Third (fourth and fifth) nonocular tumors in survivors of retinoblastoma

OBJECTIVE: This study aimed to investigate the incidence, timing, pattern, and distribution of, as well as survival as a result of, third, fourth, and fifth primary tumors in survivors of retinoblastoma. DESIGN: This study was a retrospective case series of patients diagnosed with retinoblastoma and a second malignant neoplasm. Records were examined for demographic, prior treatment, and second tumor information, as well as any evidence of the development of a third, fourth, or fifth nonocular tumor. When possible, telephone inquiries were conducted for follow-up. PARTICIPANTS: The study included 1506 patients followed in the Ophthalmic Oncology Center at New York-Presbyterian Hospital, New York Weill Cornell Medical Center, 211 of whom developed a second tumor and had sufficient treatment data to be useful for analysis. MAIN OUTCOME MEASURES: The development of third and additional nonocular tumors and survival from these tumors were the primary outcome measures. RESULTS: Of 211 second-tumor patients, 142 died before an additional malignancy developed (median survival time, 1.8 +/- 0.3 years) and in 28, third tumors developed (5-year incidence rate, 11%; 10-year incidence rate, 22%; median time to third tumor development, 5.8 +/- 8.3 years). The 5- and 10-year survival rates for this group were 41% and 30%, respectively (median survival time, 4.1 +/- 1.0 years). Of 28 patients in whom third tumors developed, 27 (96%) had received radiation therapy for their retinoblastoma. The most common sites for third tumors were soft tissues of the head (36% of all third tumors) and skin (36% of all third tumors). In six patients, a fourth tumor developed, and in two patients a fifth tumor developed. All fourth and fifth tumors were found in the soft tissues of the head, the skin, or the bones. CONCLUSIONS: Survivors of retinoblastoma in whom second malignant neoplasms develop are at a higher risk for the development of additional tumors than they were for the development of a second tumor. The locations and expected ages at which additional tumors develop are consistent with the patterns we have seen in second tumors.     

The Importance of Biometry to Cataract Outcomes in a Surgical Unit in Africa

Purpose: To determine how much difference biometry makes to refractive outcomes in a population in Sub-Saharan Africa compared to using standard-power intraocular lenses (IOLs).

Methods: In a secondary eye-clinic in Kenya, IOL-powers in half diopters (D) were implanted according to biometry prediction in patients undergoing routine cataract surgery with small-incision techniques. A model was generated to predict refractive outcomes if standard-IOLs had been used.

Results: Three-hundred-twenty-five eyes of 290 patients were operated on; 232 (71%) using phacoemulsification, the remainder using manual small-incision cataract surgery. Two-hundred-sixty-seven eyes (82.2%) achieved corrected visual acuity (VA) ≥6/18 and 202 eyes (62%) uncorrected VA ≥6/18. Pre-existing comorbidity was the single most common reason for a worse postoperative VA. Restricting analysis to one eye per patient, with biometry 71.1% had a good refractive outcome (defined as +1 to -1.5 D spherical equivalent), 27.6% became more than ?1.5 D myopic and 1.3% more than +1.00 D hyperopic. With standard-power-IOLs 57.3% would have had a good refractive outcome and 16% would have become >1 D hyperopic. Using the post-op refractive data for A-constant optimization could potentially further increase good refractive outcomes to over 80%.

Conclusion: Biometry in combination with small-incision techniques improves refractive outcomes and decreases undesired postoperative hyperopia. Assuming good surgical skills, better outcomes with biometry justify cataract operation at an earlier stage, thereby reducing intra- and postoperative complications and avoiding years of visual disability.     

