The effects of California Proposition 187 on ophthalmology clinic utilization at an inner-city urban hospital

PURPOSE

To determine the effect on ophthalmology clinic utilization at a major public inner-city hospital of California Proposition 187 and the debate surrounding its passage. Proposition 187 was a statewide referendum passed by 63% of the electorate in the November 1994 election that would restrict social services to undocumented immigrants and require providers to report them to immigration authorities.

METHODS

The ophthalmology clinic volume at the Los Angeles County/ University of Southern California Medical Center was analyzed from October 1 to December 31, 1993 and 1994.

RESULTS

New walk-in patients significantly decreased (P < 0.001) for a 2-month period around the election, but returned to baseline levels in December 1994. The new patient cancellation and no show rate was not affected. No change in return patient behavior was noted for general and specialty clinics.

CONCLUSIONS

Proposition 187 may have caused a statistically significant decrease in new walk-ins to the ophthalmology clinics during a 2-month period surround the November 1994 election, but it had no measurable effect on other indicators of utilization. In addition, utilization rates returned to baseline after the implementation of Proposition 187 was stayed by the judicial system, and concern that providers would be required to report undocumented immigrants to authorities was alleviated.

Laser suture lysis after mitomycin C trabeculectomy

PURPOSE

To evaluate the timing, efficacy, and complications of laser suture lysis (LSL) after mitomycin C trabeculectomy in patients with glaucoma at high risk for failure of filtering surgery.

METHODS

The authors retrospectively reviewed the charts of 62 consecutive patients who underwent a total of 66 sessions of LSL after trabeculectomy with mitomycin C.

RESULTS

The interval from surgery to LSL ranged from 2 to 65 days (mean +/- standard deviation, 17.9 +/- 14.9 days). The average intraocular pressure (IOP) reduction after LSL was 11.9 +/- 8.9 mmHg (range, 3-40 mmHg). A longer interval to LSL was correlated with a lesser degree of pressure reduction (P=0.0004, Wilcoxon rank-sum test). After LSL, hypotony developed in 13 (21%) patients (IOP < 6 mmHg on 2 consecutive measurements at least 24 hours apart). This resolved spontaneously after 7 to 304 days (104.1 +/- 109.1 days) in 12 (92%) of the 13 patients. Life-table success rates (success defined as 6 mmHg </= final IOP </= 21 mmHg) for the hypotony and no hypotony groups were 100% and 86% (at 6 months) and 96% and 86% (at 12 months), respectively. The final visual acuity worsened in a significantly greater percentage of patients in the hypotony group (46%) compared with the no-hypotony group (18%) (P = 0.06), Fisher's exact test).

CONCLUSIONS

Laser suture lysis is safe and effective in augmenting aqueous filtration after mitomycin C trabeculectomy. A longer time interval between surgery and LSL may result in both a lesser degree of IOP reduction and a lower incidence of subsequent hypotony.

The role of smears, cultures, and antibiotic sensitivity testing in the management of suspected infectious keratitis

PURPOSE

To examine the role of routine smears, cultures, and antibiotic sensitivity testing in the treatment of suspected infectious keratitis.

METHODS

A retrospective chart and laboratory data review was performed for 81 consecutive patients seen in the Los Angeles County/University of Southern California Department of Ophthalmology between June 1991 and December 1993 with a primary diagnosis of community-acquired infectious keratitis. No patients were treated with antibiotics before evaluation in the author's department, and all underwent corneal scrapings for gram-stain and bacterial, fungal, and mycobacterium cultures. Ulcers were classified as moderate or severe. All initially were treated as inpatients with a regimen including fortified cefazolin and a fortified aminoglycoside.

RESULTS

Of 81 patients, 74 ulcers were either culture- negative (n=18) or grew bacteria (n=56). Fungal infection was suggested in seven patients. Of the nonfungal ulcers, 33 were classified as moderate, and 41 as severe; all moderate ulcers improved without requiring a modification in antibiotic treatment, whereas 3 severe ulcers required a change in treatment.

CONCLUSION

Most community-acquired bacterial ulcers resolve with broad spectrum empiric therapy. Alternatives to universal culture and sensitivity testing that might be considered include selectively performing cultures for more severe or suspected non-bacterial ulcers or routinely obtaining cultures in all cases, but pursuing identification and sensitivity studies only when those data are required for therapy modification.

