Is percutaneous medial hamstring myofascial lengthening as anatomically effective and safe as the open procedure?

BACKGROUND

Medial hamstring fractional lengthening is commonly performed in children with cerebral palsy (CP) to decrease contracture and/or to improve gait. Percutaneous procedures are gaining more and more popularity, even in the paediatric population, with equivocal results. The purpose of this paper was to determine the efficacy and safety of percutaneous medial hamstring myofascial lengthening (PHL).

METHODS

This is a prospective randomised controlled trial including 31 knees from 18 consecutive patients with CP scheduled for medial hamstring lengthening in the setting of multilevel tendon lengthening procedures in a university hospital. Other concomitant lower extremity surgeries were not exclusionary. A first paediatric orthopaedic surgeon executes the PHL at one level, as recently described in the literature. Another surgeon opens and extends the wound to explore what had been cut during the PHL and completes fractional lengthening (OHL) of both the semimembranosus (SM) and semitendinosus (ST) when possible. Popliteal angle (PA) was assessed by a third surgeon immediately before PHL, after PHL and then after OHL, using a goniometer in a standardised reproducible manner. All three surgeons were blinded to the others' findings. Primary endpoints included ease of performing PHL, the percentage of tendon-fascia/ muscle portion sectioned percutaneously and improvement of PA. Comparison between improvement of PA after PHL and OHL was done using a paired t-test with a 95% confidence interval.

RESULTS

The first surgeon was at ease in palpating and identifying the semimembranosus tendon before PHL in ten knees only. PHL led to an undesirable cut of the semimembranosus muscle fibres to more than 50% of the muscle section area in eight cases (<50% in 23 cases, between 50% and 75% in eight cases), and of the semitendinosus muscle fibres to more than 50% in all cases (complete rupture in six cases, more than 75% in eight cases and approximately 50% in 17 cases). Mean PA measured 52° pre-operatively and decreased to 40° after PHL. After OHL, the PA averaged 22°. There was a significant difference between the PA value after PHL (M = 40, SD = 11.8) and the PA value after OHL (M = 22, SD = 8.7), p < 0.0001. The gain in PA did not correlate with the extent of semimembranosus muscle divided (p = 0.38) nor with the extent of semitendinosus muscle divided (p = 0.35). No major iatrogenic neurovascular injury was observed.

CONCLUSIONS

To the authors' knowledge, this is the first prospective study concerning the anatomic effects of PHL. Although it is a quick procedure, it is often associated with difficulty by the operating surgeon to identify and evaluate what should be cut percutaneously, leading to abusive injury of the muscle itself rather than the fascia alone. In addition, the gain in PA is statistically less following PHL than following OHL despite undesirable extensive muscle injury following PHL. This may be due to the multiple fascial cuts (fractional lengthening) usually performed in OHL.

Retinal pigment epithelial cell necroptosis in response to sodium iodate

Age-related macular degeneration (AMD) is a degenerative disease of the retina and the leading cause of blindness in the elderly in developed countries. The late stage of dry AMD, or geographic atrophy (GA), is characterized by extensive retinal pigment epithelium (RPE) degeneration. The underlying molecular mechanism for RPE cell death in GA remains unclear. Our previous study has established that RPE cells die predominantly from necroptosis in response to oxidative stress in vitro. Here, we extend our study and aim to characterize the nature of RPE cell death in response to sodium iodate (NaIO₃) in vitro and in a NaIO₃-induced retina degeneration mouse model. We found that NaIO₃ induces RPE necroptosis in vitro by using a combination of molecular hallmarks. By using TUNEL assays, active caspase-3 and HMGB1 immunostaining, we confirmed that photoreceptor cells die mainly from apoptosis and RPE cells die mainly from necroptosis in response to NaIO₃in vivo. RPE necroptosis in this model is also supported by use of the RIPK1 inhibitor, Necrostatin-1. Furthermore, using novel RIPK3-GFP transgenic mouse lines, we detected RIPK3 aggregation, a hallmark of necroptosis, in the RPE cells in vivo after NaIO₃ injection. Our findings suggest the necessity of re-evaluating RPE cell death mechanism in AMD models and have the potential to influence therapeutic development for dry AMD, especially GA.

