Vitreous Hemorrhage

The incidence of spontaneous vitreous hemorrhage is approximately 7 cases per 100,000 population. Proliferative diabetic retinopathy (32%), retinal tear (30%), proliferative retinopathy after retinal vein occlusion (11%) and posterior vitreous detachment without retinal tear (8%) are the most common causes of spontaneous vitreous hemorrhage. Vitreous hemorrhage can be caused by the pathologic mechanisms of disruption of normal retinal vessels, bleeding from diseased retinal vessels or abnormal new vessels, and extension of hemorrhage through the retina from other sources. Hemorrhage into the vitreous gel results in rapid clot formation and is followed by slow clearance of approximately 1% per day. The cellular response to vitreous hemorrhage is unusual with regard to hemorrhage in any tissue outside the vitreous cavity and has been compared to a "low-turnover" granuloma. Unique clinicopathologic features of long-standing vitreous hemorrhage include cholesterolosis bulbi (synchysis scintillans), hemoglobin spherulosis, and vitreous cylinders. Complications of nonclearing vitreous hemorrhage are hemosiderosis bulbi and glaucoma. Ghost cell glaucoma, hemolytic glaucoma, and hemosiderotic glaucoma may result from vitreous hemorrhage. The established treatment option for nonclearing vitreous hemorrhage is pars plana vitrectomy. Experimental nonsurgical treatment options involve improvement of physiologic clearance mechanisms in order to accelerate fibrinolysis, liquefaction, hemolysis and phagocytosis.     

Molecular evidence for the early history of living amphibians

PURPOSE: To evaluate the feasibility of introducing exogenous genes and phosphorothioate oligonucleotides into the anterior chamber tissues of rats and monkeys using the authors' fusogenic liposomes. METHODS: Hemagglutinating virus of Japan liposomes containing LacZ DNA-high-mobility group 1 complexes or fluorescein isothiocyanate (FITC)-labeled phosphorothioate oligonucleotides were prepared and injected into the anterior chambers of rats (3 microliters) and rhesus monkeys (30 microliters). The expression of LacZ DNA was visualized histochemically by beta-Galactosidase assay and was followed for as long as 60 days in rats and 30 days in monkeys. FITC-labeled phosphorothioate oligonucleotides were observed by fluorescence microscopy for as long as 14 days in rats and 7 days in monkeys. RESULTS: Injection of LacZ DNA-high-mobility group 1 complexes encapsulated in hemagglutinating virus of Japan liposomes resulted in blue staining in the trabecular meshwork and iris-ciliary body of rats and selectively in the trabecular meshwork of monkeys at the concentrations used. This LacZ expression lasted for as long as 14 days after injection in both animals. Phosphorothioate oligonucleotides (3 microM) also were introduced into the rat trabecular meshwork and iris-ciliary body and into the primate trabecular meshwork when encapsulated in hemagglutinating virus of Japan liposomes, although the injection of naked FITC-labeled phosphorothioate oligonucleotides at the same concentration resulted in little fluorescence in any anterior chamber tissue. CONCLUSIONS: This study shows that the use of hemagglutinating virus of Japan liposomes can transfer LacZ DNA and phosphorothioate oligonucleotides to adult rat and primate trabecular meshwork. This system may enable progress in glaucoma research and in the development of nonviral somatic gene therapy of the trabecular meshwork to treat glaucoma.     

Fuchs' heterochromic cyclitis. Clinico-histopathologic findings of nodular iritis