The importance of initial management in the treatment of severe infectious corneal ulcers

PURPOSE

To identify factors that influence the outcome of patients with severe infectious corneal ulcers.

METHOD

A retrospective review was performed of the hospital records of all such patients admitted to the Doheny Eye Hospital during a 30 month period. Outcome variables examined were change in visual acuity, duration of hospitalization, hospital charges, and percentage of patients who required penetrating keratoplasty.

RESULTS

Sixty-two ulcers were included. An organism was identified and antibiotic sensitivities established in 52 patients (84%). Inpatient therapy involved a combination of fortified aminoglycoside and cephalosporin antibiotics in 39 patients (63%) and was found to be appropriate on the basis of sensitivity studies in 49 (94%) of 52 patients. Inappropriate initial treatment was related to increased hospital charge (P = 0.024) as well as increased risk of penetrating keratoplasty (P = 0.001).

CONCLUSIONS

Appropriate initial therapy is most critical in the course of serious corneal ulcers, and aggressive, broad-spectrum antibiotic coverage is advocated.

Estimating eye care workforce supply and requirements

PURPOSE

To estimate the workforce supply and requirements for eye care in the United States.

METHODS

Three models were constructed for analysis: supply of providers, public health need for eye care, and demand (utilization) for eye care. Ophthalmologists, other physicians, and optometrists were included in the models. Public health need was determined by applying condition-specific prevalence and incidence rates from population-based and other epidemiologic studies. Demand was determined by use of national databases, such as the National Ambulatory Care Survey, National Hospital Discharge Survey, and Medicare Part B. Time requirements for care were obtained through a stratified sample survey of the membership of the American Academy of Ophthalmology.

RESULTS

Under modeling assumptions that use a work-time ratio of one between optometrists and ophthalmologists and between specialist and generalist ophthalmologists, a significant excess of eye care providers exists relative to both public health need and demand. Changes in the work-time ratio, work-hours per year per provider, care patterns for the same condition, or other factors could significantly reduce or eliminate the surplus relative to need.

CONCLUSION

If optometrists are the preferred primary eye care provider, ophthalmologists would be in excess under all demand scenarios and all need scenarios where the optometrist to ophthalmologist work-time ratio is greater than 0.6. No excess of ophthalmologists would exist if ophthalmologists are the preferred primary eye care provider. Data on the appropriate work time ratio will help refine estimates of the imbalance between supply and requirements.

Tissue plasminogen activator and glaucoma drainage implants

PURPOSE

The tube lumen of a glaucoma drainage implant is prone to occlusion by a blood or fibrin clot due to its small caliber, relatively low flow rate, and the plasmoid nature of the aqueous humor passing through it in the early postoperative period. The use of tissue plasminogen activator in the management of drainage tube obstruction is described herein.

METHODS

Two cases of drainage tube obstruction in patients with neovascular glaucoma treated with an intracameral injection of tissue plasminogen activator are reported.

RESULTS

Resolution of tube obstruction following tissue plasminogen activator administration with spontaneous lowering of the intraocular pressure and bleb formation was achieved in both cases. Differentiation of tube obstruction from other causes of elevated intraocular pressure following installation of glaucoma drainage devices is discussed.

CONCLUSION

The intracameral injection of tissue plasminogen activator may relieve drainage tube obstruction secondary to a blood or fibrin clot, even in the absence of any visible clot covering the proximal tube ostium or within the anterior chamber portion of the tube. This approach should be considered, in selected cases, prior to more invasive surgical revision.

Visual recovery after trabeculectomy

PURPOSE

We retrospectively analyzed 155 eyes of 155 patients who underwent trabeculectomy with and without antimetabolites to determine the time for recovery of visual acuity postoperatively and to determine factors associated with delayed recovery of visual acuity and visual loss.

METHODS

Factors examined included age, race, preoperative visual field grading. Humphrey Field Analyzer's indices (mean deviation and corrected pattern standard deviation), optic nerve cup-to-disk ratio, antimetabolite use, postoperative complications, and postoperative hypotony. The mean age of the patient was 63.6 +/- 15.7 years. Mean follow-up was 14.4 +/- 8.5 months (range 6-30).

