Published papers

Objective: To validate the revised Japanese Ministry of Health criteria for the diagnosis of Sjögren's syndrome (SS) (JPN) (1999), The American-European Consensus Group classification criteria for SS (AECG) (2002), and American College of Rheumatology classification criteria for SS (ACR) (2012). Methods: The study subjects were 694 patients with SS or suspected SS who were followed-up in June 2012 at ten hospitals that form part of the Research Team for Autoimmune Diseases, The Research Program for Intractable Disease by the Ministry of Health, Labor and Welfare (MHLW). All patients had been checked for all four criteria of the JPN (pathology, oral, ocular, anti-SS-A/SS-B antibodies). We studied the clinical diagnosis made by the physician in charge and the satisfaction of the above criteria. Results: Of the 694 patients, 499 patients did not have other connective tissue diseases (CTDs). SS was diagnosed in 476 patients (primary SS in 302, secondary SS in 174), whereas non-SS was diagnosed in 218 patients (without other CTDs in 197, with other CTDs in 21) by the physician in charge. The sensitivities of JPN, AECG, and ACR in the diagnosis of all forms of SS (both primary and secondary SS) were 79.6, 78.6, and 77.5 %, respectively, with respective specificities of 90.4, 90.4, and 83.5 %. The sensitivities of the same systems in the diagnosis of primary SS were 82.1, 83.1, and 79.1 %, respectively, with specificities of 90.9, 90.9, and 84.8 %, respectively. The sensitivities of the same systems in the diagnosis of secondary SS were 75.3, 70.7, and 74.7 %, respectively, with specificities of 85.7, 85.7, and 71.4 %, respectively. Conclusion: The sensitivity of JPN to all forms of SS and secondary SS, the sensitivity of AECG to primary SS, and the specificities of JPN and AECG for all forms of SS, primary SS, and secondary SS were highest in the diagnosis of SS in Japanese patients. These results indicate that the JPN criteria for the diagnosis of SS in Japanese patients are superior to ACR and AECG. © Japan College of Rheumatology 2012.

Stem cells have a specialized microenvironment for maintaining self-renewal and multipotent capacities. It is believed that a cornea epithelial stem cell niche exists in the limbus. To characterize the niche of limbal epithelial stem cells, we observed the limbal basal epithelial layer by histological analysis.Cell clusters or cell suspensions from limbal tissue were prepared with collagenase or dispase II and fixed for cytospin sections. Adhesion assays were done to quantitate calcium-dependent cell adhesion. Limbal tissue and cytospin sections were analyzed by immunohistochemistry, transmission electron microscopy and confocal microscopy.AQP1 positive (AQP1+) cells were observed as non-epithelial cells in the subepithelial stroma. AQP1 expression did not co-localize with CD31, podoplanin, MART-1 positive cells, but were observed in vimentin positive stromal cells. When we made a thorough search of limbal basal cells by confocal microscopy, AQP1+ were observed in the proximity of N-cad, K15 and p63 positive limbal basal epithelial cells. Furthermore, electron microscope revealed stromal cells penetrating the epithelial basal membrane and forming calcium-dependent cellular adhesions with N-cad+ limbal basal epithelial cells.Although we could not clearly detect the expression of N-cad in the AQP1+ cells, AQP1+ cells immediately beneath the epithelial basement membrane may be stromal niche-like cells that directly interact with N-cad+ limbal basal epithelial progenitor cells. © 2012 Elsevier B.V.

Aims: To study serum levels of soluble vascular adhesion protein (sVAP)-1 in type II diabetic patients with retinopathy. Methods: Serum samples were obtained from 53 consecutive patients, including 14 cases with non-angiogenic ocular diseases, i.e., epiretinal membrane (ERM) and idiopathic macular hole (MH), 19 cases with age-related macular degeneration (AMD), and 20 cases with diabetic retinopathy (DR). Protein levels of sVAP-1, intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1, and vascular endothelial growth factor (VEGF) were determined by enzyme-linked immunosorbent assay. Enzymatic activity of semicarbazide-sensitive amine oxidase (SSAO) was also measured. Results: Serum level of sVAP-1 showed a moderate correlation with SSAO activity in all cases. Patients with DR had higher levels of serum sVAP-1 than subjects with ERM and MH, or those with AMD; however, severity of DR is not related to the serum levels of sVAP-1. Serum sVAP-1 correlated positively with VEGF in patients with DR, but not in those with ERM and MH, or those with AMD. Neither soluble ICAM-1 nor VCAM-1 correlated with VEGF, even in subjects with DR. Conclusion: The current data demonstrate the elevated serum levels of sVAP-1 and correlation between sVAP-1 and VEGF in patients with type II diabetes. © 2013 Elsevier Inc. All rights reserved.

