Ophthalmologic vascular occlusions and oral contraceptives

PURPOSE/MATERIAL AND METHOD: We present two cases of vascular ocular occlusion occurring during oral contraceptive use. Different contraceptive related risk factors are discussed. RESULTS/CONCLUSIONS: Although ocular complications are rare, they should be kept in mind since these drugs (contraceptives) are not recommended when vascular occlusion risk factors are present.     

The ocular complications of smallpox and smallpox immunization

Although smallpox was eradicated worldwide, concerns have been raised about the use of smallpox as a biological weapon. Plans are being considered for smallpox immunization in the United States. Variola virus, the cause of smallpox, and vaccinia virus, used in smallpox immunization, are both orthopoxviruses that are associated with serious ocular complications, including eyelid and conjunctival infection, corneal ulceration, disciform keratitis, iritis, optic neuritis, and blindness. About 5% to 9% of patients with smallpox develop ocular complications, and case-fatality rates reach 20% to 35% among unvaccinated individuals. About 10 to 20 patients develop ocular complications per 1 million smallpox immunizations, usually through autoinoculation, in which the patient transfers vaccinia from the immunization site to the eye. The risk of ocular vaccinia infection may be reduced by instructing patients and individuals in close contact with the vaccinee to wash their hands often and avoid touching the immunization site and their eyes. Topical antiviral therapy, topical steroids, and topical and oral antibiotics have been used to reduce the ocular complications of smallpox immunization. In contrast, there has been little experience with the use of these therapies for the ocular complications of smallpox.     

The influence of gender on the ocular surface.

PURPOSE: Dry eye is more prevalent among women than men. To examine whether gender influences the ocular surface, conjunctival goblet-cell density was monitored for a 30-day period. Changes in goblet-cell density are a sensitive marker for ocular surface disease. METHODS: Six men and twelve women who were free from ocular surface disease were sampled by impression cytology on the inferior bulbar conjunctiva every other day for 30 days. Samples were analyzed for goblet-cell content. The mean age of the subjects was 24 years for the men and 25.4 years for the women. A minimum of 200 epithelial cells were scored per microscopic field examined. RESULTS: There is a statistically significant difference in goblet-cell count between men and women over the 30-day test period. The mean goblet-cell count measured for men was 3.75% +/- 1.04%, while the mean count for women was 2.545% +/- 0.8%. When the data on women were replotted with reference to the menstrual cycle, the largest and longest depression of goblet-cell count occurs midcycle, around the time of ovulation. A significant difference in goblet-cell count was also noted when subjects using oral contraceptives (3.065% +/- 0.98%) are compared with those not using oral contraceptives (2.28% +/- 0.92%). CONCLUSION: It appears there may be a reproductive hormonal influence on conjunctival goblet-cell count.     

Effect of single-dose ivermectin therapy on human Onchocerca volvulus infection with onchocercal ocular involvement.

Ivermectin has shown promise as a potentially safe and effective microfilaricidal drug for the treatment of onchocerciasis. Several limited studies have shown it to have fewer side effects, especially ocular complications, than the currently available drug, diethylcarbamazine. The detailed ocular findings in 200 moderately to heavily infected Liberians who were enrolled in a safety and dose-finding study are presented. They received either 0, 100, 150, or 200 micrograms/kg of ivermectin and were followed up for 12 months. In clinical studies so far carried out ivermectin in a dose of 100, 150, or 200 micrograms/kg has not been associated with any major adverse reactions nor were there any sight-threatening effects even in the presence of severe ocular disease. Each of these doses significantly reduced the ocular microfilaria load for at least 12 months when compared with either the placebo (p less than 0.05) or pretreatment values (p less than 0.001). However, the 100 and 150 micrograms/kg doses caused fewer minor side effects than the higher dose. These results confirm that ivermectin in a single oral dose may be a safe and effective microfilaricidal drug for the treatment of onchocerciasis and that it appears to be free of major ocular side effects.     

