The role of early trabeculectomy in the control of chronic simple glaucoma

Seventy patients of bilateral chronic simple glaucoma with a mean age of 59.7 years, an intra-ocular pressure over 25 mmg Hg, optic disc cupping, and without visual field loss were selected. The eye with higher intra-ocular pressure or the larger optic disc cup was treated by early trabeculectomy while the other eye of the same patient was subjected to medical therapy with topical beta blockers for 3 years (without any surgical treatment). Both the eyes of 70 patients were compared after 3 years. Eyes which had undergone trabeculectomy had a mean intra-ocular pressure of 11.7 mm Hg against 18 mm Hg in the medically treated eyes. Surgically treated eyes had decrease in the mean cup : disc ratio (from 0.54 : 1 to 0.48 : 1) whereas medically treated eyes showed an increase from 0.41:1 to 0.51: 1. Visual field loss occurred in 3/70 operated eyes and in 27/70 medically treated eyes. Twenty-one of 70 treated eyes developed cataract and 12 of these required cataract surgery. Only 18/70 medically treated eyes developed cataracts but none of these required cataract surgery. Early trabeculectomy in cases of chronic simple glaucoma resulted in a large reduction of intra-ocular pressure and consequently reduced the size of optic disc cup and the chances of visual field loss.     

Novel approaches to the study of autoregulation of alternative complement pathway

Forty patients without eye disease, undergoing elective nonophthalmic surgery, were studied in a double-blind, randomised, placebo-controlled study evaluating the efficacy of mivacurium pretreatment in attenuating the rise in intra-ocular pressure in response to suxamethonium administration, laryngoscopy and intubation. The patients were randomly allocated to receive either mivacurium 0.02 mg.kg-1 or normal saline as pretreatment 3 min before a rapid sequence induction technique using alfentanil, propofol and suxamethonium. Suxamethonium induced a significant increase in intra-ocular pressure in the control group but not in the mivacurium pretreatment group (mean (SEM) increase = 3.5 (1.2) mmHg vs. 0.4 (0.8) mmHg, p < 0.05). There was a decrease in intra-ocular pressure in both groups after laryngoscopy and intubation with no significant difference between the two groups. These results show that mivacurium pretreatment is effective in preventing the increase in intra-ocular pressure after suxamethonium administration.     

Intraocular pressure during operations using the heart-lung machine (author's transl)

The results of the investigations reported here show that contrary to expectations, the drop in mean arterial blood pressure (up to 57 mm Hg) during extracorporal circulation does not result in a simultaneous drop in intra-ocular pressure. Other factors, affect intra-ocular pressure during extracorporal circulation, causing it to rise. Postoperative studies of vision led to the conclusion that the elevations of intraocular pressure measured during extracorporal circulation with the heart-lung machine do not adversely affect ocular function.     

Ocular involvement in tuberculoid leprosy--a case report

Leprosy is rarely diagnosed in our part of the world. In our 26-year-old patient, borderline lepromatous leprosy was first diagnosed in 1992 and was treated with Rifoldin, Lemprene and Dapson according to the standard WHO scheme of treatment. Ophthalmic examination showed minor epithelial lesions of the cornea in both eyes, a reduced corneal reflex in the left eye and a scleral leproma nasally and close to the limbus, also in the left eye. In 1995, the patient was examined again and was treated as above for lepromata of the left eyebrow nasally and of both lower legs. Ophthalmic examination revealed conjunctival irritation, anterior uveitis with leprosy pearls on the pupillary margin and secondary glaucoma. The glaucoma was treated with hypotonics, the uveitis was treated with topical cortisone. The intra-ocular pressure normalised and the uveitis improved. Of the two main types of leprosy, lepromatous leprosy and tuberculoid leprosy, our patient had the second, milder form.     

Co-injection of adenovirus expressing CTLA4-Ig prolongs adenovirally mediated lacZ reporter gene expression in the mouse retina

There is growing interest in gene delivery to the eye in order to develop gene therapy for the many ocular disorders which may be amenable to this approach. To date, recombinant adenoviruses (AV) have been the main vector used for gene delivery to anterior and posterior segments in animal models. As with delivery to other organs, immune responses to vector and transgene limit the duration of expression in the eye. Using an E1-deleted adenoviral vector carrying a lacZ reporter gene, we have previously demonstrated that a T cell-mediated immune response reduces the level of intra-ocular transgene expression over time and limits it to around 3 weeks in mice. This report describes a strategy for prolonging gene expression by blocking the B7-CD28 interactions between antigen presenting cells (APC) and T cells in order to prevent the costimulatory signals required for T cell survival and proliferation. This was achieved by the co-injection of AV encoding a secreted immunomodulatory molecule (CTLA4-Ig) which consists of the extra-cellular domain of mouse CTLA4 fused to the Fc region of human IgG. Subretinal co-injection of AV encoding beta galactosidase with AV encoding CTLA4-Ig results in prolonged expression in retinal cells compared with subretinal injection of only adenovirus encoding beta galactosidase.     

