Trends in diabetic retinopathy screening attendance and associations with vision impairment attributable to diabetes in a large nationwide cohort

AIMS

To investigate diabetic retinopathy screening attendance and trends in certified vision impairment caused by diabetic eye disease.

METHODS

This was a retrospective study of attendance in three urban UK diabetic eye screening programmes in England. A survival analysis was performed to investigate time from diagnosis to first screen by age and sex. Logistic regression analysis of factors influencing screening attendance during a 15-month reporting period was conducted, as well as analysis of new vision impairment certifications (Certificate of Vision Impairment) in England and Wales from 2009 to 2019.

RESULTS

Of those newly registered in the Routine Digital Screening pathway (n = 97 048), 80% attended screening within the first 12 months and 88% by 36 months. Time from registration to first eye screening was longer for people aged 18-34 years, and 20% were unscreened after 3 years. Delay in first screen was associated with increased risk of referable retinopathy. Although 95% of participants (n = 291 296) attended during the 15-month reporting period, uptake varied considerably. Younger age, social deprivation, ethnicity and duration of diabetes were independent predictors of non-attendance and referable retinopathy. Although the last 10 years has seen an overall reduction in vision impairment certification attributable to diabetic eye disease, the incidence of vision impairment in those aged <35 years was unchanged.

CONCLUSIONS

Whilst the majority of participants are screened in a timely manner, there is considerable variation in uptake. Young adults, have sub-optimal attendance, and levels of vision impairment in this population have not changed over the last 10 years. There is an urgent need to explore barriers to/enablers of attendance in this group to inform policy initiatives and tailored interventions to address this issue.

Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature

AIMS

To identify and synthesize studies reporting modifiable barriers/enablers associated with retinopathy screening attendance in people with Type 1 or Type 2 diabetes, and to identify those most likely to influence attendance.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Cochrane Library and the 'grey literature' for quantitative and qualitative studies to February 2017. Data (i.e. participant quotations, interpretive summaries, survey results) reporting barriers/enablers were extracted and deductively coded into domains from the Theoretical Domains Framework; with domains representing categories of theoretical barriers/enablers proposed to mediate behaviour change. Inductive thematic analysis was conducted within domains to describe the role each domain plays in facilitating or hindering screening attendance. Domains that were more frequently coded and for which more themes were generated were judged more likely to influence attendance.

RESULTS

Sixty-nine primary studies were included. We identified six theoretical domains ['environmental context and resources' (75% of included studies), 'social influences' (51%), 'knowledge' (51%), 'memory, attention, decision processes' (50%), 'beliefs about consequences' (38%) and 'emotions' (33%)] as the key mediators of diabetic retinopathy screening attendance. Examples of barriers populating these domains included inaccurate diabetic registers and confusion between routine eye care and retinopathy screening. Recommendations by healthcare professionals and community-level media coverage acted as enablers.

CONCLUSIONS

Across a variety of contexts, we found common barriers to and enablers of retinopathy screening that could be targeted in interventions aiming to increase screening attendance.

Multi-stakeholder perspectives of locally commissioned enhanced optometric services

OBJECTIVES

To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services.

DESIGN

Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups).

SETTING

A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists.

PARTICIPANTS

189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners.

RESULTS

Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists' examination. The vast majority rated the following as 'very good'; examination duration, optometrists' listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a 'pro-optometry' area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently.

CONCLUSIONS

Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners.

Global prevalence of childhood cataract: a systematic review

Childhood cataract is an avoidable cause of visual disability worldwide and is a priority for VISION 2020: The Right to Sight. There is a paucity of information about the burden of cataract in children and the aim of this review is to assess the global prevalence of childhood cataract. The methodology for the review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed a literature search for studies reporting estimates of prevalence or incidence of cataract among children (aged<18 years) at any global location using the Cochrane Library, Medline and Embase up to January 2015. No restrictions were imposed based on language or year of publication. Study quality was assessed using a critical appraisal tool designed for systematic reviews of prevalence. Twenty prevalence and four incidence studies of childhood cataract from five different geographical regions were included. The overall prevalence of childhood cataract and congenital cataract was in the range from 0.32 to 22.9/10000 children (median=1.03) and 0.63 to 9.74/10000 (median=1.71), respectively. The incidence ranged from 1.8 to 3.6/10000 per year. The prevalence of childhood cataract in low-income economies was found to be 0.42 to 2.05 compared with 0.63 to 13.6/10000 in high-income economies. There was no difference in the prevalence based on laterality or gender. This review highlights substantial gaps in the epidemiological knowledge of childhood cataract worldwide, particularly from low and lower middle-income economies. More studies are needed using standard definitions and case ascertainment methods with large enough sample sizes.

Evaluation of a minor eye conditions scheme delivered by community optometrists

BACKGROUND

The establishment of minor eye conditions schemes (MECS) within community optometric practices provides a mechanism for the timely assessment of patients presenting with a range of acute eye conditions. This has the potential to reduce waiting times and avoid unnecessary referrals to hospital eye services (HES).

OBJECTIVE

To evaluate the clinical effectiveness, impact on hospital attendances and patient satisfaction with a minor eye service provided by community optometrists.

METHODS

Activity and outcome data were collected for 12 months in the Lambeth and Lewisham MECS. A patient satisfaction questionnaire was given to patients at the end of their MECS appointment. A retrospective difference-in-differences analysis of hospital activity compared changes in the volume of referrals by general practitioners (GPs) from a period before (April 2011-March 2013) to after (April 2013-March 2015) the introduction of the scheme in Lambeth and Lewisham relative to a neighbouring area (Southwark) where the scheme had not been commissioned. Appropriateness of case management was assessed by consensus using clinical members of the research team.

