Diagnosis of a neonatal ophthalmic discharge, Ophthalmia neonatorum, in the molecular age: investigation for a correct therapy

An early double case of acute Ophthalmia neonatorum in 3-day-old twins is reported. Culture of eye swabs showed a wide bacterial polymorphism, in which common bacteria, such as Klebsiella pneumoniae, Streptococcus pneumoniae, Corynebacterium ulcerans and other Enterobacteriaceae, coexisted with atypical Mycoplasmataceae and Chlamydiaceae from resident cervical-vaginal maternal microbiota. The neonates were in an apparently healthy state, but showed red eyes with abundant greenish-yellow secretion, mild chemosis and lid edema. The maternal cervical-vaginal ecosystem resulted differently positive to the same common cultivable, atypical bacteria culturally and molecularly determined. This suggested a direct maternal-foetal transmission or a further foetal contamination before birth. An extended culture analysis for common bacteria to atypical ones was decisive to describe the involvement of Mycoplasmas (M. hominis and U. urealyticum) within the scenario of the Ophthalmia neonatorum in a Caucasian couple. The introduction of a routine PCR molecular analysis for Chlamydiaceae and N. gonorrhoeae allowed to establish which of these were present at birth, and contributed to determine the correct laboratory diagnosis and to define an adequate therapeutic protocol obtaining a complete resolution after one year for culture and atypical bacteria controls. This study suggests to improve the quality of laboratory diagnosis as unavoidable support to a correct clinical diagnosis and therapy, in a standardized modality both for swabbing and scraping, to check the new-born microbial programming starting in uterus, overtaking the cultural age to the molecular age, and to revise the WHO guidelines of SAFE Strategy for trachoma eye disease, transforming it into SAFES Strategy where the S letter is the acronym of Sexual ecosystem and behavioural valuation/education.

Enigmatic question of early reactive arthritis disclosed after researches of mycoplasmas, Chlamydia trachomatis and enteropathogens following the holistic vision of human being

An HLA-B27 genetic profile patient is fully investigated by molecular analyses after an anamnestic assessment of multi-site ecosystems, following the holistic vision of human being.VDRL and Widal-Wright (WWR) resulted positive, showing at Wright’s reaction a title of 1:40. Of all the enzymatic activities measured, only the ALP enzymatic pool activities showed a low increasing value of 297 U/L. Of all later acute phase proteins, Only C3 c protein value (127 mg/dL) and fibrinogen (376 mg/dL) were altered. Cultural and molecular oropharyngeal ecosystem investigation resulted significantly positive to Mycoplasmas(Mhand Uu) and Chlamydia trachomatis(Ct) together with a spread of saprophytic flora. From an accurate anamnesis, several and severe uro-genital clinical symptomatology emerged from birth until the beginning of rheumatologic symptomatologies that were confirmed by oldest Mh, Uu and Ctsilent chronic infections between these ecosystems. The molecular HPV research was negative, while the Thin prep pap-test was indicative of vaginosis and cellular reactive changes associated with inflammation. Parasitological research resulted positive for presence of 5-7 newly-formed G. lambliacysts for microscopic field, while digestibility test was positive for presence of several free fatty acid crystals. The remarkable presence of indigested meat fibre and several mucous dense filaments were observed. The pH value was 6.5, while blood faecal test was positive. The values observed were: ferritin 12 microg/L (10-120), total iron-binding capacity (TIBC) 310 &mgr;g/dL (300+-20), unsaturated iron-binding capacity (UIBC) 286 microg/dL (200-220) and iron seric level 24 microg/dL (60-130). Faecal research highlighted a very scarce presence of E. coli, resulting in 102 UFC/g of stool. Of all enteroinvasive pathogens, researched by molecular analyses, only Yersinia spp. was positive. After several specific cycles of antibiotic and antinflammatory therapies, the patient improved its general health condition considerably and showed almost complete regression of aching inguinal lymph node inflammation. In a picture of a worsening inflammatory process, produced by pathogens like Mycoplasmas, chronic silent or low grade inflammation atypical agents, in young HLA-B27 positive patient, VDRL test resulted positive. This value represents the first non-specific unique spy to reveal the precocious immunological signal in order to register the beginning of early innate immune system decay, keeping in mind that mycoplasmal and chlamydial infections are the triggering of cancer in patients genetically susceptible.

Can latent synergism of intestinal pathogens be responsible for inflammaging process causing Reiter's syndrome in a young patient HLA-B27 infected by atypical pathogens? A holistic view and clinical biochemical reinterpretation

A case of a genetically HLA-B27 patient fully investigated by molecular analyses, following a holistic vision and an anamnestic assessment of multi-site ecosystems is repeated. VDRL, Lupus anti-coagulant (LAC) and Widal-Wright (WWR), resulted positive. The antibodies (IgG/IgA anti-Ct) against chronic Chlamydia trachomatis inflammation were positive. In the context of all the enzymatic activities in reference range, the AMS and the ALP enzymatic activities showed an increasing trend and a time course augment depending respectively. Cultures, parasitological, digestibility tests and molecular analyses were then performed to investigate the different human ecosystems. Parasitological research and digestibility test were performed, resulting a latent chronic bowel inflammation, including certain enteroinvasive pathogens, such as, Salmonella, Shigella, Yersinia and Campylobacter (Enteric Pathogens Group, EPG) and Escherichia Coli pathogens (Escherichia Coli Pathogens Group, ECPG). The Salmonella typhi-DNA resulted positive, while 90% of the total microbic charge (TMC) was represented by C. freundi in culture analyses. Interpreting the VDRL positive test as early triggering of autoimmune disease, a few acute phase proteins as a pauci-symptomatic chronic phlogistic process, the amylase and alkaline phosphatase alterations as tissue markers of early intestinal inflammation, the Widal's reaction positivity together with the precocious clinical and faecal manifestations, this study suggests the prime triggering role of these atypical pathogens to cause a chronic low grade autoimmune response against the tissue/organ susceptible target, causing inflammaging phenomenon in young patient with chronic latent infection by Salmonella typhi, leading to Reiter's syndrome, in HLA-B27 positive patient.