Microsurgery for the treatment of windshield injuries

During the last few years, eye injuries caused by fragments of shattered windscreen have increased enormously in the Federal Republic of Germany and in West Berlin. About 1000 people per year suffer severe eye- and eyelid injuries due to traffic accidents. Microsurgery of ocular injuries allows particular attention to be paid to each part of the eye and restoration of its functions. Although the prognosis of such injuries has been improved by a more developed surgery technique using microscopes, the eye specialist as well as legislation should make every possible effort to diminish eye injuries and their serious consequences for the patients.     

Investigation of limbal touch sensitivity using a Cochet-Bonnet aesthesiometer

Using the hypertensive gas technique, before touching the melanoma eye for enucleation intraocular pressure is raised to maximum by an intravitreal gas injection (average 1.2 ml of perfluorocarbon or air), resulting in a rock-hard eye. Changes in intraocular pressure are no longer possible, since the hard eye condition and avascularity persist during enucleation. The vortex veins appear collapsed. Before cutting the optic nerve and vessels, they are compressed by a broad hemostatic clamp for three minutes and then severed by a blade located in the middle of the clamp. With the hypertensive gas technique there is neither bleeding of vortex veins nor of proximal end of stump, which continues to be compressed by the hemostatic clamp. Fifteen patients with choroidal melanomas were enrolled in a prospective study with the hypertensive gas technique from 9/1987 to 6/1989; prior radiotherapy was not performed. Average base diameter of melanoma measured 13.2 mm, height 8.4 mm. Cytology was: 11x spindle, 3x mixed, 1x epitheloid cells. At reexamination in 7/1991 (average follow-up 2.75 years), 2 diabetics had died with no detectable metastases, and 1 of the 15 melanoma patients (6.7%) had died with metastases 2 years after enucleation. The hypertensive gas technique does not postpone enucleation of a melanoma eye while presumed prophylaxis is administered, does not require additional instruments, and takes only a minute when the eye is already draped for surgery. The firm and avascular globe facilities a faster removal of the melanoma eye with practically no bleeding from the bulb.     

Reduced intraocular pressure after phacoemulsification and posterior chamber intraocular lens implantation

PURPOSE: To ascertain whether phacoemulsification with posterior chamber intraocular lens (IOL) implantation causes long-term reduction in intraocular pressure (IOP). SETTING: Private practice, Kempten, Germany. METHODS: Intraocular pressure was measured in both eyes of 120 consecutive patients who were unilaterally phakic after phacoemulsification a mean of 17 months +/- 17 (SD) previously. Mean age of the 36 men and 84 women was 76 +/- 10 years. Data were analyzed using binomial distribution and the Wilcoxon signed-rank test. RESULTS: The median ratio of IOP in the pseudophakic eye to IOP in the phakic eye was 0.83. The IOP was lower in the pseudophakic eye in 96 patients (80%). The median IOP was 12 mm Hg in the pseudophakic eyes and 14 mm Hg in the phakic eyes (P < .001). As measured by the interquartile range, IOP distribution was more centered in the pseudophakic than in the phakic eyes (3 versus 4). The IOP in the pseudophakic eyes remained lower to the last measurement, 5 years postoperatively, and appeared to be independent of patient age. Lower IOP in the pseudophakic eye was consistently present in patients with higher IOP in the phakic eye (16 to 22 mm Hg). CONCLUSION: Phacoemulsification with posterior chamber IOL implantation reduced IOP in most but not all patients with a preoperative IOP of 22 mm Hg or less. This reduction was maintained over several years, with the cause yet to be established. Lower IOP may decrease the risk of subsequent glaucomatous nerve damage in these patients.     