Effects of drugs on the lens

The effects of drugs that cause changes in the lens, principally cataractous changes, are discussed. The cataractogenic compounds reported on include 1) drugs used in ophthalmic practice (miotics and topical steroids), 2) compounds used in systemic therapy of a wide range of disorders (corticosteroids andphenothiazines), and 3) compounds that are known to be cataractogenic in animals but not in man (Myleran). Of special interest to family planners is a section on the effects of oral contraceptives on lens changes. Whether long-term use of oral contraceptives would produce ocular complications was queried by Cogan. The influence of these drugs on ocular tissues was subsequently studied, but no significant lens changes were described. Other ocular abnormalities were, however, detected. In rabbit studies, it was shown that mestranol in norethynodrel caused anterior lens changes. Cataracts and other lesions were produced in rats fed a synthetic progestin-estrogen. In vitro changes in lens permeability caused by progestins and progestins and estrogens were demonstrated by Lambert. A dose-dependent increase in rubidium-86 efflux (a measure of lens cell permeability) was demonstrated for several progestins and estrogens. An alteration in cation and water content and lens clarity was also observed. Such physiological changes are similar to those induced by progestins and estrogens in erythrocytes, mitochondria, and lysosomes. It is noted that although the concentrations of drugs used in animals and in vitro studies are high, there is a need for well-controlled, long-term opthalmological studies on women who have chosen oral contraceptives.     

Perioperative nuances of cataract surgery in ocular surface disorders

Ocular surface disorders (OSDs) constitute a varied spectrum of conditions that could be associated with dryness, compromised limbal status, varying grades of forniceal obliteration, corneal scars, and a possible underlying immune etiology. These associations adversely impact surgical outcomes in the eye. One of the treatable causes of decreased vision in these eyes is cataracts which could be secondary to the disease, its treatment, or age-related. The compromised ocular surface status can interfere with decision-making regarding the technique of cataract surgery, preoperative biometry for intraocular lens (IOL) power calculation, and intraoperative visibility, increasing the possibility of complications and compromising the final visual outcome. The postoperative course can be affected by complications, including melt and infection. Stabilization of the ocular surface by medical or surgical means, and appropriate management of underlying immune etiology, if any, helps improve and maintain a healthy ocular surface, optimizing cataract outcomes. With the help of pre, intra, and postoperative tools and means, such as punctal occlusion, ocular surface reconstruction, systemic immunosuppression, illuminators, capsule staining dyes, optical iridectomy, prosthetic replacement of the ocular surface ecosystem (PROSE) lenses, and others, the visual outcome post-cataract surgery in these eyes can be maximized. This article highlights the nuances of performing cataract surgery in various OSDs and the need to have a comprehensive stepwise approach is emphasized.     

Effect of oral contraceptives on lacrimal fluid peroxidase activity in women

Lacrimal fluid peroxidase has been supposed to be involved in the protection against oxidative damage to the ocular surface. Our recent findings showed the existence of significant cyclic variations in lacrimal fluid peroxidase activity that were positively correlated with those of 17beta-estradiol plasma levels throughout the menstrual cycle of fertile women. In the present study lacrimal fluid peroxidase activity of 8 healthy normocyclic women using low-dose oral contraceptives during the monthly cycle was determined. Data showed that low-dose oral contraceptives caused a decrease in lacrimal fluid peroxidase activity and a lack of its cyclic pattern with respect to the enzyme activity of 8 untreated age-matched women. Moreover, this result suggests that lacrimal fluid peroxidase activity could be regulated by estrogen.     