Michelangelo's eye disease

Charged by the Pope Julius II for painting the Cappella Sistina in Rome (between 1508 and 1512), Michelangelo worked in an elevated scaffolding, in an anomalous position with dyes (including poisoning lead salts) and solvents (such as toxic turpentine) dripping on his face and continuously inhaling, in a dim environment illuminated only with oil lamps and candles, as he described himself and sketched in a sonet addressed to Giovanni da Pistoia. In 1510 he began suffering from eye disease: the main symptom was the necessity to elevate the document he was reading up to the level of his eyes. This defect disappeared few months after he finished painting his masterpiece. We hypothesize that the Michelangelo's eyes disease was a form of acquired and transitory nystagmus induced by the many hours he spent in up gaze, with a skew deviation, a form of ocular tilt reaction resulting from the impairment of spatial sensitivity (inversion illusion) due to the persistence of the artist's head in a horizontal position, looking upward.

Color vision and macular recovery time in epileptic adolescents treated with valproate and carbamazepine

Visual dysfunction has been reported in patients diagnosed with epilepsy. Some of these visual disturbances may be attributable to either the disease process, or the anticonvulsant therapy prescribed to control the seizures. The aims of our study were to evaluate whether color vision and macular function are impaired in epileptic adolescents, to study if the monotherapy with valproic acid (VPA) and carbamazepine (CBZ) can affect color vision and macular function and to determine the possible relationship between color vision, retinal function and antiepileptic drugs (AEDs) dosage and their serum concentrations. We examined 45 (16 male and 29 female, mean age +/- SD, 15.71 +/- 2.01 years) Caucasian epileptic patients suffering from various types of cryptogenic epilepsy before the beginning of therapy and after 1 year of VPA or CBZ monotherapy and 40 sex- and age-matched healthy controls. Color vision was assessed by Farnsworth Munsell (FM) 100-hue test and total error score (TES) was evaluated. This test consists of colored caps: the testee has to arrange the caps according to their colors macular function was assessed by nyctometry evaluating initial recovery time (IRT) and summation method (SM). This test evaluates visual acuity after a period of intense illumination of macula. Analysis of variance was used to evaluate the difference between controls and patients; moreover, Pearson's correlation test have been performed. Before the beginning of therapy, there were no differences in color vision and macular function between controls and epileptic patients. After 1 year, the patients, treated with VPA or CBZ, showed a deficit in FM 100-hue test. At nyctometry, all patients showed no significant variation of macular function between baseline evaluation and second evaluation at end of the follow-up. Our study demonstrates that, in our group of epileptic patients, epilepsy per se does not affect color vision and retinal function. In contrast, after 1 years of therapy with VPA and CBZ these patients showed a deficit in FM 100-hue test although nyctometry evaluation continued to be normal allowing to exclude an impairment in macular function. Further investigations are required to determine the pathophysiological alteration(s) that are at the basis of color perception defects.

Color vision in epileptic adolescents treated with valproate and carbamazepine

OBJECTIVE

The aims of our study were to evaluate whether deficits in color vision exist in epileptic adolescents, to study if monotherapy with valproic acid (VPA) and carbamazepine (CBZ) can affect color vision, and to determine the possible relationship between abnormal color vision tests and AEDs dosage and their serum concentrations.

PATIENTS

We examined 45 epileptic patients before the beginning of therapy and after 1 year of VPA or CBZ monotherapy and 40 sex- and age-matched healthy controls.

METHODS

Color vision was evaluated with Farnsworth Munsell 100 (FM100) hue test and achromatic and short-wavelength automated perimetry (SWAP).

STATISTICAL ANALYSIS

To evaluate intergroup differences we used ANOVA with Scheffe's post hoc test, when appropriate. Repeated measures ANOVA was used to evaluate the intragroup modifications of total error score (TES) and perimetric threshold during the follow-up. Pearson's correlation test was performed to correlate chromatic sense and perimetric data and AEDs dosage and serum concentrations.

RESULTS

Before the beginning of therapy, there were no differences in central color vision and SWAP between controls and epileptic patients. After 1 year, patients treated with VPA or CBZ showed a deficit in FM100 hue test and SWAP parameters while no significant deficit was found in achromatic perimetry. In particular, with the FM100 hue test a higher number of errors was found in both groups of patients (CBZ patients: 166.00 +/- 27.72 TES; VPA patients: 151.19 +/- 44.09, P < 0.001) in comparison with controls (controls: 109.29 +/- 24.73) and baseline values (CBZ patients: 110.65 +/- 22.9; VPA patients 107.43 +/- 21.70). With SWAP patients of both groups showed significant variation of foveal threshold (controls: 21.07 +/- 2.01 dB; CBZ patients: 19.35 +/- 1.32, P < 0.001; VPA patients: 18.88 +/- 1.89, P < 0.001), full-field mean threshold perimetric sensitivity (controls: 18.50 +/- 1.24 dB; CBZ patients: 16.60 +/- 1.47, P < 0.001; VPA patients: 16.23 +/- 1.55, P < 0.001) and mean threshold perimetric sensitivity of the three evaluated subareas of the visual field (area 1 controls: 21.01 +/- 1.15; CBZ patients: 19.45 +/- 1.74, P = 0.001; VPA patients: 18.25 +/- 1.61, P < 0.001; area 2 controls: 18.40 +/- 1.43; CBZ patients: 16.07 +/- 1.58, P +/- 0.001; VPA patients: 16.13 +/- 1.46, P = 0.001; area 3 controls: 17.20 +/- 1.49; CBZ patients: 14.28 +/- 1.51, P < 0.001; VPA patients: 14.31 +/- 2.90, P = 0.001).

CONCLUSIONS

Our study demonstrates that treatment with VPA or CBZ can affect significantly both central and paracentral color vision after a short treatment period.

Static perimetry and diabetic retinopathy: a long-term follow-up

In order to evaluate if central static perimetry is useful to identify patients at risk of developing diabetic retinopathy, 60 (27 male, 33 female) adolescents and young adults (mean age, 15.9 years) with insulin-dependent diabetes mellitus were studied prospectively. No patient showed fluorescein angiographic signs of retinopathy initially. The patients were evaluated at the beginning of the study and after 8 years. At the beginning of the study, mean defect in the population was -2.34 dB as determined by perimetry; no patient showed significant impairment of foveal threshold (mean, 33.17 dB). After 8 years of follow-up, 7 patients had developed fluorangiographic signs of retinopathy. Life-table analysis showed that the overall probability of retinopathy development was significantly higher in subgroups of patients with mean sensitivity in areas 2 and 3 below the cutoff. These results suggest that central static perimetry is a useful tool in predicting the development of retinopathy in children with insulin-dependent diabetes mellitus who do not have fluorescein angiographic signs of retinopathy. This tool can help the physician to identify those patients at risk of developing fluorangiographic signs of retinopathy.

