Transforming and insulin-like growth factors in the aqueous humour of patients with exfoliation syndrome.

BACKGROUND: Growth factors circulating with the aqueous may play an important role in the pathogenesis of exfoliation syndrome (XFS), which is characterized by excessive synthesis and accumulation of abnormal extracellular material. METHODS: We investigated the concentration of three ubiquitous growth factors (TGF-beta1, TGF-beta2 and IGF-1) in the aqueous humour of 50 patients with XFS (27 from Erlangen, 23 from Thessaloniki) and 54 age-matched controls (27 from Erlangen, 27 from Thessaloniki). This study was performed in two centres, independently of each other, using different assay systems. RESULTS: In the aqueous humour samples collected in Erlangen, both the levels of total TGF-beta1 (P<0.001) and mature TGF-beta1 (P<0.05) were significantly increased in XFS patients compared with controls. Specifically, for total TGF-beta1 patients with XFS exhibited higher a mean value (90.5 +/- 37.4 pg/ml) than controls (30.2 +/- 8.3 pg/ml). The mean level of mature TGF-beta1 was also higher in XFS (14.2 +/- 2.8 pg/ml) than in controls (4.9 +/- 5.5 pg/ml). No difference was found between XFS and controls in the levels of total or mature TGF beta2 in the aqueous or in the level of these two growth factors in the serum. In aqueous humour samples collected in Thessaloniki a significant difference between XFS and controls was also observed for mature TGF-beta1 (XFS 17.06 +/- 11.02 pg/ml vs controls 9.01 +/- 5.69 pg/ml; P=0.006). No difference was observed in TGF-beta2 concentration or IGF-1 concentration in the aqueous. No correlation could be established between protein concentration and the levels of the three growth factors measured. A significant correlation was found between age and protein concentration in XFS, but not in the controls. CONCLUSION: Since TGF-beta1 induces the synthesis and accumulation of extracellular matrix, it is hypothesized that TGF-beta1 plays an important role in the pathogenesis of XFS. Our data suggest that the increased levels of TGF-beta1 are most likely due to enhanced local synthesis.

Contact lens fitting difficulties following refractive surgery for high myopia.

PURPOSE: To describe the clinical and optical problems encountered in contact lens fitting following refractive surgery for high myopia. METHODS: Following refractive surgery for high myopia (greater than -10.00 D) we corrected residual refractive errors with contact lenses in the four eyes of two patients. The first patient had undergone bilateral laser in situ keratomileusis (LASIK),with two subsequent LASIK retreatments in the left eye. Ten months later she was fit with rigid gas permeable (RGP) lenses in both eyes. The second patient had undergone a clear lens extraction in the right eye and radial keratotomy followed by photorefractive keratectomy(PRK) in the left eye. She was fit with toric soft lenses six years postoperatively. RESULTS: Final visual acuity obtained with contact lenses was 20/25-20/20 in all eyes. The first patient required significant minus lens power compensation. Furthermore, the RGP lens in the left eye was slightly decentered due to corneal irregularity induced by LASIK. The second patient had regular corneal surfaces and was successfully fit with daily wear toric soft lenses despite the 2.75 D of residual astigmatism in the left eye. CONCLUSIONS: Following refractive surgery for high myopia a proportion of patients will remain undercorrected. In these patients the alterations in corneal architecture that ensue make contact lens fitting more challenging. Patients with regular astigmatism may be fitted successfully with toric soft lenses. Patients with corneal irregularities should be fit with RGP lenses.

Twenty-four hour control of intraocular pressure with dorzolamide and timolol maleate in exfoliation and primary open-angle glaucoma.