Monocular deprivation induces homosynaptic long-term depression in visual cortex

Brief monocular deprivation during early postnatal development can lead to a depression of synaptic transmission that renders visual cortical neurons unresponsive to subsequent visual stimulation through the deprived eye. The Bienenstock-Cooper-Munro (BCM) theory proposes that homosynaptic mechanisms of long-term depression (LTD) account for the deprivation effects. Homosynaptic depression, by definition, occurs only at active synapses. Thus, in contrast to the commonly held view that the synaptic depression caused by monocular deprivation is simply a result of retinal inactivity, this theoretical framework indicates that the synaptic depression may actually be driven by the residual activity in the visually deprived retina. Here we examine the validity of this idea by comparing the consequences of brief monocular deprivation by lid suture with those of monocular inactivation by intra-ocular treatment with tetrodotoxin. Lid suture leaves the retina spontaneously active, whereas tetrodotoxin eliminates all activity. In agreement with the BCM theory, our results show that monocular lid suture causes a significantly greater depression of deprived-eye responses in kitten visual cortex than does treatment with tetrodotoxin. These findings have important implications for mechanisms of experience-dependent plasticity in the neocortex.     

Positive correlation between Tono-Pen intraocular pressure and central corneal thickness

OBJECTIVE: To examine the relationship between intraocular pressure (IOP) readings taken by the Tono-Pen tonometer (Mentor O&O, Norwell, MA) and central corneal thickness (CCT). DESIGN: Prospective cross-sectional population study. PARTICIPANTS: There were 651 eyes of 332 healthy subjects. MAIN OUTCOME MEASURES: A questionnaire was given to each subject requesting information on gender, age, race, and other factors that can influence IOP. The IOP then was measured using the Tono-Pen followed by measurements of CCT using an ultrasonic pachymeter. RESULTS: The IOP was found to increase by 2.9 mmHg/100 microns CCT in males and 1.2 mmHg/100 microns in females. For males, CCT was found to be statistically significant in predicting IOP (P < 0.001 in the right and left eyes) and diabetes was of borderline significance (P = 0.012 in the right eye, P = 0.089 in the left eye). For females, CCT was of borderline significance (P = 0.064 in the right eye, P = 0.019 in the left eye). In females, a family history of glaucoma (P = 0.021 in the right eye, P = 0.022 in the left eye) and hypertension (P = 0.010 in the right eye, P = < 0.001 in the left eye) were also significant in the prediction of IOP. Race was found to be a significant predictor of CCT (P < 0.001 in both right and left eyes) for both males and females. CONCLUSION: Clinicians should be aware that, as with the Goldmann applanation tonometer, the Tono-Pen has a systematic error in IOP readings caused by its dependence on CCT. Tono-Pen IOP readings are positively correlated to CCT in males and, to a lesser extent, in females as well. The CCT measurements should be considered to ensure proper interpretation of IOP measurements in the diagnosis and management of disorders in which the CCT or IOP readings are outside normal limits.     

Biologic effects of nonsteroidal anti-inflammatory drugs

Experimental glaucoma was induced in 1 eye of 6 cynomolgus monkeys by laser treatment of the trabecular meshwork. In 5 of the 6 monkeys the increased intraocular pressure (IOP) caused marked glaucomatous damage in the experimental eye. Ocular blood flow was determined with labeled microspheres 4 years after the laser treatment. IOP was regulated with an external reservoir. With the same perfusion pressure in both eyes no statistically significant difference was observed between the 2 eyes for total ocular blood flow or for blood flow through any of the ocular tissues. Total ocular blood flow was 343.5 +/- 61.4 mg/min (mean +/- SEM) in the control eye and 385.3 +/- 107.7 mg/min in the experimental eye.     

Percentage change rather than plasma level of LDL-cholesterol determines therapeutic response in coronary heart disease

PATIENT: A 35-year-old female patient with Marfan's syndrome presented with fast progressive reduction of visual acuity (hand movements) of her right eye and lens-related glaucoma on both eyes. On examination, subluxation of the lens and nuclear cataract were seen on both eyes. Diurnal pressure curve showed great fluctuations in pressure with normal IOP in the morning and elevated pressure in the evening. Pressure measurement revealed great fluctuations depending on positioning. Because of cataractous lens in the right eye blocking the visual axis and uncontrollable, phacogenic glaucoma removal of the lens by cryoextraction was necessary. Visual acuity increased to 0.5 and IOP was normal after three weeks. To improve safety of topical medication of lens-related glaucoma in Marfan's syndrome regular measurement of IOP at different times of the day is especially important. Measurement of IOP at different positions seems to be an effective provocation test in cases of phacogenic glaucoma in Marfan's syndrome. Examination of all members of a family with Marfan's syndrome should include regular measurement of IOP at different times of the day. In suspected cases, measurement of IOP at different positions that may provoce IOP-increase could be useful in the early detection of lens-related glaucoma.     

