The evaluation of uveitis in juvenile idiopathic arthritis (JIA) patients: are current ophthalmologic screening guidelines adequate?

OBJECTIVE

The aims of this study are to examine in our juvenile idiopathic arthritis (JIA) population: 1) the prevalence and characteristics of uveitis, 2) the complications and outcome of uveitis, 3) prognostic factors, and 4) the adequacy of the current ophthalmologic screening guidelines.

METHODS

Retrospective analysis of medical records.

RESULTS

1) Of the 153 JIA patients included, 27 developed asymptomatic anterior uveitis (17.6%) - 7 unilateral and 20 bilateral. The 27 uveitis patients were significantly younger at JIA presentation than the 126 JIA patients without uveitis. 2) The following uveitis complications were noticed: glaucoma, cataract, posterior synechiae, cystoid macular oedema and papillitis. A visual outcome was acquired in 25 patients - 21 patients had a known visual acuity of > or = 0.1. Four patients had a visual acuity of <0.05 - 3 unilateral and 1 bilateral. 3) Female gender could not be confirmed as an independent risk factor for uveitis, neither was Anti Nuclear Antibody (ANA) positivity. We did not find a significant relationship between the moment of clinical remission of arthritis and of uveitis. 4) When applying current uveitis screening guidelines to our JIA population, we found that the optimum screening regimen would consist of a combination of the higher screening frequency of Southwood (1) and the longer screening period of the American Academy of Pediatrics (2) (AAP) screening guidelines.

CONCLUSIONS

Uveitis is often encountered in JIA patients. It is a serious cause of morbidity. The use of disease-modifying antirheumatic drugs (DMARDs) probably has a positive effect on the preservation of visual function. We recommend a uveitis screening regimen which combines the AAP and Southwood guidelines and which includes rheumatoid factor positivity (RF+) and systemic onset patients in the quarterly screening.

Vascular remnants in the rabbit vitreous body. II. Enzyme digestion and immunohistochemical studies

The purpose of this study was to evaluate the composition of ghost vessels and the newly identified intravitreal structures type 1 and 2 (IVS-1 and 2) observed in the rabbit vitreous body. Rabbit eyes (n = 10, 0.5- approximately 36 months of age) were fixed and embedded in plastic. Post-embedding immuno transmission electron microscopy and enzyme digestion methods specifically directed at vascular extracellular matrix components (collagen IV, elastin and hyaluronan) were used in order to confirm the postulated vascular origin of IVS-1 and 2. In addition, markers of vitreous extracellular matrix components (collagen II, hyaluronan) were used. The postulated vascular nature of ghost vessels and IVS-1 was confirmed by a positive labelling with anti-collagen IV, whereas the demonstration of elastin (by anti-elastin antibodies and elastase digestion) in IVS-1 and 2 confirms their arterial origin. These vascular remnants were also labelled with a hyaluronan marker and with anti-collagen II. The presence of remnants of the hyaloid artery system throughout the vitreous matrix is in conflict with a strict spatial separation between the primary and secondary vitreous during embryonic development as proposed in the literature. It strongly supports an alternative theory which suggests an interactive remodelling of this matrix. The presence of hyaluronan in remnants of the hyaloid system is inconclusive, since hyaluronan is a component both of the adult vitreous matrix and of the vascular extracellular matrix. The presence of collagen II in vascular structures is highly interesting, since it supports another challenging theory, which suggests that lamellae develop alongside tracts formerly occupied by the larger hyaloid vessels.

Vascular remnants in the rabbit vitreous body. I. Morphological characteristics and relationship to vitreous embryonic development

Using light and transmission electron microscopy, we observed novel structures in the rabbit vitreous body. They were found in 18 out of 27 eyes from rabbits 0.5-36 months of age. These structures are scattered throughout the entire vitreous matrix. By light and transmission electron microscopy, they appear to be made up of the same structural components. Based upon their morphological appearance, they can be subdivided into two groups which we provisionally named 'intravitreal structure type 1 and 2' or 'IVS-1' and 'IVS-2'. IVS-1 has a highly variable morphology (e.g. star-shaped, round, oval), whereas IVS-2 is tubular. The dimensions of IVS-1 vary in relation to the mesh diameters of the collagen matrix, while those of IVS-2 do not. In adult rabbit eyes, we observed transitions between IVS-1 and intravitreal ghost vessels (acellular remnants of blood vessels), and between IVS-1 and IVS-2. In very young rabbits (14 days) we observed intravitreal ghost vessels consisting of tightly-packed IVS-1. Therefore, we concluded that IVS-1 and 2 are related structures presumably of vascular origin. It appears that they represent fragmented and non-fragmented acellular remnants of hyaloid blood vessels. The presence of vascular remnants throughout the entire vitreous matrix of adult rabbit eyes is in conflict with existing theories on the embryonic development of the vitreous body, which describe a strict spatial separation between the primary (vascular) and secondary (avascular) vitreous. However, it strongly supports an alternative theory that explains the formation of the secondary vitreous by a process of continuous remodelling of the primary vitreous.

