One-stage reconstruction of eye socket and eyelids in orbital exenteration patients.

Reconstruction of the exenterated orbit is a difficult problem with several advantages and disadvantages. Satisfactory reconstructive results for both the physician and the patient may need multistage operations that are time consuming and disfiguring. A simple and effective one-stage technique that combines two regional flaps is described for reconstruction of deformities of orbital exenteration. A temporalis muscle flap is transposed for orbital filling, and a prefabricated frontal island flap based on superficial temporal vessels is used for eye socket and eyelid reconstruction. For patients who oppose living with exenteration deformity and request quicker reconstruction, this new and simple technique may be used successfully.

Removal of serum from primary cultures of cerebellar granule neurons induces oxidative stress and DNA fragmentation: protection with antioxidants and glutamate receptor antagonists.

Cerebellar granule neurons undergo apoptosis when deprived of chronic depolarization; serum deprivation has not been considered as a trigger of apoptosis in this culture. Here we report that serum removal triggers cell injury, which is characterized by signs of apoptosis. Actual cell death (trypan blue permeability) occurred 24 and 48 hr after serum removal. At earlier times (6 and 8 hr after serum removal) we found significant impairment of mitochondrial functioning [3-(4,5-dimethyl thiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay] and an increase in the percentage of neurons showing signs of DNA fragmentation (insitu terminal deoxynucleotidyl transferase assay, fluorescent assay). Protection was obtained by inhibiting RNA synthesis with actinomycin D and by antioxidants [1mM: 1,4-diazobicyclo(2.2.2)octane, histidine, mannitol; 1% dimethyl sulfoxide; 0.01-1 microM ascorbic acid]. We also measured neuronal oxidation utilizing the oxidation-sensitive fluorescent dye 2', 7'-dichloro- fluorescin diacetate, and found a significant increase in the rate of neuronal oxidation as early as 15 min after serum deprivation. The blockade of glutamate receptors by (+)-5-methyl-10,11-dihydroxy-5H-dibenzo(a,d)cyclohepten-5,10-imine (MK-801) and 6-cyano-7-nitroquinoxaline-2,3-dione also provided neuroprotection. However, oxidative stress appears to precede glutamate receptor activation: within the 8 hr period of serum deprivation, mannitol was protective when present either during only the first or last 4 hr; MK-801 was protective only when present for the entire 8 hr period or in the last, but not first 4 hr of serum deprivation. Serum deprivation of mature cerebellar granule neurons can be used to study mechanisms of oxidative stress-induced apoptosis.

Apoptosis induced in neuronal cultures by either the phosphatase inhibitor okadaic acid or the kinase inhibitor staurosporine is attenuated by isoquinolinesulfonamides H-7, H-8, and H-9.

Protein phosphorylation is kept in balance by an orchestrated action of kinases and phosphatases; when this balance is lost, neuronal apoptosis may occur. Okadaic acid (OKA), a marine toxin that inhibits specifically protein phosphatases 1 and 2A (EC 3.1.3.16), and staurosporine, an inhibitor of protein kinase C (PKC; EC 2.7.1.37), induced apoptosis in primary cultures of rat cerebellar granule neurons. We assayed apoptosis by the DNA gel electrophoresis, by the in situ TUNEL assay, and by morphological appearance following propidium iodide staining. Cell viability was assessed by the Trypan blue assay. Both OKA- and staurosporine-induced neuronal apoptosis were prevented by a macromolecular synthesis inhibitor actinomycin D and by a group of isoquinolinesulfonamide kinase inhibitors (H-7, 1-[5-isoquinolinesulfonyl]-2-methylpiperazine; H-8, N-¿2-[methylamino]ethyl¿-5-isoquinolinesulfonamide; H-9, N-(2-aminoethyl)-5-isoquinolinesulfonamide, but not by inhibitors of PKC, cyclic-GMP- and cyclic-AMP-dependent kinases, calcium/calmodulin-dependent kinases, tyrosine kinases, or by antioxidants. We postulate that a common mechanism, possibly an increased protein phosphorylation, is responsible for apoptosis triggered by an inhibition of phosphatases 1 and 2A and PKC. Elucidating the isoquinolinesulfonamide-sensitive mechanism may help us find new therapies for neurodegenerative diseases that involve apoptosis.

Protective action of isoquinolinesulfonamides in in vitro models of neuronal apoptosis.

We have previously reported that a group of isoquinolinesulfonamide kinase inhibitors (H7, 1-(5-isoquinolinesulfonyl)-2-methylpiperazine; H8, N-[2-(methylamino)ethyl]-5-isoquinolinesulfonamide; and H9, N-2-(aminoethyl)-5-isoquinolinesulfonamide) prevents apoptosis triggered in neurons by an inhibition of phosphatases 1 and 2A with okadaic acid, and by inhibition of protein kinase C with staurosporine and chelerythrine. In the present study we assessed the capability of isoquinolinesulfonamides (IQS) to prevent different types of apoptosis in primary cultures of cerebellar granule neurons. We induced apoptosis by: a) serum removal, b) potassium deficiency, c) serum removal + potassium deficiency, and d) beta-amyloid peptide (beta AP). The IQS prevented apoptosis in all the above models. Thus, it appears that the IQS-sensitive pathway is a common mechanism in different types of neuronal apoptosis, and that it might be used as a target in the development of novel neuroprotective drugs.