In vitro Staphylococcus epidermidis growth in some viscoelastic substances containing sodium hyaluronate

The aim of our study was to verify the in vitro growth of Staphylococcus epidermidis in various dilutions of some viscoelastic substances containing hyaluronic acid (Healon and Healon GV, IAL, Biolon). Serial twofold dilutions of each sterile viscoelastic substance, prepared so as to obtain a final concentration ranging from 50 to 0.78% of the product in sterile saline solution (0.85% NaCl), were taken out with a pipette that delivered 1.0 ml/tube. One hundred microliters of the S. epidermidis inocula, used for the evaluation of the positive control of the test organism, was dispensed into each tube. After 24 h of aerobic incubation at 37 degrees C, 100 microl of sample was taken out from each tube and plated into the specific medium for the growth of the test organism. After 24 h of incubation at 37 degrees C, these agar plates were examined and the colony-forming unit count of the test organism was compared to the corresponding total colony count, acting as a positive control, in order to determine the quantitative variation of the test organism grown in the presence of the viscoelastic compounds. For the lowest dilutions (from 1:2 to 1:8) statistically significant bacterial growth was detected in all tested viscoelastic substances. For the highest dilutions (1:64 and 1:128) Biolon and Healon GV showed a significant inhibition of S. epidermidis growth. A significant inhibition was also observed in the highest dilution (1:128) of Healon. In every dilution of IAL a statistically significant increase in bacterial growth was observed. It remains to be carefully considered whether S. epidermidis, accidentally penetrating the eye via the intraocular lens, could find a culture medium in a small amount of sodium hyaluronate left in the capsular bag behind the optic.

A case of quiescent choroidal melanoma: early echographic signs of reactivation

A medium-sized choroidal melanoma was studied during a 5-year phase of remission. The tumour presented signs of reactivation with changes in the echographic features without a significant increase in size. The echographic signals in the reactivation phase and the echographic evolution after treatment are described.

Congenital retinoblastoma: appearance of calcifications during short-term follow-up

An echographic follow-up of a case of congenital retinoblastoma was performed by monitoring variations in the tumoral echostructure concomitant with the appearance of microcalcifications. A previously unreported echo-graphic aspect regarding the first phase of observation is described. The calcifications in the tumour were evidenced on the 41st day of the patient's life.

A family with autosomal dominant distal arthrogryposis multiplex congenita and brown syndrome

Arthrogryposis multiplex congenita is a heterogeneous condition found in a number of different disorders and characterized by congenital joint contractures. We describe typical signs of congenital Brown syndrome (inability to elevate the affected eye actively or passively in full adduction) in three relatives with distal arthrogryposis multiplex congenita. We found a thickening of the superior oblique muscles in these patients with pain and increased intraocular pressure in upgaze. The pathogenesis of clinical and morphological findings is discussed. The association of Brown syndrome with distal arthrogryposis multiplex congenita has not been previously reported and provides us with an important point of reference in the understanding of both syndromes.

Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study

BACKGROUND/AIMS

Fellow eye prophylaxis for retinal detachment (RD) is still a controversial issue since opinions are not unanimous regarding the kind of lesions to be treated or the method of treatment. This prospective clinical study aimed to follow the course of vitreoretinal conditions in 150 high risk fellow eyes.

METHODS

150 consecutive patients with unilateral rhegmatogenous RD were included in this study. Inclusion criteria were good explorability of fellow eye retinal periphery and one of the following conditions in the fellow eye-aphakia, pseudophakia with capsulotomy, high myopia (>-6D), contralateral eye to a giant retinal tear. Prophylactic treatment (photocoagulation or scleral buckling) was performed in the presence of retinal tears and lattice degenerations. The state of the vitreous body was determined at the beginning of the study and at the end, when RD occurred.

RESULTS

Follow up ranged from 36 to 132 months. 95 fellow eyes were subjected to laser treatment; five eyes underwent prophylactic surgical treatment. Initially, in the treated group posterior vitreous detachment (PVD) was present in 100 eyes (100% of cases), but as a complete PVD only in 42 of them (42%). 10 eyes in the treated group developed RD during the follow up period. In five of these cases the partial PVD had progressed and a retinal tear in a previously healthy area was the cause of the retinal detachment. In the other five eyes RD apparently developed from previously treated lesions. Progression of PVD was evident in four out of these five eyes. The untreated eyes had no visible degenerative lesions. During follow up eight eyes developed RD. These eyes had no PVD at the beginning of the study, but showed a partial PVD at the time of the diagnosis of RD.

CONCLUSION

Fellow eyes with pre-existing retinal tears and PVDs can go on to retinal detachment in spite of laser prophylactic treatment. When PVD is not detectable or a partial PVD is present, the progression of posterior vitreous separation can account for retinal tears and RDs arising in formerly healthy areas.

Topical lomefloxacin 0.3% twice daily versus tobramycin 0.3% in acute bacterial conjunctivitis: A multicenter double-blind phase III study

AIMS/BACKGROUND

To evaluate in a double-masked comparative, prospective, randomized multicenter trial the efficacy of lomefloxacin 0.3% eye drops twice daily and of tobramycin eye drops 4 times daily in patients with acute bacterial conjunctivitis.

METHODS

Ninety-nine subjects were enrolled: 50 were treated with lomefloxacin 0.3% eye drops twice daily and 49 with tobramycin 0.3% eye drops 4 times daily. In all patients, conjunctival swabbing and assessment of objective signs and of subjective symptoms were performed.

RESULTS

There was no statistical difference for any individual sign or symptom or for the sum score of either key or other signs and symptoms at any of the examination days. The sum score of both key and other signs and symptoms decreased in both groups at day 3-4 as compared to baseline values (p < 0.0001). The decrease in both these scores continued significantly from day 3-4 to day 7-8 (p < 0.05) and was similar in the two treatment groups (p > 0.4). The lowest resistance rate was seen in lomefloxacin (3.5%) and in neomycin (7.0%), while tobramycin showed resistance in 10 out of 88 resistance strains (11.4%).