Organization of the rabbit vitreous body: lamellae, Cloquet's channel and a novel structure, the 'alae canalis Cloqueti'

Even though the rabbit is a frequently used animal model for studies on vitreous function and pathobiology, data on the structural organization of the rabbit vitreous are scarce. The aim of the present study is to give a detailed description of rabbit vitreous structure in order to provide a basis for studies on changes in vitreous organization induced by pathophysiological processes. We studied the vitreous body of adult rabbit eyes by complementary anatomical evaluation methods, by light microscopy and by transmission electron microscopy. Regional and local variations in vitreous matrix organization were observed. Regionally, a cortex, an intermediate area, and a centre were distinguished. In addition, specific structures were locally observed. Lamellae run through the intermediate area in a funnel-like pattern, converging upon the asymmetrically positioned optic disc. A central channel (Cloquet's channel) was found in all eyes. We demonstrated a novel structure, attached to Cloquet's channel and to the medullary rays. Because of its wing-shaped sheet-like morphology, we named it the 'alae canalis Cloqueti'.

The Morgagnian and Brunescens cataract morphology studied with with SEM and TEM

The Morgagnian cataract lenses--pre-fixed with GA for SEM & TEM and post-fixed with tannic-acid-arginine-OsO4 for SEM and OsO4/K4Fe(CN)6 for TEM after staining with Ur-acetate/Pb-citrate--showed areas in the cortex with radial instead of concentric running lens fibres, degeneration of lens fibres with vacuoles and defected "ball & socket" connections. The presence of oval/spherical bodies of 0.5-20 microns was acknowledged, the largest of them having a golf-ball appearance and originating from the cytoplasm of the degenerating lens fibres; the smallest of them with an approximate size of 0.2-0.5 micron seemed to be formed by budding off from the microvilli of the furrowed lens epithelium. The Brunescens cataract lenses showed at low magnification no difference between lens fibres from the cortical area and the nucleus. The disintegration process of the lens fibres was observable as degradation of the ball & socket system and the existence of holes in the lens fibre body and emerging of spherical bodies from the cytoplasm. The globular structures seemed to be covered with a thin coating and were partly filled with a low density membranous-like material. In TEM-sections of the cataractous lens aterial vacuoles were visible consisting of a large number of smaller globules with a contents of low contrast low density membranous-like material, comparable with the globular structures seen in SEM.

Microorganisms found in secondary cataract material of ECCE patients, a study with SEM and TEM

Globular secondary cataract material, removed from 24 patients with ECCE after ophthalmic cleaning of the anterior capsule, were investigated with SEM and TEM. Besides spherical, somewhat oval shaped bodies of various shape and size comparable with those found in cataractous lenses, (an)aerobic bacteria and yeast cells were found in approximately 70% of the cases, all of them in eyes without intra-ocular inflammation. Probably these bacteria have been transferred from the conjunctiva during IOL.-implantation and were encapsulated without starting an inflammation.

Comparative anatomy of the vitreous body in rhesus monkeys and man

In the isolated unfixed vitreous body a structural organization can be visualized by slitlamp microscopy or by an ink-injection technique. We discuss the observations on human and rhesus monkey (Macaca mulatta) vitreous bodies using the ink-injection technique. Advantages and disadvantages of this method compared with slitlamp microscopy are described. Eventual functional implications of vitreal organization are mentioned briefly.

(An)aerobic bacteria found in secondary-cataract material. A SEM/TEM study

Twenty four patients, who had marked reduction of vision due to secondary-cataract developed after an ECCE, were treated by surgical cleaning of the posterior lens capsule. During this procedure globular secondary-cataract material was removed and collected for morphological examination by SEM and TEM. Fragments of various sizes and shapes, including some with a 'golf ball' structure, were seen; these closely resembled particles frequently found in cataractous lenses. In addition, in 18 patients micro-organisms were found: rod-shaped bacteria, cocci, and in 2 cases yeasts. These findings were the more remarkable because these were clinically quiet eyes with no signs of intra-ocular inflammation and cultures have been persistently negative. We imagine that these bacteria must have entered the eye during the cataract extraction and have settled there without causing an infection.