Life expectancy of patients with neovascular glaucoma drained by Molteno implants

PURPOSE: To determine the survival of patients with sighted eyes who had Molteno implants inserted for neovascular glaucoma. METHODS: Patients who had Molteno implants inserted for neovascular glaucoma between October 1977 and March 2001 at Dunedin Hospital, New Zealand, were reviewed. Relative survival analysis was then used to compare survival in this group to survival of the New Zealand population of the same age. RESULTS: A total of 114 patients had 131 Molteno implants inserted for neovascular glaucoma. Neovascular glaucoma was secondary to central retinal vein occlusion in 66 eyes (50%) and diabetes in 42 eyes (32%), and patients lost 52% or 6.53 years of their expected remaining life span. Age, sex and postoperative intraocular pressure control did not predict survival. The only predictor of improved survival was a preoperative visual acuity of 6/48 or better. These patients lost 21% (or 2.43 years) of expected remaining life compared to 62% (or 10.78 years) in those patients who had a presenting visual acuity of 6/60 or worse. CONCLUSIONS: Patients with neovascular glaucoma had a markedly reduced life expectancy, which has improved in recent years when compared to that of the normal sex and age-matched New Zealand population. Patients presenting with better vision (6/48 or better) survived significantly longer than those presenting with poorer vision.     

Monitoring the effectiveness of soft-tipped tweezers to reduce hydrogel lens damage

After monitoring the numbers and types of torn or perforated lenses in his practice during 1987, the author began providing tweezers with soft plastic tips to all new and previously fitted soft lens wearers. He instructed the wearers to use the tweezers when transferring each lens from the storage case to the hand and vice versa. Three years later, in 1991, a second monitoring took place. In addition, the number and type of lenses seen on routine examinations were recorded for the 2 years. Even though the number of lenses being worn had increased by 84% in 1991 compared to 1987, the number of damaged lenses in 1991 had dropped by 90% from the 1987 total. None of the major lens types showed a change in its damage rate, which corresponded with the expected change in its numbers.     

Experience in therapy and prophylaxis of epidemic keratoconjunctivitis (author's transl)]

101 patients with epidemic keratoconjunctivitis were treated with different eye drops: cortisone, antibiotics and P.V.P.-Iodine. The treatment of 19 patients with P.V.P.-Iodine showed that inflammatory symptoms disappeared rapidly; corneal complications however such as superficial keratitis could not be prevented. After the outbreak of epidemic keratoconjunctivitis, severe hygienic measures had been taken at the eye-clinic. On account of the hygienic prophylactic measures further infections could be prevented at the clinic almost completely.     

Impact of enucleation versus plaque radiotherapy in the management of juxtapapillary choroidal melanoma on patient survival.

The records of 265 consecutive patients with juxtapapillary choroidal melanoma were reviewed and a statistical non-randomised retrospective study was performed to evaluate the risk for metastasis and compare the survival rate of patients treated with plaque radiotherapy or enucleation. To obtain sufficient overlap between the enucleation and plaque radiotherapy, the statistical analysis was limited to an adjusted subgroup of 127 patients who met eligibility criteria for plaque radiotherapy and who had a minimum of 3 years of follow up after treatment. In the adjusted subgroup of 127 patients, 92 patients (72%) were initially treated with enucleation and 35 (28%) with plaque radiotherapy. In both univariate and multivariate logistic analysis models, the age of the patient (> 50 years), tumour thickness (> 3 mm), and treatment by age interaction were found to be significant factors for development of distant metastasis. In patients younger than 50 years, the method of treatment (enucleation versus plaque radiotherapy) did not significantly affect the risk of metastasis. For those older than 50 years, there was a non-significant trend for patients in the enucleation group to be at a higher risk for metastasis than those in the plaque group. In the enucleation group, patients older than 50 years had a significantly higher incidence of distant metastasis than those younger than 50 years. In the plaque radiotherapy group, there was no significant higher incidence of metastasis in patients younger than 50 years than in those older than 50 years. When a Cox proportional hazards model was used to evaluate the survival rate, there was the same statistically significant effect of treatment by age interaction as was found in the multivariate logistic model on survival time. Moreover, there was a significant effect of treatment by tumour thickness interaction on survival time. Patients in the enucleation group had a better survival rate when the thickness of the tumour was less than 3 mm compared with a tumour of more than 3 mm. There were no apparent effects of tumour thickness on survival for patients treated with plaque radiotherapy. From these results, the authors currently recommend plaque radiotherapy as a viable option to enucleation in patients with juxtapapillary choroidal melanoma.     

