After-cataract in the rabbit eye following extracapsular cataract extraction--a wound healing reaction

The cellular response in lens remnants was studied after ECCE in the rabbit eye. Following capsulotomy, the lens content was gently exprimated. No aspiration/irrigation was performed. Degenerative changes were found in the lens fibers and lens epithelium at the equator. Proliferation of lens epithelium started early. Lens fibers break-down almost ceased when lens fibers had been enclosed by proliferating epithelium, that also formed new foci for lens fiber formation. In the opening between the anterior and posterior capsule fibroblastlike cells emerged proliferating on to the posterior capsule.

Universal opacity standard for Scheimpflug photography

PURPOSE

To develop a universal standard for comparison of the results from different studies using Scheimpflug photography.

MATERIAL AND METHOD

A suspension including polystyrene spheres was selected as the universal standard. The polystyrene suspension was diluted into 10 concentrations by adding spectroscopic quality water. An artificial eye chamber was designed to hold the diluted suspension for photography. Each concentration was photographed by both a Topcon SL-45 slit-lamp camera and a Nidek EAS-1000 system. The intensity of back-scattered light was analyzed statistically.

RESULTS

The relationship between the concentration of the polystyrene suspension and the internal gray scale step within the Topcon SL-45 camera can be described by a second-order polynomial. The relationship between the concentration of the polystyrene suspension and the measurement of the Nidek EAS-1000 system can also be expressed by a second-order polynomial. The relationship between the Topcon SL-45 camera and the Nidek EAS-1000 system is linear.

CONCLUSIONS

The results of lens nuclear opacity measured with different Scheimpflug cameras can be compared using the method established in the study. The linear relationship between the Topcon SL-45 and Nidek EAS-1000 systems can be used to convert measurements from one system to the other.

3 year simvastatin treatment and lens nuclear back scattering

AIM

To determine if 3 year treatment of hypercholesterolaemia with simvastatin causes an increase of lens nuclear back scattering.

METHODS

160 patients with hypercholesterolaemia in the Scandinavian Simvastatin Survival Study (4S) were followed for 3 years. Half (80) of the patients took simvastatin and half (80) received placebo. The lens was photographed with a Topcon SL-45 slit lamp camera at the beginning and at 1 year intervals. A common lens nuclear area was used for measuring lens nuclear back scattering.

RESULTS

Nuclear back scattering increased with age and there was more pronounced scattering in women than in men. Lens nuclear back scattering did not differ significantly between the simvastatin and placebo groups, but the power was low (0.2). Lens nuclear back scattering increased during the study period independently of baseline back scattering, age, and sex for both groups.

CONCLUSION

Although no significant difference was found between the simvastatin and placebo groups, the currently available data are insufficient for exclusion of the possibility that taking simvastatin during a 3 year period increases nuclear back scattering. However, a possible minor increase of nuclear back scattering is clinically irrelevant considering known beneficial effects of simvastatin on coronary heart disease.

Reliability of the drop test for the lacrimal drainage function

PURPOSE

The purpose of this study was to investigate the reliability of the drop test.

METHODS

The repeatability of the test was studied with the same and three different examiners. The influence of the blink rate was investigated by recording the blink frequency in 63 subjects. The degree of reflex lacrimation during the test was assessed in ten patients. The effect of different test solutions was investigated in ten test subjects.

RESULTS

There was no significant difference when the test was repeated either by the same or different examiners. The reflex lacrimation during the drop test was not significant. There was no correlation between drop test result and blink rate. A moderate increase in the viscosity of the test solution affected the lacrimal drainage.

CONCLUSION

The drop test is a reliable test for the lacrimal drainage function.