Opposite effect of protein synthesis inhibitors on potassium deficiency-induced apoptotic cell death in immature and mature neuronal cultures.

Typically, primary cultures of rat cerebellar granule neurons are grown in the presence of 25 mM KCl and are considered to mature by approximately 7 days in vitro. Potassium deficiency was created by growing the neurons from days 1 to 4 in the presence of 12.5 mM KCl (immature cultures) or by switching the mature neurons grown with 25 mM KCl to 12.5 mM KCl. In both conditions we observed neuronal death that bears the signs of apoptosis, i.e., DNA fragmentation determined qualitatively by agarose gel electrophoresis of DNA and quantitatively by in situ terminal deoxynucleotidyl transferase assay. The protein synthesis inhibitors cycloheximide and anisomycin provided neuroprotection in the mature cultures but potentiated the toxic effect of KCl deprivation in the immature neurons. The results suggest that a prudent use of protein synthesis inhibitors is critical in experiments with primary neuronal cultures.

Neuronal apoptosis in an in vitro model of photochemically induced oxidative stress.

In neurons, oxidative stress can be triggered by neurotransmitter-linked mechanisms and may lead to apoptotic cell death. A simple and reproducible model of inducing oxidative stress is needed to elucidate mechanisms which link oxidative stress and neuronal apoptosis. We report here a method of inducing apoptosis in cell cultures by loading them with a photosensitive dye, rose bengal, and exposing the cultures to light, a procedure which generates reactive singlet oxygen. We used this model in primary culture of rat cerebellar granule neurons, and in a nonneuronal human embryonic kidney 293 cell line. We have measured the following: (a) metabolic activity of the mitochondria by quantitative staining with 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT), (b) DNA fragmentation by quantitative in situ terminal deoxynucleotidyl transferase assay, and (c) cell viability by a trypan blue exclusion test. The oxidative stress caused an early impairment of mitochondrial function (MTT assay). This was followed by DNA fragmentation and ultimately by cell death. Protection was obtained with an inhibitor of macromolecular synthesis, anisomycin, and with antioxidant, vitamin E. This model can be used to study the mechanism of oxidative stress-triggered neuronal apoptosis, and it may help in discovering new targets for neuroprotective drugs.

Melatonin protects neurons from singlet oxygen-induced apoptosis.

Singlet oxygen (O2[1 delta g]) is a very reactive molecule that can be produced by living cells and may contribute to cytotoxicity. The pineal hormone melatonin has been reported to possess potent antioxidant activity, and to be capable of scavenging O2(1 delta g). We investigated whether melatonin might reduce the neurotoxic action of O2(1 delta g). The cytotoxic effect of singlet oxygen was studied in primary cultures of cerebellar granule neurons pretreated with a photosensitive dye, rose bengal, and exposed to light--a procedure that generates O2(1 delta g). We found that this procedure triggers neuronal death, which is preceded by mitochondrial impairment (assayed by the rate of the reduction of MTT, 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide, into formazan), and by DNA fragmentation--a marker of apoptosis. DNA fragmentation was determined in situ by terminal deoxynucleotidyl transferase assay; cell death was assayed with 0.4% trypan blue solution--viable cells with an intact membrane are not permeable to trypan blue; dead cells are, and thus, they are stained blue. Neuroprotection was obtained with the pineal hormone melatonin. In a cell-free system, melatonin also protected the enzyme creatine kinase (EC 2.7.3.2) from the rose bengal-induced injury. The results suggest that melatonin might counteract the cytotoxic action of singlet oxygen. Further studies are needed to clarify the exact role singlet oxygen and melatonin might play in neurodegenerative diseases.

Serum antibodies reactive with eye muscle membrane antigens are detected in patients with nonspecific orbital inflammation.