Neuro-ophthalmological complications of contraceptive pills

An increasing number of complications are being noted with the widespread use of oral contraceptives (OCs). In opthalmology, migraine like headaches are frequently encountered. This report presents observations of 4 different neurological manifestations in 4 different individuals in addition to the headache for which they were referred to the Neuro-Ophthalmology Clinic of the Philippine General Hospital. The 4 cases clearly demonstrate that aside from the headache neuro ophthalmologic abnormalities can occur during OC use: left facial paresis, left Horner's syndrome, bilateral ptosis, and left mydriasis. The abnormalities disappeared on withdrawal of the OCs, suggesting that they are caused by the drug. They were reversible after 2 months to 4 years of medication. OCs are combinations of semisynthetic progesterone and estrogen. A study of 2 of the cases suggests that the estrogen portion may be the responsible agent for these pathologies. They did not reappear with the intake of another OC containing a lower concentration of ethinyl estradiol (.035 mg instead of .05 mg). This may present some problems in family planning for it is recommended that at least .05 mg of estrogen be incorporated with progesterone in order to have the pill most effective as a contraceptive agent. Examination of the neurologic complications encountered in these 4 patients suggests that intracerebral vascular deficiency has occurred simulating isolated small arterial occlusions.     

Stevens-Johnson综合征眼部病变的研究进展

Stevens-Johnson综合征(SJS)为一类主要由药物过敏引起的皮肤和黏膜的不良反应,严重者可危及生命。对于SJS存活者,眼部损害被认为是最严重的并发症,近年来大量研究对其遗传易感性及免疫机制进行了探讨,已发现多个易感基因参与其发生发展,但鉴于较高的种族及药物特异性,相关机制仍需进一步明确。SJS的眼部病变早期易被忽视,患者往往出现严重视力下降后才考虑眼科治疗,尤其在我国,一定数量的患者在就诊时眼表已遭到严重破坏,而现有治疗方法对此类患者的视力恢复并不理想。因此,本文主要针对病因及治疗对SJS眼部病变相关研究进展进行综述,以期提高临床医生对患者眼部病变的警惕性,并为疾病的诊疗及相关领域的研究提供参考。     

Sinusitis and ocular motility disorders

BACKGROUND: Secondary inflammatory orbital involvement due to acute or chronic sinusitis is common. The pneumatized system of the paranasal sinuses is abut to the bones of the orbit in up to 80 percent, therefore the association is a seductive theory due to their anatomic closeness. Typically, sinusitis can influence ocular motility by affecting single muscles or a combination of muscles/cranial nerves due to a local inflammatory tissue reaction. The expected picture would be a more or less complex restriction of eye movements. PATIENTS AND METHODS: In this case study nine consecutive patients were prospectively included between January 2006 and August 2007. RESULTS: Five of the patients did not experience any motility disorder, the other four had a restricted motility. Case reports of the four patients are presented to demonstrate the range of ocular motility disorders related to sinusitis. CONCLUSIONS: Orbital complications due to sinusitis include motility disorders among others. They can even cause orbital sepsis and cavernous sinus thrombosis. On the one hand sinusitis can affect almost the whole spectrum of ocular motility disorders, on the other hand it may mask a dangerous cerebral aneurysm. The "close-lying" connections, as seductive they are, should not divert from the rule: infrequent causes are infrequent and frequent causes are frequent!     

Toy gun ocular injuries associated with festive holidays in Kuwait

Background  Ocular trauma is one of the important causes of preventable blindness and visual impairment among children worldwide. Prevalence of pediatric ocular trauma associated with toy guns appear to be on the rise, although they are fully preventable. The purpose of this study is to report ocular trauma secondary to toy-gun pellets in Kuwait. Methods  We conducted a non-comparative case series based on review of the medical records of children who suffered ocular injury from toy-gun pellets and were admitted to a tertiary eye center during a 7-day Eid el-Fitr holiday season in Kuwait. Results  A total of 19 children were identified. Mean age was 7.8 years. Mean days of admission per patient was 3.6 days, with a total of 68 days of hospitalization. Variable anterior segment findings were identified, including lid edema, sub-conjunctival hemorrhage, corneal abrasion, and abnormal intraocular pressure. Most notably, different grades of hyphaema were seen in all patients, and traumatic cataract was identified in a 30-month-old child. The final visual acuity was 6/18 or better in nine patients and worse than 6/18 in eight patients. Conclusions  Eye trauma with toy guns resulted in significant injuries that required medical intervention and hospitalization for variable lengths of time, with a potential of causing long-term ocular complications. Our findings should assist public health workers in formulating specific prevention strategies, including a health educational program to make parents and health care professionals aware of the potential harm of these toys. The authors have full control of all primary data, and they agree to allow Graefe’s Archive for Clinical and Experimental Ophthalmology to review their data upon request. There is no financial interest in the subject of this work, as it was not sponsored by any organization.     

