESULTS:Patients with partial posterior vitreous detachments (PVDs) around the macula and complete PVDs in high myopia were significantly (P < 0.0001) younger (47.1 ± 14.1 and 61.2 ± 12.0 years, respectively) than controls (59.0 ± 9.6 and 69.7 ± 6.6 years). The PPVPs with no PVDs were significantly (P < 0.001) higher in 32 eyes with high myopia (984 ± 292 μm) than 164 controls (553 ± 166 μm). After a complete PVD with a Weiss ring developed, the vitreous cortex was on the macula in 40.5% of the eyes with high myopia, which differed significantly (P < 0.0001) from the 8.7% of the controls. Myopic foveoschisis was present in 14 (9.3%) of 151 eyes. In eyes with foveoschisis, three (21.4%) eyes had partial PVDs and 11 (78.6%) eyes had complete PVDs; there was no residual cortex in 8 (72.7%) of 11 eyes with complete PVDs.CONCLUSIONS:Highly myopic eyes may have larger PPVPs than normal eyes. Partial PVDs around the macula and complete PVDs occur at younger ages. The vitreous cortex more frequently remains on the macula after development of complete PVDs in highly myopic eyes.

Background: Multiple evanescent white dot syndrome (MEWDS) is an acute and usually unilateral retinopathy that occurs predominantly in young adults. This report presents the outcomes of ganglion cell analysis (GCA) in MEWDS.Case presentation: A 41-year-old woman was diagnosed as MEWDS in right eye. At her initial visit, the deviation map of the ganglion cell analysis showed there was a decrease of the ganglion cell layer (GCL) + inner plexiform layer (IPL) thickness in both eyes, even though her left eye was not affected. A 29-year-old woman was also diagnosed as MEWDS in right eye. Although the deviation map of ganglion cell analysis showed there was a decrease of the GCL + IPL thickness in both eyes at her initial visit, her right eye was not affected.Conclusion: GCA indicated there was a decrease (<1% of the distribution of normals) of the ganglion cell layer + inner plexiform layer thickness in both the affected and fellow eyes in 7 of 9 patients diagnosed as MEWDS in our hospital. Although the lesions responsible for MEWDS are thought to disrupt the photoreceptor outer segments, we observed changes in the inner retina in both the affected and fellow eye of MEWDS patients.

PURPOSEWe observed the posterior vitreous in children using swept-source optical coherence tomography (SS-OCT).METHODSThe normal right eyes of 73 children (ages, 3-11 years) were studied using SS-OCT with 12-mm horizontal and vertical scans in the posterior fundus.RESULTSPosterior precortical vitreous pockets (PPVPs), narrow liquefied spaces along the vitreoretinal interface in the macula (mean, 165.4 ± 35.2 μm [depth] × 3327 ± 615.7 μm [width]), were observed at age 3 in horizontal scans. The PPVPs enlarged to 382.9 ± 51.8 × 4486.5 ± 342.3 from ages 4 to 6 (P < 0.01) and 524.9 ± 60.3 × 5485.9 ± 307.5 after age 7 (P < 0.01). In all subjects, the depth and width were means of 426.4 ± 38.2 and 4834.4 ± 228.1 μm, respectively. There were significant correlations between the PPVP size and age (PPVP depth, r = 0.42, P < 0.001; PPVP width, r = 0.42, P < 0.001), but not refractive error. The PPVP posterior wall was not visible in all eyes. The PPVP and Cloquet's canal appeared as separate spaces at ages 3 and 4 years. The connecting channel between the PPVPs and Cloquet's developed in 7.7%, 11.1%, 12.5%, 27.3%, 40%, 37.5%, and 50% at ages 5, 6, 7, 8, 9, 10, and 11, respectively.CONCLUSIONSThe PPVPs emerged in front of the macula as a solitary space in early childhood. They first were narrow liquefied spaces anterior to the macula at age 3 and evolved to small boat-shaped spaces that gradually enlarged with age. The channels connecting the PPVPs and Cloquet's canal begin to form after age 5. Their presence suggests a physiologic role of the PPVPs.

Purpose: To investigate the morphologic features of posterior precortical vitreous pockets (PPVPs) with positional changes using spectral domain optical coherence tomography. Methods: The authors measured the distance between the fovea and anterior PPVP border on spectral domain optical coherence tomography scans in both eyes of 20 consecutive individuals and compared the differences with changes in position from sitting to supine. Results: A PPVP was identified in both eyes of 14 individuals (70%). In the vertical scan, the superior portion of the pocket was larger than the inferior portion in all 28 eyes when the participants were sitting. The mean distances between the fovea and the anterior PPVPs that border in the right and left eyes, respectively, were 477.6 ± 40.7 &mgr;m and 497.1 ± 31.8 &mgr;m when the participants were sitting and 665.6 ± 51.6 &mgr;m and 750.5 ± 48.2 &mgr;m when the participants were supine. The differences between the 2 positions were significant (P < 0.005). Conclusion: The superior portion of the PPVPs enlarged when the participants were sitting. The anterior border of the pocket moved anteriorly when the participants were supine.