Background: Previous studies have reported the effects of statistics of luminance distribution on visual freshness perception using pictures which included the degradation process of food samples. However, these studies did not examine the effect of individual differences between the same kinds of food. Here we elucidate whether luminance distribution would continue to have a significant effect on visual freshness perception even if visual stimuli included individual differences in addition to the degradation process of foods. Methodology/principal findings: We took pictures of the degradation of three fishes over 3.29 hours in a controlled environment, then cropped square patches of their eyes from the original images as visual stimuli. Eleven participants performed paired comparison tests judging the visual freshness of the fish eyes at three points of degradation. Perceived freshness scores (PFS) were calculated using the Bradley-Terry Model for each image. The ANOVA revealed that the PFS for each fish decreased as the degradation time increased; however, the differences in the PFS between individual fish was larger for the shorter degradation time, and smaller for the longer degradation time. A multiple linear regression analysis was conducted in order to determine the relative importance of the statistics of luminance distribution of the stimulus images in predicting PFS. The results show that standard deviation and skewness in luminance distribution have a significant influence on PFS. Conclusions/significance: These results show that even if foodstuffs contain individual differences, visual freshness perception and changes in luminance distribution correlate with degradation time. © 2013 Murakoshi et al.

Corneal endothelial dysfunction remains a major indication for corneal transplantation. Both corneal endothelial cells and stromal cells originate from the neural crest, but have distinct phenotypes and function in the adult cornea. We previously reported that stem cells isolated from the adult corneal stroma [cornea-derived precursors (COPs)] show characteristics of multipotent neural crest-derived stem cells. In this study, we report the induction of functional tissue-engineered corneal endothelium (TECE) from mouse and human COPs. TECE was engineered from Wnt1-Cre/Floxed EGFP mouse COPs in a medium containing retinoic acid and glycogen synthase kinase (GSK) 3β inhibitor (activator of Wnt/β-catenin signaling). The expression levels of major markers characterizing corneal endothelial function (Atp1a1, Slc4a4, Car2, Col4a2, Col8a2, and Cdh2) were significantly upregulated. Both retinoic acid and GSK 3β inhibitor upregulated the expression of Pitx2, a homeobox gene involved in the development of the anterior segment of the eye. GSK 3β inhibitor increased Atp1a1 expression and Na,K-ATPase pump activity of TECE, which was significantly higher than COPs or control 3T3 cells, and 2.6-fold higher than cultured mouse corneal endothelial cells. Mouse TECE transplanted into rabbit corneas maintained transparency and corneal thickness, whereas control corneas without TECE showed marked edema and increased corneal thickness. Furthermore, we successfully induced TECE from human COPs, and human TECE transplanted into rabbit corneas also maintained corneal transparency and thickness. This protocol enables efficient production of corneal endothelium from corneal stromal stem cells by direct induction, which may lead to a novel stem cell therapy for corneal endothelial dysfunction. © 2013, Mary Ann Liebert, Inc.

To report a case who received exchange of intraocular lens (IOP) for impaired vision due to glistening and whitening. Case: A 78-year-old woman presented with impaired vision in her right eye. She had received cataract surgery with implantation of IOL 6 years before. She had had reportedly visual acuity of 0.8 immediately after surgery. Findings: Corrected visual acuity was 0.4 in the right eye. Slitlamp examination showed glistening and whitening of IOP. Funduscopy showed slight chorioretinal atrophy which was the same as immediately after surgery. She received exchange of IOL resulting in corrected visual acuity of 0.8. Conclusion: This case illustrates that glistening and whitening of IOL may result in impaired visual function. Exchange of IOL may be useful in such a situation.