CONCLUSION

Both lomefloxacin 0.3% twice daily and tobramycin 0.3% administered 4 times daily were well tolerated and showed a high degree of clinical and microbiological efficacy in the treatment of acute bacterial conjunctivitis. Lomefloxacin caused less resistance than other antibiotics evaluated.

In vitro viability of external eye microbial flora in hydroxy-propyl-methylcellulose

The aim of this study was to verify the in vitro influence of various dilutions of a viscoelastic substance containing 2% hydroxy-propyl-methylcellulose (HPMC) on the viability of some microbial strains representative of the normal flora of the external eye. Pure reference strain cultures of Candida albicans, Pseudomonas aeruginosa, Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis and a fresh clinical isolate of Proteus mirabilis were selected for this study. Serial twofold dilutions of 2% HPMC, prepared so as to obtain a final concentration ranging from 50 to 0.78% of the product in sterile saline solution (0.85% NaCl), were taken out with a pipette that delivered 1.0 ml per tube. One hundred microliters of the abovementioned microbial inocula, used for the evaluation of the positive control of the test organism, were dispensed into each tube. After 24 h of incubation, 100 microl of samples were taken from each tube and plated into the specific medium for the growth of the test organism. After 24-48 h of incubation, these agar plates were examined and the colony-forming-unit count of each test organism was compared to the corresponding total colony count, acting as a positive control, in order to determine the quantitative variation of the test organism grown in the presence of the viscoelastic compounds. C. albicans and P. aeruginosa showed a statistically significant increase in growth with HPMC dilutions varying from 1:2 to 1:16. P. acnes and P. mirabilis growth was significantly reduced by all dilutions except for the 1:128 one. S. epidermidis growth was also significantly reduced in the presence of HPMC dilutions varying from 1:2 to 1:64. S. aureus growth was not significantly influenced. The viability of P. aeruginosa in HPMC dilutions needs to be carefully considered because of the ability of this organism to induce endophthalmitis, and the possibility that during cataract surgery, a small amount of HPMC may be left in the eye, trapped behind the intraocular lens optic.

A 12-month, randomized, double-masked study comparing latanoprost with timolol in pigmentary glaucoma

OBJECTIVE

To compare the efficacy and side effects and the effect on aqueous humor dynamics of 0.005% latanoprost applied topically once daily with 0.5% timolol given twice daily for 12 months to patients with pigmentary glaucoma.

DESIGN

Prospective, randomized, double-masked, clinical study.

PARTICIPANTS

Thirty-six patients affected with bilateral pigmentary glaucoma controlled with no more than a single hypotensive medication were enrolled in the study.

INTERVENTION

The sample population was randomly divided into 2 age- and gender-matched groups each of 18 patients. Group 1 received 0.005% latanoprost eyedrops once daily and the vehicle (placebo) once daily; group 2 was assigned to timolol 0.5% eyedrops twice daily.

MAIN OUTCOME MEASURES

Diurnal curves of intraocular pressure (IOP) were performed on the baseline day and after 0.5, 3, 6, and 12 months of treatment. The IOP measurements were performed at 8:00 AM, 12:00 noon, 4:00 PM, and 8:00 PM. Outflow facility ("C") was measured on the baseline day and on the last day of the study with a Schiotz electronic tonometer. A two-tailed Student's t test for paired or unpaired data was used for statistical evaluation of differences between treatment and baseline values or between the latanoprost and timolol group. Diurnal IOP measurements were compared hour by hour. Mean values of the two eyes IOP and "C" were used for analysis.

RESULTS

Compared with baseline measurements, both latanoprost and timolol caused a significant (P < 0.001) reduction of IOP at each hour of diurnal curve throughout the duration of therapy. Reduction of IOP was 6.0 +/- 4.5 and 5.9 +/- 4.6 with latanoprost and 4.8 +/- 3.0 and 4.6 +/- 3.1 with timolol after 6 and 12 months, respectively. Comparison of mean diurnal measurements with latanoprost and timolol showed a statistical significant (P < 0.001) difference at 3, 6, and 12 months. Mean "C" was found to be significantly enhanced (+30%) only in the latanoprost-treated group compared with the baseline (P = 0.017). Mean conjunctival hyperemia was graded at 0.3 in latanoprost-treated eyes and 0.2 in timolol-treated eyes. A remarkable change in iris color was observed in both eyes of 1 of the 18 patients treated with latanoprost and none of the 18 patients who received timolol. Darkening of the peripheral iris stroma was suspected in two patients treated with latanoprost. In the timolol group, heart rate was significantly reduced from 72 +/- 9 at baseline to 67 +/- 10 beats per minute at 12 months.

CONCLUSIONS

Although further studies may need to confirm these data on a larger sample and to evaluate the side effect of increased iris pigmentation on long-term follow-up, in patients with pigmentary glaucoma, 0.005% latanoprost taken once daily was well tolerated and more effective in reducing IOP than 0.5% timolol taken twice daily.

Effects of brimonidine 0.2% on blue-yellow perimetry of glaucomatous patients

A cross-over double-blind study was performed to evaluate the effect of acute administration of brimonidine on the blue-yellow perimetry. Thirty patients with primary open-angle glaucoma were admitted. After brimonidine administration, IOP and pupil diameter showed a significant reduction (p < 0.01) without modification in systolic and diastolic blood pressure. Blue-on-yellow perimetry showed a significant reduction in CPSD from 3.81 +/- 1.60 to 2.71 +/- 1.92 (p < 0.05). This result suggests that brimonidine improves ocular perfusion via a reduction of IOP.

Dry eye in allergic conjunctivitis: role of inflammatory infiltrate

Dry-eye associated symptoms are frequently present in patients affected with allergic conjunctivitis. We evaluated the relationship between ocular inflammation and the tear film parameters in patients affected with chronic allergic conjunctivitis. Eighty-two subjects (age 23.00 &#x00B1; 7.61: range 10-40) affected with chronic allergic conjunctivitis and thirty age- and sex matched healthy controls were enrolled. In all patients tear film qualitative and quantitative tests were performed. To determine the immune activation state, conjunctival biopsies were obtained from the inferior conjunctival fornix. Immunocytochemical markers for CD45RO, CD8, CD20 and EG2 (monoclonal antibody binding eosinophil cationic protein) were evaluated semiquantitatively. All tear film tests were found altered. They were reduced in allergic patients (p&#x003C;0.001). In conjunctival biopsies of allergic patients a very high number of CD45RO+ and EG2+ cells were found (p&#x003C;0.001): a lower number of CD45RO+ cells and no EG2+ cells in control biopsies were found. Multivariate analysis showed a significant relationship between tear tests and conjunctival infiltrate (CD45RO+ and EG2+): The tear film alterations are strictly related to the conjunctival immune infiltration. In particular, the reduction of the mucin-related component of tear film can be related to the toxic effect of the granule cationic proteins released by the conjunctival activated eosinophils (EG2+ cells).