RESULTS

One hundred forty-four patients (93%) regained their preoperative visual acuity, and 11 patients (7%) sustained visual loss. For the 144 patients who regained visual acuity, recovery time ranged between 1 and 244 days (median 6); recovery occurred before the second month in 128 patients (89%) and was delayed beyond 2 months in 16 patients (11%). Among the 60 primary open-angle glaucoma patients with preoperative visual acuity better than 20/200, those with delayed visual recovery had significantly worse preoperative visual field grades than did those with early recovery (p = 0.04). The preoperative Humphrey mean deviation was also higher (16.3 dB vs. 11.2 dB, p = 0.04). All 16 patients with delayed visual recovery also had postoperative hypotony (p = 0.01); this was transient (<2 weeks) in 12 patients and prolonged in four. In patients who failed to regain visual acuity, the visual loss did not correlate with any preoperative risk factors or hypotony, but these patients did have a higher incidence of postoperative complications (p = 0.05).

CONCLUSION

We conclude that patients with primary open-angle glaucoma who have advanced visual field defects are at greater risk of delayed visual recovery after trabeculectomy and that postoperative hypotony contributes to this delay.

Histomorphometric study in children with idiopathic nephrotic syndrome

From 1981 to 1987, renal specimens obtained from 91 children with idiopathic nephrotic syndrome were categorized into 5 histologic subgroups, according to the WHO classification. We analyzed differences in the ratios of the size of the mesangial stalks and attached capillary, including the Bowman's space between the capillary tufts (E), mesangial matrix (Mx), and approximate capillary lumens (E-Mx) to the whole glomerular area of these subgroups using the histomorphometer-IBAS. Focal segmental glomerulosclerosis with diffuse mesangial proliferation (FSGS + DP) had the largest matrix area (Mx/G > 0.5), and smallest capillary lumen size (E/G-Mx/G) (0.3474 +/- 0.0702). On the contrary, FSGS with minimal change (FSGS + MC) had the smallest mesangial matrix (Mx/G), 0.2834 +/- 0.07726, but preserved a larger capillary lumen (0.427 +/- 0.1215). The approximate size of capillary lumens, from the smallest to the largest, was in the following order: FSGS + DP, diffuse mesangial proliferative glomerulonephritis (DPGN), focal segmental proliferative glomerulonephritis (FSPGN), FSGS + MC and minimal change nephrotic syndrome (MCNS). The ratio of the total number of mesangial cells to the area of the whole glomerulus (MCN/G) derived from the light microscopic examination was parallel to the value of Mx/G obtained by the histomorphometric technique. In summary, we introduced the histomorphometric technique using the histomorphometer-IBAS for quantitative measurement of various areas in the glomeruli. The data derived from the system is compatible with those obtained by experienced nephrologists, suggesting that the histomorphometric technique is helpful in histopathology. It is hoped that this new methodology will be used more extensively in the near future.

A clinicopathological study of idiopathic nephrotic syndrome in children

This paper retrospectively examines the association of outcome with histological and clinical manifestations in 107 pediatric patients with idiopathic nephrotic syndrome (INS). At the time of renal biopsy, the patients were between 2 and 15 years of age. The interval from the onset of the disease to renal biopsy ranged from 1 to 156 months with a mean of 21 months. Continuous clinical follow-up was successfully conducted in 96 patients. The average duration of INS in these patients was 86.6 months (31 to 208 months). IgM deposition in the mesangium may play an important role in the pathogenesis of INS and our data showed that even in a minor glomerular abnormality (MCNS) subgroup, nearly half of the cases (42.9%) showed mesangial IgM deposition. However, the severity of hematuria, response to drug therapy with either steroids or cyclophosphamide, and the outcome, were not related to the presence or absence of IgM deposition, but were more closely associated with the type of histological category. The subgroup of patients with focal segmental glomerulosclerosis (FSGS) and diffuse mesangial proliferation (FSGS + DP) showed the most significant ultrastructural changes with positive mesangial IgM deposition (73.6%). The presence of IgM deposition in most of the patients in the subgroups with diffuse mesangial proliferative glomerulonephritis (DPGN) and FSGS + DP closely corresponded to the presence of electron-dense mesangial deposition. The FSGS + DP subgroup had a high incidence of denudation, vacuolization and detachment of podocytes, partial collapse of the glomerular basement membrane, and a very high incidence of resistance to steroid therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between visual acuity and functioning and well-being among diabetics