Background: Gait speed and sleep quality are health indices related to longevity and mortality. In the present study, we measured sleep quality, quality of life, gait speed, and visual acuity before and after cataract surgery to evaluate the efficacy of the procedure on systemic health. Methods: The study was conducted on 155 patients (93 women; average age 74.8 years) undergoing cataract surgery with the implantation of a yellow soft acrylic lens. Patients were evaluated using the Pittsburgh Sleep Quality Index (PSQI) and the National Eye Institute Visual Function Questionnaire 25 (VFQ-25; vision-related quality of life) before and then 2 and 7 months after surgery. Four-meter gait speed was also determined. Results: Of the 155 patients, 68 (43.9%) were classified as poor sleepers (PSQI>5.5) prior to surgery. Significant improvements were noted in sleep 2 months after surgery (p<0.05, paired t-test), but thereafter the improvements were not significant. Prior to surgery, 117 patients (77.0%) were classified as slow walkers (speed<1.0 meter/s). Gait speed increased significantly in these patients 2 months after surgery (p<0.001, paired t-test). Multiple regression analysis revealed significant correlations between the preoperative VFQ-25 score and both PSQI (p<0.05) and gait speed (p<0.001). Postoperative increases in the VFQ-25 score were positively correlated with decreases in the PSQI (p<0.05). Improvements in visual acuity were correlated with improvements in the VFQ-25 score, but not with either PSQI or gait speed. Conclusion: Cataract surgery effectively improves sleep quality and slow gait speed. © 2013, Mary Ann Liebert, Inc.

PURPOSE: To study the effect of pupil size on the relationship between refractive astigmatism and uncorrected distance visual acuity (UDVA) and pseudoaccommodation in pseudophakic eyes. METHODS: Thirty-six eyes from 36 patients who underwent phacoemulsifi cation and intraocular lens (IOL) implantation were included. All eyes were divided into two groups based on the presence of postoperative with-therule astigmatism or against-the-rule astigmatism. Uncorrected and corrected distance visual acuity (CDVA), refractive astigmatism, subjective accommodation amplitude, and pupil sizes under photopic and mesopic conditions were measured 1 month postoperatively. The effects of pupil size on the relationship between refractive astigmatism and UDVA were investigated. RESULTS: Against-the-rule astigmatism had a moderate but signifi cant negative linear correlation with UDVA irrespective of the pupil size (R2=0.60, P<.01). A moderate but signifi cant negative linear correlation was found when the pupil diameter exceeded 2.9 mm in eyes with with-the-rule astigmatism (R2=0.46, P=.04). Refractive astigmatism was not signifi cantly correlated with pseudoaccommodation regardless of the pupil diameter in either group. CONCLUSIONS: The results of the current study suggest that pupil size may have an impact on postoperative UDVA in eyes having against the-rule astigmatism and in eyes with a large pupil diameter and with-the-rule astigmatism. Copyright © SLACK Incorporated.

Purpose: To analyze the influence of oxidative stress on retinal ganglion cells (RGCs) by using a selective culture system of rat RGCs. Methods: Rat RGCs were purified by a two-step immunopanning procedure and cultured either with or without antioxidant (AO) compounds. Reactive oxygen species (ROS) in RGCs were analyzed using dihydroethidium. Expression of angiotensin II, cleaved caspase 3, and netrin-1 was analyzed by immunocytochemistry. Live RGCs were detected by use of calcein-acetoxymethyl ester. The roles of angiotensin II type 1 receptor (AT1R) signaling and netrin-1 were analyzed by use of an AT1R blocker (telmisartan) and an anti-netrin-1 neutralizing antibody, respectively. Results: ROS and angiotensin II were induced in RGCs cultured without AO compounds (AO-). In these cultures, the number of live RGCs decreased and expression of cleaved and activated caspase 3 increased, but these changes were attenuated by addition of the AT1R blocker. Reduction in netrin-1 expression under the AO- condition was also prevented by the AT1R blocker. The AT1R blocker's effects on RGC survival and reduction in cleaved caspase 3-positive cells were cancelled by the anti-netrin-1 neutralizing antibody. Conclusions: Oxidative stress induced cell death through AT1R signaling and netrin-1 reduction in cultured RGCs. © 2012 Japanese Ophthalmological Society.