AN AUSTRALIAN CHOROIDAL MELANOMA SURVEY Factors affecting Survival following enucleation

This study is based on a computer-assisted analysis of 484 enucleated malignant melanomas of the choroid from The Royal Victorian Eye & Ear Hospital, Melbourne. The following factors which might influence survival were analysed; the sex and age of the patient, the interval between presentation for medical opinion and enucleation, the size of the melanomaand its position in the eye, the cell type of the melanoma and the presence of extraocular extension.
From this analysis it was found that: 1) The overall 15-year relative survival rate following enucleation was 75%. 2) the survival curve flattened out at six years after enucleation indicating relatively few melanoma-related deaths for the remainder of the 15-year period. 3) there was no increase in death rate at 2 years after enucleation. 4) considering only melanoma-related deaths, increasing age is a strongly depressing influence on survival after enucleation, the 15-year relative survival being 80% for those less than age 40 and only 30% for patients aged 70 and over. 5) submacular melanomas had a very good prognosis for patient survival due in part to their small size and benign cytology. 6) extension into a scleral emissary appeared to exert an unexpectedly depressing effect on prognosis. 7) as in other published series, small melanomas tended to have a good prognosis, and survival rates diminished with increasing size. 8) there was a possibility, to be further explored, that ciliary body melanomas may over all have a worse prognosis than melanomas of the choroid.     

Retinoblastoma in Great Britain 1969-80: incidence, treatment, and survival.

Patients with retinoblastoma diagnosed from 1969 to 1980 have been followed up for periods of up to 17 years. Data from a previous study of patients diagnosed from 1962 to 1968 have been included for analysis of incidence and second primary tumours, and for study of trends in treatment. The registration rate in Britain (which may be about 10% less than the true incidence) is about one in 23,000 live births, approximately 40% of cases being known to be genetic. There is no apparent trend in incidence during the period covered by these two studies. The three-year survival rate in 88%. Patients with bilateral tumours have a better survival rate than those with unilateral tumours for the first few years, but their long-term survival rate is worse because of later deaths from ectopic intracranial retinoblastoma or second primary neoplasms. Older children tend to have a worse prognosis, which is related to the fact that their tumours are diagnosed at a more advanced stage. There is a significantly higher survival rate for boys than for girls; this is partly accounted for by difference in age and stage at diagnosis between the sexes. Children referred to units specialising in the treatment of retinoblastoma have a higher three-year survival rate than those treated at other hospitals. Comparing methods of treatment between the periods 1962-8 and 1969-80, we find there has been a trend towards more conservative treatment. The use of chemotherapy is now usually reserved for recurrences and metastases and for palliative treatment in terminal retinoblastoma.     

Intraocular lymphoma: a series of 14 patients with clinicopathological features and treatment outcomes

AIMS: To assess the clinical features, pathology, mortality (systemic outcome) and ocular complications (visual outcome) of a cohort of patients treated for intraocular lymphoma. METHODS: Retrospective case analysis of medical records and review of pathology of a consecutive series of patients presenting with intraocular lymphoma in Melbourne over 11 years between 1990 and 2000. Categorical factors influencing survival were examined by the Kaplan-Meier estimator and groups compared with the log rank test. RESULTS: A total of 14 patients were included. The median age of onset of symptoms was 62.5 years. Most were male (64%) and had bilateral eye involvement (64%). The commonest presentation was vitritis in 12 patients, with a median delay of 4 months before diagnosis. In all, 10 patients had B-cell lymphoma, three patients T-cell lymphoma and one null-cell. Four patients had prior systemic lymphoma. Eight patients had primary central nervous system non-Hodgkin's lymphoma (PCNSL). Treatment included combined radiation to the eye and chemotherapy in 10 patients. Complications of radiotherapy included cataract in five (50%), dry eyes in four (40%), punctate keratopathy in two (20%), radiation retinopathy in two (20%), and optic atrophy in one (10%). A total of 11 patients died of lymphoma (79%). One has residual ocular disease, while two have survived for more than 5 years from initial presentation. Although currently disease free, one of these has a poor visual outcome with acuity less than 6/60 secondary to ocular complications of treatment. CONCLUSIONS: Our study had 29% with prior systemic lymphoma, 57% associated with PCNSL and 14% with intraocular disease only. Overall survival is low (21%) and relapses common in those surviving beyond 12 months. Visual outcome in survivors is very poor due, in large part, to significant complications from radiotherapy.     