Comparison of visual function and ocular hemodynamics between pre- and post-menopausal women

PURPOSE: The incidence of eye disease increases with age and can often be linked to worsening cardiovascular function and increasing intraocular pressure. Estrogen is known to have vasodilatory effects in the systemic circulation. Decreased estrogen levels during menopause may therefore complicate or contribute to ocular pathologies as estrogen receptors are found in both retinal and choroidal tissue. The purpose of this investigation was to determine the effects of menopause on visual function and cardiovascular and ocular hemodynamics. METHODS: Twelve premenopausal and 24 postmenopausal women were evaluated at the Indiana University School of Medicine during a single study visit. Vision screening and ocular blood flow evaluations were performed, including blood pressure, heart rate, visual acuity, contrast sensitivity, intraocular pressure, and retinal capillary and retrobulbar blood flow imaging. Vision and ocular hemodynamics were compared using unpaired Student t-tests with p<0.05 regarded as statistically significant. RESULTS: The premenopausal group had significantly lower heart rate (-16.1 b/m, p=0.0001) and systolic blood pressure (-17.7 mmHg, p=0.003) than postmenopausal subjects. Contrast sensitivity was significantly higher (measured in log units) in premenopausal women in both the right (0.25, p=0.039; 0.16, p=0.039) and left (0.45, p=0.001; 0.27, p=0.032) eyes at 9 and 18 cycles per degree, respectively. Premenopausal women also had significantly lower intraocular pressure in both the right (-2.19 mmHg, p=0.024) and left (-1.74 mmHg, p=0.035) eyes. Total ocular perfusion was not significantly different between groups. CONCLUSIONS: This pilot work suggests that postmenopausal women have lower contrast sensitivity detection and elevated intraocular pressures compared to premenopausal women. Premenopausal women have lower cardiovascular risk factors, while total ocular circulation was similar to postmenopausal women.     

Ocular surface,ocular adnexal,and lacrimal complications associated with the use of systemic 5-fluorouracil

PURPOSE: To determine the prevalence rates and associated characteristics of patients who have ocular surface, ocular adnexal, and lacrimal complications associated with the systemic use of the cancer chemotherapeutic agent 5-Fluorouracil (5-FU). METHODS: An exposure-based cohort study was designed. Adult patients who had completed at least 3 months of systemic 5-FU therapy within the past 5 years were eligible for enrollment. Study subjects had a detailed medical history taken with emphasis on preexisting conditions known to be associated with the development of ocular surface, ocular adnexal, and lacrimal complications. An ocular examination was then performed. A complete nasolacrimal system evaluation was performed if symptoms or findings were identified. The prevalence was then determined for each ocular symptom and each ocular finding identified that was not present pretreatment. An exploratory analysis was then performed to identify patient characteristics that might influence the likelihood of developing any of the above complications. RESULTS: Fifty-two patients were enrolled in the study. The prevalence rates of the following ocular abnormalities were calculated: ocular irritation, 5.8%; blepharitis, 3.8%; conjunctivitis, 3.8%; keratitis, 3.8%; eyelid dermatitis, 5.8%; cicatricial ectropion, 1.9%; tearing, 26.9%; punctal-canalicular stenosis, 5.8%; and blurred vision, 11.5%. Blacks had tearing at a significantly higher rate when compared with whites (P = 0.022, 2-sided Fisher exact test). Three patients had permanent complications that will require surgery for correction. Of the 7 patients who had a single abnormality, 6 had tearing and one had eyelid dermatitis. All of the 8 patients who had multiple findings had tearing as one of their abnormalities. CONCLUSIONS: Ninety-three percent of the patients who had an ocular abnormality had tearing as one of the complications. Patients who are receiving systemic 5-FU and begin to tear should have an ocular examination, looking for ocular surface, ocular adnexal, and lacrimal complications.     

