Induction of anterior chamber-associated immune deviation by corneal allografts placed in the anterior chamber

PURPOSE: Although mice with long-accepted orthotopic corneal allografts display donor-specific anterior chamber-associated immune deviation (ACAID), this deviant response is not detected until well after the fate of the grafts is decided. To determine the efficiency with which corneal tissue itself can induce ACAID, allogeneic corneal segments were inserted into anterior chambers (AC) of normal mouse eyes. METHODS: Central corneas from normal eyes of C57BL/6 (allogeneic) and BALB/c (syngeneic) donors were cut into wedge-shaped fragments measuring approximately 0.3 x 2.0 mm (in some experiments the corneal epithelium was removed) and inserted into the AC adjacent to recipient endothelium. Recipients of these fragments were evaluated for donor-specific delayed hypersensitivity (DH) and ACAID, and fragment-containing eyes were tested for their capacity to support ACAID to an irrelevant antigen. RESULTS: Syngeneic and allogeneic corneas survived indefinitely in the AC without evidence of inflammation or rejection. Although fragments of cornea (with or without epithelial layers) placed at extraocular sites were potent inducers of DH, within the eye only epithelium-bearing grafts induced DH. Moreover, this DH response was short-lived. Recipients of allogeneic corneal fragments in the AC developed ACAID by 8 weeks, but not at 1 week. Moreover, fragment-containing eyes supported ACAID induction when bovine serum albumin was injected into the AC. CONCLUSIONS: Anterior chamber-associated immune deviation can be induced by allogeneic corneal tissue inserted into the AC, but its onset is delayed. The delay may be dictated by persistence of donor epithelium on the graft, which promotes DH. Once the epithelium is lost, DH disappears and ACAID emerges. Anterior chamber-associated immune deviation may contribute to the maintenance of corneal allograft viability.     

Urethral protrusion caused by blunt trauma of the anterior urethra

We report an uncommon case of complete rupture of the anterior urethra secondary to blunt trauma, with protrusion of the urethral mucosa through the urinary meatus. The singular images of this case are presented and the mechanisms involved in this unusual type of lesion are analyzed.     

Corneal endothelial cell loss caused by detached opacified anterior lens capsule in the anterior chamber

From 1984 to 1986, we performed cataract surgery through a 1.5 mm anterior capsule hole in 77 eyes. The hole was enlarged to 6.0 mm by a slit incision, and an intraocular lens was implanted into an almost completely intact capsular bag. Twelve (16%) eyes developed severe postoperative anterior capsule opacification. The opacified central anterior capsule, approximately 5 mm in diameter, was detached by can-opener anterior capsulotomy using a neodymium:YAG laser and fell into the inferior anterior chamber. Inferior corneal endothelial cell loss occurred in nine of the 12 eyes within 20 months after detachment; in six of the nine, inferior corneal endothelial cell density decreased 50% more than central cornea cell density. This method will be unsuitable for treating the extensive anterior capsule opacification that will occur when endocapsular cataract surgery that retains most of the lens capsule is widely performed in the future.     

Complex anterior chamber dysgenesis with bilateral corneal ectasia

BACKGROUND: Sclerocornea is a congenital, uni- or bilateral, non-progressive, non-inflammatory malformation characterized by histological changes of the cornea resembling scleral tissue. CASE REPORT: We report the case of a 2-month-old child with bilateral dysplasia of the anterior segment including: 1. extreme corneal ectasia; 2. vascularized, opacified microcornea; 3. presence of rudimental limbus; 4. anterior scleral dysplasia. The axial length measured by means of ultrasonography (A-scan) was about 24 mm in both eyes. A penetrating keratoplasty was first performed in the right eye and one week later in the left eye. Intraoperatively an advanced iris atrophy with extensive anterior synechiae, as well as a localized anterior subcapsular cataract were seen bilaterally. A pale optic disk with a maximally enlarged optic cup could be seen only in the left eye. CONCLUSION: Although the histologic examination was compatible with the diagnosis of sclerocornea, the presence of atypical clinical findings previously unreported does not allow a definite classification of the case reported herein.     