BACKGROUND: Despite the fact that in 1906 Fuchs described the first case of Fuchs' heterochromic cyclitis histopathologic reports of this disease are still rare. PATIENT AND METHODS: A clinicopathologic correlation of findings in Fuchs' heterochromic cyclitis is presented. In a patient with a history of Fuchs' heterochromic cyclitis for 15 years a secondary open-angle glaucoma developed. Several operations were performed including intracapsular cataract extraction, goniotrephanation (Elliot) and repeated cyclocryotherapy. The eye finally had to be enucleated because of a painful absolute glaucoma. RESULTS: Clinical hallmarks of Fuchs' heterochromic cyclitis in this patient include cataract formation and secondary open-angle glaucoma. Histology revealed accumulations of mononuclear cells on the surface of the iris and the corneal endothelium, as well as sparse inflammatory cells within the anterior chamber. The trabecular meshwork showed an infiltration of mononuclear inflammatory cells, chiefly lymphocytes and plasma cells. DISCUSSION: Accumulations of mononuclear cells on the surface of the iris, which histopathologically have not been described before, could represent the clinicopathologic correlate of Koeppe and Busacca nodules. Histologically, the cell deposits on the iris were similar to those in the anterior chamber and to larger corneal precipitates. It is supposed that the cells, which originally emigrated from the iris vessels, may form primary cell deposits on the iris surface or endothelium. Such iris precipitates may also be secondarily attracted by the endothelium in whole. An autoimmune-reaction against the corneal endothelium may be the underlying reason.     

Immediate assessment of fine needle aspiration cytology of lung

BACKGROUND AND OBJECTIVE: To report five cases of vitreous opacification in phacolytic glaucoma (PG). PATIENTS AND METHODS: The records of patients with PG were retrospectively reviewed. A total of 135 eyes with PG were studied to determine the presence of vitreous opacification. RESULTS: Five eyes with PG demonstrated opacification of the vitreous, which was first noted at surgery and confirmed postoperatively. All patients had had symptoms of PG for 7 days or more (mean +/- SD, 10.6 +/- 2.4 days) before they sought medical attention. Three eyes had a hypopyon on preoperative examination; two of these eyes showed refractile crystals in the anterior chamber. The opacities resolved spontaneously in all five eyes over a period of 12 weeks and interfered with visual activity only in the immediate postoperative period. CONCLUSION: Vitreous opacification in PG is a self-limited process that may not require surgical intervention unless more rapid visual rehabilitation is desired. The vitreous opacification probably results from an exaggeration of the process causing the anterior chamber reaction.     

Some aspects of congenital glaucoma (author's transl)

The following paper on certain aspects of congenital glaucoma was read at a meeting for advanced medical education. Particular emphasis was placed on a review of the theories and concepts dealing with pathogenetic factors of congenital glaucoma. Two main concepts appeared to be most prominent in past and current literature: 1. The concept of a membrane obstructing the chamber angle, 2. underdevelopment or malformation of all or some structure of the chamber angle region. In order to clarify the above mentioned concepts, three stages of development of normal human chamber angles were demonstrated by light and electronmicroscopy. Aspects of surgical treatment of congenital glaucoma were discussed. Light and electronmicroscopic findings in some trabeculectomy specimens were shown. In eyes which underwent repeated surgery, marked scar tissue was seen in the area of trabecular meshwork, thus obliterating aqueous pathways. In those cases, an excision of trabecular tissue (trabeculectomy) was recommended rather than destruction of remaining trabecular tissue (trabeculotomy).     

Gorham disease with prominent pleuropulmonary manifestation

PURPOSE: Examination of the efficacy of pore formation in the trabecular meshwork by excimer laser to reduce intraocular pressure in glaucoma eyes. PATIENTS AND METHODS: In 27 consecutive eyes with chronic simple glaucoma and 8 eyes with low-tension glaucoma, 3 to 5 pores were ablated into the trabecular meshwork with an excimer laser (308 nm, 35-55 mJ/mm2), creating an open communication between the anterior chamber and Schlemm's canal. This was accomplished by the use of a 400-micron quartz fiber and a modified Trokel goniolens. All patients were candidates for trabeculectomy because visual fields continued to deteriorate in spite of maximum medication. RESULTS: Intraocular pressure was median reduced by 7 mmHg (range 10.5 to 1.5 mmHg) in 22 of 27 eyes with chronic simple glaucoma over a median follow-up of 7 months. In 12 eyes, further medication has to be continued, yet at a lower dose and lower level of intraocular pressure. In five eyes therapy failed. In three of these eyes, a trabeculectomy had to be performed. In eight eyes with low-tension glaucoma, a median reduction of intraocular pressure of 5 mmHg (range 10 to 0.5 mmHg) was accomplished over a median follow-up of 7 months. In five of these eyes, further medication on a lower level was continued. No further surgery was necessary. CONCLUSIONS: With the microsurgical method of pinpoint ablation of the trabecular meshwork by excimer laser, intraocular pressure was reduced in 30 of 35 eyes over a median follow-up period of 7 months. These results encourage us to continue the development of this procedure, perhaps with a microendoscope. The minimal trauma to the eye of this procedure leaves all other options of surgery open.     