RESULTS

A total of 2123 patients accessed the scheme. Approximately two-thirds of patients (67.5%) were referred by their GP. The commonest reasons for patients attending for a MECS assessment were 'red eye' (36.7% of patients), 'painful white eye' (11.1%) and 'flashes and floaters' (10.2%). A total of 64.1% of patients were managed in optometric practice and 18.9% were referred to the HES; of these, 89.2% had been appropriately referred. First attendances to HES referred by GPs reduced by 26.8% (95% CI -40.5% to -13.1%) in Lambeth and Lewisham compared to Southwark.

CONCLUSIONS

The Lambeth and Lewisham MECS demonstrates clinical effectiveness, reduction in hospital attendances and high patient satisfaction and represents a successful collaboration between commissioners, local HES units and primary healthcare providers.

A qualitative study of stakeholder views regarding participation in locally commissioned enhanced optometric services

OBJECTIVES

To explore the views of optometrists, general practitioners (GPs) and ophthalmologists regarding the development and organisation of community-based enhanced optometric services.

DESIGN

Qualitative study using free-text questionnaires and telephone interviews.

SETTING

A minor eye conditions scheme (MECS) and a glaucoma referral refinement scheme (GRRS) are based on accredited community optometry practices.

PARTICIPANTS

41 optometrists, 6 ophthalmologists and 25 GPs.

RESULTS

The most common reason given by optometrists for participation in enhanced schemes was to further their professional development; however, as providers of 'for-profit' healthcare, it was clear that participants had also considered the impact of the schemes on their business. Lack of fit with the 'retail' business model of optometry was a frequently given reason for non-participation. The methods used for training and accreditation were generally thought to be appropriate, and participating optometrists welcomed the opportunities for ongoing training. The ophthalmologists involved in the MECS and GRRS expressed very positive views regarding the schemes and widely acknowledged that the new care pathways would reduce unnecessary referrals and shorten patient waiting times. GPs involved in the MECS were also very supportive. They felt that the scheme provided an 'expert' local opinion that could potentially reduce the number of secondary care referrals.

CONCLUSIONS

The results of this study demonstrated strong stakeholder support for the development of community-based enhanced optometric services. Although optometrists welcomed the opportunity to develop their professional skills and knowledge, enhanced schemes must also provide a sufficient financial incentive so as not to compromise the profitability of their business.

An economic comparison of hospital-based and community-based glaucoma clinics

INTRODUCTION

We have established one model for community care of glaucoma clinic patients. Community optometrists received training and accreditation in glaucoma care. Once qualified they alternated between running half day glaucoma clinics in their own High Street practices and assisting in a hospital-based glaucoma clinic session. This paper reports the cost of this model.

METHODS

Micro-costing was undertaken for the hospital clinic. A consensus meeting was held to agree costs for community clinics involving all optometrists in the project along with representatives of the multiple chain optometry practices who had participated. Costs to patients both indirect and direct were calculated following structured interviews of 197 patients attending hospital clinics and 194 attending community clinics.

RESULTS

The estimated cost per patient attendance to the hospital clinic was £63.91 and the estimated cost per attendance to the community clinic was £145.62. For patients the combined direct and indirect cost to attend the hospital clinic was £6.15 and the cost to attend the community clinic £5.91.

DISCUSSION

The principal reason for the higher cost in the community clinic was higher overhead costs in the community. Re-referral to the hospital system only occurred for 9% of patients and was not a large contribution to the increased cost. Time requested to next appointment was similar for the two clinics. Sensitivity analysis shows a strong effect of increasing patients seen per clinic. It would, however, require 25 patients to be seen per clinician per day in the community in order to make the costs comparable.

Development of a competency framework for optometrists with a specialist interest in glaucoma

PURPOSE

To develop a competency framework, using a modified Delphi methodology, for optometrists with a specialist interest in glaucoma, which would provide a basis for training and accreditation.

METHODS

A modified iterative Delphi technique was used using a 16-member panel consisting almost exclusively of sub-specialist optometrists and ophthalmologists. The first round involved scoring the relevance of a draft series of competencies using a 9-point Likert scale with a free-text option to modify any competency or suggest additional competencies. The revised framework was subjected to a second round of scoring and free-text comment. The Delphi process was followed by a face-to-face structured workshop to debate and agree the final framework. The version of the framework agreed at the workshop was sent out for a 4-month period of external stakeholder validation.

RESULTS

There was a 100% response to round 1 and an 94% response to round 2. All panel members attended the workshop. The final version of the competency framework was validated by a subsequent stakeholder consultation and contained 19 competencies for the diagnosis of glaucoma and 7 further competencies for monitoring and treatment.

CONCLUSIONS

Application of a consensus methodology consisting of a modified Delphi technique allowed the development of a competency framework for glaucoma specialisation by optometrists. This will help to shape the development of a speciality curriculum and potentially could be adapted for other healthcare professionals.

Acquired colour vision deficiency in patients receiving digoxin maintenance therapy

BACKGROUND/AIMS

Disturbances of colour vision are a frequently reported sign of digoxin toxicity. The aim of this study was to investigate the incidence of acquired colour vision deficiency in elderly hospitalised patients receiving maintenance digoxin therapy.

METHODS

30 patients (mean age 81.3 (SD 6.1) years) receiving digoxin were tested using a battery of colour vision tests (Ishihara, AO Hardy Rand Rittler plates, City tritan test, Lanthony tritan album, and the Farnsworth D15). These were compared to an age matched control group. Serum digoxin concentrations were determined from venous blood samples.