Liminality: a major category of the experience of cancer illness

Narrative analysis is well established as a means of examining the subjective experience of those who suffer chronic illness and cancer. In a study of perceptions of the outcomes of treatment of cancer of the colon, we have been struck by the consistency with which patients record three particular observations of their subjective experience: (1) the immediate impact of the cancer diagnosis and a persisting identification as a cancer patient, regardless of the time since treatment and of the presence or absence of persistent or recurrent disease; (2) a state of variable alienation from social familiars, expressed as an inability to communicate the nature of the experience of the illness, its diagnosis and treatment; and (3) a persistent sense of boundedness, an awareness of limits to space, empowerment and available time. These subjectivities were experienced in varying degree by all patients in our study. Individual responses to these experiences were complex and variable. The experiences are best understood under the rubric of a category we call "liminality". We believe that all cancer patients enter and experience liminality as a process which begins with the first manifestations of their malignancy. An initial acute phase of liminality is marked by disorientation, a sense of loss and of loss of control, and a sense of uncertainty. An adaptive, enduring phase of suspended liminality supervenes, in which each patient constructs and reconstructs meaning for their experience by means of narrative. This phase persists, probably for the rest of the cancer patient's life. The experience of liminality is firmly grounded in the changing and experiencing body that houses both the disease and the self. Insights into the nature of the experience can be gained from the Existentialist philosophers and from the history of attitudes to death. Understanding liminality helps us to understand what it is that patients with cancer (and other serious illnesses) seek from the system to which they turn for help. Its explication should therefore be important for those who provide health care, those who educate health care workers and those concerned to study and use outcomes as administrative and policy making instruments.

Randomized study of the blood-aqueous barrier reaction after phacoemulsification and extracapsular cataract extraction

PURPOSE

To compare the blood-aqueous barrier (BAB) breakdown after endocapsular phacoemulsification and extracapsular cataract extraction (ECCE).

METHODS

Forty-two patients (64-82 years) enrolled for cataract surgery were randomly assigned to phacoemulsification (group I) or ECCE (group II). Patients with pseudoexfoliation syndrome, small pupils, glaucoma, uveitis, dark brown irides, diabetes, treatment with eye drops or anti-inflammatory drugs were excluded. In group I the patients were operated with continuous curvilinear capsulorhexis (CCC), phacoemulsification and implantation of a poly-(methyl methacrylate) (PMMA) intraocular lens (IOL) through a 5.2 mm self-sealing incision. In group II linear capsulotomy, nucleus expression and PMMA IOL implantation through a large incision (10-11 mm) were performed. The incision was sutured. Before surgery and three days and three months after surgery postoperative inflammation and BAB reaction were measured by laser flare photometry and anterior chamber fluorophotometry after intravenous administration of fluorescein. The BAB diffusion coefficient was calculated. Laser flare photometry was performed also after one and two years.

RESULTS

According to fluorophotometry, ECCE induced significantly more postoperative BAB breakdown than did phacoemulsification at three days (p=0.00016) and three months (p=0.00829). Laser flare photometry showed more inflammation in the ECCE group than in the phacoemulsification group at three days postoperatively (p=0.00005).

CONCLUSIONS

This study suggests that cataract surgery performed with a small, self-sealing incision, CCC and phacoemulsification induces a reduced surgical trauma with less BAB breakdown compared to ECCE using a large sutured incision, linear capsulotomy and nucleus expression.

Risk of acute suprachoroidal hemorrhage with phacoemulsification

PURPOSE

To establish whether small incision cataract surgery with phacoemulsification decreases the risk of acute suprachoroidal hemorrhage (ASCH) compared with traditional nucleus expression by extracapsular cataract extraction (ECCE).

SETTING

St. Erik Eye Hospital, Stockholm, Sweden.

METHODS

A retrospective study was done on the incidence of ASCH in cataract surgery between July 1990 and July 1996. During this period, 37,565 cataract extractions (phacoemulsification and ECCE) were performed at St. Erik Eye Hospital, combined procedures excluded. The criteria for diagnosis were the suspicion of ASCH during surgery and a verified diagnosis via an expulsive hemorrhage into the wound (4 cases), postoperative ultrasonic examination (20 cases), or a choroidal mass on performing ophthalmoscopy together with a postoperative history alluding to the diagnosis (2 cases).

RESULTS

Twenty-six eyes were identified with ASCH, including 7 during phacoemulsification and 19 during ECCE. The incidence of ASCH was 0.03% in the 23,213 phacoemulsification cases and 0.13% in the 14,352 ECCE cases. The difference was statistically significant (P = .0003; chi-square test).

CONCLUSION

Small incision surgery with phacoemulsification decreased the risk of ASCH in cataract surgery compared with the traditional nucleus expression technique.

Contrast sensitivity after implantation of diffractive bifocal and monofocal intraocular lenses

PURPOSE

To compare contrast sensitivity (CS) after implantation of a diffractive bifocal intraocular lens (IOL) and a monofocal IOL of similar design.