Recently, a new treatment to the vitreoretinal interface diseases, vitreous injection of enzymatic vitreous melting drug is beginning to take place [1]. This is a treatment to release the adhesion between the incompletely detached vitreous and the retina. Because the vitreous is transparent, to observe the relationship between the vitreous and the retina using only slit lamp microscope is difficult, optical coherence tomography (OCT) is necessary for adaptation decision of the vitreous injection [2]. How useful is the diagnostic imaging of the vitreous by current OCT?

IMPORTANCE:Development of posterior vitreous detachment (PVD) plays an important role in vitreomacular diseases. Spectral-domain optical coherence tomography (SD-OCT) with noise reduction can visualize a posterior precortical vitreous pocket (PPVP) and classify PVD stages according to the state of the posterior wall of the PPVP.OBJECTIVE:To describe the role of the PPVP in early-stage PVDs in healthy individuals.DESIGN, SETTING, AND PARTICIPANTS:We performed biomicroscopy and SD-OCT in the right eyes of 368 healthy volunteers (188 males and 180 females; mean [SD] age, 57.1 [19.4] years; range, 12-89 years).RESULTS:The condition of the posterior wall of the PPVP was classified into stages according to the biomicroscopic findings and SD-OCT images: stage 0, no PVD with PPVP (134 eyes; mean [SD] subject age, 38.7 [16.5] years; range, 12-76 years); stage 1, paramacular PVD with PPVP (47 eyes; mean age, 55.2 [10.3] years; range, 36-77 years); stage 2, perifoveal PVD with PPVP (27 eyes; mean age, 62.0 [8.7] years; range, 46-81 years); stage 3, vitreofoveal separation with persistent attachment to the optic disc (19 eyes; mean age, 65.8 [6.2] years; range, 55-80 years; stage 3a, vitreofoveal separation with an intact posterior wall of the PPVP in 12 eyes; stage 3b, vitreofoveal separation with a defect in the posterior wall of the PPVP in 7 eyes; and stage 4, complete PVD (141 eyes; mean age, 73.2 [8.3] years; range, 48-89 years).MAIN OUTCOMES AND MEASURES:Ages in each PVD stage.CONCLUSIONS AND RELEVANCE:The posterior wall of the PPVP initially detaches at the paramacular area and extends to the perifoveal area, which results in a perifoveal PVD. A vitreofoveal detachment may develop with or without a defect in the PPVP. When the vitreous detaches from the optic disc, a complete PVD develops. An anatomical feature of the PPVP may play a role in the development of a perifoveal PVD.

Administration of topical rebamipide increases the mucin level of tear film and improves the ocular surface in short break-up time type of dry eye. Lid wiper epitheliopathy (LWE) is a disorder of the marginal conjunctiva of the upper eyelid with dry eye symptoms. LWE may be related to mechanical forces during blinking resulting in inflammation of the ocular surface. Rebamipide also has various anti-inflammatory effects. In this report, we tried treatment with topical rebamipide for two cases of LWE. One case had been treated with sodium hyaluronate ophthalmic solution and diquafosol sodium eye drops by other doctors for several weeks. The other case was not previously treated. In both cases, fluorescein staining of the cornea and lid margin was remarkably improved, ocular symptoms decreased, and tear film break-up times increased with rebamipide eye drops four times daily for 2-3 weeks. Topical rebamipide was effective for corneal and conjunctival disorders in LWE. This drug may provide a novel approach to the treatment of LWE.

PURPOSE:To observe posterior precortical vitreous pockets (PPVPs) using swept-source optical coherence tomography (SS-OCT).METHODS:We performed SS-OCT in both eyes of 58 volunteers (36 men, 22 women) using 12-mm horizontal vertical scans through the macula and optic disc. To minimize age-related changes (liquefaction or posterior vitreous detachment), all subjects were a mean of 26.2 years (range, 22-40 years). The refractive errors ranged from -9.5 diopters (D) to +3.0 D. To estimate the PPVP size, we measured the height between the fovea and the anterior border of the PPVP and the maximal width in the 12-mm horizontal scan through the fovea and disc.RESULTS:SS-OCT visualized the PPVPs as boat-shaped lacunae in the macular area bilaterally in all subjects (maximal width, 3114-9887 μm; mean width, 6420.6; central height, 208-1877 μm; mean height, 708.1 in the right eyes, with no significant difference in the left eyes). There was a significant correlation between the PPVP height and myopic refractive error. The posterior wall of the PPVP was a thin vitreous cortex, thinnest at the fovea. The septum was between the nasal border of the pocket and Cloquet's canal, which extended forward and tilted superiorly in all cases. A channel connected Cloquet's canal and the PPVPs bilaterally in 54 (93.1%) of 58 cases.CONCLUSIONS:SS-OCT clarified the boat-shaped PPVP structure in vivo. Although the central height increased with the myopic refractive error, the width was unchanged. A channel connecting Cloquet's canal and PPVP suggested the route of aqueous humor into the PPVP.