OCT angiography and sequential quantitative analysis of type 2 neovascularization after ranibizumab therapy

PURPOSE

To study the precise structural aspects of a type 2 neovascular membrane in a patient with age-related macular degeneration (AMD) using optical coherence tomography (OCT) angiography and perform sequential quantitative analysis of the membrane after ranibizumab therapy.

PATIENTS AND METHODS

Split-spectrum amplitude-decorrelation (SSADA) OCT angiography macular cubes (3 × 3 mm) were acquired with a light source centered at 840 nm, a bandwidth of 45 nm, and an A-scan-rate of 70 000 scans per second. Visible pathologic vessels were outlined manually on average intensity projection en face images, and the area of the lesion and the vessel density were measured at baseline and follow-up.

RESULTS

At baseline, the neovascular lesion measured 4.12 mm(2) and the vessel density was 19.83 mm(-1). Four weeks after the first, and 2 and 4 weeks after the second ranibizumab injection, OCT angiography revealed a progressively smaller vascular lesion (2.32, 1.77 and 1.64 mm(2)), and vessel density (10.24, 8.52 and 7.57 mm(-1)), although the large central trunks of the lesion were unchanged.

CONCLUSIONS

In this study, an obvious reduction in size and vessel density of the neovascular lesion was noted after treatment with ranibizumab using SSADA OCT angiography technology. Microvascular components can be delineated with precision, suggesting that this technique may be useful for the management of patients with neovascular AMD in a clinical setting as well as for future clinical trials.

Earlier therapeutic effects associated with high dose (2.0 mg) Ranibizumab for treatment of vascularized pigment epithelial detachments in age-related macular degeneration

SUMMARY STATEMENT

Intravitreal high dose (2 mg) ranibizumab may lead to quicker resolution of choroidal neovascularization (CNV) and associated retinal pigment epithelial detachment in eyes with exudative age-related macular degeneration, although it may possibly correlate with RPE tears in certain cases.

PURPOSE

This prospective study compared the outcomes of 0.5 vs 2.0 mg intravitreal ranibizumab injections (RI) for treating vascularized pigment epithelial detachment (vPED) due to age-related macular degeneration.

METHODS

Patients with vPED were randomized to receive 2.0 vs 0.5 mg RI monthly for 12 months or for 4 months and then repeated on a pro-re nata basis. Optical coherence tomography, fundus photography, and fluorescein and indocyanine-green angiography were obtained at baseline and subsequent specific intervals. Outcome measures were best-corrected standardized visual acuities, central 1-mm thickness, surface area (SA), greatest linear diameter (GLD), heights (PED and CNV), and amount of subretinal fluid (SRF) and cystoid macular edema (CME).

RESULTS

Both groups yielded reductions of the central 1-mm thickness, PED and CNV SA and PED height and GLD, SRF, and CME. Vision improvement and reduction in SRF and PED height occurred earlier for eyes receiving the 2.0 mg dose. Cataract progression was similar but RPE tears developed more often with the 2.0 mg dose.

CONCLUSIONS

There were similar visual and anatomical outcomes at the end of the study; however, the higher dose yielded more rapid reductions and more complete resolution of the PED, although there was possible increased tendency for an RPE tear with the higher dose.

Retinal function in X-linked ocular albinism (OA1)

PURPOSE

To characterize retinal function in human recessive X-linked ocular albinism (OA1) across the normal lifespan.

METHODS

Retinal function was evaluated in 14 OA1 patients (ages 11 to 71 years) and five obligate carriers (ages 41 to 50 years) and compared to normal controls using full-field and multi-focal electroretinograms (ERG and mERG, respectively) and electro-oculography (EOG).