Delayed post-operative use of 5-fluorouracil as an adjunct in medically uncontrolled open angle glaucoma

PURPOSE

The current study was performed to evaluate the efficacy and safety of late post-operative use of subconjunctival 5-fluorouracil (5-FU) with ocular massage (OM) after trabeculectomy with or without intraoperative mitomycin C (MMC) in patients with medically uncontrolled primary open angle glaucoma (POAG).

METHODS

Initial trabeculectomy was performed in 60 eyes of 60 consecutive patients with medically uncontrolled POAG. Thirty eyes (group 1) were randomly assigned to intraoperative MMC (0.2 mg/ml for 3 min) and 30 (group 2) were randomised to standard trabeculectomy. During the first 3 months post-operatively OM and subconjunctival injections of 5-FU (5 mg in 0.5 ml of balanced salt solution) were performed in both groups every time the clinical evaluation suggested imminent bleb failure. Suture lysis was not performed in any patient.

RESULTS

Follow-up ranged from 14 to 53 months (mean 30.17, SD 9.23) in trabeculectomy + MMC treated eyes and from 6 to 54 months (mean 27.37, SD 10.83) in trabeculectomy treated eyes. During the first 3 months of follow-up OM and subconjunctival injections of 5-FU were performed in 14 cases in group 1 and in 18 cases in group 2 (p = NS). A positive response to OM was obtained in 14 of 14 eyes and in 14 of 18 eyes in group 1 and in group 2, respectively (p = 0.042). The difference in post-operative mean IOP between the two groups was statistically significant at each time interval studied (p < 0.001). Success (complete or qualified) was achieved in 50 of 60 eyes (83.33%): 28 (93.3%) in the trabeculectomy + MMC treated group and 22 (73.3%) in the trabeculectomy treated group (p = 0.039). Among the complications seen, the incidence of bleb fibrosis was higher in group 2 (p = 0.0026). By means of post-operative treatment four nonrandomised subgroups were identified: intraoperative MMC + post-operative 5-FU, intraoperative MMC + no post-operative 5-FU, no intraoperative MMC + post-operative 5-FU, no intraoperative MMC + no post-operative 5-FU. The eyes treated with intraoperative MMC and post-operative 5-FU had a better long-term (48 months) cumulative probability of success (100%); treatment with intraoperative MMC or post-operative 5-FU alone was followed by a success rate of 87.1% and 72.2%, respectively. The cumulative probability of success after only trabeculectomy was 56% (p < 0.05). One case of hypotony maculopathy was found in the subgroup treated only with intraoperative MMC.

CONCLUSIONS

This study confirms the effectiveness and relative safety of delayed post-operative 5-FU treatment in patients with clinical evidence of bleb failure. Only when OM had caused a lowering of IOP were late subconjunctival injections of 5-FU followed by good control of IOP. The use of intraoperative MMC may ensure a greater IOP decrease after OM.

Blue-on-yellow and achromatic perimetry in diabetic children without retinopathy

OBJECTIVE

We compared blue-on-yellow perimetry with achromatic perimetry to determine whether the first was more sensitive in detecting visual field defects.

RESEARCH DESIGN AND METHODS

We studied 50 children and adolescents (22 male, 28 female) with IDDM, ranging in age from 10.1 to 16.3 years (mean 13.3+/-2.1 years), with a disease duration of 5.2-10.0 years (mean 7.1+/-1.9 years). Patients were divided into subgroups according to the presence of persistent microalbuminuria. No one had signs of diabetic retinopathy when studied with fluorescein angiography.

RESULTS

By achromatic perimetry, the analysis of subareas of the central 30 degrees of the visual field (0-9 degrees; 10-18 degrees; out of 18 degrees) showed no differences between diabetic subgroups in the central 18 degrees of the visual field, while a significant difference between the same subgroups was found outside the 18 degrees of the 24-2 program of the Humphrey perimeter (P = 0.027). By blue-on-yellow perimetry, in all three of the perimetric subareas evaluated, the sensitivity was lower in microalbuminuric patients than in normoalbuminuric ones. The differential sensitivity between the perimetric tests performed with blue-on-yellow and with achromatic stimuli showed statistically significant data, with a higher level of significance in the central 18 degrees (P < 0.0001) than outside the 18 degrees (P = 0.033).

CONCLUSIONS

Our study suggests that blue-on-yellow perimetry is more useful and more sensitive than achromatic perimetry in the detection of preclinical visual field defects in diabetic children with microalbuminuria but without clinically detectable retinopathy.

Relationship between contrast sensitivity and metabolic control in diabetics with and without retinopathy

Contrast sensitivity was studied in diabetic adolescents and young adults with and without retinopathy in order to evaluate their central vision, to analyze the relationship of metabolic control to the presence and severity of retinopathy, and to re-evaluate the response to this test after a significant improvement in metabolic control. Twenty adolescent and young adult diabetics without retinopathy and 40 diabetics with retinopathy of varying degree were enrolled in the study; 20 healthy age and sex-matched subjects served as controls. Contrast sensitivity was assessed with a CSV-1000 contrast testing instrument, testing for four spatial frequencies, 3, 6, 12 and 18 cycles per degree (cpd). Diabetics with no retinopathy showed a weak but significant difference at 18 cpd compared with controls (P = 0.04), while diabetics with background retinopathy showed a significant reduction of contrast sensitivity at 12 and 18 cpd when compared with controls (P < 0.001). In patients with preproliferative/proliferative retinopathy a highly significant reduction of contrast sensitivity at all frequencies was found compared with controls. Furthermore, these patients had a significantly lower mean contrast sensitivity than patients without retinopathy. The patients were re-evaluated after a significant amelioration of metabolic control. An improvement in contrast sensitivity was found in diabetics without retinopathy and with background retinopathy, while there was no change observed in diabetics with severe retinopathy. These results show that diabetic adolescents and young adults with and without signs of retinopathy observed by fluorescein angiography have a reduced contrast sensitivity, which is more severe in patients with preproliferative/proliferative retinopathy. A significant amelioration of metabolic control is associated with an improvement of contrast sensitivity in all patients with the exception of those patients who had signs of preproliferative/proliferative retinopathy observed by fluorescein angiography. In summary, this longitudinal study provides the first evidence that reduced contrast sensitivity is reversible in diabetics with or without background retinopathy only.