Use of of the high frequency capsulotomy instrument in cataract surgery--effect of coagulation on corneal endothelium

Intumescent or hypermature cataracts make a safe capsulorhexis impossible. High frequency capsulotomy represents a satisfying solution for this problem. Primary goal of the present study was to investigate a possible damage to the corneal endothelium by this method. MATERIALS AND METHODS: 55 patients with an uncomplicated senile cataract were enclosed into a prospective randomized study undergoing cataract surgery with capsulorhexis or with high frequency capsulotomy. Corneal endothelium was examined preoperatively as well as postoperatively at several intervals. RESULTS: Concerning loss of endothelial cells and parameters of polymegatism and pleomorphism there were no statistically significant differences between both groups. CONCLUSION: The diathermy during high frequency capsulotomy does not show any clinically relevant negative effects on the corneal endothelium within cataract surgery.     

Airway obstruction caused by an oleothorax

PURPOSE: This article describes the possible role of various peptides in producing pain and inflammation in the temporomandibular joint (TMJ). MATERIAL AND METHODS: Current research findings on the spectrophotometric quantification of TMJ synovial fluid for neuropeptide Y (NPY), serotonin (5HT), and interleukin-1beta (IL-1beta) are presented. FINDINGS: NPY was found in high levels in the synovial fluid of arthritic TMJs with resting pain, and serotonin (5-HT) was found in patients with pain perceived on mandibular movement. These pain-related mediators were also associated with restricted mandibular mobility. Interleukin-1beta (IL-1beta) was found to be strongly associated with hyperalgesia over the TMJ as well as resting pain. Anterior open bite as a clinical sign of joint destruction was found to be associated with high levels of NPY and IL-1beta in the synovial fluid. IL-1beta was also related to the radiographic signs of joint destruction. CONCLUSIONS: Interaction between the peripheral nervous system (sensory and sympathetic nerves) and the immune system is probably of importance for the modulation of pain and inflammation in the TMJ, but this subject has to be investigated further with experimental clinical studies.     

Technical note--modified above-knee socket to relieve anterior pressure caused by abdominal hernia

The plastic quadrilateral socket has a high anterior brim which can cause considerable discomfort in some patients, especially when seated. A simple modification to the anterior brim is described allowing a female patient with a huge abdominal hernia a considerable degree of comfort when both sitting and standing. The creation of a large radius producing a wide area for adequate pressure relief proved valuable. This might be considered for patients with less pendulous abdomens who find conventional methods inadequate.     

Repair of mitral regurgitation caused by prolapse of the anterior mitral leaflet

Mitral regurgitation caused by prolapse of the anterior mitral leafleft has been considered to be difficult for reconstruction. In Japan, these cases have been repaired mainly by replacement of chordae with artificial sutures. We have repaired them by Carpentier's technique. We report a series of 9 patients with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. Two of them had lesions at both anterior and posterior leaflet. All patients underwent mitral valve repair by segmental transposition of the posterior leaflet. As for associated procedures, there were ring annuloplasty with Carpenter rings (9 cases), sliding technique (8 cases) reported by Carpentier, reinforcement by transposition of secondary chordae of the posterior leaflet (6 cases), commissuroplasty (1 case), and closure of leaflet perforation. All patients survived operations and all patients except one underwent left ventriculography postoperatively. In only 2 patients, residual mitral regurgitation classed as I/IV was observed. All patients returned home in New York Heart Association class I. Follow-up ranged from 7 to 45 months (mean follow-up 20 months). All patients were free from reoperation or thromboembolism. Although longer follow-up is necessary, this technique appears to be adequate for the repair of patients with anterior leaflet prolapse.     