Microbial and immunological investigations of chronic non-ulcerative blepharitis and meibomianitis.

Concentrations of tear lysozyme, lactoferrin, ceruloplasmin, IgG, and IgA have been measured by enzyme linked immunosorbent assay (ELISA) in patients with chronic non-ulcerative blepharitis and meibomianitis at the same time as the lid and conjunctivae were cultured for bacteria and fungi by a semiquantitative method. A group of normal controls aged 20 to 80 were similarly sampled, when strains of Staphylococcus epidermidis from their eyes and the patients' eyes were biotyped according to Baird-Parker's scheme. 5% of blepharitis cases had increased numbers of Staph. aureus present on the lids, compared with only a scanty growth obtained from 5% of normals. 7% of blepharitis cases had increased numbers of Staph. epidermidis type VI (coagulase-negative, mannitol-fermenting) present compared with a scanty growth obtained from 6% of normals. Isolation rates of other types of Staph. epidermidis did not differ from those in normals; no types were associated with meibomianitis. Tear protein profiles were normal in most patients, and there was no increase in tear IgA or IgG, which is expected with chronic infection. Overall our evidence suggests that in 88% of cases these lid conditions have an inflammatory aetiology not associated with infection. Staphylococcal isolates often found in the eye usually represent a normal commensal rather than pathogenic flora.     

Corneal transplantation using 4-week banked donor material. Long-term results

Thirty-six corneal transplantations employing banked donor material maintained during prolonged storage (mean: 29.5 days) in organ culture at 31 degrees C were followed for 5 years. The overall graft survival was 80% , and graft failures were almost exclusively found in a pre-operatively defined risk group where the survival rate was 49.6% compared with 95.5% in the non-risk group. Five years after transplantation the mean central thickness of surviving grafts was 0.52 mm and the mean endothelial cell density 862 cells/mm2. All grafts were optically clear judged by slit-lamp appearance even though a higher degree of light-scatter was demonstrated compared with controls. The functional results were satisfactory with an over-all mean visual acuity of 0.67 cc. Excluding cases where low visual performance had non-corneal causes, 88% of patients obtained 0.5 cc or better. The median spherical equivalent of corneal curvature was 8.23 mm and the median astigmatism 4 diopters. Intraocular pressure was normal, and all grafts had obtained some degree of sensibility, although reduced compared with controls. The study demonstrates that banked donor material can be successfully employed for corneal transplantation achieving favourable long-term results.     

Visual function in 6 to 7 year‐old children born extremely preterm: a population‐based study

Purpose: Progress in neonatal care has caused an increased survival of children born extremely preterm. The aims of this study were to examine the long‐term visual function and ocular development in an unselected cohort of extremely preterm infants and relate the results to neonatal morbidity and long‐term neurodevelopmental outcome. Methods: All children with gestational age of 22–27 completed weeks or birth weight of 500–999 g born in the years 1999–2000 in two counties of Western Norway (n = 52) were invited to an eye examination that included visual acuity, refractive error, binocular function, accommodative amplitude and fundus examination. Cognitive function was assessed with the WPSSI‐R test and motor abilities with the ABC movement test. Results: Neonatal morbidities and neurodevelopmental outcome were known for all, while 37 of the 52 children underwent the eye examination. None were blind or visually impaired, but 46% had subnormal visual acuity (logMAR ≥0.1). Ninety per cent were emmetropic or slightly hypermetropic (0 to +3D), while 10% had manifest and 51% latent strabismus. Performance IQ on the WPSSI‐R test and ABC total score were associated with best visual acuity (p = 0.03 and p < 0.01, respectively). In a multiple linear regression model, visual acuity in the best eye was significantly associated with performance IQ (p = 0.03) and ABC total score (p = 0.02). Conclusion: This study suggests a more favourable long‐term prognosis on important ocular and visual parameters in survivors of extreme prematurity than expected from similar reports on children born less prematurely and that performance IQ and motor function are related to visual acuity.     