Given the enormous recent interest in functional capabilities related to vision, the goal of this study was to examine the relationship of standard clinical measures of vision (e.g. Snellen acuity) to functioning and well-being. The association between Snellen visual acuity, Amsler grid distortion and presence of diabetic retinopathy with self-reported functioning and well-being (SF-36) were examined in a sample of 327 diabetics from the Medical Outcomes Study (MOS). There was little or no correlation between Snellen visual acuity, Amsler grid distortion or diabetic retinopathy and functioning and well-being (i.e. SF-36 scales). Maximum product-moment correlation was 0.15 with worst eye visual acuity, 0.13 with best eye visual acuity, 0.08 with presence of retinopathy, and 0.10 with Amsler grid distortion. Analysis of variance revealed that visual acuity (both best and worst eye) was statistically related only to the physical function scale; no other exam measure was related to any other SF-36 scale score. Snellen visual acuity, Amsler distortion and diabetic retinopathy correlate weakly with patient self-reported functioning and well-being. Thus, the information provided by functioning and well-being measures is complementary to that of standard clinical measures of visual ability.

Experience with the Baerveldt glaucoma implant in treating neovascular glaucoma

PURPOSE

The authors present a retrospective study designed to assess the effectiveness of the Baerveldt glaucoma implant in controlling intraocular pressure (IOP) and maintaining visual function in eyes with neovascular glaucoma.

METHODS

The medical records of all 36 patients (36 eyes) who underwent Baerveldt glaucoma implantation for medically uncontrolled neovascular glaucoma between February 1991 and December 1992 were reviewed.

RESULTS

Eighteen patients received Model 350 implants, 16 received Model 500 implants, and 2 received Model 200 implants. The 12- and 18-month life-table success rates (success defined as 6 mmHg < or = final IOP < or = 21 mmHg without additional glaucoma surgery or devastating complication) were 79% and 56%, respectively. Visual acuity remained stable or improved in 10 (31%) patients. Postoperative complications included flat anterior chamber, serous choroidal detachment, and obstruction of the proximal tube tip with fibrovascular tissue, each of which occurred in four (11%) patients. Eleven (31%) patients lost light perception. There were no significant differences between the groups receiving the Model 350 and Model 500 implants with respect to life-table success rates, percentage of postoperative IOP reduction, or complication rates. Patients in the Model 500 implant group required significantly fewer antiglaucoma medications post-operatively, but also demonstrated a significantly greater mean visual acuity reduction. Better preoperative visual acuity and increased patient age were positively correlated with a successful outcome.

CONCLUSIONS

Baerveldt implantation is effective in controlling IOP elevation associated with neovascular glaucoma. Postoperative visual loss, despite adequate IOP control, is common. Young patient age and poorer preoperative visual acuity are significant predictors of surgical failure.

Regional and diurnal studies of melatonin and melatonin binding sites in the duck gastro-intestinal tract

Since melatonin and putative melatonin receptors can be detected in a variety of peripheral tissues, direct endocrine and paracrine actions of melatonin on the physiological functions of different organ systems in response to internal and external stimuli probably exist. As an extension of our earlier work on the pharmacological characterization of 2-[125I]iodomelatonin binding sites in the duck jejunum, the regional and diurnal variations of melatonin and putative melatonin receptors of different segments of the duck gastro-intestinal tract were studied in an attempt to understand the role of melatonin in the physiology of the digestive system. Although no significant effects of diurnal variation and pinealectomy on the regional distribution of melatonin were observed, significant regional variations of melatonin levels were detected with decreasing levels as follows: colon > oesophagus, caecum > duodenum, jejunum > ileum. The densities of melatonin binding sites showed a significant variation between different intestinal regions at either mid-light or mid-dark, with the following descending order: ileum, jejunum > duodenum, colon > caecum > oesophagus. Analysis of the distribution of melatonin binding sites in the wall of the intestine revealed maximal binding in the mucosa and minimal binding in the muscular layers of the jejunum. Similar results were obtained for other intestinal regions as revealed by autoradiography. No significant changes in the affinities of melatonin binding sites were detected between different regions and tissue layers of the alimentary canal. Moreover, the densities and affinities of melatonin binding sites among different regions of the gut exhibited no significant diurnal variations. The demonstration of regional variations in melatonin levels and the density of melatonin binding sites along the gastro-intestinal tract, with a concentration of the putative melatonin receptors in the mucosal layer, suggests a possible direct action of melatonin in the regulation of fluid/electrolyte transport and nutrient absorption in the gut.

