Silent myocardial ischemia in glaucoma and cataract patients

Background: Glaucoma and cataract are multifactorial diseases. They have been described to be associated with cardiovascular risk factors. Methods: Twentyfour-hour ECG monitoring was done in 22 normal-tension glaucoma patients, 27 open-angle glaucoma patients, 25 cataract patients, and 20 normal controls. The frequency of silent myocardial ischemia (SMI) as well as that of ventricular extrasystoles (VES) was evaluated. Results: At least one episode of significant asymptomatic ST-T segment depression occurred in 45% of the normal-tension glaucomas, in 25.9% of open-angle glaucomas, in 12% of cataract patients, and in 5% of normal controls. The frequency of VES was not significantly different among the groups. Conclusions: Glaucoma, especially normal-tension glaucoma, is significantly associated with the occurrence of episodic asymptomatic myocardial ischemias. Cataract patients, however, had only a slightly, statistically not significantly increased frequency of both SMI and VES compared with normals.     

Precision of ultrasonic estimates of choroidal melanoma regression

Background: Important prognostic information may be gained from knowledge of the volume and, over time, the change in volume of intraocular tumours such as choroidal melanomas. Methods: The precision and time consumption of three different ultrasonographic methods were evaluated. Seven choroidal melanomas were analysed after placement of a ruthenium plaque and again after tumour regression had occurred. Perpendicular ultrasound B-scans were printed and analysed by overlay grid counting or outline tracing of tumour structures to calculate the volume. These two methods, using only two perpendicular scans, were compared with a micro-computer-controlled ultrasonographic three-dimensional rotation scanning system, where each tumour was manually outlined in 20 revolving scan planes. Results: The three-dimensional volume scanning method was the most precise, but also the most demanding in hardware and time consumption. Conclusion: Increased precision and less observer-dependent estimation of shrinkage rate after radiotherapy is available at the cost of sophisticated equipment.     

Adult-onset foveomacular vitelliform dystrophy and indocyanine green videoangiography

Background Adult-onset foveomacular vitelliform dystrophy (AOFVD) represents a heterogeneous group of disorders with different clinical, angiography, and histopathological features. The most common form is characterized by a yellow, round to oval subretinal macular lesion with or without central pigmented spot. Methods Eight patients affected by typical AOFVD underwent fluorescein an giography and indocyanine green videoangiography (ICGV). Results Fluorescein angiography showed a central hypofluorescent spot surrounded by an irregular hyperfluorescentring ICGV demonstrated a foveal nonfluorescent spot, visible during the entire examination, and a hyperfluorescent area surrounding the central spot, which became evident soon after the beginning of the examination. Conclusions In light of previous histopathological studies, the central nonfluorescent spot may be interpreted as a masking effect of a pigment clump, whereas the hyper-fluorescent area may represent dye pooling or staining of the subretinal pigment epithelial material.     

The use of tissue plasminogen activator in post-traumatic total hyphaema

Background: We wanted to evaluate whether intracameral injection of tissue plasminogen activator (tPA) is useful in managing traumatic hyphaema. Methods: Two eyes with total hyphaema after a severe penetrating injury were treated with a single intracameral injection of 25 g of tPA 5 and 14 days after the injury, respectively. Results: Most of the blood coagulum dissolved within 24 h, and in one of the two eyes the intraocular pressure decreased from 45 to 8 mmHg. The other eye was hypotonic. No re-bleeding or complications related to the use of tPA were noticed. Conclusion: The results in these two cases suggest that tPA is a useful adjunct in managing total hyphaema.     

Corneal neovascularization in rats as a model for photothrombotic therapy using bacteriochlorin a and an argon laser

Background: The presence of vessels has a negative influence on corneal transplant survival. Closure of such vessels prior to transplantation may improve the transplant results, and this might be achieved by irradiating the vessels with argon laser light after intravenous administration of a photosensitizer, e.g. bacteriochlorin a (BCA). A suture-induced corneal neovascularization model in rats was set up to test this hypothesis. Methods: Suture-induced vessels in the cornea of male Wistar rats were irradiated with argon laser light after intravenous administration of BCA. We applied irradiation of varying energy levels and duration and assessed the changes in the vessels by slit-lamp examination, fluorescein angiography and histology. Results: Suture-induced corneal vessels in the rat could be used effectively to study photothrombosis therapy. Intravenous administration of BCA prior to irradiation (=514.5 nm) of the corneal vessels led to vessel closure at lower energy levels and of longer duration than occurred with laser treatment alone. Conclusion: Suture-induced corneal neovascularization in the rat can be used as a model to study the efficacy of photothrombosis therapy. BCA can be used to enhance the rate and duration of vessel closure.     