The role of patient age and intraocular gas use in cataract progression after vitrectomy for macular holes and epiretinal membranes

PURPOSE: To evaluate the rate of increase in nuclear sclerosis and posterior subcapsular cataracts in eyes as a function of patient age and use of intravitreal gas at the time of vitrectomy. DESIGN: Observational case series. METHODS: Nuclear sclerosis and posterior subcapsular cataracts were evaluated as a function of patient age and use of intravitreal gas at vitrectomy. SETTING: A clinical practice. STUDY POPULATION: The study population consisted of 301 consecutive eyes. OBSERVATIONAL PROCEDURE: Nuclear sclerotic cataracts and posterior subcapsular cataracts were graded on a scale from 0 to 4.0 before and after vitrectomy. MAIN OUTCOME MEASURE: Linear regression analysis was performed to measure and compare the rate of change in cataract score over time based on patient age and use of intraocular gas. RESULTS: Nuclear sclerotic cataracts showed minimal increase in patients younger than 50 years of age after vitrectomy (0.13 grades/year). Nuclear sclerotic cataracts increased at a rate of 0.7 to 0.9 grades/year (mean, 0.812) in patients aged 50 to 60 years, 60 to 70 years, 70 to 80 years, and 80+ years, even though the baseline nuclear sclerosis scores were progressively greater for each decade. The increase in nuclear sclerotic cataracts in patients younger than 50 years of age was significantly less (P <.001) than in patients aged 50 years or older. Eyes with intraocular gas use had a higher rate of nuclear sclerosis progression (0.8 grades/year) compared with eyes without intraocular gas bubbles (0.5 grades/year; P <.001). Posterior subcapsular cataract scores showed minimal or no increases in all groups. CONCLUSIONS: Patients older than 50 years of age have a similar rate of increase in nuclear sclerotic cataracts, independent of age. The rate is approximately sixfold greater than in patients younger than 50 years of age. Intravitreal gas bubbles are associated with a nuclear sclerosis increase of approximately 60% compared with eyes without use of a gas bubble.     

Long-term results of penetrating keratoplasty

Background The aim of this study was to retrospectively analyse the outcome of a series of grafted patients over a period of more than 10 years and to determine their long-term survival probability.Methods The records of 89 patients who had 103 grafts performed in 97 eyes were analysed. Mean follow-up was 12.8 years (range 10–17 years). Life table analysis (Kaplan–Meier) was used to evaluate the graft survival of the total population and of different groups.Results Eighteen out of 89 patients (20.2%) had died. At the last visit before their death, 10 of the 21 grafts in those patients were still clear. Graft survival rates after 1, 2, 5 and 10 years were 79%, 73%, 59% and 50%; the rate at the end of follow-up was 47%. Survival rate at the end of the study was 94.7% for keratoconus, 57.1% herpes keratitis, 33.3% for pseudophakic keratopathies, 28.5% for post-traumatic keratopathies and 11.1% for re-grafts. In the group of patients grafted for aphakic or pseudophakic keratopathy, 40% died during the study. In 45% of cases their grafts were clear at the time of death. Endothelial decompensation and definitive graft rejection were the main causes of failure.Conclusions The outcome of keratoplasty is progressively getting worse with time in pseudophakic or traumatic keratopathies whereas survival rates are still stable from 10 to 17 years in grafts performed after keratoconus or herpetic keratitis.The authors hereby confirm that there were no financial or proprietary interests and no public or private support for this study     

Comparison of outcomes of penetrating keratoplasty versus Descemet’s stripping automated endothelial keratoplasty for penetrating keratoplasty graft failure due to corneal edema