Meibography is used to study morphological changes in the meibomian glands (MGs), and semiquantitative analysis has been used for MG assessment. We conducted a detailed morphometric assessment of MGs using noncontact infrared meibography (NIM) and investigated the relationship between MG morphology and the ocular surface and MG morphology associated with aging and sex in 37 subjects. The MGs in the upper and lower eyelids showed significant correlations in their morphology, with the former having longer ducts than the latter. The mean length of the MG ducts, percent area of MG acini, and number of gland dropouts were significantly correlated with age. The mean length of the MG ducts in the upper and lower eyelids showed negative correlations with the meibum (P=.043) and fluorescein staining score (P=.008), respectively. The percent area of MG acini in the upper eyelid showed a positive correlation with tear film breakup time (P=.012) and negative correlations with tear film lipid layer interferometry and meibum (P=.005 and .002, respectively). The mean length of the male's MG ducts in the lower eyelid was significantly longer than that of the females (P=.03). These results indicate that morphometric analysis using NIM may be useful for assessing ocular surface conditions. © 2013 Elsevier Inc.

PURPOSE. We evaluated the levels of lipid oxidative stress markers and inflammatory cells from tears and conjunctiva of patients with Sjögren syndrome (SS) and normal subjects. METHODS. We examined 31 eyes of 16 patients (16 females) with SS and 15 eyes of 10 healthy controls (2 males and 8 females) in this prospective study. All subjects underwent a Schirmer test, measurement of tear film break-up time, vital stainings, confocal microscopy of the conjunctiva, tear collection for hexanoyl-lysine (HEL), ELISA, and conjunctival brush cytology. Brush cytology samples underwent immunohistochemistry (IHC) staining with HEL and 4-hydroxy-2- nonenal (4HNE). Hematoxylin-eosin and IHC staining with HEL and 4HNE also were performed on conjunctival samples of SS patients and controls. RESULTS. The tear stability and vital staining scores were significantly worse in eyes of SS patients compared to the controls. Conjunctival inflammatory cell density was significantly higher in SS subjects compared to controls. The numbers of conjunctival cells stained positively for HEL and 4HNE were significantly higher in SS patients compared to controls. Tear HEL concentrations correlated significantly with staining scores and inflammatory cell density in confocal microscopy. Conjunctival specimens also revealed higher numbers of cells stained positively for inflammatory markers, as well as HEL and 4HNE in the IHC stainings. CONCLUSIONS. Increase of the oxidative stress status in the conjunctiva of SS patients appears to have a role in the pathogenesis of dry eye disease. A close relationship may exist between reactive oxygen species (ROS) production, lipid peroxidation related membrane damage, and inflammatory processes in dry eye. © 2013 The Association for Research in Vision and Ophthalmology, Inc.

PURPOSE: To report the changes in functional visual acuity (FVA) in eyes with experimentally induced astigmatism. METHODS: This study included 26 right eyes from 26 healthy participants (mean age: 27.0±4.4 years). After confi rming best correction under cycloplegia, the cylinder power ×90° and ×180° (against-the-rule [ATR] and with-the-rule [WTR] astigmatism, respectively) were added with 0.50-diopter (D) steps, from 0.50 to 2.50 D. Conventional visual acuity (VA), FVA as measured by the FVA Measurement System (NIDEK Co Ltd), and 10% low-contrast visual acuity (LCVA) were measured with 3-mm artifi cial pupil under each condition. RESULTS: The mean corrected logMAR VA, FVA, LCVA were -0.18±0.00 (20/13), -0.10±0.08 (20/16), and 0.06±0.06 (20/23), respectively. The VA, FVA, and LCVA had a signifi cant linear negative correlation with the addition of cylinder irrespective of the axes. A significant decrease in FVA was noted on addition of ≥0.50 D WTR astigmatism and ≥1.00 D ATR astigmatism. With the addition of 1.00 D of cylindrical lens, 96% of eyes with WTR and ATR astigmatism could maintain 20/20 in VA testing, whereas only 50% and 62% of eyes with WTR and ATR astigmatism, respectively, could maintain 20/20 in FVA testing. CONCLUSIONS: Astigmatism may be associated with deterioration of visual function even when conventional VA of 20/20 is attained. Functional VA testing seems to be useful in evaluating the masked astigmatic visual impairment that cannot be detected by conventional VA testing. Copyright © SLACK Incorporated.