Differential diagnosis of cervical lymphadenopathy with intranodal color Doppler flow signals in patients with oral squamous cell carcinoma

OBJECTIVE: To investigate the mechanism by which pilocarpine causes increased aqueous humor (AH) flare, hypotony, and miosis in dogs. ANIMALS: 6 dogs with normal eyes. PROCEDURE: Both eyes of each dog were treated topically with a 2% solution of pilocarpine, and 1 eye of each dog was additionally treated with commercially available ophthamic solutions. Breakdown of the blood-aqueous barrier (BAB) was quantitated in each eye, using laser flaremetry to measure AH flare. Intraocular pressure and pupil size were also measured. RESULTS: Pilocarpine caused increased flare from BAB breakdown that was inhibited by the drugs tested. Inhibition (most to least) of BAB breakdown was flurbiprofen more than diclofenac, proparacaine, or suprofen, which were more than 0.125 or 1.0% prednisolone. Inhibition appeared dose-dependent and caused consensual inhibition in the contralateral eye. Intraocular pressure was decreased only in proparacaine-treated eyes and increased in eyes treated with nonsteroidal anti-inflammatory drugs (NSAID). Flurbiprofen and proparacaine were the most effective at blocking miosis. CONCLUSIONS: Pilocarpine produced a predictable, reproducible BAB breakdown in dogs. Miosis and increased AH flare were inhibited equally by proparacaine or NSAID, suggesting that these signs were caused by neuropeptide release into the AH from antidromic stimulation, which subsequently triggers prostaglandin production. Hypotony was inhibited only by anti-inflammatory drugs. CLINICAL RELEVANCE: Proparacaine in combination with pilocarpine would be the best choice for treating dogs with acute glaucoma. Topical administration of NSAID should not be used to treat dogs with acute glaucoma, because they increase intraocular pressure and negate the effects of pilocarpine.     

Follow-up report of a case of surgical aphakia with an analysis of equine visual function

More work is necessary to establish corneal dimensions and retinal structure and neural organisation in the equine eye. This paper reports a case of surgical management of bilateral cataracts in a pony and the results of a survey of refractive error in normal horses. Aspects of accommodation are discussed. It is suggested that a difference in retinal receptor organisation between horse and human eyes could explain the good visual performance of the aphakic pony; and that the degree of blurring of vision in the aphakic situation is less, both in absolute terms and in proportion to presumed normal levels of vision, in the horse than in man. It would not seem necessary to consider intra-ocular implants for horses at this stage. The authors feel it is unwise to extrapolate too freely from human data. More information is needed on the optics and retinal topography of many species, particularly horses and dogs, before routine implant surgery on eyes is undertaken.     

Retinopathy and vision loss in insulin-dependent diabetes in Europe. The EURODIAB IDDM Complications Study

PURPOSE: To assess the frequency of retinopathy and vision loss in patients with insulin-dependent diabetes mellitus and their relations to potentially modifiable risk factors. METHODS: The authors conducted a multicenter cross-sectional study of diabetic complications and their risk factors using standardized methods of assessment. The sample was comprised of 3250 insulin-dependent diabetic patients (1668 men, 1582 women) aged 15 to 60 years with mean (standard deviation) duration of diabetes of 14.7 (9.3) years from 31 European diabetes centers; 2991 of the patients were eligible for retinal photography. Visual acuity was measured using the Snellen chart. Retinopathy was evaluated by retinal photographs (two fields per eye) graded at a central facility. Glycated hemoglobin (HbA1c), cholesterol, triglyceride, fibrinogen, von Willebrand factor, and urinary albumin excretion rate were assessed at a single location. RESULTS: Corrected visual acuity was greater than or equal to 1.0 in both eyes in 69.7% of patients and less than or equal to 0.1 in the best eye in 2.3%. Factors significantly related to vision loss were age, duration of diabetes, glycated hemoglobin (HbA1c), and level of retinopathy. Mild nonproliferative retinopathy was found in 25.8% of the patients, moderate-severe nonproliferative retinopathy in 9.8% of the patients, and proliferative retinopathy in 10.6% of the patients. After adjustment for age, duration of diabetes, HbA1c, and albumin excretion rate, significant risk factors for moderate-severe nonproliferative retinopathy were blood pressure and triglyceride, and risk factors for proliferative retinopathy were triglyceride and fibrinogen. CONCLUSION: Vision loss is a common complication of patients with insulin-dependent diabetes, with diabetic retinopathy an important cause. Apart from poor glycemic control, several other potentially modifiable risk factors for retinopathy may be important, including elevated blood pressure, plasma triglyceride, and fibrinogen. In view of the possible barriers to the full implementation of strict glycemic control in this type of diabetes, additional strategies for the prevention and slowing of progression of retinopathy should be investigated, such as blood pressure and lipid lowering therapies.     