To evaluate the outcomes of repeat corneal transplantation, either penetrating keratoplasty (PKP) or Descemet’s stripping automated endothelial keratoplasty (DSAEK), for penetrating keratoplasty grafts which failed due to corneal edema. The charts of 24 eyes with failed PKP grafts, due to corneal edema, which underwent a repeat corneal transplant (PKP in 17 eyes [Group 1] and DSAEK in seven eyes [Group 2]) between 2003 and 2007 were retrospectively reviewed. There was no statistically significant difference in the median postoperative visual acuity between the two groups at 1, 2, or 3 years. In Group 1, two (18%) eyes had a final visual acuity ≥20/40, in contrast to four (80%) eyes in Group 2, which was statistically significant (P = 0.038). Seven (41%) of the Group 1 eyes developed postoperative complications compared to only one (14%) eye in Group 2. Eleven (65%) of the Group 1 eyes and five (71%) of Group 2 eyes had clear grafts on the last examination. There was no statistically significant difference in the graft survival rate for Group 1 versus Group 2 at 3 years (57.9% vs 68.6%, P = 0.507). There was a trend towards better postoperative visual acuity, a lower postoperative complication rate, and a higher graft survival rate in eyes that underwent DSAEK rather than repeat PKP for graft failure secondary to corneal edema. Given this small, retrospective study, future studies comparing repeat PKP with DSAEK are warranted to determine which procedure allows for improved outcomes.     

Uveal melanoma survival in Sweden from 1960 to 1998

PURPOSE: To investigate the crude and relative survival rates in patients with uveal melanoma in Sweden during the period from 1960 to 1998. METHODS: A population-based national survey revealed 2997 cases of uveal melanoma in the Swedish Cancer Registry. The survival rates were calculated by the Hakulinen life-table method, using relative survival as an estimate for deaths due to uveal melanoma. The excess mortality rates were calculated with confidence intervals for the first 15 years after diagnosis. Multivariate regression analysis was undertaken to evaluate the influence of gender, age, and calendar period on relative survival the first 5 years after diagnosis. The underlying causes of deaths in the patients with uveal melanoma, as found in the Cause of Death Registry were also investigated. RESULTS: Up to December 31, 1998, 2003 patients had died. The 5-year crude survival rate was 60.3% and the relative survival 70.1%. After 10 years, the rates were 42.5% and 59.4%, respectively. Significant excess mortality existed up to 5.5 years after diagnosis. In the multivariate model, younger age (P < 0.001) and later calendar period (P = 0.002), but not gender (P = 0.117), were associated with better relative survival. Deaths due to uveal melanoma were misclassified in the Cause of Death Registry in more than half of the cases. CONCLUSIONS: This study, covering more than 95% of the uveal melanoma cases in the Swedish population revealed an improvement in relative survival rates for patients with uveal melanoma over time and a significant excess mortality up to 5.5 years after diagnosis.     

A study analyzing the health-related quality of life of retinoblastoma survivors in India

Purpose:Retinoblastoma (RB) is the commonest intraocular tumor in children. Despite high cure rates, data on health-related quality of life (HRQoL) of RB survivors are limited. This study aimed to analyze parent''s perspective and self-report of HRQoL of RB survivors, using healthy siblings as controls. It also evaluated the impact of socio-economic status (SES), gender, disease laterality, treatment modality, duration since diagnosis, and visual outcomes, on HRQoL.Methods:Ninety-two RB survivors were enrolled in this observational, cross-sectional questionnaire-based study conducted at a tertiary care center. QoL was analyzed in four dimensions: physical, emotional, social, and school, using both self-report (for children >6 years) and parent proxy report (for children 2–18 years) using Pediatric Quality of Life Inventory™ (PedsQL™) 4.0 Generic Core Scale. Seventy-seven healthy siblings served as controls.Results:The mean age of both cohorts was 5.7 years. Thirty-six (39%) patients had bilateral RB. Of the 92 survivors, 43 (47%) had undergone enucleation. The HRQoL of RB survivors was significantly lower compared to sibling controls (P < 0.01) in all four domains, the physical domain being most affected followed by social domain. Parents reported an inferior QoL than patient''s self-report. Vision <6/18 in the best eye and enucleation had a negative impact on HRQoL whilst gender, disease laterality, duration since diagnosis and SES had no impact.Conclusion:QoL assessment is often neglected but an important aspect of survivorship. Results of our study will help in formulating awareness of the domains affected and allow timely advocacy of initiatives for addressing each issue individually. Remedial measures aimed at optimizing QoL should be incorporated as part of their rehabilitation.     