Purpose: To report and compare the long-term outcome of penetrating and deep anterior lamellar keratoplasty. Cases and Method: This retrospective study was made on 36 cases who received keratoplasty by a single surgeon during past 10 years. The series comprised 27 males and 9 females. There were 25 eyes of keratoconus, 7 eyes of corneal leukoma, and 3 eyes of corneal degeneration. Deep anterior lamellar keratoplasty was performed on 21 cases and penetrating keratoplasty on 21 eyes. Cases were followed up for 2 to 10 years, average 5 years. Results: Final visual acuity averaged 0.72 after lamellar and 0.85 after penetrating keratoplasty. There was no significant difference. Spherical equivalent of refraction showed a tendency to myopia with no difference between the two groups. Corneal endothelial cell density decreased by 11.0±6.6% immediately after lamellar and 59.5±29.0% after penetrating keratoplasty (p< 0.01). Conclusion: There was no difference in visual function and safety between deep anterior lamellar keratoplasty and penetrating keratoplasty for 2 years or longer.

We demonstrated that spiral microchannels could efficiently separate plasma from whole human blood toward autologous serum eye drop, which provides benefits for all dry eye patients. The optimized spiral microchannels realized 100% separation of 10 μm particles and over 90% separation of blood samples.

The renin-angiotensin system (RAS) is a hormone system that has been classically known as a blood pressure regulator but is becoming well recognized as a proinflammatory mediator. In many diverse tissues, RAS pathway elements are also produced intrinsically, making it possible for tissues to respond more dynamically to systemic or local cues. While RAS is important for controlling normal inflammatory responses, hyperactivation of the pathway can cause neural dysfunction by inducing accelerated degradation of some neuronal proteins such as synaptophysin and by activating pathological glial responses. Chronic inflammation and oxidative stress are risk factors for high incidence vision-threatening diseases such as diabetic retinopathy (DR), age-related macular degeneration (AMD), and glaucoma. In fact, increasing evidence suggests that RAS inhibition may actually prevent progression of various ocular diseases including uveitis, DR, AMD, and glaucoma. Therefore, RAS inhibition may be a promising therapeutic approach to fine-tune inflammatory responses and to prevent or treat certain ocular and neurodegenerative diseases. © 2012 Toshihide Kurihara et al.

Background: Central serous chorioretinopathy (CSC) has been traditionally treated with laser photocoagulation. We thought that transpupillary thermotherapy (TTT) utilizing a lower temperature than that of conventional laser photocoagulation might minimize permanent retinal and choroidal damage. Studies suggest that undesirable effects on vision due to TTT are minimal even if it is applied to foveal and/or parafoveal lesions when TTT requires a larger irradiation spot. The aim of this study was to evaluate the efficacy of TTT in the management of atypical CSC. Methods: We defined atypical CSC as bullous retinal detachment with diffuse or several leakages, severe leakage with fibrin formation under serous retinal detachment, or leakage within a pigment epithelium detachment. Eight consecutive patients with atypical CSC underwent visual acuity testing, ophthalmic examination, color photography, fluorescein angiography, and optical coherence tomography to evaluate the results of transpupillary thermotherapy. Retreatment of atypical CSC was based on ophthalmic examination, optical coherence tomography, and fluorescein angiography. TTT was performed on the leaking spots shown in fluorescein angiography, with a power of 50-250 mW, spot size of 500-1200 μm, and exposure time of 13-60 seconds to minimize retinal damage. Results: In five of eight affected eyes, serous detachments completely resolved within 1 month after the initial TTT. One eye had persistent subretinal fluid and required a second TTT treatment. Two eyes showed no resolution of CSC and were treated by conventional photocoagulation. Initial best-corrected visual acuity (BCVA) ranged from 20/600 to 20/20 (mean, 20/40; median, 20/30). Final BCVA ranged from 20/200 to 20/20 (mean, 20/25; median, 20/20). BCVA improved in all cases. Only two eyes with persistent subretinal fibrin and existing retinal pigment epithelial alternations in macular area showed limited improvement of BCVA despite the absence of subretinal exudation. The presence of retinal attachment was confirmed by optical coherence tomography in six eyes (75%). Conclusions: TTT seems to be effective for the treatment of atypical CSC in the short term. Additional studies are necessary to evaluate the long-term effectiveness and safety. © 2012 Kawamura et al, publisher and licensee Dove Medical Press Ltd.