Spectrum of trabecular pigmentation in open-angle glaucoma: a clinicopathologic study

In eight patients with chronic open-angle glaucoma and associated trabecular pigmentation, trabeculectomy and peripheral iridectomy specimens were studied by light and electron microscopy. Clinically, three patients displayed signs of classic pigmentary glaucoma (Group 1). In the other cases chronic open-angle glaucoma was associated with varying degrees of expression of the full pigmentary glaucoma syndrome (Group 2). Histopathologic examination of peripheral iridectomy and trabeculectomy specimens from Group 1 showed: (1) marked focal atrophy and hypopigmentation of iris pigmented epithelium with an apparent delay in melanogenesis. The dilator muscle was thickened except for occasional thinned areas. (2) The trabeculectomy specimens revealed excessive amounts of pigmented epithelial melanosomes and moderate accumulation of electron-dense basement membrane-like material in the juxtacanalicular meshwork. Similar specimens from Group 2 showed: (1) minimal hypopigmentation of the iris pigmented epithelium with normal melanogenesis. The iris stroma and dilator muscle were normal. (2) Trabeculectomy specimens displayed excessive electron-dense basement membrane-like material in the juxtacanalicular meshwork and minimal to moderate accumulation of melanosomes.     

Laser therapy and angle-closure glaucoma

All forms of primary and secondary pupillary block angle-closure glaucoma result in an increased resistance to aqueous flow at the pupil margin. As the pressure in the posterior chamber increases, the iris bows forward until the trabecular meshwork is occluded and aqueous outflow is interrupted. Most pupillary block glaucomas are ocular urgencies and require immediate medical therapy to lower intraocular pressure. The definitive treatment for pupillary block is laser therapy. By creating a hole in the iris, the pressure in the anterior and posterior chambers is equalized, allowing the angle to remain open. This discussion reviews the indications, contraindications, and techniques involved in the laser management of angle-closure glaucomas.     

High-level expression of a viscotoxin in Arabidopsis thaliana gives enhanced resistance against Plasmodiophora brassicae

PURPOSE: Primary open-angle glaucoma (POAG) is associated with a decreased content of hyaluronan in the trabecular meshwork and in the juxtacanalicular connective tissue. In this study, the authors examined selected regions of the anterior segment to localize and determine the content of CD44H, a transmembrane multifunctional glycoprotein and the principal receptor of hyaluronan. METHODS: Sections of ethanol-fixed anterior segments of six POAG and six normal postmortem eyes were analyzed by immunostaining with and without the nonionic detergent Triton X-100, using the CD44H monoclonal antibody, and the avidin/biotin complex. They were visualized by Vector VIP substrate and were quantitated by computer-aided color image analysis. RESULTS: CD44H was expressed in all regions. Statistically significant decreased content of CD44H was observed in the POAG regions compared with normal regions--ciliary muscle (P < 0.001), ciliary stroma (P < 0.001), anterior iris (P < 0.05), iris root (P < 0.05), and trabecular meshwork (P < 0.05)--and in a subgroup of nonlaser POAG juxtacanalicular connective tissue (P < 0.05) and trabecular meshwork (P < 0.01). In sections treated with Triton X-100 a further increase in immunostaining was observed in normal eyes. As evidenced by scattergram plots of the ciliary body stroma region of the change in the optical density of CD44H between pretreatment with Triton X-100 and without Triton X-100 (y axis) versus the optical density of CD44H without Triton X-100 (x axis), individual cases of POAG were separated from normals. CONCLUSIONS: These results indicate that CD44H may represent a marker of POAG and an etiologic factor in the POAG disease process.     