SETTING

Seven European centers.

METHODS

In this randomized, prospective study, CS was tested 5 months after cataract and IOL implantation surgery in 115 patients with a diffractive bifocal IOL and 106 patients with a monofocal IOL. It was also tested in a subgroup of 38 patients who had bilateral implantation of a diffractive bifocal IOL. Contrast sensitivity was tested using the Vision Contrast Test System (VCTS).

RESULTS

In patients with a best corrected visual acuity (BCVA) of 1.0 or better, the CS at all spatial frequencies (1.5 to 18 cycles/degree), both at distance and near, was slightly lower in the bifocal IOL group than in the monofocal group. Mean values were within the normal range. In patients with a BCVA of less than 1.0, the CS was lower and the difference between the bifocal and monofocal groups was less. In patients with bilateral bifocal IOLs, CS was better when tested bilaterally than when testing the better eye alone. Pupil size affected the results to a small degree. Contrast sensitivity appeared to improve over time after implantation of a diffractive bifocal IOL.

CONCLUSIONS

In patients with cataract and no other eye pathology, the diffractive bifocal IOL with slightly reduce the CS at all spatial frequencies. In those with reduced visual acuity after cataract surgery, CS will be reduced accordingly. In this situation, the reduction from the diffractive bifocal optic would be minor.

Lens epithelial growth on the anterior surface of hydrogel IOLs. An in vivo study

PURPOSE

Descriptive study designed to investigate the cellular event occurring on the anterior surface of a hydrogel intraocular lens (IOL), Hydroview model H60M over 3 years following implantation.

METHODS

Slitlamp photos and specular microscopy were performed on 25 subjects at specified intervals following implantation in order to document the morphology and extent of the cellular reaction on the anterior surface of the IOLs. A laser flare meter was used to evaluate the post-op inflammation.

RESULTS

In 13 of the 25 cases proliferation of lens epithelial cells (LECs) was detected on the anterior surface at various levels of severity.

Growth factors and their receptors in the anterior chamber. Absence of epidermal growth factor and transforming growth factor alpha in human aqueous humor

The involvement of growth factors such as epidermal growth factor (EGF) in regenerative processes of corneal endothelium and lens epithelium has recently been suggested. However, knowledge on the presence of growth factors in anterior chamber fluid (ACF) is still very restricted. Although we have previously shown that EGF is undetectable in the ACF of normal eyes undergoing cataract surgery even by the use of high-sensitivity assays, this does not exclude the possible presence of other, EGF-like proteins in ACF such as transforming growth factor alpha (TGF-alpha). In the present study, we have hence determined in ACF samples of 70 human eyes the concentrations of both EGF and TGF-alpha. As assays served ELISA techniques and RIA. In none of all the samples investigated could detectable amounts of EGF, i.e. above 0.2 pg/ml (detection limit of the assay), be found, confirming earlier results. Interestingly, however, also no TGF-alpha could be detected in ACF. If present at all, the level of any TGF-alpha concentration in ACF was hence below the detection limit, i.e. less than 20 pg/ml. Based on the results of this study, it seems therefore that under physiological conditions there is no measurable presence of free EGF or TGF-alpha in human ACF. Existing receptors in the structures of the anterior segment must hence have ample binding capacity which could explain the effect of externally applied growth factors. The physiological and clinical importance of this result is briefly outlined.

Spatial distribution of back scattering in the nuclear area of the non-cataractous human lens

The spatial distribution of back scattering from a vertical cross-section of the nuclear area in non-cataractous human lens was investigated. The cross-section was centred on the pupil. There is no significant difference in average nuclear back scattering between sides. The distribution of back scattering along an axis perpendicular to the anatomical axis can be modelled as a second-order polynomial. It is believed that the increase of back scattering in the central region corresponds to the peak protein concentration in the centre of the nucleus. This information was obtained by imaging back scattering with Scheimpflug photography. The back scattering was measured photometrically in a 3 x 10 matrix of measuring areas within the lens nucleus. Each measuring area was 0.20 x 0.20 mm in size. It is anticipated that the established model will allow detection of nuclear cataract with high sensitivity, especially in early stages.