Treatment of ocular cicatricial pemphigoid with sulfasalazine

PURPOSE: To assess the outcome of patients with ocular cicatricial pemphigoid (OCP) treated with sulfasalazine as an alternative to dapsone. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Nine patients with biopsy-proven OCP and previous dapsone-related adverse effects (hemolysis and gastrointestinal disturbances) treated with oral sulfasalazine. METHODS: Clinical data were abstracted from patients' medical records. MAIN OUTCOME MEASURES: Patients' symptoms, ocular inflammation, conjunctival scarring, complete blood cell count (including reticulocyte count). RESULTS: At the initiation of sulfasalazine therapy, ocular inflammation was controlled in all patients but one. Mean follow-up was 12 months (range, 2-35 months). Median oral sulfasalazine dosage was 3 g (range, 1-4 g). The disease remained controlled with sulfasalazine alone in four patients (45%). Two patients (22%) required adjunctive oral cyclophosphamide. Adverse effects necessitating drug withdrawal occurred in three patients (33%): hemolysis in two and gastrointestinal disturbances in one. CONCLUSIONS: Sulfasalazine may be useful in OCP patients with previous dapsone-related adverse effects.     

Midterm results on ocular surface reconstruction using cultivated autologous oral mucosal epithelial transplantation

PURPOSE: To perform a midterm assessment of the integrity and reproducibility of cultivated autologous oral mucosal epithelial sheets, and to evaluate the clinical efficacy of their transplantation in ocular surface. DESIGN: Observational case series. METHODS: Cultivated autologous oral mucosal epithelial sheets were created using amniotic membrane and buccal mucosal epithelium from 12 patients with Stevens-Johnson syndrome, chemical and thermal injury, pseudo-ocular cicatricial pemphigoid, and idiopathic ocular surface disorder. They were transplanted onto 15 eyes from these patients who were then followed up for a mean of 20 months; with the longest follow-up being 34 months. We assessed their clinical outcomes with special reference to neovascularization. RESULTS: Cultivated autologous oral mucosal epithelial sheets could be generated from all patients. On the second postoperative day, 14 of 15 sheets transplanted demonstrated total re-epithelialization on the cornea. During the follow-up, the ocular surface was stable and transparent without any major complications in 10 of 15 eyes (67%), and the transplanted epithelium survived for at least 34 months. There were five eyes (33%) with small but long-standing epithelial defects, three of these healed spontaneously, and two (13%) required reoperation. In 10 eyes, postoperative visual acuity was improved by more than 2 lines. All eyes manifested some peripheral corneal vascularization. CONCLUSIONS: We established a successful tissue-engineering technique to generate cultivated autologous oral mucosal epithelial sheets and succeeded in reconstructing the ocular surface. We suggest that this surgical modality may be both safe and useful, especially in younger patients with the most severe ocular surface disorders.     