Localization and possible gene expression of proteoglycan decorin in the trabecular meshwork

It is known that trabecular meshwork cells produce proteoglycans and that local production may be associated with aqueous outflow resistance. In an attempt to identify intraocular production of proteoglycan decorin in the anterior chamber angle of mammalian eyes, we conducted a Northern blot analysis and immunohistochemical studies. Northern blot analysis suggested gene expression of proteoglycan decorin in trabecular meshwork cells. Also, immunohistochemical studies using anti-decorin antibody demonstrated decorin-like immunoreactivity in the trabecular meshwork and around the Schlemm's canal. Our data demonstrate the presence of proteoglycan decorin in the outflow pathway, suggesting that decorin is a component of extracellular matrices in these regions and may be associated with outflow resistance.     

The cyclopentolate provocative test in suspected or untreated open-angle glaucoma. III. The significane of pigment for the result of the cyclopentolate provocative test in suspected or untreated open-angle glaucoma

Significant elevations of IOP, i. e. responses, occurred in eyes with suspected or untreated open-angle glaucoma during the mydriasis test with 1% cyclopentolate (CPT). The possible role of pigment in the IOP elevations seen in the responders was studied. Pigment was liberated in the aqueous, sometimes very profusely, in 88 (31.9%) of 276 eyes during CPT. The maximal IOP elevations, ad 20 mmHg, were seen in just these eyes. They were eyes with capsular or pigmentary glaucoma or eyes in which exceptionally heavy pigment was demonstrated in the chamber angle for other reasons. There was a statistically significant correlation between pigment liberation and IOP elevation during CPT. Evidently profuse pigment liberation may have caused transient blocking of the trabecular meshwork, obstruction of aqueous outflow and elevation of IOP. Liberation of pigment in the aqueous during CPT was statistically highly significantly more profuse in eyes with pseudoexfoliation than in eyes without pseudoexfoliation. An equally significant correlation with demonstrated between the grade of chamber angle pigmentation and the degree of pigment liberation during CPT. The significance of pigment for IOP elevation was seen also in the statistically highly significantly more profuse pigmentation of the chamber angle in the responder than in the non-responder eyes.     

Microvascular injection studies in rubeosis iridis and neovascular glaucoma

Microvascular silicone injection, tissue clearing, and histologic examination were used to demonstrate the origin, distribution, and interconnections of newly formed iris and chamber angle blood vessels in four eyes with rubeosis iridis and neovascular glaucoma associated with diabetic retinopathy and central retinal vessel occlusion. The newly formed iris vessels that formed either a tight, evenly distributed (diabetic) or loose, irregularly distributed (central vessel occlusion) network in the iris originated from the normal iris arteries that were branches of either the major arterial circle or of the perforating branches of the anterior ciliary arteries, and drained into the normal iris and ciliary body veins and occasionally into the paralimbal episcleral veins. These newly formed iris vessels appeared to shunt intravascular fluid from arteries to veins. The newly formed anterior chamber angle vessels that formed tufts and arcades at the trabecular meshwork also originated from the roots of the iris arteries and the ciliary body arteries and connected with the peripheral neovascular iris network. In addition, the circumferentially running angle vessels that coursed within the trabecular meshwork branched into and coursed within a fibrosed Schlemm's canal and into two of its intrascleral collector channels. No open communication between these newly formed vessels and the Schlemm's canal-aqueous outflow system was seen.     

Prophylactic Nd:YAG-laser iridotomy versus surgical iridectomy: a randomized, prospective study

Both surgical iridectomy and YAG-laser iridotomy have been shown to prevent angle-closure glaucoma. However, it remains unknown as to which procedure is superior. We therefore conducted a prospective randomized study, which compared the effect of the two methods on visual acuity, intraocular pressure, endothelial cell density, depth of the anterior chamber, and iris configuration as well as acceptance by the patients. A total of 30 patients, who were treated for acute angle-closure glaucoma in one eye, were subjected to either surgical iridectomy or Nd:YAG-laser iridotomy in the other eye according to a randomized protocol. All patients were followed for 12 months by examination at the 1st, 6th, and 12th month post treatment. No significant difference between the two treatments was found regarding visual acuity or intraocular pressure. The peripheral anterior chamber increased in depth following both methods, whereas the central depth of the anterior chamber was unaffected. A better gonioscopic visibility of the trabecular meshwork resulted from the increased width of the chamber angle. Whereas the number of endothelial cells remained constant in the patients treated with laser iridotomy, a small decrease was observed in the group of patients who underwent iridectomy (-7.2% after 12 months; difference not significant). The subjective acceptance by the patients was better in the group treated with laser iridotomy. We conclude that the two methods are equivalent with regard to intraocular pressure and visual acuity. The constant number of endothelial cells and the better acceptance by the patients suggest Nd:YAG-laser iridotomy to be the preferable method for prophylaxis of acute angle-closure glaucoma.     