Diode laser cyclophotocoagulation of secondary glaucoma caused by anterior, necrotizing scleritis

PATIENT: A 60-year-old female patient presented with recurrent anterior, necrotizing scleritis with inflammation and a newly developed secondary glaucoma in the right eye. Anterior uveitis occurred some years before. Severe scleral thinning was circumferentially present and focal scleral ectasia was found. Physical examination revealed no systemic association of scleritis. Immunosuppressive therapy with metotrexate was initiated and control of scleritis achieved. Intraocular pressure elevation persisted and was refractory to glaucoma medication. Diurnal pressure curve showed IOP-values of 40 mm Hg despite the use of systemic carbonic anhydrase inhibitors. Visual acuity was 20/50 in the right and 20/25 in the left eye. METHOD: Diode laser cyclophotocoagulation (Oculight SLx 810 nm, Iris Medical Instruments Inc. California, USA) was performed under general anaesthesia using reduced parameters for application (12 laser spots, 1 second, 1.25 W). No complications occurred during and after laser application. Postoperatively, intraocular pressure was within normal range between 14 and 18 mm Hg. No reactivation of scleritis or uveitis was seen. CONCLUSION: In our experience, diode laser cyclophotocoagulation is effective and safe in treating secondary glaucoma associated with anterior, necrotizing scleritis with inflammation and uveitis using reduced parameters for application.     

Hyperthyroidism caused by an ectopic TSH-secreting pituitary tumor

The glycophorin A (GPA) somatic cell mutation assay is being applied widely as an in vivo biomarker in molecular epidemiologic studies of human populations. The assay uses two-color immunolabeling and flow cytometry of peripheral blood samples to enumerate allele-loss variant erythrocytes that appear as a result of mutations at the GPA locus in bone marrow erythroid cells. We have developed an improved version of the assay in which both anti-GPA monoclonal antibodies are directly conjugated with distinguishable fluorophores, fluorescein and phycoerythrin. Parallel analyses of 77 blood samples using the existing BR6 assay and our new DB6 assay demonstrate that the DB6 assay produces cleaner bivariate flow histograms with generally lower variant cell frequencies and lower coefficients of variation on replicate analyses of individual blood samples. With the BR6 assay, an artifact was shown to exist that results in enumeration of high frequencies of variant erythrocytes in a small fraction of samples that have been subjected to poor shipping and/or storage conditions. Using DB6, these same samples display acceptable histograms and low frequency of variant cells. High speed cell sorting followed by immuno analysis indicates that the BR6 artifact results from inhibited binding of the very high molecular weight antibody plus secondary reagent, which is used for the BR6 assay. We therefore recommend that DB6 be adopted as standard protocol for the GPA assay, and to assist other researchers in standardization and comparison, we are making available a set of calibrated, fixed blood samples.     

Spondylodiscitis caused by Enterococcus: an unusual entity

BACKGROUND: Spondylodiscitis by enterococcus is a very infrequent disease with only 2 cases caused exclusively by this microorganism having been reported in the literature. METHODS: Two clinical cases of spondylodiscitis by enterococcus diagnosed in the authors' department are presented with the clinical, radiologic and evolutive features of both. RESULTS: In the first case the spondylodiscitis was secondary to endocarditis with lumbosacral involvement and formation of an anterior epidural inflammatory mass. The second case was the consequence of an infection of urinary origin with lumbosacral involvement. Both patients responded favorably with only antibiotic treatment. CONCLUSIONS: Spondylodiscitis by enterococci is an unusual disease with no therapeutic experience. The authors report 2 cases which were treated exclusively with antibiotics.     

Virus-associated haemophagocytic syndrome caused by rubella in an adult

Haemophagocytic syndrome is a systemic clinicopathological entity characterized by systemic proliferation of benign haemophagocytic histiocytes, fever, cytopenia, abnormal liver function and, frequently, coagulopathy and hepatosplenomegaly. Its occurrence has been documented in association with viral, bacterial, fungal and parasitic infections, a wide spectrum of malignant neoplasms, autoimmune diseases and drugs. We report a case of rubella virus-associated haemophagocytic syndrome in a previously healthy 29-year-old woman. Blood tests showed cytopenia, especially severe thrombocytopenia, liver dysfunction, hyperferritinaemia and hypercytokinaemia. Bone marrow examination showed many mature histiocytes with active haemophagocytosis. A skin biopsy from the rash revealed perivascular lymphohistiocytic infiltrates with haemophagocytic histiocytes in the upper and mid-dermis. The patient was treated with antibiotics and immunoglobulin, and by supportive measures including platelet transfusion, and recovered completely.     