Detection of an insertion deletion of region 8q13-q21.2 in a patient with Duane syndrome: implications for mapping and cloning a Duane gene

Duane syndrome (MIM126800) is an autosomal dominant disease responsible for 1% of all strabismus cases and has been related to a 8q12-13 contiguous gene syndrome. We report on an insertion of chromosome region 8q13-q21.2 on to band 6q25 in a patient presenting with Duane syndrome, mental retardation, and other dysmorphisms. FISH analysis using chromosome 8 radiation hybrid LIA2L indicated a concurrent deletion within the 8q rearranged region. These results were corroborated by STR-PCR analysis and FISH using YAC contig WC8.8 disclosed a deletion in 8q13. Comparison of the two known patients with Duane syndrome associated with deletion of 8q identifies a small region of overlap (SRO) of < 3 cM extending from D8S533 and D8S1767 in which a Duane syndrome locus is assigned. In addition YAC analysis in our patient showed that 8q rearrangement was rather complex since 8q deletion and insertion occurred in two distinct segments separated by a region which maintained its location on 8q.

Lipids and lipoproteins in diabetic adolescents and young adults with retinopathy

PURPOSE

To compare serum concentrations of lipoproteins and apolipoproteins in insulin-dependent diabetic patients with and without retinopathy.

METHODS

A cross-sectional study was performed on 42 diabetic adolescents and young adults with different degrees of retinopathy. The mean +/- SD age of the patient was 21.1 years (range 12.8-27.9 years); their mean duration of diabetes was 12.3 years (range 7.1-19.9 years). Their glycosylated haemoglobin (HbA1c) and fructosamine were respectively 10.2% (8.2-15.4%) and 280.8 mumol/l (202.1-458.5 mumol/l). Forty-two diabetics without retinopathy similar to the study population as regards age, sex, duration of disease, HbA1c and microalbuminuria values, and 42 healthy subjects, served as controls.

RESULTS

Serum lipid and lipoprotein concentrations were not different from those of healthy controls in patients either with or without retinopathy. The diabetic patients were subdivided in two groups according to the degree of their retinopathy: background and preproliferative/proliferative retinopathy. Patients with preproliferative/proliferative retinopathy were found to have significantly higher lipoprotein (a) values than the other group (background, 73.3 IU/l; preproliferative/proliferative, 205.9 IU/l; p < 0.001).

CONCLUSION

The increase in lipoprotein (a) levels might play a role in the development of severe retinopathy.

Flicker perimetry in diabetic children without retinopathy

OBJECTIVE

To determine the flicker fusion frequency in children and adolescents with insulin-dependent diabetes mellitus (IDDM) who did not have fluorescein angiographic signs of retinopathy.

DESIGN

Cross-sectional study.

SETTING

Antidiabetic Centre, departments of Ophthalmology and Pediatrics, University of Chieti, Chieti, Italy.

PATIENTS

Forty-five patients aged 9 to 18 years with IDDM without fluorescein angiographic signs of retinopathy. Forty-five healthy subjects matched for sex and age constituted the control group. The patients were classified into two subgroups according to their metabolic control: good (percentage hemoglobin Alc 9% or less) or poor (percentage hemoglobin Alc greater than 9%).

OUTCOME MEASURES

Retinal flicker fusion frequency, evaluated with an automated flicker perimeter in the central 30 degrees of the visual field.

RESULTS

The subjects with poor metabolic control had a significantly lower mean flicker fusion frequency than the control subjects (27.43 Hz [standard deviation (SD) 5.16 Hz] vs. 38.72 Hz [SD 4.27 Hz]) and the patients with good metabolic control (33.94 Hz [SD 5.54 Hz]) (p < 0.001). There was a significant relation between flicker fusion frequency and the percentage of hemoglobin Alc (r = -0.533, p < 0.001).

CONCLUSIONS

Our results show that children with poorly controlled IDDM without fluorescein angiographic signs of retinopathy have an impairment of retinal flicker sensitivity in the central 30 degrees of the central visual field and that this impairment is related to the degree of metabolic control. Flicker perimetry is a simple, noninvasive tool that may be useful to evaluate the eye function of diabetic children.

Heparin eyedrops to prevent posterior capsule opacification

PURPOSE

To evaluate whether heparin eyedrops prevent or reduce posterior capsule opacification (PCO) after extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation.

SETTING

Institute of Ophthalmology, University G. d'Annunzio, Chieti, Italy.

METHODS

This 4 year, prospective, case-controlled study evaluated 200 patients who had ECCE and implantation of the same type of posterior chamber IOL. Patients were randomly assigned to receive topical heparin eyedrops postoperatively (heparin group, n = 100) or not to receive the eyedrops (control group, n = 100). Postoperative cell response, cellular precipitates on the IOL, and presence of PCO were evaluated.

RESULTS

There were no significant differences between groups in postoperative inflammation. The incidence of cellular precipitates was significantly lower in the heparin group than in the control group (P < .001). A neodymium:YAG (Nd:YAG) posterior capsulotomy was done in 7 patients in the heparin group and 14 in the control group (P = .15). During the first 24 months after surgery, the heparin group had a significantly lower incidence of Nd:YAG capsulotomy (P < .05) and fibrotic PCO (P = .02).

CONCLUSION

Topical heparin eyedrops were effective in reducing fibrotic PCO in the long term, indicating their usefulness in the postoperative management of ECCE.