Study of the substructure of the Morgagni and Brunescens cataract with the TAO non-coating technique. Part 1: Morgagni cataract

Lens tissue from a Morgagni cataract was examined by SEM and TEM. For SEM, after prefixation with glutaraldehyde and postfixation with the tannic acid/arginine/OsO4 non-coating (TAO) technique, and for TEM, after prefixation with glutaraldehyde, postfixation with OsO4/K4Fe(CN)6 and poststaining with uranyl acetate/lead citrate. The TAO technique seems to be a particularly suitable postfixation method for the SEM investigation of cataract tissue because of the presence of the protein structures present. The cortical region showed areas of radially, instead of concentrically, arranged lens fibres, degenerated lens fibres with holes (vacuoles), broken ball and socket connections between the lens fibres, and oval or spherical structures varying in size from 0.5-20 microns, the largest resembling a golfball, arising from the cytoplasm of degenerating lens fibres. The smallest, 0.2-0.5 microns, appear to have been expelled from the furrowed lens epithelium.

Study of the substructure of the Morgagni and Brunescens cataract with the TAO non-coating technique. Part 2: Brunescens cataract

Lens tissue from a Brunescens cataract was prepared for SEM study by prefixation with glutaraldehyde and postfixation with the tannic acid/arginine/OsO4 combination; for TEM study the material was prefixed with glutaraldehyde, postfixed with OsO4/K4Fe(CN)6 and poststained with uranyl acetate/lead citrate. At low magnification, in contrast to the Morgagni cataract, no difference could be seen between the lens fibres in the cortical and nuclear areas. Morphologically, the destruction of the ball and socket system and the development of holes and spherical structures was striking. The latter appeared to have a thin coating and, after fracture, were either empty or showed remnants of material resembling membranes. In sections of the cataractous material, larger vacuoles containing smaller spheres were indistinctly visible.

A combined scanning and transmission electronmicroscopic investigation of human (secondary) cataract material

Cataract lenses from patients of advanced age were processed for SEM by standard pre-fixation followed by treatment by the Tannin-Arginine-Osmium-tetroxide (TAO) method and critical point drying, and for TEM by standard pre-fixation followed by vibratomation, standard post-fixation, ultramicrotome sectioning and staining with uranyl acetate/lead citrate. Secondary cataract material was brought onto a Millipore filter, fixed by standard methods, dried in air and sputter-coated with Au. Both SEM and TEM images revealed degeneration processes in lensfibre material, such as swelling of the lensfibre, protrusion of the cytoplasm, fibrillation of the cell membrane, loss of the nucleus, spherical bodies of various sizes between 0.5-1.5 microns, sometimes surrounded by a (double) membrane with different contrast but without cellular evidence, and small and large vacuoles partly filled with granular material both in and at the periphery of the lensfibre-body. The secondary cataract material on the Millipore filter revealed erythrocytes and more or less spherical bodies with high contrast, measuring between 0.5-1.5 microns, often referred to as Elschnig's pearls, besides non-definable organic material. The SEM and TEM micrographs of the cataract lens material strongly suggest that the spherical bodies with sizes of approximately 0.5-1.5 micrometer and high contrast without cellular evidence, are similar to the more or less spherical bodies found in the secondary cataract material on the filter, referred to as Elschnig's pearls.

Morphological aspects of human lens capsules. A comparative LM, SEM and TEM examination

Lens capsules of patients of advanced age, obtained after extracapsular cataract surgery, were carefully prepared for a combined LM, TEM and SEM investigation, after preliminary washing and mounting onto a holder in a buffer solution. After pre-fixation with GA, samples were postfixed for LM/TEM and OsO4/K4Fe)CN)6 and stained with toluidine-blue/basic fuchsin for LM and with uranyl acetate/lead citrate for TEM; for SEM the GA-pre-fixed samples were post-fixed by the Tannin Arginine-OsO4 non-coating technique. At LM-level discrimination between healthy and degenerating cells was possible after toluidine staining. At SEM-level protrusion of the cell nucleus and fibrillation and blebbing of the cell membrane as the result of capsular degeneration could be observed with the TAO-method. At TEM-level protrusion of the cell nucleus, degeneration of the cytoplasm, ballooning of the mitochondria, the presence of microfilaments and the occurrence of vacuoles were visible as the result of capsular degeneration on cataract formation.