Prolactin and epidermal growth factor regulation of the proliferation, morphogenesis, and functional differentiation of normal rat mammary epithelial cells in three dimensional primary culture

The epithelial cell-specific effects of prolactin and epidermal growth factor (EGF) on the development of normal rat mammary epithelial cells (MEC) were evaluated using a three dimensional primary culture model developed in our laboratory. Non-milk-producing MEC were isolated as spherical end bud-like mammary epithelial organoids (MEO) from pubescent virgin female rats. The cultured MEO developed into elaborate multilobular and lobuloductal alveolar organoids composed of cytologically and functionally differentiated MEC. Prolactin (0.01-10 micrograms/ml) and EGF (1-100 ng/ml) were each required for induction of cell growth, extensive alveolar, as well as multilobular branching morphogenesis, and casein accumulation. MEO cultured without prolactin for 14 days remained sensitive to the mitogenic, morphogenic, and lactogenic effects of prolactin upon subsequent exposure. Similarly, cells cultured in the absence of EGF remained sensitive to the mitogenic and lactogenic effects of EGF, but were less responsive to its morphogenic effects when it was added on day 14 of a 21-day culture period. If exposure to prolactin was terminated after the first week, the magnitude of the mitogenic and lactogenic effects, but not the morphogenic response was decreased. Removal of EGF on day 7 also reduced the mitogenic response, but did not have any effect on the magnitude of the lactogenic or morphogenic responses. These studies demonstrate that physiologically relevant development of normal MEC can be induced in culture and that this model system can be used to study the mechanisms by which prolactin and EGF regulate the complex developmental pathways operative in the mammary gland.

Hydrocortisone and progesterone regulation of the proliferation, morphogenesis, and functional differentiation of normal rat mammary epithelial cells in three dimensional primary culture

The mechanisms of action of, and resistance to, the steroidal regulators of normal mammary epithelial and breast cancer cell development are only partially understood. A major obstacle to research progress has been the difficulty in supporting physiologically relevant development of normal mammary epithelial cells (MEC) under defined serum-free conditions. A primary culture system was developed in our laboratory that permits nonfunctional rat MEC to undergo extensive proliferation, functional differentiation, as well as multilobular and lobuloductal branching alveolar morphogenesis. In the studies reported here, the contributions of hydrocortisone and progesterone during the coordinate induction of cellular proliferation, organoid morphogenesis, and functional capacity were assessed. Hydrocortisone (0.1-10 microgram/ml) induced alveolar and multilobular branching morphogenesis, suppressed lobuloductal branching morphogenesis, and enhanced casein accumulation. Hydrocortisone also played a role in maintaining alveolar as well as multilobular branching morphogenesis and casein levels. Progesterone (0.01-1 microgram/ml) induced cellular proliferation as well as multilobular and lobuloductal branching morphogenesis, and suppressed casein accumulation. At a supraphysiological concentration (10 micrograms/ml), progesterone inhibited cell growth, alveolar branching morphogenesis, and casein accumulation. MEC cultured without progesterone for up to 1 week retained the ability to respond when subsequently exposed to this steroid. Reversibility studies suggested that progesterone was required for the induction, but not the maintenance of the mitogenic, morphogenic, and lactogenic effects. This physiologically relevant primary culture system can be used to study the factors that regulate steroid responsiveness as well as the cross-talk between steroid and growth factor receptor signaling pathways in normal MEC and breast cancer cells.

Mass spectrometric identification and quantification of endogenous 5-methoxyindole-3-acetic acid in quail tissues

The endogenous levels of 5-methoxyindole-3-acetic acid (5-MIAA) in quail pineal gland, retina and serum were determined by capillary column gas chromatography/mass spectrometry/selected ion monitoring using a deuterated internal standard and the N-pentafluoropropionyl-O-pentafluorobenzyl ester derivative. Diurnal rhythms of pineal and serum 5-MIAA with high levels at mid-light and low levels at mid-dark suggest a pineal origin of 5-MIAA in the blood. In contrast, retina displayed an opposite diurnal rhythm of 5-MIAA with high levels at night, suggesting that the biosyntheses of 5-MIAA in the quail pineal gland and retina were different. In vitro studies on incubation media indicated that both the pineal gland and retina are capable of synthesis/secretion of 5-MIAA.