RESULTS

No consistent differences in ERG response parameters were observed when OA1 patients were compared as a group to normal controls. A trend in the direction of better correlations of response parameters with age was, however, observed in OA1. EOG Arden ratios were normal or hypernormal for all patients, but were uncorrelated with age. Central retinal function measured with the mERG suggested a flat response topography with depressed macular function compared to normal controls.

CONCLUSIONS

Panretinal function in OA1 is within normal limits at all ages, consistent with previous reports in generalized albinism. The stronger correlations with age in OA1 may suggest a different rate of age-related change in OA1 compared to normal populations, but the precise nature of this change must await an appropriate prospective study. The topography of mERG amplitudes in OA1 is relatively flat across the central retina with a reduction in amplitude in the macular region consistent with anatomical studies demonstrating an underdeveloped macular region in albinism.

Familial cavernous hemangioma: An expanding ocular spectrum

OBJECTIVE

To describe the clinical and genetic findings in a family with multiple cases of cavernous hemangiomas.

DESIGN

Investigational clinical and genetic study in which 3 generations of a family consisting of 12 members were screened with magnetic resonance brain imaging, dilated ophthalmoscopic examination, and cutaneous survey coupled with linkage analysis to determine affected individuals and to better define manifestations of this neuro-oculo-cutaneous syndrome.

RESULTS

The proband had multiple cerebral cavernous hemangiomas and a choroidal hemangioma. Her son was found to harbor a retinal cavernous hemangioma. The proband's sister manifested a cerebral cavernous hemangioma, cutaneous hemangiomas, and a presumed choroidal hemangioma; her daughter demonstrated radiological findings suggestive of a cerebral cavernous hemangioma. The father of the proband demonstrated multiple, cutaneous hemangiomas. The remaining family members were free of lesions. The 7q locus could not be excluded as harboring the causative gene.

CONCLUSIONS

This family may have a dominantly inherited neuro-oculo-cutaneous condition of cavernous hemangiomas with variable expressivity. The presence of choroidal hemangiomas in this phacomatosis has not been described previously to our knowledge.

CLINICAL RELEVANCE

The presence of either retinal cavernous or choroidal hemangioma should alert the physician to search for features suggestive of systemic and familial involvement; either lesion may constitute the ocular component of the neuro-oculo-cutaneous phacomatosis, sometimes referred to as cavernoma multiplex. Arch Ophthalmol. 2000;118:969-973

Long-term drusen study

PURPOSE

To determine the yearly incidence of visual loss in the fellow eyes of patients with unilateral neovascular age-related macular degeneration (ARMD) and to assess the drusen characteristics portending the greatest risk for this outcome.

METHODS

A total of 101 patients with unilateral exudative ARMD and drusen only in the fellow eye were entered into the study and prospectively followed up to 9 years. Visual acuity, color fundus photography, fluorescein angiography, and grading of drusen characteristics were obtained for each patient on entry into the study. Patients were followed at annual intervals with color fundus photography. The study endpoint was the development of choroidal neovascularization (CNV) or geographic atrophy (GA) in the fellow eye.

RESULTS

Yearly incidence rates for the development of an endpoint lesion were between 5 and 14%. The risk of CNV peaked at 4 years and dissipated thereafter. Longer follow-up was associated with a slightly increased incidence of GA. Greater drusen number was most highly associated with the development of an endpoint lesion. Drusen size and confluence were also significant.

CONCLUSIONS

The risk of CNV in patients with ARMD is heralded by an increase in the number, size, and confluence of drusen. This risk eventually declines and is followed by later increased risk of GA.

AIDS and the eyes

The eye is affected in 50-75% of adult AIDS patients. This rate of ocular involvement is much higher than that in symptom-free HIV-seropositive patients, and seems to increase in incidence with severity of disease. These observations indicate that regular screening of HIV-positive patients is warranted to allow early identification of potential vision and life threatening disease.