RESULTS

Slight to moderate red-green impairment was found in approximately 20-30% of patients taking digitalis, and approximately 20% showed a severe tritan deficiency. There was no correlation between colour vision impairment and serum digoxin level.

CONCLUSIONS

Formal colour vision testing of elderly patients taking digitalis showed a high incidence of colour deficiency, suggesting that impairment of retinal function can occur even at therapeutic drug levels. As a result, colour vision testing in this population would have limited value for the detection of drug toxicity.

Pericytes: cell biology and pathology

Pericytes are perivascular cells with multifunctional activities which are now being elucidated. The functional interaction of pericytes with endothelial cells (EC) is now being established, using current molecular and cytochemical techniques. The detailed morphology of the pericyte has been well described. Pericytes extend long cytoplasmic processes over the surface of the EC, the two cells making interdigitating contacts. At points of contact, communicating gap junctions, tight junctions and adhesion plaques are present. Pericytes appear to show both structural and functional heterogeneity. The coverage of EC by pericytes varies considerably between different microvessel types and the location of pericytes on the microvessel is not random but appears to be functionally determined. Interaction between pericytes and EC is important for the maturation, remodelling and maintenance of the vascular system via the secretion of growth factors or modulation of the extracellular matrix. There is also evidence that pericytes are involved in the transport across the blood-brain barrier and the regulation of vascular permeability. The long-standing view that pericytes are the microvessel equivalent of larger vessel smooth muscle cells and are contractile is being reassessed using current methods. An important role for pericytes in pathology, and neuropathology in particular, has been indicated in hypertension, diabetic retinopathy, Alzheimer's disease, multiple sclerosis and CNS tumour formation.

Contractile proteins in pericytes at the blood-brain and blood-retinal barriers

Evidence from a variety of sources suggests that pericytes have contractile properties and may therefore function in the regulation of capillary blood flow. However, it has been suggested that contractility is not a ubiquitous function of pericytes, and that pericytes surrounding true capillaries apparently lack the machinery for contraction. The present study used a variety of techniques to investigate the expression of contractile proteins in the pericytes of the CNS. The results of immunocytochemistry on cryosections of brain and retina, retinal whole-mounts and immunoblotting of isolated brain capillaries indicate strong expression of the smooth muscle isoform of actin (alpha-SM actin) in a significant number of mid-capillary pericytes. Immunogold labelling at the ultrastructural level showed that alpha-SM actin expression in capillaries was exclusive to pericytes, and endothelial cells were negative. Compared to alpha-SM actin, non-muscle myosin was present in lower concentrations. By contrast, smooth muscle myosin isoforms, were absent. Pericytes were strongly positive for the intermediate filament protein vimentin, but lacked desmin which was consistently found in vascular smooth muscle cells. These results add support for a contractile role in pericytes of the CNS microvasculature, similar to that of vascular smooth muscle cells.

The blood-nerve barrier: enzymes, transporters and receptors--a comparison with the blood-brain barrier

The blood-brain barrier (BBB) has been much more extensively investigated than the blood-nerve barrier (BNB). Nevertheless it is clear that there are both similarities and differences in the molecular and morphophysiological characteristics of the two barrier systems. A number of enzymes, transporters and receptors have been investigated at both the BNB and BBB, as well as in the perineurium of peripheral nerves, which is also a metabolically active diffusion barrier. While there have been few systematic comparisons of the distribution of these molecules in both the BNB and BBB, it is apparent from the data available, reviewed in this article, that their distribution also supports the concept of the BNB and BBB having some features in common but also showing distinct identities. These similarities and differences cannot simply be accounted for by the presence of the inductive influences of astrocytes at the BBB and absence at the BNB. Whether the Schwann cell also has the capacity to induce some BNB properties remains to be determined.

Endothelial glycoconjugates: a comparative lectin study of the brain, retina and myocardium

There is evidence that the endothelial cell (EC) glycocalyx is a significant determinant of vascular permeability, acting as a charge-size filter to permeant molecules. We have therefore examined its oligosaccharide composition in 3 classes of microvessel with differing permeabilities. EC in rat brain, retina and myocardium were labelled with a panel of lectins and subjected to a semiquantitative analysis. Surprisingly, no substantial differences were evident for any lectin labelling between the 3 microvessel types despite their marked morphophysiological diversity. In particular, all showed substantial sialic acid expression, with Maackia amurensis (MAA) labelling sialic acid in an alpha2-3 linkage to beta-galactose and Sambucus nigra (SNA) recognising sialic acid in an alpha2-6 linkage to beta-galactose. Arachis hypogaea (PNA) binding after neuraminidase digestion indicated the presence of Gal beta1-3GalNAc attached to terminal sialic acid. The results therefore show that the sequences NeuNAc alpha2-3Gal beta1-3GalNAc and NeuNAc alpha2-6Gal beta1-3GalNAc are strongly expressed in the 3 microvessel types irrespective of their permeability properties. This homogeneity suggests that these lectin ligands may be involved in a common set of EC functions, e.g. cell:cell and cell:matrix interactions. However, we cannot rule out the possibility that glycocalyx differences may exist between vessels in the paracellular cleft which may alter its filtration properties.