严重眼外伤玻璃体手术后并发症分析

目的探讨严重眼外伤玻璃体手术治疗效果、术后并发症及防治。方法53例(53眼)严重眼外伤行玻璃体手术治疗,对其术后效果和术后并发症进行回顾性分析。结果术后视力较术前提高者38眼(71.70%),但部分患眼出现不同程度的并发症,包括角膜水肿、角膜上皮愈合不良、高眼压、视网膜干性裂孔、视网膜脱离、白内障、眼内出血、眼球萎缩等。结论严重眼外伤进行玻璃体手术能挽救大多数受伤眼球并恢复一定的有用视力,但对术后出现的并发症应重视并积极预防治疗,以提高玻璃体手术的效果。     

Transplantation of cultivated autologous oral mucosal epithelial cells in patients with severe ocular surface disorders

BACKGROUND/AIMS: To determine outcomes of transplants of cultivated autologous oral epithelial cells in patients with severe ocular surface disorders. METHODS: The eyes (n = 6) of four patients with Stevens-Johnson syndrome (three eyes) or chemical burns (three eyes) were studied. Autologous oral epithelial cells, grown for 2-3 weeks on a denuded amniotic membrane carrier in the presence of 3T3 fibroblasts, were air lifted. The resultant sheet was transplanted onto the damaged eye, and acceptance of the sheet by the corneal surface was confirmed 48 hours after surgery. The success of ocular surface reconstruction, graft survival, changes in visual acuity, and postoperative complications were assessed and the quality of the cultivated oral epithelial sheet was evaluated histologically. RESULTS: At 48 hours after transplant, the entire corneal surface of all six eyes was free of epithelial defects indicating complete survival of the transplanted oral epithelium. Visual acuity was improved in all eyes. During follow up (mean 13.8 (SD 2.9) months), the corneal surface remained stable, although all eyes manifested mild peripheral neovascularisation. CONCLUSIONS: Autologous oral epithelial cells grown on denuded amniotic membrane can be transplanted to treat severe ocular surface disorders.     

Prevalence of systemic and ocular diseases in age-related cataract patients

BACKGROUND: Cataract patients often display concomitant ocular and systemic diseases which may influence the decision between general and regional anesthesia. The aim of this study was to quantify co-morbidity of these patients and assess the influence of the two types of anesthesia an the anesthesiological risk on the frequency of intra- and post-operative complications and visual outcome. METHODS: In this prospective study, in patients scheduled for cataract extraction at the University Eye Hospital and Clinic of Ulm (tertiary eye care center) all systemic and ocular diseases as well as intra- and postoperative complications were analyzed. The prevalence of the co-morbidity in our patients was compared to other studies including age-matched controls. The anesthesiological risk was quantified using the classification scheme of the American Society of Anesthesiologists (ASA). RESULTS: Eighty-eight patients with a mean age of 70.4 +/- 11.7 years were analyzed. Sixty-one% of patients displayed systemic as well as ocular co-morbidity. Only systemic or ocular comorbidity was present in 32% and 5% of patients, respectively. Two% of patients exhibited neither ocular nor systemic comorbidity. In 61% of patients the surgery was performed in regional anesthesia and in 39% in general anesthesia. The prevalence of systemic and ocular co-morbidity as found in our study was significantly higher as compared to that in the general population of the same age. Visual improvement and the frequency of intra- and postoperative complications were independent on type of anesthesia and anesthesiological risk. CONCLUSIONS: Patients who were scheduled at our institution for cataract surgery exhibited a high frequency of ocular as well as systemic co-morbidity. This can be interpreted in such a way that patients with a high level of co-morbidity are referred to tertiary eye care centers for cataract surgery.     

高氧诱导眼损伤机制及其防治的研究进展

高氧包括高压氧和高浓度氧,在多种眼科疾病的治疗中发挥重要作用,如视网膜静脉阻塞、缺血性视神经病变、中心性浆液性脉络膜视网膜病变等。但是,长时间吸入的氧气浓度过高或压力过大可导致眼部组织损伤,其中晶状体混浊、早产儿视网膜病变、近视是应用高氧治疗后较常见的眼部并发症。目前,高氧性眼损伤的发病机制尚未完全明确,许多学者认为其发生与氧化应激、脂质过氧化反应、炎性反应等多种因素有关。就高氧对晶状体和视网膜等眼内组织损伤机制及其防治措施的最新研究进展进行综述。