Inhibition of wild-type HIV-1 virus production by a matrix deficient Gag mutant

Previous studies have shown that certain HIV-1 Gag mutants can interfere with the production of infectious HIV-1 when coexpressed with wild-type virus. In this paper, we studied two mutants of HIV-1 for their ability to interfere with the production of wild-type virus. Both mutants lack the entire matrix domain of gag and either lack [myr(-)MA(-)] or contain [myr(+)MA(-)] an amino-terminal myristate (myr) addition sequence at the beginning of the capsid domain. Previously we have demonstrated that expression of both mutant constructs leads to assembly and release of mutant viruses, although only myr(+)MA(-) particles are released efficiently. Particles produced by both matrix-deficient mutants are noninfectious and poorly incorporate and/or retain viral envelope glycoproteins. In this study, we further show that expression of myr(+)MA(-), but not myr(-)MA(-) interferes with wild-type HIV-1 virus production in transient expression assays. Our data suggest that wild-type and myristylated MA(-) Gag protein interacts at some point during assembly and that Gag myristylation has a greater effect on the assembly pathway than the matrix domain.

Modulation of normal mammary epithelial cell proliferation, morphogenesis, and functional differentiation by retinoids: a comparison of the retinobenzoic acid derivative RE80 with retinoic acid

The ability of retinoids to modulate the proliferation as well as the morphological and functional differentiation of normal mammary epithelial cells isolated from pubescent female virgin rats was evaluated in serum-free primary culture. The retinobenzoic acid derivative RE80, present continuously or for only a limited time in culture, inhibited proliferation with an IC50 of less than 10(-10) M. In contrast, all-trans-retinoic acid (RA) inhibited proliferation with an IC50 of approximately 10(-8) M. In addition to effects on proliferation, RE80 and RA stimulated end bud colonies to differentiate to lobular alveolar colonies, inhibited alveolar budding, and suppressed the outgrowth of squamous colonies. Both retinoids also markedly stimulated functional differentiation, as assessed by accumulation of the major milk protein casein, and stimulated the synthesis of a approximately 73- to 74-kilodalton protein identified as a member of the transferrin family. Moreover, both retinoids stimulated cell death in the differentiated cell population. RE80 was approximately 100-fold more potent than RA for all of these effects. These data suggest that several mechanisms may contribute to the chemopreventive and/or therapeutic efficacy of retinoids in breast cancer, including inhibition of proliferation, stimulation of cell death, and/or induction of differentiation.

Hypotony following trabeculectomy

OBJECTIVE

To determine the risk factors for development of postoperative hypotony and the effects of hypotony on the outcome of surgery in terms of intraocular pressure (IOP) control and final visual acuity in patients who underwent standard trabeculectomy, trabeculectomy with postoperative 5-fluorouracil injections, trabeculectomy with intraoperative mitomycin-C, or trabeculectomy with both antimetabolites.

PATIENTS AND DESIGN

We retrospectively reviewed the outcome in 155 eyes of 155 patients who underwent standard trabeculectomy (n = 15), trabeculectomy with postoperative 5-fluorouracil injections (n = 81), trabeculectomy with intraoperative mitomycin-C (n = 55), or trabeculectomy with both antimetabolites (n = 4).

RESULTS

Hypotony developed in 108 (69.6%) eyes (IOP < 6 mm Hg) at some point postoperatively; this was transient (< 14 days) in 75 eyes, and prolonged (> 14 days) in 33 eyes. The positive preoperative factors for the development of prolonged hypotony were young age, myopia, and preoperative use of carbonic anhydrase inhibitor. The mean age of patients in whom prolonged hypotony developed was 57.3 +/- 18.3 years (compare the mean age without prolonged hypotony, 65.3 +/- 14.5 years, p = 0.02). Sixteen of 33 (48%) patients in whom prolonged hypotony developed were myopic (p = 0.02), and 23 of 33 (70%) patients in whom prolonged hypotony developed used preoperative carbonic anhydrase inhibitor (p = 0.07).