Inhibition of corneal allograft reaction by CTLA4-Ig

Background: Activation of T cells requires both the interaction of T-cell receptor with major histocompatibility complex on the antigen-presenting cell and costimulatory signals, for instance the B7 antigens expressed on antigen-presenting cells and the CD28 molecule expressed on T cells. A recombinant fusion protein, CTLA4-Ig, has been produced that contains the extracellular domain of human CTLA4 fused to IgGl constant region and that binds the B7 molecule with high affinity. Blocking the CD28/B7 interaction with CTLA4-Ig inhibits T cell activation in vitro and in vivo. Methods: We used CTLA4-Ig in a fully MHC-mismatched mouse keratoplasty model. The animals were divided into four groups: (1) no treatment, (2) intraperitoneal treatment with 130 g CTLA4-Ig, (3) intraperitoneal treatment with 300 g CTLA4-Ig, (4) subconjunctival treatment with 290 g CTLA4-Ig. Results: The allograft reaction occurred in untreated animals between days 12 and 16 (mean 13.5). While topical application of CTLA4-Ig seemed to shorten the graft survival (mean 11.6 days) and systemic application of 130 g had no influence (mean 14.0), only intraperitoneal injection of 300 g of CTLA4-Ig prolonged the survival of allografts (mean >20 days) (P<0.01). Conclusion: CTLA4-Ig prolonged significantly the survival of corneal allografts in a fully MHC-mismatched mouse keratoplasty model, but the small antigen load of the corneal transplant and the anterior chamber-associated immune deviation (ACAID) may have a disadvantage to induce tolerance in this model of CTLA4-Ig therapy.Presented at JERMOV 1996 in Montpellier     

Increased release of tenascin in tear fluid after photorefractive keratectomy

Background: Extracellular matrix protein tenascin (TN) is expressed in the anterior stroma during corneal wound healing. In this study we analysed TN release in tear fluid after photorefractive keratectomy (PRK). Methods: Tear fluid TN concentrations of ten PRK patients were measured with an immunoassay. Tear fluids were collected preoperatively and 1, 2 and 7 days after PRK. The tear fluid collection time and the volume of tears collected were registered. Because tear fluid flow was greatly increased postoperatively, tear fluid flow-corrected release (TN flux) was calculated. Results: The tear fluid flow was 4.50±0.94 l/min (mean±SEM) preoperatively, 55.48±16.70 l/min (P<0.01) on the 1st, 33.91±7.91 l/min (P<0.01) on the 2nd, and 13.79±5.49 l/min (P>0.05) on the 7th postoperative day. The preoperative TN concentration was 0.85±0.20 g/ml. On the 1st postoperative day it decreased to 0.37±0.17 g/ml (P>0.05), most likely due to the dilution effect caused by hypersecretion after PRK. The TN concentration was 0.67±0.12 g/ml (P>0.05) on the 2nd and 0.78±0.15 g/ml (P>0.05) on the 7th postoperative day. The preoperative TN flux was 5.23±1.88 ng/min. On the 1st and 2nd postoperative days the TN flux was 14.40±4.99 ng/min (P<0.05) and 22.66±6.I2 ng/min (P<0.05), respectively. On the 7th postoperative day a tendency towards decreased flux (14.00±6.02 ng/min, P>0.05) was observed. Conclusion: Although there is a minor decrease in TN concentration after PRK due to increased tear fluid flow, a significant increase in TN flux was observed. Complete reepithelialization of the ablated area was observed in all eyes at the follow-up visit on postoperative day 7.     

The role of inner wall retinectomy in the management of juvenile retinoschisis

Purpose: The purpose of this paper is to describe the technique and application of relief of vitreous traction and inner wall retinectomy in the management of juvenile retinoschisis (JRS). In addition, during the course of this study a previously undescribed form of tractional retinal detachment associated with retinal schisis was observed. Methods: Six eyes of four children with visual field and/or central vision loss underwent vitrectomy (in five of the six eyes the lenses were preserved), inner wall retinectomy and photocoagulation for rhegmatogenous/schisis retinal detachment, tractional retinal detachment and reduced central vision secondary to intraschisis hemorrhage overhanging the macula. Results: The children were followed up for 1 to 4 years. All eyes showed anatomic reattachment. Three of the four eyes that could be tested for vision showed improved visual function postoperatively. One eye showed marked enlargement of visual field and central visual acuity improvement from 20/200 preoperatively to 20/50 postoperatively. Conclusion: Inner wall retinectomy can be a useful adjunct in the management of the retinal complication of JRS. Appropriate case selection of eyes with associated central traction retinal detachment can result in improved visual field and central visual acuity. The success of this technique suggests that the mechanical and/or pharmacological relief of vitreous traction may be able to alter the clinical course of JRS.     