A comparison of blood-brain barrier and blood-nerve barrier endothelial cell markers

A number of major properties of endothelial cells (EC) at the blood-brain barrier (BBB) have been shown to be astrocyte-dependent. Whether analogous properties at the blood-nerve barrier (BNB) are induced and maintained by Schwann cells has not been investigated. As a preliminary investigation we have undertaken a comparative study of six EC membrane markers at the BBB and BNB and perineurium. Employing immunoblotting and immunocytochemistry the relative distribution between rat brain cortex and sciatic nerve was determined for the glucose transporter (GLUT-1), the transferin receptor (OX-26), the endothelial barrier antigen (EBA) and the OX-47 antigen. Using enzyme cytochemistry the same comparison was made for gamma-glutamyl transpeptidase (GGTP) and alkaline phosphatase. By immunocytochemistry GLUT-1 was uniformly strongly represented in brain EC, nerve EC and perineurium. OX-26 was strongly positive in brain EC but present only in trace quantities in nerve EC and perineurium. EBA similarly showed strong positivity in brain EC and trace amounts in nerve EC but was absent from perineurium. OX-47 was present moderately in brain EC and perineurium but absent from nerve EC. Quantitative immunoblotting of brain and sciatic nerve homogenates showed statistically significant differences in the level of expression of EBA and OX-26 between the two tissues. Enzyme cytochemistry showed that GGTP was strongly positive in brain EC but absent from nerve EC and perineurium. Alkaline phosphatase stained strongly in brain and nerve EC and was absent from perineurium. In summary the six membrane markers were heterogeneously represented in nerve compared with brain. This pattern of distribution in the nerve cannot simply be accounted for by the absence of astrocytes and their inductive influences. Any inductive influences of Schwann cells require investigation.

Effects of dipivefrin and pilocarpine on pupil diameter, automated perimetry and LogMAR acuity

BACKGROUND

A study was carried out to ascertain, in ophthalmologically normal subjects, the short-term effects of dipivefrin hydrochloride 0.1% on visual performance and make comparisons with pilocarpine.

METHODS

Twelve normal volunteers aged 20-26 years attended on three occasions. One eye, randomly selected, received one drop of either pilocarpine 2%, dipivefrin or saline 0.9%. High- and low-contrast LogMAR acuity at 6 m and pupil diameter (measured by infra-red pupillometry) were recorded at baseline (T0) and at intervals up to 90 min following instillation of drops. Program 30-2 of the Humphrey Visual Field Analyzer (HFA) was run at T0 and at 60 min after treatment instillation (T60). Saline was always instilled at visit 1, to allow for learning effects. On visits 2 and 3 either pilocarpine or dipivefrin was randomly instilled into the treated eye.

RESULTS

Pilocarpine significantly worsened the field global indices mean deviation (P < 0.001) and pattern standard deviation (P < 0.01) compared with T0. There was no significant change with dipivefrin. A significant (P = 0.01) pupil dilation from 5.44 mm (SD 0.79) at T0 to 6.19 mm (SD 1.09) at T90 occurred with dipivefrin. Pilocarpine caused significant miosis. No significant changes in LogMAR values were found with dipivefrin. Pilocarpine significantly (P < 0.01) increased LogMAR values (i.e. reduced acuity) compared with dipivefrin. At T30 the mean increase in LogMAR was 0.76 (SD 0.30) for high and 0.83 (SD 0.11) for low contrast. By T90 recovery of acuity was virtually complete.

CONCLUSIONS

In normals dipivefrin causes mydriasis but does not affect the central visual field global indices (as assessed by STATPAC), or high- and low-contrast LogMAR acuity. Pilocarpine adversely affects the visual field and both measures of acuity. Knowledge of these effects is of value in glaucoma therapy and when monitoring the progression of visual loss.

Cerebral and pial microvessels: differential expression of gamma-glutamyl transpeptidase and alkaline phosphatase

Pial microvessels have several important blood-brain barrier (BBB) characteristics in common with cerebral microvessels, despite lacking their astrocytic ensheathment. We have therefore determined whether they have the same distribution of two enzymes, gamma-glutamyl transpeptidase (GGTP) and alkaline phosphatase, both of which are known to be astrocyte-dependent. GGTP was absent from all rat pial microvessels but strongly present in brain cortical capillaries. Alkaline phosphatase was heterogeneously expressed in pial microvessels, including capillaries, but strongly positive in brain cortical capillaries. Diffusible, inductive factors produced by astrocytes could account for these differences in enzyme distribution between the two vessel types. Furthermore, differences in expression between the two markers may reflect their differing sensitivities to the astrocytic factors. Caution is urged in the common usage of the pial microvessel as a model system in BBB studies.

Reliability of the non-contact corneal aesthesiometer and its comparison with the Cochet-Bonnet aesthesiometer

AIMS

To determine the repeatability of measurement of the corneal sensation threshold using the Non-Contact Corneal Aesthesiometer (NCCA); to evaluate the effect of the air-jet diameter and stimulus duration on the threshold; and to compare the sensation thresholds found with the NCCA and with the Cochet-Bonnet Aesthesiometer (C-BA), on the same group of normal, human subjects.

METHODS

For all experiments, only the central corneal sensation thresholds were measured. (1) NCCA Repeatability; 17 subjects tested at the same time on five separate days. (2) NCCA Air-Jet Diameter; 15 subjects tested using four different air-jets: 0.35, 0.5, 1 and 2 mm. (3) NCCA Stimulus Duration; 15 subjects tested using three stimulus durations: 0.5, 0.9 and 1.5 sec. (4) NCCA and C-BA; 43 subjects tested using each instrument in turn.

RESULTS

(1) No significant differences in mean sensation threshold were detected across the five days of testing, or between individual days. (2) 0.5 and 1 mm air-jets produce least variability in mean sensation threshold. (3) No significant difference in mean sensation thresholds was found between the three test durations. (4) For each subject, there was no correlation between each instrument's mean sensation threshold.

CONCLUSIONS

(1) The NCCA was able to assess the corneal sensation threshold in an accurate and repeatable manner. (2) The optimum test parameters were found using the 0.5 mm air-jet, over a stimulus duration of 0.9 sec. (3) The C-BA has serious deficiencies in its design which limit its ability to accurately measure corneal sensitivity at low stimulus thresholds.