Severe lead poisoning caused by an ingested fishing weight

Authors describe the case-history of a 17 year old male who accidentally ingested a fishing weight that was retained in the stomach and caused a serious lead poisoning. It is worth mentioning that beside the wellknown symptoms and signs of lead intoxication also the liver was seriously affected. The histologically verified toxic lesion of the liver presumably can be attributed to the large quantities of lead absorbed within a short period. This also explains the appearance of symptoms and signs indicating to encephalopathy beside the young age of the patient. The foreign body could not be removed by means of gastroscopy, therefore a gastrotomy was carried out followed by chelating treatment with i.v. CaNa2EDTA that resulted in complete clinical and laboratory recovery. The case history draws the attention to the importance of the quick removal of the retained lead containing objects out of the gastrointestinal tract.     

Objective tinnitus caused by an aberrant internal carotid artery

(+)-Norfenfluramine is the main metabolite of the serotoninergic anorectic agent (+)-fenfluramine. Both compounds inhibit 5-HT reuptake and stimulate its release, although they induce release from different pools, with (+)-norfenfluramine acting primarily on the cytoplasmic pool. Moreover, (+)-norfenfluramine was more potent than the parent drug in inducing dopamine release. In order to investigate whether (+)-norfenfluramine induces a Ca2+-dependent vesicular release, like some amphetamine derivatives, in the present study we preloaded synaptosomes with the [3H]neurotransmitter ([3H]5-HT or [3H]dopamine), superfused (washed) them for 47 min in the absence of pargyline and then exposed them to the releasing stimulus. With this protocol, the cytoplasmic pool should be absent and the [3H]neurotransmitter should mainly be stored in synaptic vesicles, where (+)-norfenfluramine should act to induce release. This was confirmed by a significant decrease of (+)-norfenfluramine-induced [3H]5-HT and [3H]dopamine release after reserpine pretreatment. The dose-response curves of (+)-norfenfluramine-induced [3H]5-HT release were superimposable in hippocampus and hypothalamus, and also superimposable on the curve for (+)-fenfluramine-induced [3H]5-HT release; the dopamine releasing potency of (+)-norfenfluramine in the striatum was more than ten times lower. The [3H]5-HT release induced by (+)-norfenfluramine was partly (about 50%) but significantly Ca2+-dependent, and it was also markedly (68%) inhibited by Cd2+, a non-specific blocker of voltage-dependent Ca2+ channels, suggesting that the Ca2+-dependent release is mediated by entry of Ca2+ into the synaptosomes through these channels. The [3H]dopamine release induced by 5 microM (+)-norfenfluramine was completely Ca2+-independent whereas at higher concentrations (10 and 20 microM) it was only slightly (20%) Ca2+-dependent. We have no clear explanation why (+)-norfenfluramine has these different effects on serotoninergic and dopaminergic synaptosomes.     

Evaluation of an electronic corneal pachometer

Sixteen patients who had never worn contact lenses underwent measurement of their central corneal thicknesses with the standard corneal pachometer and a new electronic corneal pachometer. Both instruments were able to produce repeatable and accurate results, although the overall measurements obtained were thicker with the electronic pachometer. The advantage of the electronic pachometer over the standard pachometer is that one is able to easily measure areas other than the central cornea with repeatable accuracy. With the addition of a microcomputer and print-out system, large populations can be studied, and changes in corneal thickness can be recorded on a day-to-day or hour-to-hour basis.     

The limbus vertebra: an anterior disc herniation demonstrated by discography

Limbus vertebra results from an intrabody herniation of disc material. It can be mistaken for a fracture, infection, or tumor, resulting in unnecessary invasive diagnostic procedures. A case is presented in which the lesion was diagnosed by discography. Most radiologists are unfamiliar with discograms, yet they are useful because they opacify the anteriorly herniated portion of the nucleus pulposus.