Self-assessment of angles of strabismus with photographic Purkinje I and IV reflection pattern evaluation

Background: Accurate assessment of the angle of strabismus, e.g. of variable angles of strabismus, is crucial in preoperative patient management and is usually performed in a clinical environment. Objective assessment by patients themselves, under everyday conditions, could contribute to a better preoperative work-up. A new objective evaluation procedure for the measurement of manifest angles of strabismus for near and distance fixation by the patient himself is presented. Methods: To account for the modified experimental setup used for the self-assessment, an amended computation procedure of Purkinje reflection pattern evaluation was developed. For measurement, patients and controls placed their head on a head/chin rest and fixated at 33 cm or 4 m distance in primary position. A reflex camera and three photo flash units were positioned on a special frame underneath the visual axis and in front of the subject so that both eyes could be photographed simultaneously. The camera's remote shutter control was released together with the photo flash units by the properly fixating subject. The angles of strabismus were obtained from the series of pictures through later evaluation of the Purkinje I and IV reflection patterns recorded in the photographs of the eyes. Results: Measurements of the ocular alignment in two control groups and in a group of strabismic subjects showed satisfactory accuracy of the self-assessment method compared to standard Purkinje reflection pattern evaluation and orthoptic measurements of the angle of strabismus. Conclusion: The modified self-assessment method can be used for the objective recording of angles of strabismus as needed in the preoperative work-up of patients with variable angles of strabismus, over prolonged periods of time, and outside a clinical setting.Presented in part as a poster at the 88th Annual Meeting of the Deutsche Ophthalmologische Gesellschaft in Baden-Baden, 1990     

Orbital exenteration: Surgical and reconstructive strategies

Background: Radical exenteration procedures, which include the removal of orbital content and eyelids, result in serious functional limitations, especially with respect to eating and speaking. Therefore we have recently changed our surgical concept. Methods: Seventy-seven patients underwent orbital exenteration during the 20-year period from 1974 to 1995 at the Department of Maxillofacial Surgery, Essen University. The simultaneous removal of periorbital bone was performed in 45 of these cases. Results: The 1-year survival rate was 89%, the 5-year rate was 63% and the 10-year rate was 48%. The surgical approach, the amount of resected orbital tissue and the reconstructive procedure have been adapted to the individual needs, depending on the location and extent of the tumor. Subsequently, the surgical morbidity has decreased. Discussion: Detailed consideration of all clinical and histological findings is essential before surgery, in order to prevent a higher rate of recurrence following these modified operations.     

Multiple ocular impairment in a patient affected by Waldenström's macroglobulinaemia

Background: We studied a bilateral tumefaction of the lacrimal gland in a female patient. Method: Ocular and general clinical examinations were carried out. Result: Computerized tomography (CT) of the cranial orbit showed a tumefaction of solid density in the lacrimal gland. Histological examination of material removed by needle aspiration revealed the presence of elements of a lymphoplasmacytoid nature. Fluorescein angiography showed dilatation of the veins, intraretinal flame haemorrhages and small ischaemic areas. Chest CT showed an increase in the size of the middle and upper mediastinal lymph nodes, and examination of a specimen of bone marrow from the chest revealed the presence of small lymphocytes with a plasmacytoid tendency. Conclusion: On the basis of the findings, we diagnosed Waldenström's disease with rare multiple ocular impairment (lacrimal gland and retina) in an early stage.     

Detection of herpes simplex virus after penetrating keratoplasty by polymerase chain reaction: correlation of clinical and laboratory findings

Background: The study was carried out to investigate the possible correlation of clinical findings, histopathologic features and detection of herpes simplex virus DNA in corneal buttons obtained after penetrating keratoplasty. Methods: We examined 47 consecutive corneal buttons sent for histopathologic examination by light microscopy and using the polymerase chain reaction for the detection of HSV1 and HSV2. Twenty-one corneal buttons from eyes with bullous keratopathy served as controls. Results: The 47 cases were graded from the clinical information available as unproven, suspected and clinically proven cases of herpetic keratitis. This grading did not correlate to specific histopathologic features or to the results of HSV1 DNA testing. None of the cases were positive for HSV2 DNA. Conclusion: HSV DNA was detected in some of the cases of clinically unsuspected herpetic keratitis. This technique of demonstrating the presence or absence of HSV in the cornea after keratoplasty is more reliable than clinical data or histopathologic findings and may be important in cases of recurrent inflammatory episodes involving grafts after keratoplasty.Presented in part at the meeting Frontiers in Penetrating Keratoplasty on 22 September 1994, Heidelberg, Germany     