Comparison of the tolerability and efficacy of unit-dose, preservative-free topical ocular anaesthetics

Several topical ocular local anaesthetics are available in preservative-free unit-dose applicators. There is little comparative data as to the efficacy and tolerability of these drugs. The purpose of this study was to compare the tolerability, and the depth and duration of corneal anaesthesia following instillation of one drop of 0.4% oxybuprocaine (benoxinate), 0.5% amethocaine, or 0.5% proxymetacaine. The tolerability of each anaesthetic was assessed using a linear ten point arbitrary comfort scale. A group of 14 healthy male subjects, with a wide variation in iris pigment levels, participated in the study (mean age 26.6 years, range 18-40 years). Corneal sensitivity was measured using a slit-lamp mounted Cochet-Bonnet aesthesiometer prior to instillation, and at 1, 2, 5, 10, 15, 20 and 30 min after instillation, and continued if necessary until corneal sensitivity had returned to pre-instillation levels. For each anaesthetic, complete anaesthesia occurred within 1 min of instillation and a return to baseline sensitivity levels occurred by 45 min. No significant difference in anaesthesia was found between the drugs at each time point. Tolerability profiles indicated that proxymetacaine was significantly better tolerated than either amethocaine (p < 0.01) or oxybuprocaine (benoxinate) (p < 0.001). There was considerable inter-subject variability in the duration of anaesthesia, and practitioners should be alert to this when allowing patients to leave the practice following the production of corneal anaesthesia. There seems little to choose clinically between the three active agents as regards clinical effectiveness. Proxymetacaine was significantly better tolerated than either amethocaine or oxybuprocaine.

Corneal glycoconjugates: an ultrastructural lectin-gold study

The oligosaccharide chains of cell surface and extracellular matrix glycoconjugates are essential for the biological properties of these molecules. We have, therefore, investigated carbohydrate residues in the rat cornea using biotinylated lectin-gold probes. Fixed corneas were removed and embedded in Lowicryl HM20 or LR White. Ultrathin sections were incubated in one of the lectins: Triticum vulgare (WGA), Canavalia ensiformis (Con A), Griffonia simplicifolia (GS-1), Limax flavus (LFA) and Allomyrina dichotoma (Allo A), followed by streptavidin-gold, or the sections were incubated in cationic colloidal gold. Semi-quantification of gold labelling was determined for corneal endothelium, Descemet's membrane, stroma and epithelium from electron micrographs. WGA and Con A binding sites were expressed either moderately or strongly throughout the cornea, suggesting a preponderance of alpha-mannose and N-acetylglucosamine residues. A particular concentration of these sugars was found in Descemet's membrane. In contrast, GS-1 (specific for alpha-galactose) and Allo A (specific for beta-galactose) labelled all regions weakly. Sialic acid residues, as defined by LFA labelling and the expression of neuraminidase-sensitive cationic colloidal gold binding sites, were sparsely distributed throughout the stroma, Descemet's membrane and endothelium. In contrast, sialoglycoconjugates were found in significant concentrations in the epithelium. Electron microscopy proved useful in providing new information on the cellular and subcellular localization of these lectin binding sites.

Development of endothelial paracellular clefts and their tight junctions in the pial microvessels of the rat

The microvessels of the pia mater lack an investment with astrocyte processes but nonetheless have a high transendothelial electrical resistance which has caused them to be regarded as part of the blood-brain barrier. This high resistance is known to be acquired in the perinatal period. The aim of our study was to relate the known physiological changes with differentiation of the endothelial paracellular clefts and especially of their tight junctions which provide the basis for the high transendothelial resistance of blood-brain barrier vessels. Tight junctions of endothelial cell paracellular clefts in pial microvessels were examined by transmission electron microscopy using goniometric tilting to reveal and measure membrane separations at tight junctions in fetal, postnatal and adult rats. These tight junctional membrane separations narrowed over the period (E16: 6.3 nm, D1: 6.4 nm, D7: 5.4 nm) and differentiated into two groups by the adult stage: one with a membrane separation of 2.8 nm and the staining characteristics of non-brain endothelial junctions, and the other with no detectable membrane separation and the staining characteristics of blood-brain barrier endothelial junctions. This patchy and incomplete differentiation of pial tight junctions into a blood-brain barrier-like form could result either from non-uniform exposure to inductive signals or to local variation in responsiveness to such agents. Although these changes in junction organization may be related to the known increase in pial transendothelial resistance in the perinatal period, we have not yet identified any sharply defined structural change which coincides with this physiological event.

Effect of beam variables on corneal sensitivity after excimer laser photorefractive keratectomy

AIM

To investigate changes in corneal touch sensitivity following excimer laser photorefractive keratectomy (PRK) using different beam configurations.

METHODS

20 subjects were given a unilateral -3.00 D correction with either a 5 mm (26 micrograms, n = 10) or 6 mm (42 micrograms, n = 10) beam diameter. Thirty subjects underwent a unilateral -6.00 D correction with 5 mm (62 micrograms, n = 10), 6 mm (78 micrograms, n = 10), or multizone (62 micrograms, n = 10) treatments. The multizone treatment was 6 mm in diameter with the depth of the 5 mm treatment. Corneal sensitivity was measured using a slit-lamp mounted Cochet-Bonnet aesthesiometer before and at 1, 3, 6, and 12 months after PRK. Stimulus locations included points lying within the ablated zone (central) and outside (peripheral). These were compared with the equivalent locations in control (untreated) eyes.