A common lens nuclear area in Scheimpflug photographs

Scheimpflug photography has been proven to be a useful method for documentation of opacification of the lens nucleus. In the present study, a common lens nuclear area (CNA) is established for photometry of nuclear cataract on Scheimpflug photographs. Using the established method, one measurement for one photograph, and one photograph for each subject is enough for the photometry of nuclear density. Further, this method allows detection of a 10% change in nuclear density between two occasions with a group of at least 7 subjects, and for independent groups with at least 95 subjects in each group (alpha = 0.05, beta = 0.10). It is anticipated that the CNA will provide a useful tool for quantitative determination of nuclear cataract.

Evaluation of gray scale steps on Scheimpflug photographs

A method for the calibration of gray scale density in a Scheimpflug photograph was established. Based on the result of statistical analysis, it was found that variability in the film emulsion was insignificant if the measuring area > or = 0.01 mm2. Each lens image should be calibrated with the reference gray scale in the same photograph. Photometric readings of the lens image was converted to gray scale levels. This conversion can be obtained from fitting photometric readings of the gray scale as a function of gray scale steps with a third order polynomial. Adopting this calibration procedure, 95% of estimated nuclear densities are within +/- 3-5% of the real value.

Heparin surface modified intraocular lenses. Three-month follow-up of a randomized, double-masked clinical trial

Two types of intraocular lenses (IOLs) were used in a controlled, randomized, double-masked clinical trial. The study lens was a one-piece, poly(methyl methacrylate) (PMMA) lens with heparin grafted on the entire surface. The control lens was identical in all respects but lacked the heparin surface. The IOLs were implanted in the capsular bag after extracapsular cataract extraction in 266 patients. No unexpected reactions or severe complications occurred. The postoperative visual acuity of all cases at the three-month visit was 20/40 or better in 91.6% of the heparin group and in 86.2% of the control group. When excluding cases with preoperative pathology, 97% of the heparin group and 95% of the control group had a visual acuity of 20/40 or better. A mild iritis was observed in one case of the heparin group and in four cases of the control group at three months. At three months there was a statistically significant difference between the heparin surface modified and control IOLs for both the number of patients with cellular precipitates and the number of precipitates per IOL. From the present data we conclude that during the first three postoperative months heparin surface modified lenses are more biocompatible than PMMA lenses.

A superficial corneal lesion of unknown origin

Three patients are described showing corneal changes of unknown origin previously not described. The changes consist of discrete opacities mostly located in the epithelium of the cornea. The opacities are arranged in a continuous are originating from the limbus with the vertex extending towards the optic zone. The cornea inside and outside the arc was normal during the early stages of the disease. In two of the cases a progress of the changes were recorded and a stromal opacity developed inside the arc. The three cases were all unilateral. Bacterial and fungal cultures, virus isolation, several blood tests, serology and immunological tests have been negative. Light- and electron microscopy of biopsied material show intracellular specific epithelial cell changes in the form of perinuclear vacuoles. None of the treatments tried were successful.

Heparin surface modified intraocular lenses--a one-year follow-up of a safety study

PMMA intraocular lenses have been modified by bonding a monolayer of Heparin molecules to the surface. These Heparin surface modified (HSM) IOLs were implanted in the capsular bag after extracapsular cataract extraction. Sixty-six patients were followed for 12 months in an open safety study. No unexpected reactions or severe complications occurred. Eighty-nine per cent of the patients obtained a visual acuity (VA) of 0.5 or more at the 12-month visit. When excluding cases with preoperative pathology only one case (1.5%) had less VA than 0.5. A mild postoperative iritis was seen during the first week after surgery, and in only three cases at a later visit. Cell precipitates were seen in a small number of cases. From this study and from earlier in vitro and in vivo animal studies we draw the conclusion that the Heparin surface modified IOLs are safe for implantation in human eyes.

Cellular reactions on heparin surface-modified versus regular PMMA lenses during the first postoperative month. A double-masked and randomized study using specular microphotography

Specular microscopy was used for investigation of cellular reactions on the intraocular lens (IOL) anterior surface of Heparin surface-modified (HSM) versus regular polymethylmethacrylate (PMMA) lenses (Pharmacia types 700C versus 700B, respectively). The double-masked randomized study included 53 patients investigated at 1 and 4 weeks postoperatively. Giant cells were only found on control lenses and more frequently at 4 weeks. Small cells were found on both lens types, but in a higher frequency on the control lenses. The number of small cells decreased during the first 4 weeks on both the control and HSM lenses. However, those control lenses that had giant cells on their surface showed an increase in the number of small cells during the same time. The results of the current study show that HSM lenses give rise to less postoperative inflammatory cellular reactions than regular PMMA lenses.