CONCLUSIONS

There was no difference in the incidence of hypotony between patients who received 5-fluorouracil and those who received mitomycin-C. Postoperative hypotony was associated with three types of postoperative complications: shallow anterior chamber, choroidal detachment, and hypotony maculopathy (p = 0.02, 0.000, and 0.05, respectively). Hypotony did not have any effect on the success of surgery in terms of IOP control, but did have an effect on the visual outcome. Fourteen of the 33 patients (42.4%) in whom prolonged hypotony developed had worse visual acuity (p = 0.002); of these cases, four were due to hypotony maculopathy.

Pars plana Baerveldt tube insertion with vitrectomy in glaucomas associated with pseudophakia and aphakia

PURPOSE

We reviewed the course of intraocular pressure, visual acuity, and complications in patients with shallow anterior chambers or vitreous prolapse who underwent insertion of glaucoma drainage tubes through the pars plana (after a complete posterior vitrectomy).

METHODS

Thirteen patients (13 eyes) with uncontrolled glaucoma associated with shallow anterior chamber or vitreous prolapse and aphakia or pseudophakia underwent pars plana Baerveldt tube insertion after vitrectomy.

RESULTS

In 11 eyes the intraocular pressure was less than or equal to 15 mm Hg at a minimum follow-up of one year; the other two eyes underwent additional glaucoma surgery. Two of the 11 eyes with controlled intraocular pressure had limitation of ocular motility postoperatively. No retinal complications had occurred in any of the 13 eyes.

CONCLUSION

This technique of combined pars plana vitrectomy and pars plana insertion of a Baerveldt tube provides intraocular pressure control in eyes with shallow anterior chamber or vitreous prolapse and glaucoma associated with pseudophakia or aphakia.

Experience with the baerveldt implant in young patients with complicated glaucomas

PURPOSE

Previous studies have suggested that glaucoma shunt implantation may be useful in the management of glaucoma in young patients in whom goniotomy and/or trabeculotomy have failed or are inappropriate. Herein, we describe our initial experience with Baerveldt implantation in young patients with complicated glaucomas.

METHODS

Charts of all patients with glaucoma who were under 21 years of age, and who underwent Baerveldt implantation between March 1, 1991 and March 1, 1993 with at least a 6-month follow-up (30 eyes of 30 patients) were reviewed retrospectively.

RESULTS

The patients' ages ranged from 2 months to 20 years (mean, 6.6 +/- 6.4 years) with follow-up of 6-25 months (mean, 15.0 +/- 6.3 months). Intraocular pressure (IOP) was reduced from a preoperative range of 17-78 mm Hg (mean, 35.5 +/- 13.1 mm Hg) to a range of 6-22 mm Hg (mean, 13.5 +/- 4.2 mm Hg) postoperatively. Six- and 12-month life-table success rates (6 +/- IOP +/- 21 without additional glaucoma surgery or devastating complication) were 93% and 86%, respectively.

CONCLUSION

Baerveldt implantation is a useful approach to the treatment of glaucoma in young patients with complicated glaucomas.

Pharmacokinetics of 111In-labelled monoclonal antibody ZCE-025 and fragments in tumour-bearing mice

Radiolabelled anti-tumour antibodies, their fragments and derivatives hold promise for imaging and therapeutics in oncology. A better understanding of the pharmacokinetics of these entities is therefore important for clinical applications and management. In the present study, the in vivo behaviour of 111Indium-labelled monoclonal anti-CEA antibody ZCE-025 and its F(ab')2 and Fab' fragments and a Fab' derivative are compared in the nude mouse-human tumour model. The object of the derivative was to improve the tumour uptake of the fragment yet reduce its high renal uptake while continuing to achieve desirable kinetics in the normal tissues. Uptake of the derivative in the tumour was comparable to that of the intact antibody and exceeded that of the underivatized fragments. Moreover, uptake in non-target tissues was lower with the derivative than with the intact entity. The renal uptake of the derivative was dramatically lower than for the fragments. The modelling data strongly suggest that the derivatives will be advantageous for clinical use compared with the underivatized whole antibodies or their fragments.