RESULTS

There was a significant reduction in corneal sensitivity within the central (ablated) zone in all treatment groups after PRK. In most groups a return to full sensitivity was achieved by 6 months with the exception of the multizone treatment group which showed significant corneal hypoaesthesia at 12 months. Peripheral corneal sensitivity was also reduced in this group up to 3 months after the procedure. A comparison between the -3.00 D and -6.00 D treatment groups showed no significant difference. However, combining data from all treatment groups, a significant correlation was found between the interocular difference in central corneal sensitivity and postoperative haze at 3 and 6 months.

CONCLUSIONS

For corrections up to -6.00 D ablation depth and treatment zone diameter do not appear to be clinically important determinants of corneal hypoaesthesia. In contrast, postoperative corneal haze appears to correlate with sensitivity loss.

Is the pial microvessel a good model for blood-brain barrier studies?

Pial microvessels have commonly been used as model systems for studying blood-brain barrier (BBB) properties instead of cerebral cortical microvessels. Since pial microvessels are relatively accessible they have been especially employed in electrophysiological and pharmacological studies. Measurements of electrical resistance across endothelial cells (EC) as a measure of their barrier properties have been made exclusively from pial microvessels in in vivo BBB studies. Similarly the observed responses of microvessels to the application of pharmacological agents have commonly been made on pial microvessels as representative of BBB vasculature. In this review the properties of pial and cerebral microvessels are compared to determine whether the use of the pial microvessel as a model for BBB studies is valid. Similarities are described in their ultrastructural features, permeability to electron dense tracers and molecular characteristics. Measurements of electrical resistance from pial microvessels are compared with measurements from cerebral EC monolayers in tissue culture and indirect determinations for cerebral microvessels in situ. Two notable differences between pial and cerebral microvessels are described in the adult nervous system. Tight junctions between cerebral EC appear to consist of a uniform population. In pial microvessels however tight junctions consist of two populations in one the inter-EC tight junctions resemble those between cerebral EC, with fusion of adjacent EC membranes. In the second population the inter-EC tight junctions differ with a discernible gap between adjacent EC membranes. The distribution of the endothelial barrier antigen (EBA) is uniform between EC of cerebral microvessels. By contrast EC of pial microvessels from a heterogeneous population for EBA expression which is related to the proximity of the EC to the astrocytic glia limitans. The role of astrocytes in the induction and maintenance of the BBB characteristics is briefly reviewed. The possible significance of the lack of an astrocytic ensheathment of pial microvessels is assessed. In summary, caution is urged in employing pial microvessels in BBB studies and the need for more information on possible pial microvessel heterogeneity is stressed.

Molecular characteristics of pial microvessels of the rat optic nerve. Can pial microvessels be used as a model for the blood-brain barrier?

Pial microvessels have commonly been used in studies of the blood-brain barrier because of their relative accessibility. To determine the validity of using the pial microvessel as a model system for the blood-brain barrier, we have extended the comparison of pial and cerebral microvessels at the molecular level by a partial characterization of the glycocalyx of pial endothelial cells, in view of the functional importance of anionic sites within the glycocalyx. Rat optic nerves were fixed by vascular perfusion. Anionic sites on the endothelium were labelled with cationic colloidal gold by means of post- and pre-embedding techniques. The effects of digestion of ultrathin sections on subsequent gold labelling was quantified following their treatment with a battery of enzymes. Biotinylated lectins, viz. wheat germ agglutinin and concanavalin A with streptavidin gold, were employed to identify specific saccharide residues. The results demonstrate that the luminal glycocalyx of pial microvessels is rich in sialic-acid-containing glycoproteins. Neuraminidase, which is specific for N-acetylneuraminic (sialic) acid, and papain (a protease with a wide specificity) significantly reduce cationic colloidal gold binding to the luminal endothelial cell plasma membrane. Wheat germ agglutinin (with an affinity for sialic acid) binds more to the luminal than abluminal plasma membrane, whereas concanavalin A, which binds mannose, binds more to the abluminal surface. Similar results have been obtained for cerebral cortical endothelial cells. With respect to these molecular characteristics, therefore, the pial and cortical microvessels appear to be the same. However, since the two vessel types differ in other respects, caution is urged regarding the use of pial microvessels to investigate the blood-brain barrier.

Differential distribution of an endothelial barrier antigen between the pial and cortical microvessels of the rat

An endothelial barrier antigen (EBA), reported to be a marker for endothelial cells (EC) displaying blood-brain barrier (BBB) characteristics, was probed with a monoclonal antibody in pial and cortical microvessels in rat brain. In contrast to the uniform labelling of EC in cortical vessels, pial microvessels showed a heterogeneity in EBA expression. Most pial vessels consisted of a mixture of EBA positive and EBA negative cells whereas a smaller number of vessels were either completely negative or uniformly positive. Significantly, in vessels showing incomplete expression it was typically EC furthest from the brain surface that did not express EBA. Although the function of EBA is unknown, the variable expression in pial microvascular EC may be related to their incomplete barrier characteristics.

Ontogeny of four blood-brain barrier markers: an immunocytochemical comparison of pial and cerebral cortical microvessels

Pial and cortical microvessels possess many blood-brain barrier (BBB) properties in common, including impermeability to electron dense tracers, high transendothelial electrical resistance and specialised endothelial cell ultrastructural features. To compare pial and cortical microvessels further, a developmental, immunocytochemical study was undertaken of 4 BBB markers in the rat: OX-47, EBA, GLUT-1 and s-laminin. The appearance of the markers was monitored from embryonic d 16, to postnatal and adult stages. Each of the 4 markers appeared simultaneously in both pial and cortical vessels. GLUT-1 and OX-47 were present in endothelial cells of the BBB from E 16 to the adult. EBA and s-laminin appeared from postnatal d 7 through to the adult. Pial microvessels lack the ensheathment of astrocytes which may be involved in the induction and/or maintenance of BBB markers in the cortex. It is possible that astrocyte-derived factors diffusing from the brain surface are responsible for induction of BBB properties in the pial microvessels.