Heparin surface modified intraocular lenses implanted in the monkey eye

The biocompatibility of heparin surface modified poly(methyl methacrylate) intraocular lenses (IOLs) was evaluated in two experiments following implantation in the anterior and posterior eye chambers of adult cynomolgus monkeys. Throughout the study, large inflammatory cells and prominent pigment deposits were seen on the unmodified lenses, whereas the heparin surface modified IOLs remained almost free of precipitates. Similarly, fewer posterior synechias were observed in eyes implanted with surface modified IOLs in the posterior chamber than in eyes implanted with control lenses. Histopathological examination of enucleated eyes confirmed the clinical findings. These experiments strongly support the idea that surface modification with heparin is a useful way to reduce clinical complications following cataract surgery with IOL implantation.

Nuclear cataract--a microradiographic study

Nuclear cataract is a common type of senile cataract characterized by an increased turbidity and often a yellow to brown pigmentation of the nucleus. Twenty-one human lenses with different degrees of nuclear turbidity were, after intracapsular cataract extraction, examined by a quantitative microradiographic technique. The dry mass concentration was determined along the lens axis, and revealed an overall distribution similar to the normal lens. The concentration increased from the poles towards the center of the lens, to reach a mean level of 0.47 g.cm-3 (range 0.38-0.55). Though the appearance of the nucleus as well as the dry mass were relatively uniform. In addition, different types of formations with reduced or increased dry mass were found in the nucleus. The location of these formations are described and their nature discussed.

Infrared radiation and cataract II. Epidemiologic investigation of glass workers

An epidemiologic investigation on the prevalence of cataract in glass workers is presented. The study includes 209 workers over 50 years of age exposed to infrared (IR) radiation in the Swedish manual glass industry for 20 years or more, and 298 non-IR-exposed controls. The examination includes an evaluation of the individual IR-exposure and an ophthalmological examination with special reference to the lens. In IR-exposed workers 70 years of age and older there is a statistically significant increase of aphakia and of all types of cataract, subcapsular, cuneiform and nuclear, compared to the controls of the same age group. In the same age group the risk for an IR-exposed worker to have his vision reduced by cataract to 0.7 or less is 2.5 times as high as for non-exposed controls (95% confidence interval 1.4-4.4). The risk that he will have to be operated for cataract is 12 times as high (95% confidence interval 2.6-53). It is concluded, that the occupational IR-exposure of the glass workers accelerates the development of senile changes in the lens. All workers with a high exposure to IR radiation should be equipped with adequate eye protection.

Infrared radiation and cataract. I. Epidemiologic investigation of iron- and steel-workers

The aim of the presented study was to establish if occupational exposure to infrared (IR) radiation increases the risk of developing cataract, and to correlate the lens findings to the degree of exposure. The eyes of 208 IR-exposed workers and 208 controls, all from 6 Swedish iron and steel manufacturing plants, were examined. An increased prevalence of wedge-shaped opacities was found in IR-exposed persons 60 years of age and older. This type of lens opacity is normally considered to be a purely senile change. Acceleration of senile changes by IR radiation is suggested. Stratification of the material with regard to exposure was made on different grounds, but failed to show a dose-effect-correlation.

Nuclear cataract and myopia during hyperbaric oxygen therapy

The effect on the human lens of prolonged hyperbaric oxygen therapy is reported. Eye examinations were given to 25 patients before, during, and after a series of 150 or more exposures to hyperbaric oxygen. All patients changed refraction in the direction of myopia during treatment. Fifteen of the patients had clear lens nuclei before treatment. Seven of these developed a nuclear cataract with reduced visual acuity during treatment. Reversible lens myopia has previously been noticed as a side effect of exposure to hyperbaric oxygen, but the cataractogenic effect in man has not been reported by other workers. This report strongly supports the theory of an oxidative damage to the lens proteins as a cause of nuclear cataract.