Mutations in purine nucleoside phosphorylase deficiency

PURPOSE: The aim of this study was to investigate the incidence of unexpected malignant uveal melanoma in the age of ultrasound diagnostics and to highlight the reasons for misdiagnosis. PATIENTS AND METHODS: All eyes were surgically removed and histologic examination was performed between 1981 and 1995. The eyes were investigated for the incidence of uveal melanoma, and the history of the unexpected malignant melanoma of the uvea or ciliary body highlighted. RESULTS: 225 (18.7%) eyes with malignant melanoma out of 2583 enucleated eyes were found. Eight (3.6%) of 225 were clinically unexpected. The clinical misdiagnoses were secondary angle closure or open angle glaucoma (6), retinal detachment (5), iritis (1), scleritis (1), cataract (4) and an intraocular mass that was believed to be a metastasis of a colon carcinoma. Seven of eight eyes were blind, and one eye had light perception only. The longest follow up before enucleation was 13 years. On three eyes diagnostic ultrasound was reportedly performed without specific diagnosis of uveal melanoma. Surgery was performed on four eyes for reasons of uncontrollable intraocular pressure or retinal detachment up to five years before enucleation. Histologic diagnoses were 3 epitheloid-type, 2 spindel-type and 3 necrotic melanoma of the uvea. Four eyes showed scleral invasion by tumor cells and one eye an invasion into the episcleral space. CONCLUSIONS: Even today the rate of unexpected uveal melanoma, according to our study is 3.6%. Therefore, all blind eyes without visualisation of the posterior pole should be examined with ultrasound in order to diagnose an uveal melanoma prior to enucleation.     

Repair of cornea-sclera defect by autogenous sclera graft from the same eye

In order to rescue the serious cornea-sclera defect, normal piece of a sclera from the damaged eye was used to serve as a donor material to repair the cornea-sclera defect. Eighteen cases were treated by transplantation of sclera graft with the operation to decompress the intra-ocular tension and to perform an artificial pupil from 1979 to 1994. Because the ocular-store seriously lacks in mostly internal locality, in the 18 cases, laceration of avulsive in 5 cases, severe corneal fistula complicated to other corneal diseases in 8 cases, locolized staphyloma of aornea in 2, laceration of sclera fistula in 1. The resulte were: The repairs were all healed up in an average of 20 days. The tension returned to normal and the vision was improved. The scleral graft was fused with the cornea, and the white area form the graft tended to reduce in size gradually with increase in transparency. There was no sign of iritis and rejection reaction. Follow-up of 3 to 36 months showed that the grafting operation was simple and an easy method, at the same time, once gained effect if would prevent or cure blindness.     

T-cell receptor V beta-specific expansions in children from HIV-infected mothers

This paper present a tonometer incorporated in a contact lens, which allows simultaneous measurement of intraocular pressure and performance ophthalmoscopy. The tonometer can record the pulse curve continuously, which can give us an indication of any circulatory problem. The device is therefore expected to yield additional information useful for the diagnosis of early glaucoma. Te device has three force sensors built in, which allow continuous measurement of the force exerted on the eye surface by the contact lens. The force of the contact lens on the eye can be altered and makes the adjustment of different eye pressures possible. These induced changes of the eye pressure and their influence on the fundus can be checked. We have taken some measurements on enucleated human eyes to compare our device with a Statham tansducer in the vitreous. We found a good correlation. We are currently taking measurements in volunteers. The clinical relevance of these observations and measurements will be examined in a future study.     

The lacrimal drainage system: pressure changes in the canaliculus

In order for tears to be removed from the eye, pressure gradients must be created in the ducts which lead to the nose. Blinking is only one of a number of mechanisms potentially capable of doing this. Pressure in the lacrimal canaliculus was recorded during voluntary blinks, tight squeezing of the lids, eye movements, and pressure changes in the nose. The results show that all of these produce pressure changes in the canaliculus.     

Neuroleptanalgesia for intra-ocular surgery: experience in a developing country

A technique of neuroleptanalgesia is described for effective and reliable sedation during intra-ocular surgery under local analgesia. The absence of side effects using modified neuroleptanalgesia was of particular value in a situation in a developing country in which large numbers of patients had to be handled in a comparatively short period of time.