Dural microvessels: molecular properties of their luminal anionic sites

(1) Neurogenic inflammation has been implicated in the pathogenesis of the vascular headaches of migraine and cluster headaches. (2) Dural blood vessels are both pain-sensitive and show neurogenic plasma extravasation. (3) Endothelial cell (EC) surface anionic sites appear to be a determinant of vascular permeability. We therefore examined the anionic sites of dural EC to determine whether they are different from those of pial and parenchymal vessels. Luminal anionic sites of rat optic nerve EC were labelled with cationic colloidal gold (CCG) and cationic ferritin (CF) and examined by electron microscopy. Employing a battery of enzymes, the effects of digestion of ultrathin sections on subsequent labelling with CCG was quantified using image analysis software. In addition, a gold-labelled lectin, wheat-germ agglutinin (WGA), was employed to locate specific saccharide residues. Of the enzymes with a narrow specificity, only neuraminidase substantially reduced CCG binding. Of the proteolytic enzymes, papain was most effective in reducing labelling. These results show that the luminal EC anionic sites are chiefly composed of sialoglycoproteins. The labelling with biotinylated WGA-streptavidin gold was similar to that with CCG without enzyme digestion. This suggests that WGA is binding to N-acetylneuraminic (sialic) acid residues and not to the neutral N-acetylglucosamine (since CCG would not label uncharged molecules). These results do not differ significantly from those for pial and parenchymal EC. It is therefore likely that factors other than anionic site molecular composition account for the susceptibility of dural vessels to neurogenic plasma extravasation. The relevance of these observations in an experimental animal model to the human clinical condition remains to be determined.

Optic nerve microvessels: a partial molecular definition of cell surface anionic sites

Incorporated in the luminal glycocalyx of vascular endothelia (EC) are negatively charged microdomains (anionic sites). These sites are considered functionally important (a) in their interaction with circulating blood constituents, and (b) as a determinant of vascular permeability. The molecular composition of these EC sites, described for a number of tissues, has demonstrated a heterogeneity dependent on their anatomical location. Luminal anionic sites have not been characterized for EC of optic nerve. Optic nerves were removed from Sprague-Dawley rats previously fixed by vascular perfusion. EC anionic sites were labelled with the probes cationic colloidal gold (CCG) and cationic ferritin (CF), using the pre- and post-embedding techniques, and examined by electron microscopy. The effects of enzyme digestion of ultrathin sections on subsequent CCG labelling were determined using a battery of enzymes in association with the post-embedding technique. CCG labelling was quantified following each enzyme treatment using image analysis software. The biotinylated lectin wheat germ agglutinin (WGA) with streptavidin gold was also used to localize specific monosaccharide residues. The luminal front of intraneural EC showed a uniform labelling with CCG and CF which was greater than on the abluminal surface. Extracellular matrix components and basal laminae were moderately labelled. Digestion of tissue sections with heparitinase and trypsin had no significant effect on subsequent CCG labelling. Proteinase K was less effective than papain but both produced a significant reduction. Neuraminidase almost completely eliminated labelling. CCG binding to the luminal plasma membrane of optic nerve EC can be significantly reduced with proteolytic and glycolytic enzymes. The results demonstrate that sialoglycoproteins principally constitute these luminal EC anionic sites. Biotinylated WGA-streptavidin gold, which detects both N-acetylneuraminic (sialic) acid and N-acetylglucosamine, gave a similar pattern of labelling to CCG alone on the luminal versus abluminal EC fronts. These findings suggest that WGA is binding predominantly to N-acetylneuraminic acid residues since CCG would not label the neutral (uncharged) N-acetylglucosamine.

Distribution of a putative endothelial barrier antigen in the ocular and orbital tissues of the rat

BACKGROUND

A rat endothelial barrier antigen (EBA) recognised by a monoclonal antibody has been shown to be expressed strongly by endothelial cells of brain capillaries possessing a blood-brain barrier and only weakly expressed by fenestrated brain vessels.

METHODS

In this study immunocytochemical methods for light and electron microscopy were used to study EBA distribution in the eye and orbital tissues of the rat.

RESULTS

Blood-ocular barrier vessels in the optic nerve, retina, iris, and some vessels in th choroid and ciliary body were immunopositive for EBA. By pre-embedding immunocytochemistry for electron microscopy the antigen was observed on the luminal endothelial cell surface.

CONCLUSION

Surprisingly, some non-barrier vessels in the ciliary body and choroid expressed EBA suggesting that it may play a broader role in endothelial properties than previously recognised. The functional significance of EBA remains to be elucidated.

Differential expression of an endothelial barrier antigen between the CNS and the PNS

A monoclonal antibody to an antigen (EBA) expressed by neural endothelial cells (EC) was used to investigate any difference in the distribution of EBA between the CNS and PNS. Pre-embedding ultrastructural cytochemistry of rat sciatic and optic nerves was undertaken using anti-EBA, detected with a silver-enhanced gold-conjugated secondary antibody. LM immunocytochemical localisation of EBA was also performed using an HRP-conjugated secondary antibody. EC of pial and parenchymal optic nerve vessels were strongly immunopositive for EBA. Vessels of the dura were negative. At the EM level EBA was observed on the EC luminal surface. In contrast, EC of sciatic nerve were either negative or only weakly immunopositive. The molecular characteristics and function of EBA are largely unknown. Therefore the functional significance of the present findings remains to be determined.