Ocular involvement in neuroblastoma: prognostic implications

Neuroblastoma is one of the commonest childhood malignancies. The most important prognostic factor is age at diagnosis; early diagnosis, when the tumor is still localized and surgically resectable, is second in importance. On retrospective review of children seen at the Hospital for Sick Children, ophthalmic involvement was seen in 80 of 405 (20%). The three major eye signs of neuroblastoma, proptosis, Horner's syndrome and opsoclonus, are closely related to the site, stage of tumor, and outcome of the patient. Proptosis or periorbital ecchymosis due to orbital metastases was present in 60 of 80 children (bilaterally in 33). The 3-year survival rate was 11.2%. In 53 of 60 cases with orbital metastases the neuroblastoma originated in the abdomen. Unilateral Horner's syndrome occurred in 14 children, as the presenting sign in 9, related to localized disease in 11 and in a favorable location (cervical or thoracic neuroblastoma) in 8. The 3-year survival rate was 78.6%. Opsoclonus-myoclonus was the presenting sign of occult, localized neuroblastoma in all 9 children in whom it occurred. The 3-year survival rate was 100%. For all presentations, girls had a significantly better survival rate than boys (48.7% vs. 22.4%). Children presenting with any of these ophthalmological signs should undergo thorough and repeated investigations searching for neuroblastoma.     

The medium and long-term efficacy of primary argon laser trabeculoplasty in avoiding topical medication in open angle glaucoma.

PURPOSE: To study the medium and long-term efficacy of primary argon laser trabeculoplasty in open angle glaucoma with especial emphasis on avoidance of additional medical therapy. METHODS: Records of 168 patients with chronic open angle glaucoma or pseudoexfoliation glaucoma who underwent primary argon laser trabeculoplasty between 1987 and 1995 were studied retrospectively (duration of follow-up 1-8 years, mean 4.1 years). Mean baseline intraocular pressure was 28.7 mmHg (range 22-60 mmHg). Need of additional medical therapy was in each case evaluated at the surgeons' discretion, and the results were analysed by survival analysis. RESULTS: The probability of treatment success (no medication required) was for chronic open angle glaucoma 77% after 2 years, 67% after 5 years and 67% after 8 years Corresponding numbers for pseudoexfoliation glaucoma were 80%, 54% and 36%. Prelaser IOP higher than 31 mmHg, pretreatment visual field defect and sparse pigmentation of the trabecular meshwork were independent predictors of failure. CONCLUSION: Primary argon laser trabeculoplasty gives a long-lasting and favourable effect in chronic open angle glaucoma where 2/3 of the eyes still managed without additional medication for 8 years. The success in pseudoexfoliation glaucoma was even higher the first 3 years, and kept above 50% for 5 years. This makes laser a valuable option as first choice of therapy in glaucoma.     

Retinopathy of prematurity in a controlled trial of prophylactic surfactant treatment.

AIMS: To investigate the incidence of acute and cicatricial retinopathy of prematurity (ROP) in a cohort of premature neonates entered into a randomised, multicentre trial of prophylactic exogenous surfactant for respiratory distress syndrome (RDS) compared with controls receiving surfactant only if severe RDS developed. METHODS: The incidence of acute and cicatricial ROP was assessed in 304 neonates born at less than 30 weeks' gestation in a geographically defined population of approximately three million. RESULTS: There was a trend towards improved survival in the group receiving prophylactic surfactant with 102/151 (67.5%) surviving compared with 82/141 controls (58.2%, p = 0.12). The prophylactic surfactant group would be expected to have an increased risk of ROP due to improved survival, particularly of the most premature infants. However, there was no statistically significant difference in the incidence of acute ROP between the two groups and the incidence of cicatricial ROP was lower in the group receiving prophylactic surfactant (4/100 survivors, 4.0%) compared with neonates receiving rescue surfactant as required (6/81, 7.4%). This difference did not reach statistical significance (p = 0.35). CONCLUSION: The trend for a lower incidence of cicatricial ROP in those neonates treated with prophylactic surfactant compared with the rescue surfactant group, despite improved survival, suggests that the use of prophylactic surfactant also had a beneficial effect on the development of cicatricial ROP.