Polycyclic aromatic hydrocarbons in bovine lens

A study was performed to detect the presence of polycyclic aromatic hydrocarbons (PAHs) in bovine eyes. Twenty fresh bovine eyes were used to detect the presence of PAHs in lens, vitreous and aqueous by HPLC and spectrofluorometer. In lenticular tissue the mean amount of PAHs was 0.0271 microgram/g and the mean level of PAH in each lens was 0.059 microgram. Five types of PAHs (pyrene, fluoranthene, triphenylene, 1.2-benzanthracene and chrysene) were found in the lenses but none in vitreous and aqueous. These data indicate that PAHs are present only in the lens of the bovine eye. The source of these substances in mammalian clear lens is unclear.

Hypoxanthine and xanthine levels in human aqueous humor from cataractous eyes

Purine nucleotide degradation products have been determined by HPLC in aqueous humor obtained during cataract surgery and from plasma of 22 patients (12 women). Uric acid, cytosine, guanosine monophosphate, uracyl, guanine, adenosine, adenosine monophosphate, thymine, adenine, inosine, cyclic guanosine monophosphate, hypoxanthine and xanthine were evaluated. Uric acid and the last two were the only compounds detectable in measurable amounts in aqueous humor and in plasma of all patients. Aqueous humor xanthine levels were not significantly different from plasma; aqueous humor hypoxanthine concentrations were lower than those of xanthine and than plasma oxypurine levels. In 8 patients, treated with allopurinol, oxypurinol concentrations in aqueous humor and in plasma were comparable suggesting that oxypurines are transported through the blood-aqueous humor barrier.

The usefulness of dapiprazole, an alpha-adrenergic blocking agent, in pigmentary glaucoma

The aim of this study was to increase understanding of the usefulness of an alpha-adrenergic blocking agent, dapiprazole 0.5% eyedrops, as an adjunct in antiglaucomatous therapy for 20 patients with pigmentary glaucoma receiving timolol 0.5% and pilocarpine 1%. After 12 months of dapiprazole treatment, the difference from the pretreatment mean intraocular pressure (IOP) value was statistically significant (P = .005). After 12 and 36 months of treatment, an hour-to-hour comparison of diurnal IOP curve values showed a statistically significant difference in all cases (P < .001). Although further investigations may be necessary to reach a definite conclusion, dapiprazole appeared to have a beneficial, stable in time effect in these patients.

Tear deficiency in Fuchs' intermediate uveitis

OBJECTIVE

To assess quantitatively and qualitatively tear secretion in Fuchs' intermediate (heterochromic) uveitis to detect any possible anomaly linked to Fuchs' uveitis.

DESIGN

Prospective study.

SETTING

University eye clinic, Chieti, Italy.

PATIENTS

Thirty consecutive white patients aged 32 to 65 years with unilateral Fuchs' heterochromic uveitis.

OUTCOME MEASURES

Results of Schirmer's test I, tear film breakup time, conjunctival mucus ferning.

RESULTS

Schirmer's test I showed a tear deficiency in 15 patients; the tear film breakup time and ferning were abnormal in these patients. There was a significant difference in the test results between the affected eyes and the fellow, unaffected eyes (p < 0.001). There was no relation between tear deficiency and age.

CONCLUSIONS

The presence of tear anomalies only in the affected eye of patients with Fuchs' heterochromic uveitis suggests a link between Fuchs' uveitis and tear deficiency.

Are VEP abnormalities in optic neuritis (ON) dependent on plaque size? A reappraisal of the physiopathology of ON based on improved MRI and multiple-lead recordings

Twenty patients with optic neuritis (ON) described in the previous study [23] underwent serial VEP recordings (using multiple electrode arrays) for two years. The VEPs could be correlated with the lesions revealed by MRI, Visual Field tests and other clinical findings. On the basis of their scalp distribution, they were classified as "really delayed" VEPs and "pseudo-delayed" VEPs. Real delays could be recorded at the onset of ON or shortly afterwards, and their appearance indicated the recovery of visual function and a good prognosis. Pseudo-delays indicated an alteration in the visual field and, unless a breakthrough of normal or delayed components appeared in the first three months, following acute ON, indicate a poor prognosis for the recovery of visual function. The pseudo-delayed VEPs were mainly observed in patients with longer lesions revealed by means of LTE-STIR MRI [23]; there was no correlation between VEP latency and the length of plaques. Our findings contradict previous theories on the timing of conduction alterations in ON and multiple sclerosis.

The effectiveness of dapiprazole in preventing exercise-induced IOP increase in patients with pigmentary dispersion syndrome

PURPOSE

The authors investigated the use of dapiprazole, an alpha-adrenergic blocking agent, in preventing pigment release and IOP increase after exercise in patients affected with PDS.

METHODS

Three young myopic males (31, 34 and 35 years old) affected with pigmentary dispersion syndrome performed 30 minutes of jogging on a computerized treadmill. Telemetric heartbeat measurement was performed to obtain constant pulse rate training. Computerized tonography and IOP measurement were performed 10 minutes after the exercise. After one month the patients repeated the same exercise after pre-treatment with dapiprazole 0.5% eyedrops (one drop 30, 20 and 10 minutes before the exercise). Ten minutes after the exercise IOP measurements and computerized tonography were repeated.

RESULTS

After 30 minutes of exercise IOP measurements showed values ranging from 19 to 45 mmHg (mean 30.33; SD 8.73). Computerized tonography C values after exercise ranged from 0.04 to 0.16 (mean 0.09; SD 0.04). After pre-treatment with dapiprazole 0.5% eyedrops, IOP values ranged from 18 to 28 mmHg (mean 23.33; SD 3.44) and tonography C values ranged from 0.10 to 0.20 (mean 0.14; SD 0.03).

CONCLUSIONS

The study supports the concept that exercise-induced pigment release temporarily obstructs the acqueous outflow channels, causing IOP increase in some patients with PDS. Pre-treatment with dapiprazole was useful in reducing IOP spikes and in increasing tonographic total outflow facility after exercise. The absence of induced myopia and the lack of dangerous vitreoretinal tractions on retinal periphery make dapiprazole a safe method to reduce exercise-induced pigment dispersion.

Effect of dapiprazole, an alpha-adrenergic blocking agent, on aqueous humor dynamics in pigmentary glaucoma

PURPOSE

In this investigation the authors studied the effect of dapiprazole, an alpha-adrenergic blocking agent, on aqueous humor dynamics in patients affected with pigmentary glaucoma.