Atopic cataract: changes in the lens epithelium and subcapsular cortex

Two lenses with atopic cataract, one from a 33-year-old man and one from a 50-year-old man, were examined by light and electron microscopy. The younger man had an anterior polar cataract and the older a subcapsular opacification of the entire subcapsular cortex. In the younger lens the epithelial cells in front of the anterior opacity were extremely large and contained an increased number of mitochondria. In the older lens epithelial cells were missing centrally. These morphological changes probably reflect a malfunction of the lens epithelium.

Calcification in the human lens

A calcified cataractous lens from a 12 year old boy suffering from chronic uveitis was analysed using a microradiographic technique, X-ray crystallography and transmission electron microscopy. A 0.2 mm thick shell of calcified tissue was found in the subcapsular cortex. The mineral consisted of well-crystallized hydroxyapatite with a random orientation of the crystals. The underlying cortex consisted of a fibrous matrix containing collagen fibers. In the matrix, single or groups of epitheloid cells and fibroblast-like cells were found. Membrane-enclosed vesicles were found scattered in the matrix. The content of these vesicles had a wide range of electron density. A cell-induced mechanism for calcification is suggested.

Exposure to organic solvents. A cross-sectional epidemiologic investigation on occupationally exposed care and industrial spray painters with special reference to the nervous system

In the present epidemiologic study 80 car or industrial spray painters with long-term low level exposure to organic solvents were examined and compared with two matched reference groups of nonexposed industrial workers (80 persons in each group). The aim of the study was to investigate the possible effects of the solvent exposure on health. The investigation included psychiatric interviews, psychometric tests, neurological, neurophysiological and ophthalmologic examinations, and computed tomography of the brain. The painters' previous and present exposure was carefully assessed by interviews and on-the-job measurements both at modern places of work and in a reconstructed model of a workshop from 1955. On the basis of the psychiatric interviews the psychiatric symptoms were rated according to a specially designed scale of 46 different items, graded in seven steps of increasing severity. The psychological performance was assessed by a battery of 18 tests. The neurological and neurophysiological examinations comprised visual evoked responses (VER), electroencephalography (EEG), and computerized EEG analysis (SPA) for the central nervous system and electroneurography (ENeG), the estimation of vibration sense thresholds, and a quantified neurological examination for the peripheral nervous system. The ophthamologic examination concentrated on the condition of the lens. Statistically significant differences between the exposed individuals and referents were found for psychiatric items indicative of a slight cerebral lesion (ie, a neurasthenic syndrome). The psychometric tests revealed statistically significant differences between the groups with respect to reaction time, manual dexterity, perceptual speed, and short-term memory. No differences were found with respect to performance on verbal, spatial, and reasoning tests. Significant differences between the groups were also found for the majority of the neurophysiological parameters measuring peripheral nerve functions, the most pronounced occurring in the long, sensory fibers. Moreover EEG and VER showed some differences between the groups, as did the results of the ophthalmologic examination and the computed tomography. Finally, it should be emphasized that the exposure levels, as measured at modern places of work and in the reconstructed workshop from 1955, were found to be considerably lower than the valid threshold limit values in Sweden.

Fish-eye disease. A new familial condition with massive corneal opacities and dyslipoproteinaemia

A man and his three daughters had massive corneal opacities called in their home village "fish-eye disease" because of the resemblance of the eyes to those of boiled fish. The two living daughters had the same dyslipoproteinaemia, characterised by normal serum cholesterol but raised serum triglycerides, raised very-low-density lipoproteins, strikingly high levels of low-density lipoprotein (LDL) triglycerides. LDL contained normal sized as well as abnormally large particles and a 90% reduction in the level of high-density lipoprotein (HDL) cholesterol. Lecithin:cholesterol acyltransferase (LCAT) activity and the percentage of plasma cholesterol esters were normal, with excluded LCAT-deficiency. Normal electrophoretic mobility of HDL as well as other lipoprotein findings excluded Tangier disease. The clinical and laboratory abnormalities in fish-eye disease are atherosclerosis at old age, visual impairment, and dense corneal opacification. Fish-eye disease thus differs both clinically and in its lipoprotein abnormalities from LCAT-deficiency and Tangier disease.