Involvement of the eyebrow fat pad in Graves' orbitopathy

Involvement of the eyebrow fat pad in Graves' disease has never been reported. We noted that Graves' orbitopathy patients had bulkier eyebrows due to a larger eyebrow fat pad not associated with the preaponeurotic fat. A cadaver model was used to show that the eyebrow fat could be identified with magnetic resonance imaging (MRI) scans. Then, a series of Graves' orbitopathy patients were sent for orbital MRI scans, and the eyebrow fat was measured with maximum lengths and widths. The averages were compared to two groups of patients, one without orbital pathology, and one with orbital pathology causing proptosis but not due to Graves' disease. Graves' patients with early orbitopathy and incipient optic neuropathy or congestive orbits where optic neuropathy had to be ruled out had statistically significant larger eyebrow fat pads than either comparison group. This has clinical significance: The eyebrow fat may need to be debulked during operations such as blepharoplasty. Furthermore, periorbital fat may play a larger role in the disease process than previously thought.

The role of iontophoresis in ocular drug delivery

Iontophoresis has been utilized in the field of ophthalmology for many years. Present application of this technique has diminished considerably and few clinicians are currently familiar with its use. This review aims to educate the reader regarding the essential features of this procedure and to discuss the past and future role of iontophoresis in ocular drug delivery.

Aqueous and vitreous concentration of mitomycin C by topical administration after glaucoma filtration surgery in rabbits

PURPOSE

The authors investigated the aqueous and vitreous pharmacokinetics of mitomycin after postoperative topical administration in rabbits.

METHODS

Filtration surgery was performed in one eye of each rabbit. On the first postoperative day, mitomycin solution (0.4 mg/ml) was administered by either topical drop or cellulose sponge in both eyes of each rabbit. Aqueous and vitreous paracenteses were performed at 0.25, 0.5, 1, 2, 3, and 4 hours thereafter. Three rabbits were tested at each time interval for each type of administration.

RESULTS

After topical drop administration, the peak aqueous concentration was 0.03 +/- 0.02 microgram/ml (mean +/- standard error) in surgical eyes and 0.06 +/- 0.03 microgram/ml in control eyes. After sponge administration, the peak aqueous concentration was 0.10 +/- 0.03 microgram/ml in surgical eyes and 0.08 +/- 0.04 microgram/ml in control eyes. Peak aqueous concentrations from drop and sponge applications were achieved at 1 to 2 hours after administration. Vitreous levels were well below the concentration known to cause retinal toxicity at all time intervals tested.

CONCLUSION

Postoperative topical administration of mitomycin was successful in delivering mitomycin into the aqueous humor of rabbit eyes. Alternative methods of mitomycin application from the currently popular intraoperative administration may be beneficial in situations in which mitomycin delivery across intact conjunctiva may be desirable.

Transscleral iontophoresis of foscarnet

Current local treatments of cytomegalovirus retinopathy may result in serious intraocular complications. Using an animal model, we investigated transscleral iontophoresis as a technique for delivery of foscarnet to the vitreous. Using a probe tip surface area of 0.19 mm2, a current of 1 mA, and a duration of ten minutes, transscleral iontophoresis of 0.5 ml of a 24-mg/ml foscarnet solution was administered to 72 normal rabbits. Vitreous aspiration was performed at 12 intervals (15 minutes, 30 minutes, and one, two, four, eight, 16, 24, 32, 40, 48, and 60 hours) after iontophoresis, and samples were analyzed by high-performance liquid chromatography to determine the vitreous pharmacokinetics of foscarnet. A peak foscarnet concentration of 200 +/- 31 microM (mean +/- standard deviation) was attained four hours after iontophoresis and was well below the concentration reported to cause retinal toxicity. Therapeutic levels were maintained until 60 hours after iontophoresis. The elimination half-life was approximately 24 hours. No toxic effects to anterior chamber structures were observed by biomicroscopy. Transscleral iontophoresis of foscarnet may provide an effective and safe technique for local treatment of cytomegalovirus retinopathy in patients with acquired immunodeficiency syndrome.