PURPOSE: To determine the efficacy and safety of adding dorzolamide 2% twice daily to timolol maleate solution 0.5% twice daily when treating exfoliation glaucoma or primary open-angle glaucoma. METHODS: This was a single-centre, crossover intra-individually controlled comparison. Sixty-two consecutive patients (31 with exfoliation glaucoma and 31 with primary open angle glaucoma) chronically treated with timolol maleate twice daily were included in this trial. Patients then had added dorzolamide 2% twice daily (08:00 and 20:00), instilled approximately 10 min after timolol maleate. Patients underwent diurnal intraocular pressure (IOP) testing (six measurements over 24 h), first on timolol maleate monotherapy and 2 months later following the addition of dorzolamide 2% as adjunctive therapy. RESULTS: On timolol monotherapy patients with exfoliation glaucoma had a higher mean IOP at 02:00, 06:00, 10:00, 14:00 and 22:00 hour time points as well as a higher maximum, minimum and range of IOP throughout the day compared with the primary open-angle glaucoma group (p < 0.05). Following the addition of dorzolamide as adjunctive therapy to timolol maleate there was a significant reduction in IOP (p < 0.05) at all time points in both glaucomas, but mean IOP at 10:00, 14:00, 18:00 and 22:00 hour time points, as well as the peak and range of IOP, remained higher in the exfoliation glaucoma group. No serious adverse events were noted with dorzolamide. Bitter taste, the most common symptom, was noted in 30% of patients. CONCLUSIONS: These data suggest that dorzolamide 2% used adjunctively with timolol maleate 0.5% solution is effective in reducing diurnal IOP in patients with primary open-angle and exfoliation glaucoma but does not alter the characteristics of higher IOP levels in the latter disease.

The evaluation of corneal graft tissue by the use of trypan blue.

BACKGROUND: The quality of the donor cornea, which basically depends on the condition of the endothelial sheet, is an important factor for the successful outcome of penetrating keratoplasty. PATIENTS AND METHODS: In this retrospective study, we present our experience in using trypan blue staining for the examination and evaluation of 498 consecutive corneal grafts from 251 donors, concerning their suitability for penetrating keratoplasty, during the decade 1986-1995. RESULTS: Forty-two grafts out of 498 (8.5%) were considered not suitable for surgery because of the great number of destroyed cells (cell density less than 1,500 cells/mm2) and the abnormal cell size and cell shape. Nine out of the 456 (1.97%) operated eyes exhibited primary donor failure and needed re-operation, probably because of boundary cell density of the graft (ranged in those cases from 1,600 to 1,800 cells/mm2). No infections of grafts were observed. CONCLUSION: Tissue evaluation of corneal grafts by the use of trypan blue staining is a simple, cost-effective, safe and accurate method that does not influence the vitality of the endothelial layer of the grafts.

The role of computerized corneal topography in rigid gas permeable contact lens fitting.

PURPOSE: The purpose of this study was to determine the clinical utility of computerized corneal topography (CCT) in the fitting of rigid gas permeable (RGP) contact lenses. METHODS: In this prospective study, we compared the clinically determined parameters to those obtained by CCT in 50 consecutive patients who underwent RGP lens fitting. The TMS-1 program was used for CCT, and we fit patients with Boston RGP contact lenses (type II, or Equalens). The final decision on the RGP lenses dispensed relied upon the clinical evaluation (slit lamp examination, fluorescein pattern, lens centration, and visual acuity). RESULTS: The base curve of RGP lenses proposed by CCT was similar to that selected clinically (mean: 7.74 mm versus 7.81 mm). However, the mean diameter of the CCT proposed lenses was smaller than that selected clinically (9.31 mm versus 9.6 mm, P < 0.01). Divergence was more pronounced in keratoconus. CONCLUSIONS: CCT is an important tool in RGP contact lens fitting. Clinical evaluation remains mandatory in determining the appropriate RGP lens.

Preoperative features of patients with exfoliation glaucoma and primary open-angle glaucoma. The AHEPA study.

PURPOSE: To describe and compare the preoperative characteristics of Greek patients with exfoliation glaucoma (EXG) and primary open-angle glaucoma (POAG). METHODS: We prospectively investigated the preoperative features of 100 consecutive patients undergoing filtration surgery for either EXG, or POAG. We compared 74 patients with EXG and 26 with POAG. RESULTS: EXG patients were older (68.2 vs 62.4 years; p<0.05) and more often from the countryside (73%). Both glaucomas showed a preponderance for males, similar frequencies of positive family history and systemic disorders, with the exception of diabetes which was more common in POAG (19.2% vs 5.4%). The first IOP measurement, before treatment, was significantly higher in EXG (40.4 mm Hg) compared with POAG (33.9 mm Hg). Despite a shorter duration of medical therapy (25 vs 65 months) and more topical drugs EXG patients exhibited higher mean preoperative IOP (36 vs 27.8 mm Hg for POAG; p<0.05). EXG patients had significantly worse visual acuity than POAG (0.4 vs 0.6; p<0.05) and worse compliance to medical therapy (48%) compared to POAG (33%). CONCLUSION: Significant differences in preoperative features distinguish EXG from POAG.