Absorption studies in patients six to 10 years after construction of ileostomy reservoirs

The absorption of fat, bile salts, and vitamin B12 was studied in 14 proctocolectomised patients six to 10 years after construction of a continent ileostomy. All patients were in excellent health and displayed no signs of malnutrition. Schilling test disclosed subnormal absorption of vitamin B12 in one patient and borderline values in five. Faecal loss of bile acid was increased in 12 patients and fat malabsorption occurred in two. Except for slightly pathological liver tests in two patients, routine laboratory tests, including plasma concentration of vitamin B12 and folic acid, were normal. There were no signs of sodium or potassium depletion.

Mucosal morphology, bacteriology, and absorption in intra-abdominal ileostomy reservoir

Six patients who had undergone proctocolectomy and been provided with intra-abdominal ileostomy reservoirs were studied in intervals during the 24 postoperative months. The studies included the mucosal morphology, bacteriology, and the local absorption in the reservoir. The results showed that the mucous membrane of the terminal ileal segment used for construction of the reservoir underwent morphological changes characterized by an increased cell turnover and a shortening of the villi. These changes in morphological structure took place rather promptly after construction of the reservoir. No indications for a continuously progressing process could be found. The brushborder was intact and no cellular lesions were discovered. Soon after construction the reservoir was inhabited by a microbial flora which held an intermediate position between the flora of effluent from conventional ileostomies and normal faeces. The flora remained rather stable in the reservoir. In spite of the new microbial ecology and the morphological changes, the reservoir mucous membrane did retain absorptive capacity for D-xylose and phenylalanine.

Morphology in the cat ileal mucosa following construction of an ileal reservoir or transposition of patches to different locations

In an attempt to examine the response of the ileal mucosa to different noxious environments and to correlate the results with findings in human continent ileostomy reservoirs, cat intestine was subjected to various operative procedures: first, ileal reservoirs were constructed in continuity with the small intestine, a technique that was slightly different from that employed in human subjects, and secondly, segments or patches of ileum were transposed to the colon, the urinary bladder, or the jejunum. Morphometric evaluation was subsequently performed on these samples. The mucosa of the reservoir revealed a decrease in villus height accompanied by an increased mitotic index. Identical changes were observed when ileal segments or patches were inserted in the colon, whilst transposition to the urinary bladder resulted in similar but more pronounced alterations. When ileal patches from the colon or urinary bladder were replaced in the jejunum, the villi were once again enlarged. The epithelial cells remained normal in all cases except following transposition to the urinary bladder, where flattening of the cells or partial denudation of the villus tips was encountered. The changes observed represent a classical hyper-regenerative transformation of the mucosa, and correspond closely with the changes recorded in human continent ileostomy reservoirs. Furthermore, the reversibility of such alterations has been demonstrated. The experimental design permitted the exclusion of intraluminal pressure, dilatation, and nervous and vascular derangements as the cause of the transformation; it is concluded that the intraluminal environment is the factor most probably responsible for such structural alterations.

Vitamin B12 absorption in patients with continent ileostomy

Vitamin B12 absorption was studied in 34 patients, 10 months to 6 years after construction of a continent ileostomy. Normal Schilling test values (greater than 10 percent) were obtained in 21 of the cases after a single determination. Repeated tests showed a normal B12 absorption in 8 of the 13 patients who had revealed a Schilling test value below 10 percent at the first determination. In the remaining 5 patients, repeated Schilling tests showed borderline values (5-10 percent) in 4 cases and a low value (mean 4.5 percent) in one case. One of the patients with borderline values had previously undergone resection of 80 cm of the terminal ileum. When vitamin B12-intrinsic factor complex was instilled directly into the reservoir in 3 patients, it was found that the vitamin was absorbed by the mucous membrane of the reservoir. The construction of a continent ileostomy reservoir thus does not appear to expose the patient to an increased risk of developing vitamin B12 malabsorption.

Abortion studies in patients with "intraabdominal ileostomy reservoirs" and in patients with conventional ileostomies

Twenty patients with ileostomy were studied concerning the absorption of d-xylose, fat, l-phenylalanine, and vitamin B(12). Ten patients had a conventional ileostomy, whereas 10 others were provided with an intraabdominal intestinal ileostomy reservoir resulting in faecal continence. No remarkable differences in the absorption of d-xylose, fat, or l-phenylalanine were found between the two groups of ileostomy patients. Most of the absorption values were within normal or borderline ranges. In the reservoir group the Schilling test gave subnormal values in six out of 10 patients, whereas only one patient in the group with a conventional ileostomy had a subnormal value. The reason for this finding is briefly discussed.