Iontophoresis of reactive black 5 for pulsed dye laser sclerostomy

Ab interno pulsed dye laser sclerostomy uses a gonioscopic approach to form a limbal fistula for the treatment of glaucoma. This procedure requires a full thickness penetration of stain in sclera for adequate absorption of the visible light energy. Iontophoresis is a technique using an electrical current to noninvasively deliver Reactive Black 5 (RB5) stain into sclera. This project determined the stability of RB5 stain as well as the optimal parameters for iontophoresis (probe tip surface area, current, and duration) in a rabbit model. RB5 stain was stable over time (72 hr) as well as after exposure to extreme heat (120 degrees C), scleral constituents (namely collagen), high concentrations of oxidants (1.5% H2O2), and laser light energy. Ideal parameters for iontophoresis included a probe tip surface area between 0.1 and 0.7 mm2, a current of 0.5 mA, and a duration of 5 min. The maximum concentration of RB5 stain achieved in sclera was 0.15%. The threshold of ablation for RB5 using an energy of 250 mJ was 0.001%. Iontophoresis can effectively deliver RB5 stain into sclera and may be a viable adjunct to ab interno pulsed dye laser sclerostomy procedures in the eye.

Iontophoresis of methylene blue for gonioscopic pulsed dye laser sclerostomy

Iontophoresis of methylene blue using pipette tip probes is an effective means of scleral staining in preparation for gonioscopic pulsed dye laser sclerostomy. The effects of the surface area of the pipette tip and of the duration of iontophoresis on the concentration and distribution of stain were investigated in rabbit eyes. Iontophoresis of 1% methylene blue was done using currents from 0.2 to 2.0 mAmp, pipette tip probes with surface areas from 0.02 to 7.1 mm2, and durations of iontophoresis from 0.5 to 10 minutes. Optimum iontophoresis parameters for delivering methylene blue to the eye were a current of 0.4 mA, a probe tip surface area of 0.19 mm2, and a duration of five minutes. The maximal scleral stain concentration, approximately 0.4%, was achieved using these optimal parameters. Microscopic analysis of frozen tissue sections demonstrated the stain to have penetrated the full thickness of the sclera after five minutes. Tissue samples were analyzed for dye 0.5, 2, 5, 12, and 24 hours after iontophoresis was completed. Decreased dye concentration by over 50% within 2 hours and complete disappearance of dye within 24 hours were demonstrated. Methylene blue concentration thresholds for laser ablation were also examined; the threshold of ablation of methylene blue was 0.0625% when an energy level of 75 mJ was used. We propose that iontophoresis of methylene blue is a useful adjunct to pulsed dye laser sclerostomy formation.

Lymphocytotoxins in vasculitis. Correlation with clinical manifestations and laboratory variables

Twenty-eight of 53 patients with various types of vasculitis were found to have cold reacting lymphocytotoxins (LCT). LCT were cytotoxic to both peripheral blood B and T cells as well as to OKT4 and OKT8 subpopulations. The interaction with the B cells was more pronounced than with the T cells as shown by reactivity with the former at higher serum dilutions than with the latter. Similar results were obtained with eluates from the unseparated lymphocytes and from B or from T cells. Partial purification of LCT demonstrated that they belong to the IgM class. LCT correlated with the level of circulating immune complexes as determined by the fluid phase C1q binding assay, but they did not correlate with the level of immunoglobulins, complement or antinuclear factors. The presence of LCT correlated significantly with the activity but not with the disease duration or the number of involved organs. Correlation of LCT with the activity of vasculitis implies that these cytotoxins may have a pathogenetic role and perhaps may serve as a marker for disease activity.