Administration of topical rebamipide improves the ocular surface in dry eye. We consecutively studied seven eyes in seven cases (three males and four females) with mild lagophthalmos (three cases after eyelid surgery, two cases of incomplete facial nerve palsy, and two cases of senile ectropion) during the treatment of corneal disorders with rebamipide eye drops four times daily for 2 weeks. The fluorescein corneal staining (FCS) score, tear film break-up time (TBUT), Schirmer's test, and decimal visual acuity were examined. Ocular symptoms were examined and scored by questioning each patient before and after administration of the drug. In all seven eyes, inferior corneal erosion decreased or disappeared within 2 weeks after administration of topical rebamipide. The FCS score was significantly improved (P < 0.05). The TBUT was significantly extended from 2.9 ± 0.5 seconds to 5.2 ± 0.4 seconds (P < 0.05). The scores of ocular symptoms, such as eye pain, dryness, blurred vision, and foreign body sensations, were significantly improved (P < 0.05).Topical rebamipide was effective for corneal disorders in mild lagophthalmos. This drug may provide a novel approach to treat lagophthalmos.

The authors report four cases of vitreomacular traction syndrome with splitting of the posterior vitreous cortex. Spectral-domain optical coherence tomography (SD-OCT) was performed consecutively in 35 patients with vitreomacular traction syndrome between June 2007 and February 2011. SD-OCT showed perifoveal posterior vitreous detachment with splitting of the posterior vitreous cortex in 4 of 35 eyes (at the fovea in 1 eye and the perifovea in 3 eyes). The separated cortex of the posterior lamella adhered to the retina in all 4 eyes. The posterior vitreous cortex may split at the macular area in cases of vitreomacular traction syndrome.

PURPOSE:The posterior precortical vitreous pocket (the pocket) is a premacular liquefied lacuna, the physiologic presence of which was reported in autopsy eyes. We describe the morphologic features of the pocket in normal individuals.METHODS:We performed spectral-domain optical coherence tomography in 102 eyes of 51 normal subjects of various ages in a sitting position.RESULTS:The pocket was identified as an optically lucent space anterior to the posterior fundus in 85 of 102 eyes (83.3%) in the age-group. The vitreous cortex was extremely thin at the central fovea, and it gradually thickened along with age in the perifoveal area. A shallow perifoveal posterior vitreous detachment developed in 16 of 32 eyes (50%) of subjects aged >51 years. The lamellar structure of the vitreous cortex was seen in 7 of the 32 eyes (22%) of subjects aged >51 years.CONCLUSION:Spectral-domain optical coherence tomography confirmed the presence of the pocket in all ages. Thickened vitreous cortex and perifoveal posterior vitreous detachment were physiologic findings in older individuals. The lamellar structure of the vitreous cortex may be related to the vitreoschisis.

The authors report the retinal findings of the healing phase in commotio retinae. Retinal images were obtained using spectral-domain optical coherence tomography (SD-OCT) on 3 eyes from 3 patients with commotio retinae after blunt ocular trauma. The best-corrected visual acuity (BCVA) and fundus appearance from the medical records were retrospectively studied. All cases had commotio retinae in the posterior pole. OCT showed increased reflectivity of the line at the junction between the photoreceptor inner and outer segments (IS/OS) in the area of the opacified retina in all cases. The initial BCVA in cases 1, 2, and 3 was 1.5, 1.2, and 0.7, respectively. In all eyes, the neurosensory retinal edema had resolved and the IS/OS line returned to normal architecture. The final BCVA in cases 1, 2, and 3 was 2.0, 1.5, and 1.5, respectively. The authors found restored photoreceptor outer segment in commotio retinae by SD-OCT and improvement of BCVA.

PURPOSE:To determine the efficacy of intravitreal injection of sulphur hexafluoride (SF6) gas for reducing persistent subfoveal fluid after scleral buckling surgery for macula-off rhegmatogenous retinal detachments.METHODS:We injected 0.3 ml of SF6 gas into the vitreous cavity of two eyes of two patients with persistent macular retinal detachment 3 and 5 months after successful scleral buckling. Optical coherence tomography was performed before and after surgery.RESULTS:Subfoveal fluid was displaced peripheral to the fovea immediately after gas injection and the fluid was absorbed gradually in both eyes.CONCLUSIONS:Persistent subfoveal fluid after scleral buckling may be treated with intravitreal SF6 gas injection.