Ultrastructural changes in the trabecular meshwork of human eyes treated with corticosteroids

OBJECTIVES: To study the ultrastructure of the trabecular meshwork in human eyes with corticosteroid-induced glaucoma and to determine whether the changes noted also occur in the eyes of patients with primary open-angle glaucoma (POAG) who have been treated with corticosteroids. METHODS: The trabecular meshwork from 5 patients in whom corticosteroid-induced glaucoma was diagnosed and from 6 patients with POAG who had been treated with systemic or topical corticosteroids for months to years was investigated with light and electron microscopy. None of the eyes with POAG were considered to have corticosteroid-induced elevation of the intraocular pressure. RESULTS: Eyes with corticosteroid-induced glaucoma had the accumulation of extracellular material distinct from the sheath-derived plaques typical of POAG. A finger-printlike arranged material resembling basement membranes (FBM material), considered characteristic of corticosteroid-induced glaucoma, was found in all eyes with corticosteroid-induced glaucoma. In addition, an abnormal accumulation of densely packed, fine fibrils immediately beneath the inner wall endothelium of Schlemm's canal was present. The findings were similar among patients receiving topical or systemic treatment and among patients of different ages. In the eyes from donors with POAG who had been treated with corticosteroids, the fine fibrillar material and FBM material were present in small amounts in 3 of 6 donors and were not found in the other 3 donors. CONCLUSIONS: The extracellular material that accumulates in eyes with corticosteroid-induced glaucoma differs from that seen in eyes with POAG. Eyes with POAG exposed to long-term corticosteroid treatment did not all respond with the formation of the abnormal extracellular materials characteristic of those found in eyes with corticosteroid-induced glaucoma.     

A survey of respiratory and dermatological disease in the chrome plating industry in the West Midlands, UK

OBJECTIVE: To determine whether the clinical use of 5-fluorouracil (5-FU) may have any toxic effects on trabecular meshwork cells. METHODS: Bovine trabecular meshwork (BTM) cells were cultured in vitro. The effects of 5-FU on BTM cells concerning cellular morphology, ultrastructure, vitality and phagocytosis were observed. RESULT: The safe dosage of 5-FU on BTM cell was 1 x 10-6g.ml-1. CONCLUSION: Based on the pharmacokinetic data in the rabbit anterior chamber, it is suggested that the 5-FU dosage of conventional use cause no injury to human trabecular meshwork cells.     

Effect of topical anti-inflammatory treatment on the outcome of laser trabeculoplasty. The Fluorometholone-Laser Trabeculoplasty Study Group

PURPOSE: We investigated the effect of anti-inflammatory treatment on the outcome of argon laser trabeculoplasty. METHODS: In this multicenter, double-masked, randomized, placebo-controlled, parallel comparison study, 140 chronic open-angle glaucoma patients received either 0.25% fluorometholone or vehicle four times a day unilaterally, beginning 24 hours before and continuing one week after argon laser trabeculoplasty. The laser surgeon placed 50 to 60 burns over the inferior 180 degrees of the trabecular meshwork. The patients were followed up frequently for five weeks after the procedure. RESULTS: Following argon laser trabeculoplasty, signs of anterior chamber inflammation were significantly lower in the fluorometholone group. However, there was no significant difference between the fluorometholone and the vehicle groups in the incidence of increased intraocular pressure in the immediate post-argon laser trabeculoplasty period. Intraocular pressure decreased significantly in both groups from day 1 throughout the follow-up period. A significant between-group difference in intraocular pressure decrease was found only at week 5 (7.83 +/- 6.27 [S.D.] mm Hg for the fluorometholone group vs 6.63 +/- 5.79 mm Hg for the vehicle group, P = .046). No drug-related clinically significant adverse events were observed. CONCLUSIONS: Use of fluorometholone is effective in attenuating inflammation and has no clinically significant impact on the outcome of argon laser trabeculoplasty or on the incidence of intraocular pressure spikes during the immediate post-argon laser trabeculoplasty period.     