METHODS

Dapiprazole 0.5% eye drops were administered 3 times daily as adjunctive therapy to 16 pigmentary glaucoma patients in addition to timolol 0.5% eye drops twice daily. Computerized tonography was performed before and 3, 12 and 36 months after dapiprazole treatment. Sixteen sex- and age-matched pigmentary glaucoma patients treated with timolol 0.5% eye drops alone were used as a control group.

RESULTS

After 36 months of follow-up, the dapiprazole-treated group showed a significant increase in total outflow facility (C, from 0.17 +/- 0.04 to 0.22 +/- 0.07 ml min-1 mm Hg-1; p = 0.010, paired t test) and Po/C ratio (Q) significantly decreased from 113.39 +/- 31.02 to 89.22 +/- 51.66 (p = 0.036, paired t test).

CONCLUSIONS

Our results show that the introduction of dapiprazole in the therapy of pigmentary glaucoma may be useful in the long-term management of these patients. Its mechanism of action is likely to be due to iridoplegia; in fact, a decrease in the shedding of pigment occurs, with time, the outflow facility increases and the pigment clearance from the trabecular meshwork is enhanced.

Diabetic retinopathy. Relationship with nephropathy in pediatric age

In order to evaluate the relationship between diabetic retinopathy and diabetic nephropathy we studied 55 (25 females, 30 males) retinopathic diabetic children and adolescents: their age ranged from 9.0 to 17.3 (mean +/- SD 13.9 + 3.8) years and the duration of disease from 4.8 to 10.0 (6.9 +/- 3.1) years. The mean glycosilated haemoglobin (HbA1c) was 10.4 + 2.7%. Patient distribution in relation to retinal grading showed that the greatest number of patients (34: 61.82%) were in 14-20 retinopathy level (with minimal signs of retinopathy), 9 patients showed 31 retinopathy level (16.36%) and 12 (21.82%) were in the other classes. Comparison between retinal grading of retinopathy and presence/absence of microalbuminuria showed a significant difference between the evaluated subgroups (p < 0.0001). In fact, only 6 patients out of 34 (17.64%) in class 14-20 retinopathy level, 8 patients out of 16 (50%) in 31-41 retinopathy level and 5 patients out of 5 (100%) in 51 retinopathy level had microalbuminuria. Our study shows that the presence of persistent microalbuminuria is an important risk factor for diabetic retinopathy. In conclusion, we suggest that when diabetic children have persistent microalbuminuria, the eye should be carefully examined, in order to prevent a deterioration of the eye function.

Aqueous misdirection syndrome: a complication of neodymium: YAG posterior capsulotomy

A 50-year-old, white, pseudophakic man who had a neodymium:YAG (Nd:YAG) posterior capsulotomy for capsule opacification developed a persistent rise in intraocular pressure (IOP) associated with a flat anterior chamber. Full-thickness patent iridotomy performed with an Nd:YAG laser did not reduce IOP. A-scan ultrasonography showed aqueous pockets in the vitreous, leading to a diagnosis of malignant glaucoma. Medical therapy comprising atropine, phenylephrine, mannitol, and acetazolamide normalized IOP and resolved the clinical findings.

Iris chafing in pseudophakia

Iris defects occur in pseudophakic patients with posterior chamber intraocular lens in sulcus. Prevalence of pigmentary dispersion syndrome and pigmentary glaucoma has been evaluated in 920 pseudophakic patients (920 eyes). 16.08% of patients showed pigment dispersion syndrome, while 1.96% developed pigmentary glaucoma. Diabetic patients had a statistically significant greater prevalence of these complications than non-diabetic ones (p < 0.05). The authors suggest the preventive use of alpha-blockers in presence of pigment dispersion syndrome or diabetes mellitus, even in absence of ocular hypertension.

Polycyclic aromatic hydrocarbons in clear and cataractous human lenses

In this histochemical study on the ocular lens, the authors test for the presence of various sorts of the (unsaturated) polycyclic aromatic hydrocarbon (PAH) in 66, both clear and cataractous human lenses. A statistically significant greater amount of PAH is found in the cataractous lenses studied (p < 0.01), with two kind of PAH, phenanthrene and 1,2-benzoanthracene, appearing exclusively in lenses with cataracts. The authors put forward a hypothesis on the cataractogenic effect of PAH on the basis of its interference with lens metabolism and the subsequent production and release of free-radicals.

Effectiveness of intraoperative mitomycin C in the treatment of recurrent pterygium

The effectiveness of intraoperative administration of mitomycin C and the occurrence of postoperative complications have been evaluated in 30 white patients with one recurrence of pterygium. The authors employed the 'bare-sclera technique' and, intraoperatively, placed in the episcleral space for 3 min a sterile sponge soaked in a 4% mitomycin C solution. The control group (30 patients with one recurrent pterygium) underwent only surgical excision. Statistical analysis performed using the chi-square test showed a significant (p = 0.024) reduction of recurrences of pterygium in the group treated intraoperatively with mitomycin C. No heavy side effects occurred during the follow-up period. Mitomycin C, administered intraoperatively, may be considered an effective treatment to improve the success rate after surgical excision.

Topical naphazoline in treatment of myopathic ptosis

We instilled naphazoline Hcl (0.1%), an imidazole derivative with preferential alpha-2 activity, in 17 eyes of 12 patients with myopathic ptosis due to involvement of the levator palpebrae superioris, in the attempt to selectively stimulate Müller's smooth muscle. Naphazoline significantly widened the palpebral fissure with little change in pupillary diameter and no significant change in ocular pressure, visual acuity and near point determination. However, a reduction of the effect, probably due to tachyphylaxis, was noticed when using naphazoline regularly several times a day for few weeks. In conclusion naphazoline has powerful cosmetical and functional effects in mild to moderate myopathic ptosis above all if taken occasionally.

Effect of pulsed ultrasound on human erythrocytes in vitro

Pulsed echo sonication of whole blood affects the O2-Hb dissociation curve and produces modifications of the erythrocyte membrane, whereas Hb remain unchanged. After sonication ATP-ase (Na+K+ dependent) activity and agglutination disappear. Sonication detaches erythrocytes-membrane antigens which are found in the supernatant, this effect is reversible. AB antigens detached by sonication were transferred to sonicated O group erythrocytes. Examination by transmission electron microscopy suggested that the glycoproteic cup or glycocalyx of the red cells was removed as a result of sonication.