Touch sensitivity of the eyelid margin and palpebral conjunctiva

Using a slit-lamp biomicroscope mounted Cochet-Bonnet aesthesiometer, the touch sensitivity of the eyelid margin and palpebral conjunctiva was determined for both upper and lower lids in 30 subjects. Thresholds for the occlusal surface of the lid, the marginal angle and the middle of the tarsus were measured centrally. A significantly higher touch sensitivity was found for the marginal zone compared with the occlusal surface, and tarsal conjunctival sensitivity was substantially the lowest. The occlusal and marginal zones of the lower lid displayed a significantly higher touch sensitivity than the upper lid but the tarsal sensitivity of the two lids was similar. The sharp peaking of sensitivity at the leading edge of each eyelid provides a mechanism for the detection of superficial foreign bodies and presumably augments the protective role of the cornea. A large inter-subject variation in marginal touch sensitivity was found which may explain individual variation in contact lens adaptation.

Molecular characterization of anionic sites on the luminal front of endoneurial capillaries in sciatic nerve

The distribution of anionic microdomains has been described in cerebral vessels and more recently in capillaries of peripheral nerve. Evidence is accumulating that these sites play a role in the barrier function of vascular endothelia in the PNS and CNS. The chemical nature of anionic sites has been at least partly determined for cerebral vessels but not in peripheral nerve. This study reports our preliminary investigations to determine the nature of endothelial anionic sites in sciatic nerve. The effects of digestion of ultra-thin sections of nerve with a battery of proteolytic and glycolytic enzymes (papain, trypsin, proteinase K, hyaluronidase, heparinase, heparitinase and neuraminidase) on the distribution of anionic sites was determined using the label, cationic colloidal gold. Papain, a proteolytic enzyme of broad specificity, succeeded in removing the majority of cationic colloidal gold-binding sites on the luminal surface of vascular endothelia. In contrast trypsin and proteinase K were less effective, reflecting their narrower specificity. Hyaluronidase, heparinase and heparitinase did not significantly affect cationic colloidal gold-labelling. However, a considerable reduction in cationic colloidal gold-binding occurred following neuraminidase digestion. These results suggest that, as in cerebral vessels, sialic acid-containing glycoproteins are largely responsible for the negatively charged domains on the luminal membrane of endothelial cells in peripheral nerve.

A comparison of the efficacy and duration of action of topically applied proxymetacaine using a novel ophthalmic delivery system versus eye drops in healthy young volunteers

A novel ophthalmic drug delivery system (NODS) has been developed to give precise and controlled delivery of a drug to the eye. The drug is incorporated into a polyvinyl alcohol flag attached to a carrier. When applied to the eye the flag detaches and gradually dissolves, releasing the drug. We investigated corneal anaesthesia produced by different concentrations of proxymetacaine NODS, and conventional eye drops. Subjects consisted of 28 normal males (mean age 25.3 (SD 3.9) years). Corneal touch sensitivity was measured with a biomicroscope mounted Cochet-Bonnet aesthesiometer. Each subject attended for two visits separated by 7 days. On each visit each eye randomly received one of four proxymetacaine preparations: 44 micrograms, 74 micrograms, 124 micrograms NODS, or 35 microliters of 0.5% proxymetacaine drops (175 micrograms). Corneal touch sensitivity was measured before, and at 1, 2, 5, 10, 15, 20, 30, 45, and 60 minutes following instillation. Complete anesthesia was achieved in the majority of subjects within 1 minute of instillation. The lowest NODS dose (44 micrograms) produced longer lasting anaesthesia than the 35 microliters drop (175 micrograms) (p < 0.05). Higher NODS doses produced a correspondingly greater increase in the duration of anaesthesia. The greater bioavailability achieved by this vehicle allows much lower drug concentrations to be used, reducing the likelihood of systemic adverse reactions.

Investigation of limbal touch sensitivity using a Cochet-Bonnet aesthesiometer

Following the observation of complex sensory receptors concentrated within the palisade zone of the human conjunctiva, this study sought to measure limbal touch sensitivity using a Cochet-Bonnet aesthesiometer. Touch sensitivity was found to be significantly higher in the palisade zone compared with the adjacent conjunctiva. A comparison between temporal and inferior limbus showed a greater median sensitivity for the temporal zone. There was a significant reduction in touch sensitivity with age, but not with iris colour or contact lens wear. These data, showing a higher touch sensitivity for the palisade zone, provide indirect evidence for a role of complex nerve endings in mechanoreception.

The structure of corpuscular nerve endings in the limbal conjunctiva of the human eye

Corpuscular nerve endings were found to be numerous within a narrow, 1.00 mm wide, annular zone of limbal conjunctiva, located approximately 0.5 mm from the corneoscleral margin. A light and electron microscopic study was carried out on these nerve endings found within samples of human eye-bank material. Corpuscular endings were found immediately under the epithelium, often within the stromal elevations which make up the limbal palisades of Vogt. They were round to oval in shape, and varied in size, with a mean maximum diameter of 30 microns. The afferent nerve fibre lost its myelin sheath soon after entry, and subsequently branched to give rise to a variable number of axon terminal varicosities, which were characterised by an accumulation of mitochondria. Neural elements within the nerve ending were invested by the cytoplasmic lamellae of Schwann-like accessory cells. The corpuscle was demarcated from the surrounding connective tissue by a delicate fibrocyte capsule. The corpuscular nerve endings described here in the conjunctiva share features common to corpuscles found in other mucosae. The function of such complex sensory nerve endings is as yet unknown, but the possibility that they represent receptors for particular sensory modalities should be explored.