Ocular findings in trigonocephaly

Background: Trigonocephaly, caused by premature closure of the metopic suture, is a rare form of craniosynostosis. The aim of this study was to assess the visual outcome in children operated on for trigonocephaly Methods: We present eight cases of children with trigonocephaly surgically corrected by the same craniofacial technique. CT with 3D reconstruction was performed in all cases. Genitori defined three types of trigonocephaly according to the severity of the deformity of the skull base only types II and III were included in this study directed at evaluation of the ocular disorder. A complete eye examination was performed on all children by the same observer, with a follow-up of 2–6 years Results: 3D-CT reconstruction of the skull base showed that the frontozygomatic region was affected by the deformation. Ocular examination showed considerable astigmatism in most children with late operation. A low degree of strabismus was observed in most children Conclusion: This study demonstrated that reconstructive surgery should be performed by the age of 6 months, given the immaturity of the visual system up to that time. Close cooperation between neurosurgeons, pediatricians and ophthalmologists is of paramount importance in order to prevent this bone deformation exerting an adverse effect on visual development. The ophthalmologist must possess a basic understanding of the various craniosynostoses.     

Interleukin 10 inhibits inflammatory cells infiltration in endotoxin-induced uveitis

Background: Endotoxin-induced uveitis (EIU) is a model for acute anterior uveitis associated with a variety of pro-inflammatory cytokines and nitric oxide production. Interleukin 10 (IL-10) down-regulates these inflammatory mediators. We report a study of the effect of systemic administration of IL-10 on the inflammatory parameters of EIU. Methods: Uveitis was induced in C3H/HeN mice by subcutaneous injection of 200 g lipopolysaccharide (LPS) per mouse. Intraocular inflammation was assessed by leukocyte count and measurement of the protein concentration in the aqueous humor (AH). Mouse recombinant IL-10 at 1000 U or its vehicle alone were administered by three intravenous injections given 4.0 h and 0.5 h before and 8.0 h after LPS injection. Results: The inflammatory cell infiltration in the eyes was significantly reduced in four of five experiments from 40% to 64% in the groups treated with IL-10 compared to the control groups (P<0.05). In contrast, the level of protein exudation in the anterior chamber (AC) was not significantly affected by IL-10 treatment. Conclusion: IL-10 reduces the cellular infiltration in the ocular inflammation produced by endotoxin. This result suggests potential usefulness for IL-10 in the treatment of severe anterior uveitis with a strong cellular component.     

Serum-induced collagen gel contraction

Purpose: To understand the molecular events underlying disease-related vitreous gel contraction, the effect of serum components on collagen was investigated. Methods: Bovine vitreous or dermal collagen was incubated with a mixture of transglutaminase (TG; factor XIIIa) and fibronectin (FN), and the biochemical changes of collagen were monitored by gel electrophoresis. In addition, serum-induced changes in the volume of the collagen gel were monitored. Results: Gel electrophoresis revealed a new high-molecular-weight band (M_r 240 000) presumably due to intermolecular cross-links of collagen peptides and FN. The serum components also were shown to cause a significant decrease in the volume of the collagen gel. Conclusion. Collagen gel contraction could be attributed to the collagen-FN-collagen cross-links catalyzed by TG.     

Effect of corticosteroids on healing of the corneal endothelium in cats

Background: Anterior segment surgery is frequently complicated by damage to the corneal endothelium. We examined the effects of corticosteroids, which are widely used for the suppression of postoperative inflammation, on the process of endothelial cell regeneration. Methods: The effect of corticosteroids on healing of the corneal endothelium was examined in 10 domestic cats. In both eyes a circular area, 8 mm in diameter, was scraped off at the center of the corneal endothelium without damaging Descemet's membrane. Immediately after scraping, as well as 2 and 5 days later, each animal received a unilateral retrobulbar injection of betamethasone sodium phosphate (2 mg). The other eye served as a control and received a retrobulbar injection of the vehicle only. Results: Evaluation of the corneal endothelium 2, 5 and 7 days after the trauma revealed that relative to the control contralateral eyes, the corticosteroid-treated eyes exhibited a higher mean coefficient of variation of the corneal endothelium cell area, fewer hexagonal cells, a larger number of polygonal cells with 3, 4, 7 and 8 cellular facets, thinner corneas and less inflammation. Conclusions: These findings suggest that corticosteroids unfavorably affect the regeneration of corneal endothelial cells after injury. As corticosteroids appear to have both positive and adverse effects on corneal function after trauma, they should be used with caution.     