Interaction of retinoids with steroid and peptide hormones in modulating morphological and functional differentiation of normal rat mammary epithelial cells

The interaction of the retinoid RE80 with the lactogenic and mammogenic regulators of mammary gland development was investigated using a mammary epithelial cell (MEC) primary culture model in which cells from young virgin rats were cultured within a reconstituted basement membrane using defined serum-free medium. RE80 (10(-10) M) was able to substitute completely for epidermal growth factor and partially for hydrocortisone in stimulating both morphological and functional (casein accumulation) differentiation of the MEC. In contrast, the requirement of PRL for both differentiation processes was absolute. Furthermore, RE80 was found to abrogate the inhibitory effect of progesterone on casein accumulation and to act as an antiprogestin in terms of morphological effects. Under optimal medium conditions, RE80 also inhibited cell proliferation. This inhibition did not require epidermal growth factor, hydrocortisone, progesterone, or PRL, but, unexpectedly, was enhanced in medium deficient in or lacking hydrocortisone. Additionally, RE80 induced the death of differentiated MEC, an effect that was found to require hydrocortisone. These results suggest that retinoids may modulate transcription of the casein gene family, either directly by activation of the binding of retinoic acid receptors to the casein promoter or indirectly by modulation of the effects of other hormones. The antiproliferative effect of retinoid may also be direct or indirect by virtue of down-regulation of the receptors for one of the mitogenic hormones, possibly progesterone.

Evaluating quality of care in the new health care environment

Today's health care environment explicitly emphasizes quality monitoring and improvement systems. To better understand the new concepts of quality, the quality systems currently used and under development at the Doheny Eye Institute, Los Angeles, Calif, and The Wilmer Ophthalmological Institute, Baltimore, Md, were reviewed and the underlying principles and pertinent examples extracted. In the future, quality monitoring will require measurement of rates of conformance with indicators of each of the three components of quality of care, ie, structures, processes, and outcomes. As such, significant changes in the philosophy of quality monitoring and development of newer and more advanced measures and indicators will be needed to meet the challenges of quality review in the new health care environment.

Postoperative complications and short-term outcome after 5-Fluorouracil or mitomycin-C trabeculectomy

PURPOSE

This study was performed to compare the postoperative complications between trabeculectomy with 5-fluorouracil injected after surgery and trabeculectomy with mitomycin-C applied intraoperatively.

METHODS

Retrospective review was done on 77 eyes that had received 5-fluorouracil injections after trabeculectomy, 45 eyes that received mitomycin-C during trabeculectomy, 4 eyes that received both agents, and 15 eyes that received neither agent between January 1991 and July 1992. 5-fluorouracil-treated eyes received a mean of 5 +/- 2.5 subconjunctival injections of 5 mg each (5 mg/0.1 ml). Mitomycin-C-treated eyes received 3-5 min exposure to 0.5 mg/ml mitomycin-C. Several parameters were compared between groups including hypotony defined as intraocular pressure <6 mm Hg. Success was defined as IOP <21 mm Hg with or without medications. Followup averaged 6-12 months.

RESULTS

Complications including hypotony, loss of visual acuity, choroidal effusion, shallow anterior chamber, cataract progression, hyphema and procedure failure were equivalent between 5-fluorouracil and mitomycin-C-treated groups.

CONCLUSIONS

Excluding corneal epithelial toxicity that was more common with 5-fluorouracil, the two agents used had similar success and complications during the short followup period.

GATA-3 dominant negative mutant. Functional redundancy of the T cell receptor alpha and beta enhancers

The GATA family of transcription factors regulates a wide variety of genes, including those involved in differentiation of erythrocytes and T lymphocytes. We report here the creation of a dominant negative mutant of GATA-3, KRR, which effectively blocks wild-type GATA-1, GATA-2, and GATA-3 transactivation when co-expressed in transient assays. KRR was generated by site-directed mutagenesis while investigating a putative activation domain of GATA-3, located between its two zinc fingers. The GATA-3 KRR mutation does not affect expression, nuclear translocation, or the ability to bind to a consensus GATA sequence. KRR can suppress the activity of the minimal T cell receptor (TCR) alpha and beta enhancers by 12- and 3.4-fold, respectively. However, KRR did not have a significant effect on the activity of larger TCR-alpha and -beta enhancer fragments. Thus, functional redundancy in the TCR-alpha and -beta enhancers can compensate for the loss of GATA-3 activity.