Functional morphology of the trabecular meshwork in primate eyes

The trabecular meshwork forms most of the resistance to aqueous humor outflow needed for maintenance of a pressure gradient between intraocular pressure of approximately 17 mmHg and venous pressure of approximately 10 mmHg. The composition of the extracellular material in the subendothelial or cribriform layer seems to be mainly responsible for outflow resistance. The aqueous humor pathways through the subendothelial layer can be influenced by ciliary muscle contraction and presumably also by contractile elements recently found both in trabecular meshwork and scleral spur. Pharmacologically induced disconnection of inner wall and cribriform cells leads to wash out of extracellular material through breaks of the endothelial lining of Schlemm's canal and to increase of outflow facility. In glaucomatous eyes the resistance to aqueous humor outflow is increased due to an increase in different forms of extracellular material deposited within the cribriform layer. The amount of this newly developed extracellular material is correlated with loss of axons in the optic nerve, indicating that a common factor is responsible for both changes. To investigate the effect of various factors on the biology of trabecular cells monolayer cultures derived from cribriform and corneoscleral trabecular meshwork have been established. The two cell lines can be differentiated because cribriform cells in vivo as in vitro stain for alphabeta-crystallin whereas the corneoscleral cells remain unstained. The effect of TGFbeta, a growth factor increased in aqueous humor of glaucomatous eyes and glycocorticoids on trabecular meshwork cells show typical changes in formation of extracellular matrix components and of stress proteins. Dexamethasone and oxidative damage also lead to increase of trabecular meshwork inducible glucocorticoid response (TIGR) protein. A mutation of the TIGR-gene family has recently been found in families with juvenile and chronic simple glaucoma. Future research has to clarify the significance of these genetic factors for the pathophysiology of glaucoma and the role of trabecular cell activity in this respect.     

Renal microscopic polyarteritis replaced by pericarditis with episodic increases in MPO-ANCA in a patient with systemic lupus erythematosus

BACKGROUND: An abnormally increased presence of type VI collagen has been shown in the lamina cribrosa of patients with primary and secondary glaucoma. This study was undertaken to investigate the pattern of type VI collagen within the aqueous outflow structures of glaucoma patients. METHODS: Trabecular meshwork samples of eight normal donor eyes and trabeculectomy specimens of 21 patients with different types of glaucoma were processed for either cryo-sectioning or for paraffin embedding. Immunohistochemical staining was conducted by use of polyclonal rabbit antibodies against human collagen type VI. RESULTS: Immunoreactivity for type VI collagen was evident in the cores of all trabecular beams. The strongest staining was detected in the uveal region of the human trabecular meshwork. Immunohistochemical labelling for type VI collagen was not more pronounced in the aqueous outflow structures of glaucoma patients than in normal eyes. CONCLUSION: Collagen type VI is a ubiquitous structural component of the extracellular matrix in the human trabecular meshwork. However, type VI collagen does not appear to be of greater importance for the increased trabecular outflow resistance in glaucoma patients than in normal eyes.     

Implementing the SF-12 in an inner-city clinic: the importance of providing help

The size, form and charge of the stabilized water clusters present in the aqueous humour of the mammalian eye influence the facility for aqueous flow through the pupillary ball valve and through the trabecular meshwork. The properties of the clusters can be influenced in many different ways, all of which can influence the anterior and posterior chamber intraocular pressures as well as the uveoscleral outflow.     

The persistent trigeminal artery in vascular brain diseases]

Symptoms of primary open-angle glaucoma can be divided into main and accessory and risk factors. The main symptoms are increased intraocular pressure and changes in the visual field and optic disk characteristic of glaucoma. The accessory symptoms and risk factors are a family history of glaucoma, diabetes mellitus, myopia, poor discharge of aqueous humor, pseudoexfoliative syndrome, elements of goniodysgenesis and depositions of pigmented granules in the anterior chamber corner, and asymmetric intraocular pressure, humor discharge, and extent of optic disk excavation. Causes and diagnosis of nonglaucomatous hypertension and normal-pressure glaucoma are discussed.