Exfoliation syndrome in a 17-year-old girl.

A 17-year-old girl with unilateral congenital glaucoma who had undergone trabeculectomy and peripheral iridectomy in infancy developed apparent exfoliation syndrome (XFS) in the eye that underwent the surgical procedures. A conjunctival biopsy was performed and the specimen was fixed in 2.5% glutaraldehyde, embedded in epoxy resin (Epon-Araldite, Electron Microscopy Sciences, Fort Washington, Pa), and processed for routine electron microscopy and immunostaining for elastin. Results of ultrastructural study showed scattered fibrillar aggregates compatible with those of XFS in an older adult, differing chiefly in sparsity of granular interfibrillar matrix. The XFS fibers were closely associated with elastic fibers and microfibrils. Elastosis of the actinic-aging type was somewhat greater than expected for age. To our knowledge, this is the youngest patient described with characteristic ocular findings of XFS to date, supporting others who have suggested an association between iris surgery in youth and early onset XFS. Electron microscopy was essential in ruling out the possibility of a clinically similar entity caused by ultrastructurally different material.

Frequency of exfoliation syndrome in Greek cataract patients.

The frequency of exfoliation syndrome (EXS) was investigated in a group of Greek patients undergoing extracapsular cataract surgery. Five hundred and nine (509) consecutive cataract patients without any other manifest ocular abnormality were prospectively examined for the presence of EXS. Patients were clinically divided into 3 groups: group I (EXS group) consisted of patients in whom exfoliation material deposition could be seen; Group II (possible EXS group) comprised patients who demonstrated a number of pigmentary signs and group III (normal subjects) comprised patients with senile cataract and no sign of EXS. EXS was found in 140 (28%) of our patients, possible EXS in 119 (23%) and the rest (49%) had no evidence of EXS. Patients with EXS were older (mean age 73.8) when compared to the possible EXS group (70 years) and the control group (64.7 years). The IOP was significantly higher in patients with EXS (mean 15.5 mmHg versus 14.3 mmHg in the other two groups). Blue irides were significantly more common in patients with EXS (19%) than in the possible EXS group (14%) and the controls (4%). EXS is common in Greek cataract patients and this study has identified a large group of patients who may be at an early stage of development of the condition. EXS may predispose to the development of cataract in Greek patients.

Simple iris coloboma in a Greek family.

We report the presence of simple iris coloboma in 4 out of 5 female members comprising four generations of a Greek family. A varied degree of simple iris coloboma (i.e. not associated with a choroidal coloboma) was present in one eye of the maternal grandmother, mother, daughter and one out of 2 granddaughters of this family. The iris colobomata were associated with congenital lens opacities in 2 out of 4 of the females, macular degenerative changes in 2 cases and ocular hypertension in one case. The pathogenesis, heredity and associations of simple iris colobomata is discussed.

Preoperative ocular disinfection by the use of povidone-iodine 5%.

Numerous disinfective methods have been proposed in order to prevent intraocular infections during eye operations. In a clinical-laboratory study we evaluated the effectiveness of povidone-iodine solution 5% as a preventive - preoperative means of conjunctival antisepsis prior to ocular surgery. Conjunctival cultures were performed on 100 patients. Group A (50 patients) had their fornices washed with normal saline immediately before surgery. In Group B (50 patients) one drop of povidone-iodine solution 5% was applied prior to preoperative wash of the fornices with normal saline. Thirty-three out of 50 eyes from Group A had positive cultures (66%). Only 15 out of 50 eyes from Group B had positive cultures (30%). Bacteria flora differed in the two groups, with Group A exhibiting more dangerous strains. Preoperative-preventive disinfection with povidone-iodine 5% may prove to be advantageous to ocular surgery.