Blood-aqueous barrier in pseudoexfoliation syndrome: evaluation by immunohistochemical staining of endogenous albumin

Background: Alterations of the integrity of the blood-aqueous barrier (BAB) are frequent findings in eyes with pseudoexfoliation syndrome (PSX). Methods: Immunohistochemical staining for the demonstration of albumin was used to analyze the BAB in 10 eyes with PSX without previous intraocular surgery and in 10 age-matched normal control eyes. Results: In eyes with PSX, small amounts of albumin were detected along the anterior surface of the iris in 7, in the anterior chamber in 1, along the ciliary epithelium in 4, and in the trabecular meshwork in 9 of 10 eyes. PSX material was also immunoreactive. In the 10 normal control eyes, albumin was detected anterior to the iris stroma in 1 eye, in the anterior chamber in 2 eyes, in the trabecular meshwork in 1 eye, but not internal to the ciliary epithelium. Conclusions: Our findings indicate that impairment of the BAB in PSX can be localized at the level of the iris and, less frequently or to a lesser extent, at the level of the ciliary body.     

CD44 expression in the developing human retina

Background: CD44, the transmembrane adhesion molecule, is expressed in the fetal brain and supposed to mediate neuroglial interactions. We evaluated the expression and distribution of CD44 in the developing human retina. Methods: Four developing human eyes were evaluated at 6, 10, 16, and 21 weeks of gestation, as well as the eyes of one infant and four adults. Frozen sections were immunohistochemically stained with monoclonal antibodies to three human CD44 clones (BU52, F10-44-2, and DF1485) and to vimentin, and antiserum to glial fibrillary acidic protein (GFAP). Specimens were evaluated by light and electron microscopy. Results: Positive immunostaining for CD44 was first detected at 21 weeks of gestation in the longitudinal fibers that extended from the inner to the outer limiting membrane and around capillary vessels with the simultaneous expression of vimentin and GFAP. Immunoelectron microscopy demonstrated the presence of CD44 on the surface of Müller cells and astrocytes. CD44 was faintly seen in the Müller cells in the periphery and definitely present in the astrocytes in the infant and adult retinas. Conclusion: CD44 was expressed in Müller cells at a late stage of fetal development and in the fetal, infant, and adult astrocytes, which suggests that it is important in the morphogenesis and homeostasis of the neural retina.     

How often do patients need visual field tests?

Background: This study was undertaken to determine whether the interval between visual field tests affects the ability to detect progres sive glaucomatous field loss. Methods: One hundred and nineteen retinal locations which were deteriorating significantly by 1 dB/year (untreated normal tension glaucoma patients: 6 eyes) were studied. Analysis was repeated using thinned visual field tests: one test per year instead of the complete three per year over a period of 4 years. Results: The thinned tests identified only 45.4% of the deteriorating points over the 4-year period. Furthermore, there was a mean delay of 1.10 years in detection (P<0.01). Conclusions: Less frequent visual field testing detects fewer progressing locations and detects them later.Presented in part at the Association for Research in Vision and Ophthalmology Annual Meeting, May 1995 and at the American Academy of Ophthalmology Meeting, October 1995.The authors have no proprietary interest in any of the materials used in this study.     

Course of the optic nerve fibers through the lamina cibrosa in human eyes

Background: This study investigated whether regional variations in the course of the optic nerve fibers through the lamina cribrosa may be one of the reasons why the local susceptibility for glaucomatous optic nerve fiber loss differs among the various regions of the optic disc. Methods: The study included 34 human eyes enucleated because of a malignant melanoma of the peripheral choroid without involvement of the anterior chamber angle or the optic nerve. Anterior-posterior sections through the pupil and the optic disc were histomorphometrically evaluated. In the central region and the peripheral part of the optic disc, we measured the thickness of the lamina cribrosa and the length of the lamina cribrosa channels through which the nerve fibers pass. Results: In the peripheral parts of the disc, compared with its central region, the lamina cribrosa was significantly thicker (P<0.0001, Wilcoxon test), the lamina cribrosa channels with the nerve fibers passing through were significantly longer (P<0.0001), and the ratio of length of the fiber channels to the thickness of the lamina cibrosa was significantly higher (P=0.0001). Conclusion: The lamina cribrosa is thicker and the course of the optic nerve fibers through the lamina cribrosa is more curvilinear in the disc pheriphery than in the disc center. These variations in the anatomy of the lamina cribrosa may be one of several factors influencing the regional susceptibility for glaucomatous optic nerve fiber loss within the optic nerve head.