Cell-ingrowth in a silicone plombe. Interactions between biomaterial and scleral tissue after 8 years in situ: a SEM and TEM investigation

A male patients (42 years) who had been treated for retinal detachment by the implantation of a silicone plombe into the sclera, returned to the clinic 8 years after implantation because of inflammation of the tissue and partial protrusion from the sclera. After removal of the plombe this was processed for TEM and SEM and examination of the plombe material after 8 years in situ could be carried out in order to get information about the cell-biomaterial interface. A large proportion of the silicone pores was filled with cellular material, including macrophages, giant cells and erythrocytes thus indicating a foreign body granuloma. The external surface of the pores showed a granular osmiophilic dense amorphous layer including extracellular debris. Engulfing of silicone particles by macrophages and the evidence of long-term tissue response suggest partial biodegradation of the silicone and certainly not complete inertness as was formerly claimed.

Morphology of donor lens-capsule material studied by SEM

The lens capsule of a 70-year-old male donor with a cataractous lens was carefully prepared for SEM by first washing the capsule with buffer solution to remove lens-fibres and subsequently attaching it to silicon rubber. During the fixation and drying stages of the preparation procedure the capsule stayed attached to the rubber substratum. In the equatorial zone germinating cells were found with knob-shaped microvilli, closely connected to lens-fibres. Large units of pathological capsule epithelial cells were found, only slightly inter connected by a few pseudopodia. In addition, single pathological epithelial cells with pseudopodia, arranged on top of the cell in a rosette-like configuration, were found at certain locations. Both types are probably related to the original lens-cataract.

Implant surgery. Something old and something new

A description of the author's (J.W.) technique for ICCE using a 'single-handed' freon cryo-extractor is given. Flieringa's ring is used for scleral support. Implantation is performed with an Iris Claw Lens. Stainless steel is used as suturing material.

Refractive surgery for high myopia. The Worst-Fechner biconcave iris claw lens

Surgical correction of high myopia is indicated in a limited number of cases. Techniques include (epi)keratophakia, keratomileusis and implantation of a negative-power IOL. The iris claw lens, fixed to the midperiphery of the iris, has proved its safety in aphakic eyes. The model has been adapted by giving it a vault in order to make it suitable for implantation in high myopic phakic eyes. The implantation technique and short-term results of patients operated by Worst are presented.

The irrigating knife: an ultrasharp surgical blade with irrigating system

We present an irrigating microsurgical knife for ocular surgery. Irrigation of balanced salt solution through the knife tip during sectioning removes hemorrhages continuously, allowing uninterrupted sectioning, without cauterization of bleeding vessels. The "zero degree" knife can be bent in any required position.

The van Andel transparent glass microsurgical cannula

We present a disposable 21-gauge transparent glass cannula that provides optimal visual control of aspiration-irrigation procedures in cataract surgery. It is especially useful in iris coloboma repair.

Lens-capsule material of human and animal origin, studied by SEM

Lens-capsule material from healthy and cataractous human lenses and from rabbits was collected with specially designed forceps. Subsequently the capsule fragments were fastened, after short pre-fixation, onto a rubber substrate with small stainless steel tacks, to prevent rolling-up of the fragments during the fixation and drying procedure for the SEM. Finally the capsule fragments were studied by SEM. Marked morphological changes, e.g., irregular swelling (like blebs) of the nuclei, formation of deep grooves at the cell borders and complete loss of epithelial cells, were found in the lens capsules obtained from certain cataractous lenses. Differences in capsule thickness were found in pathological capsule material. The imprints (attachment-lines) of the lens-fibres on the epithelial cells were often difficult to visualize.

Air-injection of the corneal stroma: a SEM study

The corneal stroma is supposed to be a homogeneous structure both from an optical and an anatomical point of view. Intrastromal injection of glutaraldehyde as a fixative causes local swelling and opacification of the corneal tissue. Local injections of small volumes of air superficially and more deeply into the corneal stroma produce similar swellings and formation of opaque areas. SEM investigation of these areas shows the existence of stromal canals, partly pre-existing, partly caused by the internal 'explosions' due to the air-injection. This suggests an anatomically non-homogeneous, although optically homogeneous, cornea.