Purpose: To present our findings on the cause of an acute visual field defect (VFD) that developed in a patient on the day after vitrectomy for proliferative diabetic retinopathy. Case: A 50-year-old man complained of a blind area in the superior visual field that developed one day after vitrectomy. The patient had undergone uncomplicated vitrectomy for a long-duration vitreous hemorrhage associated with proliferative diabetic retinopathy. Residual vitreous hemorrhage hampered a clear view of the fundus. Goldmann perimetry showed a horizontal VFD in the superior field. The area corresponding to the VFD was examined by multifocal electroretinograms (mfERGs) and multifocal visual evoked potentials (mfVEPs). The amplitudes of the mfVEPs were reduced with prolonged implicit times especially when the superior hemifield was stimulated, while the amplitudes and implicit times were within the normal range when other parts of the visual field were stimulated. In addition, the full-field photopic ERGs and photopic negative responses were attenuated in the right eye. These findings suggested that the VFD did not originate from alterations in the retinal inner and middle layer but in the ganglion cells. The visual acuity improved to 1.2 but his optic disc became pale and the VFD remained unchanged more than 12 years after the surgery. Conclusion: We suggest that vitrectomy can cause ischemic optic neuropathy by interfering with the circulation associated with diabetes mellitus. Evaluations by mfERGs, mfVEPs, and full-field photopic ERGs were helpful in making the diagnosis. © 2012 S. Karger AG, Basel.

We investigated the efficacy of lacrimal punctal occlusion surgery with a cautery device in patients with chronic GVHD (cGVHD)-related dry eye, with recanalization of puncta and recurrent punctal plug extrusion. A total of 23 puncta from 14 eyes of 10 patients with chronic GVHD (cGVHD)-related dry eye underwent punctual thermal cauterization with a high-temperature disposable cautery device. All patients were refractory to conventional treatment, including artificial tear eye drops, autologous serum eye drops and vitamin A eye drops, and had a history of recanalization and recurrent punctal plug extrusion. The effect of lacrimal punctal cauterization by thermal cautery device was evaluated by changes in subjective symptom scores, corrected distance visual acuity, Schirmer's test values, fluorescein staining scores, rose bengal staining scores, and tear-film break-up time before and 3 months after the surgery. Subjective symptom scores, Schirmer's test values, fluorescein and rose bengal scores, and tear-film break-up time improved significantly 3 months after the surgery. Recanalization of puncta was not observed in all the cases (0 of 14 eyes, 0%). Lacrimal punctal cauterization was effective with no recanalization and significant improvements in subjective symptoms and the ocular surface environment in cGVHD-related dry eye patients who had been refractory to conventional treatments. © 2012 Macmillan Publishers Limited All rights reserved.

PURPOSE:: Oxidative damage and inflammation are proposed to be involved in the age-related functional decline of lacrimal glands. The molecular mechanism(s) of how oxidative stress affects the secretory function of lacrimal glands was investigated because this is currently unclear. METHODS:: We used a novel mev-1 conditional transgenic mouse model (Tet-mev-1) with a modified tetracycline system. The mev-1 gene encodes the cytochrome b560 large subunit of succinate-ubiquinone oxidoreductase in complex II of mitochondria. RESULTS:: Expression of the mev-1 gene induced excessive oxidative stress associated with ocular surface epithelial damage and a decrease in aqueous secretory function. Tear volume in Tet-mev-1 mice was lower than in wild-type mice, and histopathological analyses showed the hallmarks of lacrimal gland inflammation by intense mononuclear leukocytic infiltration and fibrosis in the lacrimal gland of Tet-mev-1 mice. CONCLUSIONS:: This new model provides evidence that mitochondria-induced oxidative damage in the lacrimal gland induces lacrimal dysfunction, resulting in dry eye disease. Our findings strongly suggest that oxidative stress can be a causative factor in the development of dry eye disease. Copyright © 2012 by Lippincott Williams & Wilkins.