PURPOSE: Nonspecific orbital inflammation, also called "orbital pseudotumor," has many of the features of thyroid-associated ophthalmopathy, especially when localized to the eye muscle. The purpose of this study is to test for circulating autoantibodies against eye muscle antigens and features of possible thyroid autoimmunity in patients with nonspecific orbital inflammation. METHODS: The authors studied eight patients with diffuse or localized nonspecific orbital inflammation. The presence of autoantibodies reactive with pig eye muscle membrane antigens and 1D, a recombinant 64 kilodaltons (kd) thyroid and eye muscle protein, were tested in sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting. RESULTS: The most frequently detected antibodies were those reactive with eye muscle membrane proteins of 55 and 64 kd, which were demonstrated in 62.5% and 62.5%, respectively, of patients with nonspecific orbital inflammation; antibodies against 95- and 45-kd proteins were each detected in 50% of patients. In health subjects, antibodies reactive with the 55- and 64-kd proteins were detected in 16% and 20% of patients, respectively; those reactive with the 95-kd protein were detected in 24% of patients and with the 45-kd protein in 20% of patients. On the other hand, antibodies to 1D were demonstrated in only one patient with nonspecific orbital inflammation and not at all in healthy subjects. The prevalence of positive tests were significantly greater in patients with nonspecific orbital inflammation than healthy patients only for antibodies reactive with a 55-kd protein. Of the four antigens, only the 55-kd protein was expressed in other (systemic) skeletal muscle. No patient had overt thyroid disease or detectable serum antibodies reactive with the thyroid-stimulating hormone receptor, and only one had antibodies reactive with the thyroid microsomal antigen. CONCLUSION: Serum autoantibodies reactive with eye muscle membrane proteins are demonstrated in the majority of patients with nonspecific orbital inflammation. Although the pathogenesis of this condition is unknown, autoimmunity against eye muscle antigens is a likely mechanism. While antibodies reactive with the thyroid microsomal antigen were detected in only one patient and anti-thyroid-stimulating hormone receptor antibodies in none of the patients, a possible association of nonspecific orbital inflammation with thyroid autoimmunity has not been excluded.

Macular subretinal neovascular membrane associated with pseudotumor cerebri.

We report on the development of juxtapapillary subretinal neovascular membrane and permanent severe visual loss in a patient with pseudotumor cerebri. The patient was managed by a lumboperitoneal shunt. After surgery, despite resolving papilledema and intracranial pressure control, the membrane had enlarged rapidly to involve the foveal avascular zone, and resulted in rapid visual loss. The membrane slowly regressed, and was replaced by fibrous tissue at the ninth month, causing permanent severe visual loss.

Modified split-level lid resection for blepharoptosis.

Mustardé's split-level lid resection surgery was popular through the 1980s for the correction of blepharoptosis with 7 mm or more of levator function. Although the aesthetic results gained with this technique were good, last line deformity and eyelid margin irregularities, such as central peaking at forward and upward gaze, were experienced. A simple modification of the tarsal resection pattern of Mustardés operation has solved these complications. In the treatment of 24 ptotic eyelids (12 unilateral, 6 bilateral with a modified split-level lid resection procedure), symmetrical appearance and level eyelids were obtained without lid margin peaking at 5 years' follow-up. The only persistent complication was lid lag at down-gaze in 10 eyelids.

Use of eye muscle antibody measurements to monitor response to plasmapheresis in patients with thyroid-associated ophthalmopathy.

We have measured eye muscle antibodies, in immunoblotting, in the serum from five patients with severe ophthalmopathy associated with Graves' hyperthyroidism who underwent plasmapheresis, correlating their levels with clinical features of the eye disorder and response to treatment. Blood taken before each plasma exchange was tested in SDS-polyacrylamide gel electrophoresis and Western blotting for antibodies reactive with pig eye muscle membrane (PEMM) antigens and in a 51Cr release assay for antibodies which are cytotoxic to human eye muscle cells in antibody-dependent cell-mediated cytotoxicity (ADCC). Antibodies reactive with a 64 kDa PEMM antigen were detected in three patients who had eye disease of less than six months duration, but not in the two with more chronic disease. Antibodies against a 95 kDa PEMM antigen were detected in one patient in whom anti-64 kDa antibodies were also demonstrated. All five patients showed significant improvement in their eye disease following plasmapheresis exchange and titres of the anti-64 kDa protein antibody decreased in the three patients with detectable levels before treatment. TSH receptor stimulating antibodies were detected in all five patients before treatment, falling during plasmapheresis in four and becoming undetectable in three by the end of treatment. There was no close correlation between levels of TSH receptor antibodies and titres of anti-64 kDa protein antibodies although both tended to fall during and following plasmapheresis. ADCC tests were negative in all five patients before plasmapheresis but, surprisingly, transiently positive in three following treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Late visual recovery after intravenous methylprednisolone treatment of Purtscher's retinopathy.

A 25-year-old man involved in a minor traffic accident subsequently had a Purtscher's-type retinopathy and lost visual acuity (20/800). After treatment with intravenous methylprednisolone at a dose of 1 g/day, his visual acuity improved to 20/70 three days later and to 20/50 one week later. The exudates and hemorrhages gradually disappeared. However, a localized central scotoma and afferent pupillary defect still persisted. We review previous reports on the retinal pathophysiology of Purtscher retinopathy and discuss the potential benefit of treatment with high-dose intravenous corticosteroids.

Eales disease with internuclear ophthalmoplegia.

Eales disease is an idiopathic type of retinal perivasculitis characterized by recurrent retinal and vitreous hemorrhages. Neurologic involvement is rare. We report the case of a patient with Eales disease who had internuclear ophthalmoplegia thought to be a neurologic manifestation of this disease.