PMC8418316_01
Clinical fundus images of the patient in his 40s. (A) Fundus photographs showing no apparent abnormalities. (B) Horizontal optical coherence tomography (OCT) images showing sustained macular structure whereas the macular maps show diffuse thinning of the entire retinal layers in the macular area. (C) Fluorescence angiography images in the left eye. Both images obtained 50 sec (upper) and 20 min (lower) after injection show no apparent abnormalities.
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Dilated fundus examinations showed no apparent abnormalities in either eye (Figure 1A). Optical coherence tomography (OCT) images showed sustained macular structure but diffuse thinning of the entire retinal layers in the macular area in both eyes (Figure 1B, Cirrus HD-OCT model 4000, Carl Zeiss, Germany). Fluorescein angiography (FA) revealed no apparent abnormalities (Figure 1C).
Visual field testing and retinal thickness. (A) Humphrey visual field testing showing slight relative visual field defects in both eyes. The foveal thresholds are within the normal range. (B) Kinetic visual field testing showing no obvious abnormalities in all isopters. (C) The change of median deviation (MD) in Humphrey field analyzer and averaged thickness of ganglion cell layer (GCL) and inner plexiform layer (IPL) in optical coherence tomography images showing no progressive change as glaucoma during the time course of 12 years.
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Optical coherence tomography (OCT) images showed sustained macular structure but diffuse thinning of the entire retinal layers in the macular area in both eyes (Figure 1B, Cirrus HD-OCT model 4000, Carl Zeiss, Germany). A static visual field test using a Humphrey field analyzer (HFA II 750, Carl Zeiss, Germany) showed slight relative visual field defects in both eyes (Figure 2A). A kinetic visual field test using the Goldmann perimeter did not reveal any obvious abnormalities (Figure 2B). His visual acuity and visual field were stable for over 10 years (Figure 2C).
Intraoperative images. (A) The first operation for the left eye with conventional bright light under retrobulbar anesthesia (RBA). The patient moved his head as he felt intolerable discomfort from the bright light of the light pipe. Although we reduced the luminance level to 60%, he refused vitrectomy. (B) The second operation for the right eye, the fourth surgery in total, using the heads-up surgery system with minimal illumination under RBA. Although the luminance of the light from the light pipe was as low as a quarter of that used in the previous operation (15%), the intraoperative visibility was sufficient to perform vitrectomy. The patient tolerated this light level and did not complain of photophobia. (C) The third operation for the right eye, the fifth operation in total, with inadvertent bright illumination under RBA. After encircling and vitrectomy (approximately 85 min), we inadvertently set the brightness level of the twin light chandelier to 100%. The luminance was the same as the 60% from the light pipe, which was high enough to evoke his photophobia. However, he did not feel photophobia, presumably because he had had enough time for light adaptation.
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We set the brightness of the light pipe to 15% (4.8 x 104 cd/m2) and inserted the light pipe into a cannula, which provided excellent intraoperative visibility with minimal illumination (Figure 3B, Supplemental video). Upon noticing the wrong setting, we immediately reduced the brightness to 30% (5.9 x 104 cd/m2) and asked the patient if he felt photophobia (Figure 3C, Supplemental video).
PMC8418316_02
Intraoperative images. (A) The first operation for the left eye with conventional bright light under retrobulbar anesthesia (RBA). The patient moved his head as he felt intolerable discomfort from the bright light of the light pipe. Although we reduced the luminance level to 60%, he refused vitrectomy. (B) The second operation for the right eye, the fourth surgery in total, using the heads-up surgery system with minimal illumination under RBA. Although the luminance of the light from the light pipe was as low as a quarter of that used in the previous operation (15%), the intraoperative visibility was sufficient to perform vitrectomy. The patient tolerated this light level and did not complain of photophobia. (C) The third operation for the right eye, the fifth operation in total, with inadvertent bright illumination under RBA. After encircling and vitrectomy (approximately 85 min), we inadvertently set the brightness level of the twin light chandelier to 100%. The luminance was the same as the 60% from the light pipe, which was high enough to evoke his photophobia. However, he did not feel photophobia, presumably because he had had enough time for light adaptation.
IMCRJ-14-583-g0003.jpg
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We set the brightness of the light pipe to 15% (4.8 x 104 cd/m2) and inserted the light pipe into a cannula, which provided excellent intraoperative visibility with minimal illumination (Figure 3B, Supplemental video). Upon noticing the wrong setting, we immediately reduced the brightness to 30% (5.9 x 104 cd/m2) and asked the patient if he felt photophobia (Figure 3C, Supplemental video).
PMC8418316_03
Intraoperative images. (A) The first operation for the left eye with conventional bright light under retrobulbar anesthesia (RBA). The patient moved his head as he felt intolerable discomfort from the bright light of the light pipe. Although we reduced the luminance level to 60%, he refused vitrectomy. (B) The second operation for the right eye, the fourth surgery in total, using the heads-up surgery system with minimal illumination under RBA. Although the luminance of the light from the light pipe was as low as a quarter of that used in the previous operation (15%), the intraoperative visibility was sufficient to perform vitrectomy. The patient tolerated this light level and did not complain of photophobia. (C) The third operation for the right eye, the fifth operation in total, with inadvertent bright illumination under RBA. After encircling and vitrectomy (approximately 85 min), we inadvertently set the brightness level of the twin light chandelier to 100%. The luminance was the same as the 60% from the light pipe, which was high enough to evoke his photophobia. However, he did not feel photophobia, presumably because he had had enough time for light adaptation.
IMCRJ-14-583-g0003.jpg
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We set the brightness of the light pipe to 15% (4.8 x 104 cd/m2) and inserted the light pipe into a cannula, which provided excellent intraoperative visibility with minimal illumination (Figure 3B, Supplemental video). Upon noticing the wrong setting, we immediately reduced the brightness to 30% (5.9 x 104 cd/m2) and asked the patient if he felt photophobia (Figure 3C, Supplemental video).